Blo= od Sample Collection
Blood specimens are obtained for the purpose of prov= iding the clinician with important laboratory information. To obtain the best qua= lity specimen, it must be collected under rigidly controlled condition described= in this procedure. While collecting the specimen, the human relations aspect of patient contact is equally important to the technical aspects of specimen collection.
· Needles 20-22 g
· G butterfly
· Vacutainer holde= rs
· Appropriate tubes
· Isopropyl alcohol swabs
· Gauze
· Band-Aid
· Tourniquet
· Lancet
· Appropriate unopettes, capillary tubes or microtainers
· Syringe
· Betadine swab
Follow Standard Precautions
1. Wash Hands
2. Identify yourself to the patient and explain what you are going to do.
3. Identify patient.
Outpatient
1. = Ask patient to spell his/her last name.
2. = Verify the first name.
3. = Ask patient's DOB.
Inpati= ent
1. Verify the patient's name and hospital number by checking the name and number on t= he wristband against the label.
4. Review provider's orders, labels and select appropriate tubes.
5. Confirm that any required dietary restrictions for the test have been observed.
6. Position the patient. Place a small pillow under the elbow for support if necessary.=
7. Wear disposable gloves to protect from accidental exposure to blood.
8. Apply the tourniquet about midway between the elbow and the shoulder release tourniquet and prep area. Palpate the vein and select the area for venipuncture.
9. Scrub the area for venipuncture with an alcohol pad i= n a circular motion outward.
10. Asse= mble equipment. Open the needle by twisting the seal to break. Remove rear cap a= nd thread needle into holder or syringe. Check for expired tubes and discard a= ny that are expired.
11. Reap=
ply
tourniquet and vein should be "fixed" or held taut during the
12. Remo= ve the needle cover. Perform the venipuncture. Introdu= ce the needle with the bevel up. The needle should be in line with the vein and at= a 15 degree angle with the skin.
a) = Vacutainer method
i) = Push tube towards end of holder, piercing the rubber stopper.
ii) = When the blood starts to flow, remove the tourniquet or keep tourniquet on until samples are obtained, then release.
iii) If several tubes are required, remove the tube when the blood flow has ceased = and insert the next tube straight into the holder until blood flows. Repeat unt= il all samples are collected.
iv) Multiple tubes should be drawn in a specific sequence. Never use the citrate tube as= the first tube. Tissue thromboplastin can contamina= te the initial venipuncture and yield false results. T= he sequence is as listed below:
v) = blood culture tubes
vi) non additive tubes
vii) coagulation tubes
viii) heparin tubes
ix) EDTA tubes
b) = Syringe method
i) = When blood appears in the hub of the syringe, slowly pull back on the plunger of the syringe while holding into the syrin= ge barrel.
ii) = Remove needle/syringe from the patient's arm.
iii) Fill appropriate tubes slowly with the correct volume of blood. Do not overfill tubes.
13. Gent= ly mix all tubes containing additives.
14. When sampling is completed, immediately remove the needle/holder assembly and activate needle protection device. Apply and hold a dry compress over the <= span class=3DSpellE>venipuncture site. Elevate the arm.
15. Disp= ose of needle/holder system in puncture resistant holder. Never recap, break or cut needles.=
16. Use preprinted labels or label the tube from the patient's wristband. The tubes should contain the following information Name (first and last); medical rec= ord number, hospital location.
17. Ente= r the time the specimen was drawn. Write the date if the date of collection is different that the printed date. Enter your initials. By entering your init= ials you have verified than you correctly identified the patient.
18. Insp= ect the puncture wound. Do not leave the patient until the bleeding has stopped. Place a Band-Aid or pressure dressing on the arm of outpatients when bleedi= ng has stopped.
19. Than= k the patient sincerely.
Always remove needle from patient's arm and apply pr= essure to site if a reaction occurs.
· Lower patient's head and arms
· Loosen tight clothing
· Administer ammonia inhalant
· Apply cold compresses to forehead
· Notify provider if patient does not respond =
· Instruct patient to breathe deeply and slowl= y.
· Apply cold compresses to forehead.
· Give patient emesis basis and have tissues r= eady
· Give patient water to rinse out mouth
· Do not restrain patient
· Prevent patient from injuring himself
· Call provider or nurse
1. If the patient does not have a wristband or if the information on the wristban= d is incorrect, have the patient correctly identified and place a wristband on t= he patient before drawing the specimen.
2. Avoid vigorous mixing of tubes, this can cause hemolysis.
3. After removing the needle do not bend the patient's arm. This leaves the needle puncture wound open and can cause a hematoma.
4. If you do not get blood, change the position of the needle (pull back or advan= ce further). Extensive probing is not recommended and may be painful for the patient.
5. If you do not obtain blood, release the tourniquet and give the patient a rest. Re-apply the tourniquet to the other arm and look for another vein. If you still don't get blood, DON'T TRY AGAIN. Request assistance with the phlebot= omy.
Collection of Samples Near IV Sites and Indwelling Catheters
Blood samples collected from or near indwelling cath= eters require special considerations to insure collection of blood specimens which are representative of the patient's status and free of contaminating soluti= ons, with a minimum amount of blood being discarded.
Follow Standard Precautions - Because this procedure involves the manipulation and collection of blood specimens, all personnel = that are directly involved in this procedure must wear gloves as a protective barrier. Wearing gloves will prevent the accidental contact of personnel wi= th blood, thus minimizing the risk of infections.
Whenever possible, blood samples should be collected directly into vacutainers, and the unnecessary = use of syringes avoided. This provides for a faster specimen collection with less = of a chance for accidental spillage of blood. Special Luer<= /span> adapters are available which allow for direct sampling. Syringes may be use= d as needed for special circumstances.
Do
not draw blood samples directly through a Clave Cap system. These caps are found to hemolyze specimens.
Discarded fluids that are contained in tubes or syringes, should be handled in a manner that minimizes possibility of biohazard exposure. This means that the tubes should be plac= ed into biohazard containers or sharps receptacles which will safely contain t= he liquids until terminal disposal.
Important Note: All specimens collected from s= ites other than routine venipuncture must have appro= priate notes in the result comment field. This information is valuable for the attending provider to consider when interpreting the results.
Generally, requirements for A-line specimens are the=
same
as for venipuncture. Samples should be collected
using the Vacutainer system and appropriate
A volume of 5 ml of flush solution should be removed= from A-lines by drawing directly from the stopcock into a plain red top tube. Th= is tube (a 10 ml red top) should be filled approximately 1/2 full or approxima= tely 5 ml. The "discard" volume is based upon the convention that the stopcock to arterial catheter distance will be approximately 12 inches and = the volume of fluid held by this tubing will be approximately 1 ml.
Sample volume should be kept to a minimum whenever possible to minimize the depletion of the patient's red cell volume from frequent specimen collection.
When all necessary samples have been obtained, the original tube (which was used for containing the "discard" volume= of flush solution) may be re-used to collect any additional discarded fluids. = This tube should be discarded into biohazard containers, to prevent confusion wi= th blood samples which will be submitted to the laboratory.
Laboratory reports should clearly indicate the sourc= e of these specimens in the result comment field.
These lines are generally undesirable for the collec= tion of laboratory specimens. Due to complications arising from contamination and dislodging from proper position, they should only be used when other sites = for blood specimens are unavailable and when express permission of the attending provider is given. Laboratory reports should clearly indicate the source of these specimens.
Coagulation tests should not be drawn from these lin= es since residual heparin may affect the following tests:
· PT
· PTT
· Fibrinogen
· Thrombin Time
· Coagulation Factor Assays
· Heparinized cent= ral line catheters are not recommended for collection of laboratory specimens.<= /p>
Generally, requirements for these specimens are the = same as for venipuncture.
Samples should be collected using the Vacutainer system and appropriate multisample needles. This process will facilitate specimen collection, avoiding the unnecessary trans= fer of blood from syringes to tubes.
A volume of 5 ml of flush solution should be removed= from the line by drawing directly from the line into a plain red top tube then discarding this tube.
Coagulation tests should not be drawn from these lin= es (see list above).
NOTE: Some of these lines may be difficult to = purge the flush solution completely. For that reason, if drugs have been administ= ered in the line, they are not desirable sites for the collection of tests that = are related to the drug that is administered. Providers should indicate if samp= les are to be collected from these lines, and result comments must indicate when samples are collected from these lines.
Example:
Heparin will interfere with coa= g tests
Gentamicin will interfer= e with gentamicin levels
Heparinized IV catheters= are not recommended sites for collection of Laboratory specimens.
Collection of Laboratory samples from arms which hav= e IVs located in them should be avoided if possible. At times, there may be situations where this is necessary, therefore, the following should be considered
Whenever possible, if it is necessary for a patient = to have multiple IVs, placement of both IVs in the same arm is desirable.
When this is not possible, critical or life sustaini= ng medications should be restricted to one arm, leaving the other arm with medications which may be shut off for several minutes to allow sample collection.
When it is necessary to shut off IVs, they should be= off for 3 minutes to allow IV fluids to flush through the vein completely. Inadequate flushing can cause dilutional effect= s in the laboratory specimen leading to erroneous results or testing interferenc= es.
Draw blood sample from a vein below the IV site.
Arterial punctures should be considered as an altern= ative to venous specimen collections.
IV solutions may be stopped and the catheter heparinized, to allow more complete flushing of fluid= s from the vessel.
Samples should not be collected while an IV is runni= ng. Exceptions to this should only be made by the patient's attending provider,= as needed in critical situations.
Specimens may be collected from foot veins. The pati= ent's attending provider should make an explicit request to perform this. Consideration should be given to the adverse effects that may result from vascular trauma to the lower extremities which may lead to infections and or phlebitis. Additionally, blood circulation may be poor in lower extremities leading to hemoconcentration of the blood sampl= e. This effect may cause lab data to be misleading.
Blood Culture Collection
The detection of microorganisms in a patient’s=
blood
has diagnostic and prognostic importance.&=
nbsp;
Bacteria enter the blood from extravascular sites
such as the genitourinary tract, respiratory tract, abscesses, surgical wou=
nd
infections and other miscellaneous sites either directly or via the
Blood cultures are essential in the diagnosis and treatment of the etiologic agents of sepsis. Bacterial sepsis constitutes = one of the most serious infectious diseases and, therefore, the expeditious detection and identification of blood borne bacterial pathogens is an impor= tant function of the diagnostic microbiology laboratory.
Because the Bactec Blood= culture method is so sensitive, the procedure must be carefully controlled beginnin= g at the preanalytical stage (collection), to avoid = the misinterpretation of a collection-associated skin comm= ensal microorganism as an agent of infection.
Note: = Although drawing blood cultures before or during the fever spike is optimal for orga= nism recovery, volume is more important than timing in the detection of agents of septicemia. Numerous studies have shown that 2-3 blood cultures are optimal= for the detection of septicemia. Therefore, the following protocol is recommend= ed:
Blood cultures to rule out or rule in bacteremia; a mildly febrile patient:
· Most patients are in this category
· Blood cultures should be drawn at intervals = of ½ hour-1 hour apart for a maximum of three cultures.
Patients that are crit=
ically
septic:
· Overriding concern is to start antibiotic therapy quickly.
· Two to three blood cultures should be drawn = from different anatomic sites before starting therapy
For patients with FUO due to possible abscess,
· Draw 2 blood culture sets initially, one hour apart
· Draw 1-2 more, 24-36 hours later.
· Increased yield beyond four cultures is negligible
· Acute endocarditis: Draw 3 blood culture sets 1 hour apart, then treat empirically
Subacute endocarditis
· If patient is already on antibiotics, draw 2 blood culture sets for 3 successive days, and request that the microbiology laboratory extend the incubation time to 14 days
· 20 cc Luer-lok s= yringe or blood collection set (“butterfly”)
· 10% povidone-iod= ine solution prep pad
· 70 % isopropyl alcohol pad
· Tourniquet
· Gloves
· Blood culture vials (for adults each culture consists of a Standard/10/Aerobic F “blue” vial and a Plus Anaerobic/F “Gold” vial; a pediatric blood culture consists of one Peds Plus/F “pink” blood culture vial.)
1.&n= bsp; Select a different body site for each blood culture set drawn. (Anti-cubital is usually the= best site for phlebotomy procedures).
2. =
Blood
should always be drawn from a peripheral site and never from an indwelling =
line
unless the diagnosis of catheter sepsis is suspected and the physician
specifically orders that the culture be drawn through a line. If the blood =
is
drawn from the line, a peripherally drawn culture must also be collected.
1. = Remove the plastic cap from each Bactec blood vial immediately before use.
2. = Scrub the tops of the blood culture vials with 70% isopropyl alcohol and leave the pad on top of the bottle until the blood is ready to be injected.
3. = Do not use iodine to disinfect tops of vials.= Iodine can deteriorate the rubber stopper during the culture incubat= ion period.
1.&n= bsp; Avoid touching the site of the venipuncture. All site locating should be done prior = to cleansing the site. If it is necessary to touch the site after it has been cleansed then your fingers ne= ed to be cleansed with iodine before touching the site.
2.&n= bsp; When using the Blood Collection Set(“butterfly”) the phlebotomist MUST carefully monitor the volume collected by means of the 5 graduation marks on the vial label. If the volume is not monitored, the amount collected can exceed the stated maximum amount. This condition adver= sely creates a “false” positive result due to high background from t= he increased cell count. It may = be helpful to draw a line on the bottle at the point that the maximum draw will have been achieved. Do not co= llect blood beyond this line.
3.&n=
bsp; When
using a 20 mL syringe draw 20 mL
blood for one blood culture set (aerobic and anaerobic). The aerobic vial should be inocula=
ted
with 8-10 mL and the anaerobic vial should be
inoculated with 3-10 mL (8-10 mL
is preferred). Close the safety device on the needle and remove the needle =
on
the syringe after performing the venipuncture.
Inoculate the vials with the syringe with a safety transfer device. =
The volume of blood is critical because the concentration of organisms in most cases of bacteremia= is low, especially if the patient is on antimicrobial therapy. In infants a= nd children, the concentration of organisms during bacter= emia is higher than adults, so less blood is required for culture.
1. = Infants (up to age 1 year): 1-3 mL of blood per venipuncture; transfer the entire amount to a BACTEC = PEDS Plus vial.
2. = Children (age 1-5): It is desirable to obtain as much blood as possible to ensure optimal recovery of organisms. Therefore, it is recommended that at least 5 mL= each is collected in an aerobic and an anaerobic vial. If that is not possi= ble, 5 mL in just an aerobic vial, or 1-3 mL in a PEDS vial is acceptable.
3. = Adult: 20 mL of blood per venipun= cture. For each blood culture ordered an aerobic (blue) vial and an anaerobic (gold) bottle should be drawn. The aerobic (blue) bottle should be drawn first. If it is impossi= ble to draw the required amount aliquot as follows:
|
Amount per ven=
ipuncture |
Amount in aerobic vial |
Amount in anaerobic vial |
|
16-20 mL |
Split equally betweem aerobic and anaerobic vials |
|
|
13-16 mL |
8 mL |
remaining blood |
|
10-12 mL |
5-7 mL |
5 mL |
|
5-9 mL |
entire amount |
0 |
1. = Each vial must be labeled with a barcode label which will contain the following information: inpatients - patient’s first and last name, medical reco= rd number, patient’s location (room and bed #), patient’s date of birth, outpatients - patient’s first and last name and date of birth.=
2.&n=
bsp;
Do
not deface or place labels on top of the bottle’s barcode label.
3. = Each vial will be accompanied by a label which indicates the phlebotomist’s initials and the site of specimen collection (if other than venous).
4. = Send inoculated blood culture vials to the laboratory through the pneumatic tube system using appropriate packaging to prevent breakage.
Always observe “Standard Safety Precautions” when handl=
ing
blood.
1. Wear gloves while performing venipuncture and while handling inoculated bottles.
2. Properly dispose of all contaminated materials.&nbs= p; Place syringes, needles, and other sharp contaminated materials in a puncture proof container.
3. If
bottles are being inoculated with a syringe use a safety transfer device.
1. Becton
Dickinson, Blood Specimen Collection by Skin Puncture in Infants, Becton
Dickinson Vacutainer Systems,
2. Venoject, Direction Circular to Accompany Blood Colle=
ction
Products, Terumo Medical Corporation,
3. CMMC, Laboratory Manual 2002
4. Ernst, Denis, Ernst, Catherine, Phlebotomy for Nurses Jan 2001
5. Lippincott Manual/Nursing Practice, 7th Edition, pg 864-865
Document Control
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ical
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bsp;
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