BHT-011 Basic Phlebotomy Assistance Indira Gandhi National Open University School of Health Sciences

Home , Laboratory sample tube, Thoracoepigastric vein

Block 4 TECHNIQUE OF BLOOD COLLECTION UNIT 10 Patient Preparation for Venipuncture 5 UNIT 11 Site Selection and Venipuncture 19 UNIT 12 Techniques for Collection of Blood Specimens 31 UNIT 13 Blood Collection in Special Cases and Sites 41 Technique of Blood Collection CURRICULUM DESIGN COMMITTEE Dr. A. K. Mandal Prof. Kolte Sachin Prof. T. K. Jena HOD, Department of Department of Pathology SOHS, IGNOU, Pathology, Dr. Baba Saheb VMMC and Safdurjung Hospital Maidan Garhi, New Delhi Ambedkar Medical College New Delhi New Delhi Dr. Neerja Sood Dr. Reeta Devi Assistant Professor (Sr. Scale) Prof. Neelkamal Kapoor Assistant Professor (Sr. Scale) SOHS, IGNOU, Maidan Garhi HOD, Department of SOHS, IGNOU New Delhi Pathology, AIIMS, Bhopal Maidan Garhi, New Delhi Dr. Biplab Jamatia Dr. Archana Bajpai Ms Laxmi Assistant Professor (Sr. Scale) Associate Professor Assistant Professor (Sr. Scale) SOHS, IGNOU, Maidan Garhi Transfusion Medicine SOHS, IGNOU, Maidan Garhi New Delhi AIIMS, Jodhpur New Delhi BLOCK PREPARATION TEAM Writers Unit 10 & 13 Unit 11 & 12 Prof. Neelkamal Kapoor Dr. Sachin Kolte HOD, Department of Professor, Department of Pathology, AIIMS, Bhopal Pathology, VMMC & Safdarjung Medical College, New Delhi EDITORIALTEAM

Dr. Biplab Jamatia Dr. A. K. Sood Dr Prasenjit Das Assistant Professor (Sr. Scale) Senior Consultant, Associate Professor, Dept of SOHS, IGNOU Skill Training Cell, Pathology, All India Institute of Maidan Garhi, New Delhi SOHS, IGNOU Medical Sciences, New Delhi Dr. D. C. Jain Senior Consultant, Skill Training Cell, SOHS, IGNOU, New Delhi CO-ORDINATION Course Coordinator Prof. T. K. Jena Dr. A. K. Sood Dr. Biplab Jamatia Project Director Senior Consultant Assistant Professor (Sr. Scale) Skill Training Cell, Skill Training Cell SOHS, IGNOU, SOHS, IGNOU SOHS, IGNOU Maidan Garhi, New Delhi Dr. D. C. Jain Senior Consultant Skill Training Cell, SOHS, IGNOU MATERIAL PRODUCTION Sh. Ajit Kumar Section Officer (Publication) School of Health Sciences, IGNOU The curriculum has been adapted from the “Short term Training Curriculum Handbook for Phlebotomy Assistance” prepared by MoHFW, 2017, whose Standards are on based the National Skills Qualifications Framework (NSQF), Ministry of Skill Development and Entrepreneurship (MSDE). July, 2019 © Indira Gandhi National Open University, 2019 ISBN : 978-93-89200-78-2 All rights reserved. No part of this work may be reproduced in any form, by mimeograph or any other means, without permission in writing from the Indira Gandhi National Open University. Further information on the Indira Gandhi National Open University courses may be obtained from the University’s office at Maidan Garhi, New Delhi-110 068 or the website of IGNOU www.ignou.ac.in Printed and Published on behalf of the Indira Gandhi National Open University, New Delhi, by Director, School of Health Sciences, IGNOU. LaserTypeset by : Rajshree Computers, V-166A, Bhagwati Vihar, (Near Sector 2, 2 Dwarka), Uttam Nagar, New Delhi-110059 BLOCK 4 INTRODUCTION

The Block 4, Technique of Blood Collection, has four units (Unit-10 to Unit-13) The Patient preparation for venipuncture, such as Proper patient identification procedures and protocols to follow for different age group of patients, Patient interaction and reassurance, Patient preparation, Handling patient in special conditions, Patient positioning, Cleaning the venipuncture site and the factors affecting patient preparation are given in the Unit-10. The Unit 11 describes the Principles of site selection and process for drawing blood, proper site selection for venipuncture and follows the standard precautions. The Unit 12 deals with Needle insertion techniques, Order of draw, Tube filling (vacuum), Needle removal and sharp disposal (separate unit) and the treatment in case of emergencies during drawing of blood. The blood collection in special cases and sites such as adult patients, hospitalized patients paediatric patients, arterial blood sampling, capillary sampling, paediatric and neonatal blood sampling and the collection of blood in situations like Shock, Haemorrhage, Road Traffic Accidents etc. is covered in Unit-13.

3 Technique of Blood Collection

4 UNIT 10 PATIENT PREPARATION FOR VENIPUNCTURE Structure 10.0 Objectives 10.1 Introduction 10.2 Advance Planning 10.2.1 Preparation of Phlebotomy Equipments 10.2.2 Setting for Blood Collection 10.2.3 Clear Instructions and Paperwork 10.3 Patient Education and Consent 10.4 Practical Guidelines and Steps 10.5 Special Circumstances 10.5.1 Pediatric Patients 10.5.2 Geriatric Patients 10.5.3 Patients on Dialysis 10.6 Quality Control 10.7 Let Us Sum Up 10.8 Answers to Check Your Progress

10.0 OBJECTIVES After reading this unit, you should be able to:

 arrange a phlebotomy set up;

 describe how to prepare the patient for phlebotomy procedure;

 describe how to prepare patients for venipuncture and how to answer their queries;

 describe how to check patient details and ensure various dietary requirements;

 describe in detail and be able to perform efficiently, each step in the venipuncture procedure;

 describe blood collection procedures, various needles used according to the patient and the order of draw of the samples;

 describe blood collection precautions to be followed in special situations;

 perform all the steps of phlebotomy according to standard guidelines; and

 describe quality control measures related to phlebotomy.

5 Technique of Blood Collection 10.1 INTRODUCTION To be an effective phlebotomist, you’ll need to know how to go about different parts of this process in a safe manner that protects the integrity of the samples, and the accuracy of the results, while keeping patient safety a priority. Here is an outline of what you’ll need to know about patient preparation for venipuncture. Excellence in patient care includes not only being efficient in our skills, but also having excellent bedside manners. One must also know various special situations and circumstances and how to tackle them efficiently. In this unit, you will be given an overview about patient preparation for venipuncture. The process is not only pricking the patient and collecting the blood, it involves a thorough preparation including mental make as well. Since childhood everyone is skeptical about a needle prick. Nobody likes to be get pricked. Many of the patients are apprehensive about the pain associated with needle prick. In fact some sensitive patient does not allow pricking in one request. You need to make a good conversation and make the patient feel assured that the needle prick is not very painful procedure. This is particularly applicable for the persons getting needle prick for the first time. You should also be ready to face such situations. Apart from the technical aspects about blood collection, this part should also be taken care of with due precautions. Particularly children are a difficult group to handle. They tend to resist needle prick. You really need to be very calm and composed in such situations. Even if you are working in a busy laboratory; you need to be courageous to clear the apprehensions of the children. If the children are small and cannot be counseled, you need to take help of parents of these children. Make a good conversation with the parents of the child. Explain them the procedure of blood collection procedure. The groups of patients which are a little problematic are the patients undergoing treatment for cancer of leukemia. These patients require frequent blood tests and are pricked repeatedly. Some of these patients get frequent blood transfusions and the veins at that place are thrombosed quite frequently. It is difficult to collect blood from these patients. Such patients need assurance and a good technique to with draw blood. You should be able to quickly identify such group of patients. We begin the unit with a discussion of the basic prerequisites for phlebotomy. Patient education and consent is an important part of phlebotomy, and are discussed in detail. The exact procedure and detailed steps are described next. Finally, special circumstances and quality control has also been touched upon. Check Your Progress 1 1. What are the important aspects of patient preparation for venipuncture? ...... 6 Patient Preparation for 10.2 ADVANCE PLANNING Venipuncture This is the most important step in a phlebotomy procedure and involves advance planning measures that ensure safe, efficient and patient friendly atmosphere for phlebotomy. It involves arranging an appropriate set up for blood collection and preparing equipment and paperwork. 10.2.1 Preparing Phlebotomy Equipments (PPE) 1. Personal protective equipment: it is mandatory to use personal protective equipment while performing phlebotomy procedure. This prevents infection with any blood borne illness that the patient might have. The use of gloves also protects the patient from exposure to pathogens that the phlebotomist might bear on hands. Prior to wearing gloves, the phlebotomist should thoroughly wash and dry his/her hands. When putting on gloves, it is important to select the gloves of the right size and fit and also to align the thumbs according to the design of gloves. This ensures easy handling of other phlebotomy equipment. To remove the gloves, the index finger and thumb of one hand should be used to hold the cuff of the glove of the other hand. In this way, the glove should be removed completely, turned inside out and held tightly in the gloved hand. To remove the second glove, the index finger of the bare hand should be placed inside the cuff of the glove that remains to completely pull it off the hand. Removing gloves carefully protects phlebotomists from exposed pathogens. 2. Tourniquets: A tourniquet is basically a vein compressor. It is tied on the arm to compress the veins. It thus prevents return of this venous blood to the heart momentarily. Due to this, the veins become engorged with blood and enlarged. This makes the veins more prominent and easy to puncture. 3. Antiseptics: antiseptics such as alcohol are used to disinfect the area of venipuncture. In some places, readymade antiseptic pads are available. These should be kept in a closed container until the time of venipuncture to prevent evaporation of the antiseptic. 4. Gauze pads: these are used to compress the puncture site after the removal of needle. Usually, gauze pads of size 2 inch by 2 inch are used. Applying pressure causes bleeding to cease and initiates the blood clotting process. Additionally, it prevents bruising in the form of a hematoma. 5. Lancets and needles: Needles of the smallest diameter should be used to cause minimum discomfort to the patient. Commonly needles of gauze 18-22 having a diameter of 1.20 mm to 0.70 mm respectively are used for phlebotomy. The syringe and needle combination is best used on patients with small or fragile veins. This is because in case of a syringe the amount of negative pressure applied is controlled by the phlebotomist and thus, in patients with thin fragile veins, a phlebotomist can apply less pressure and reduce the possibility of collapse of veins. Another tool available is the BD Eclipse blood collection system. It is composed of a disposable tube holder and a multi-sample vacuum needle, which is so called because it has two 7 Technique of Blood Collection needles, one on opposite sides. The first one is inserted into the vein, while the needle at the other end punctures the vacuum blood collection tube. This blood collection system also uses a needle safety device that permanently covers the needle after phlebotomy procedure has been completed to prevent needle stick injuries. Then, there is the Butterfly (winged infusion set) needle that is also used for patients that have difficult veins, such as elderly, newborns etc. Also known as a scalp vein set, it consists of a hypodermic needle, two bilateral wings, transparent tubing that is small and often measures 20 to 35cm long, and a connector that will be attached to a syringe, vacuum tube holder or infusion pump. 6. Vacutainer tubes: There are various types of vacutainer tubes containing anticoagulants which keep the blood in liquid state and prevent it from clotting. Each anticoagulant tube is used for different tests depending upon the anticoagulant used in it. You should be very clear about the tests to be done and the various anticoagulant tubes that are to be used. The number of vacutainer tubes should be selected. If you are in doubt which anticoagulated tube should be used for a particular test, it should be double checked with laboratory. You should be satisfied with the quality of the vacutainer tubes before collecting the blood, sometimes vacutainer don’t produce required amount of negative pressure in the tube. 7. Centrifuge machines: You should know which blood samples should be separated out into serum or plasma. Some of the samples need to be separated within a short span. You should make sure that the centrifuge is in working condition. 8. Laboratory label printers: If the laboratory is working with laboratory information system and bar code, they should be generated before hand, if you are going for a home collection. These labels should be pasted to the tubes and test requisition forms beforehand. 9. Blood drawing trays: It should be equipped with all the instruments required for blood collection. 10.2.2 Setting for Blood Collection Outpatient setting In an outpatient setting, there should be a separate cubicle for blood collection with a chair for the phlebotomist and a comfortable reclining couch with an arm rest for the patient. There should be a wash basin with running water, soap, towels and a hand rub solution. The door should be wide enough and suitable to allow for entry of wheelchair bound patients. There should be separate and designated waste disposal containers. A needle destroyer should be kept on the phlebotomy table for immediate destruction of needles after use to avoid any needle stick injuries. Inpatient setting For withdrawing blood from patients admitted in a ward, use the patient’s bedside table for keeping equipment and material. Always close the 8 patient’s bed side curtain and perform the procedure in a clean, private Patient Preparation for Venipuncture and safe manner. If the patient is admitted in the ward it is always necessary to collect the blood sample before starting of the treatment or IV line. So if there is a call for blood collection of an admitted patient, you should go immediately. Similarly you should attend the call immediately if the patient is admitted in an intensive care unit. Preparation in home collection of sample You may be required, in some cases, to collect sample from patients at home. In these cases, it is imperative to have an impeccable preparation beforehand. You must be ready with an equipment kit that is fully equipped as described above. You should take all necessary equipments with you, as you may not get any help at that place. Make sure you have understood the correct address for sample collection. You should call a day before and fix the time after discussion. Instruct the patient not to eat or drink at least 8 – 10 hours before sample collection, if the fasting sample is required. In such case you should be very careful to maintain the time. You should never keep the patient waiting for you if he/she is fasting. Always ensure that you reach on time. Upon reaching, make sure to greet the patient and introduce yourself. Check the patient details carefully and match them with the one provided to you. Verify the test to be done. Select an appropriate site at home, for example, a couch where the patient can be comfortably seated. After blood collection, handling of sample and the used needle is also very important, especially in a home setting. For some samples, it may be necessary to maintain an adequate transportation temperature. In hot weather, you must carry an ice pack and a polystyrene (thermocol) container to transport samples. It is necessary to transport the sample on time to the lab to prevent hemolysis of sample, or degeneration of cells. The needle that you have used needs to be carefully recapped as you may not have a needle destroyer with you. In these cases, when it is unavoidable to recap the needle, you must use the “one hand scoop” technique. It should be kept in a tamper proof container for careful and adequate sharps disposal at the laboratory. 10.2.3 Clear Instructions and Paperwork Ensure that all the requisition paperwork is complete as described in Unit 8. You must also make sure there are clear indications provided for sample collection. Check Your Progress 2 1. What are the prerequisites for a phlebotomy set up? ......

9 Technique of Blood Collection 10.3 PATIENT EDUCATION AND CONSENT

First of all, introduce yourself to the patient politely. Mention your name and ask the patient how he/she is feeling to relieve anxiety and establish a friendly rapport with the patient. Next, check the patient’s name, and medical identification number, and carefully see that it matches with the name and number on the requisition slip. In case of an inpatient (patient admitted in a ward), match the details on the patient’s armband/wristband with the information on a requisition slip. The procedure should be explained in detail to the patient. His/her doubts should be cleared. In this era of information explosion, don’t try to give false information. Plainly admit only things that you know. But you should have a sound knowledge of the procedure that you are going to do. Always explain how many tubes you are going to collect. Many of the patients especially children are apprehensive about the needle prick for blood collection. First have a talk with patient and be friendly. Ask them about a previous experience of blood collection. Some may have good and some may have bad experience. Few of these patients undergo repeated blood tests and they become irritable sometimes. Patients, who are obese, have edema, or scar marks are difficult group of patients and they require a considerate phlebotomy procedure. Explain them the exact procedure for collection of blood, site of blood collection. Sometimes patients insist to collect blood from their choice; such request should be considered only if the vein is readily palpable and feasible to collect blood. The patients who undergo a repeated blood collection know which veins are difficult to approach and they say so. In such cases their request should be considered. If there are IV lines in admitted patients, always select vein which is away from the flow of IV fluids. This avoids dilution of blood with IV fluids and gives correct test results. Mention clearly the test that is going to be performed. Explain the patient that you are going to collect the blood from the arm (or any other site). Inform that it will cause a little pain like a pinprick and will be tolerable. Ask whether the patient is willing to go through with the procedure. A cooperative patient makes the phlebotomy procedure looks easy and the reverse is also true. A un-cooperative patient may lead to failed attempt of phlebotomy. There shall always a good communication before starting of the procedure. Consent: In a simple terms consent means permission given to do something. Complete definition of consent is Permission granted in full knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with knowledge of the possible risks and benefits. Usually consent is of two types implied and informed consent. Implied consent means patient has come to you for sample collection means he is agreeing to give blood for testing. Informed consent is required when blood sample is collected for special tests such as HIV, DNA, genetic testing. An informed consent is taken before any medical procedure. It means that the entire procedure has been explained to the patient and the patient has willfully given consent for the procedure without coercion and after understanding. Explain to the patient that you are going 10 to collect blood for the said test. The format for consent is given in topic Patient Preparation for Venipuncture on recording and reporting formats (Unit 8). Check Your Progress 3 1. What do you mean by an informed consent? ...... 10.4 PRACTICAL STEPS AND GUIDELINES The guidelines and the steps for the patient preparation for venipuncture are as follow: Step 1: Review and verify information As alluded to in the last section, check to see that the information is complete. Verify the name and patient identification number with the patient. Verify the test, and date and time of collection. Check whether diet restrictions have been followed. Step 2: Approaching the patient In case of admitted patients, always knock before entering. If an examining doctor is present, ask permission to collect sample. Approach the patient after introducing yourself. Wake up sleeping patients. In case of unconscious patients, or otherwise mentally incompetent patients, ask a relative or a nurse to identify the patient. Step 3: Confirm dietary and other prerequisites As mentioned previously, confirm whether the patient has followed dietary requirements for the sample e.g fasting, post prandial etc. Whether the patient has observed 8 hour fasting for a fasting sample, or whether it has been 2 hours post meal for a post prandial sample should be further verified. This question may be repeated to ascertain the facts. These are very important aspects for a good quality test reports, where you are responsible for a good quality of sample collection. Step 4: Rule out sensitivity to latex or other products, and other allergies etc Some tourniquets and most gloves are made of latex or rubber products. Since some people may be sensitive to these products, always ask and rule out such a possibility. In case such an allergy is present, don’t use latex products. Ask about history of any other previous allergies, past history of any complications that may have occurred during blood collection. Step 5: Disinfect your hands with a alcohol based rub Always rub your hand with an alcohol based hand sanitizer. This should be done to prevent cross contamination when you are working in a hospital set up. As per WHO guidelines you should wash your hands before touching every patient. This brings down the rate of hospital acquired infections. 11 Technique of Blood Collection Step 6: Position patient 1. For outpatients, make the patient sit down in a reclining chair with arm rest. 2. For inpatients, you may or may not raise the bed according to your preference of the patient. But if you do so, make sure to lower it back to suit patient’s comfort and raise the rails on the bedside to avoid falls. 3. For patients prone to fainting, use a reclining chair, sofa or bed. Step 7: Expose the venipuncture site and apply tourniquet Select a suitable site, as described in earlier unit. The tourniquet should be applied snugly, about 3 to 4 inches above the intended site of venipuncture. Never apply a tourniquet over an open wound or sore. In case of sensitivity to tourniquet material, place a dry washcloth or gauze over the skin, and then apply the tourniquet over it. Ask the patient to clench the fist and hold. Do not make the patient pump (closing and releasing fist repeatedly to pump blood). Step 8: Select vein As the veins become prominent after clenching the fist and after tying the tourniquet, select one vein as described further. Normally, the preferred site is antecubital area and the preferred veins are the median cubital vein or the median vein. However, for each patient examine the veins by palpating the patient’s arm with your gloved index finger. Roll the finger side to side while pressing against the vein to assess the size and patency of the vein. Don’t select veins that are hard and cord like. Also, veins on underside of wrist should not be selected. After selecting an appropriate vein, release the tourniquet and ask patient to open fist. Step 9: Preparation of venipuncture site Disinfect the selected venipuncture site with 70% isopropyl alcohol in a circular motion moving outward in concentric circles. The cleaned area should cover 2-3 inches outside the selected vein. Allow the site to dry on its own. Do not blow over it, and do not use an unsterile gauze or fan etc. to dry the site. Do not touch the site after cleaning it. Step 10: Reapply tourniquet and insert needle After cleaning the site, wear gloves, reapply tourniquet, and ask patient to make a fist. Anchoring the vein Use your non dominant hand to fix/anchor the vein. In order to do so, slightly pull the skin toward the wrist, about 1-2 inches below the site. Inserting the needle Hold the collection device in your dominant hand. With the beveled side facing upwards, insert the needle at an angle of 30 degrees or less (usually 15 to 30 degrees). This should be done in one smooth and 12 steady motion. Step 11: Attaching the collection tube Patient Preparation for Venipuncture Attach the collection tube to the holder. Blood will begin to flow into the tube immediately. As soon as blood begins to flow into the tube, release the tourniquet and ask patient to open fist. Maintain the needle position in the vein. Do not lift up the tip of the needle. Step 12: remove the collection tube from the holder Once the tubes are filled up to the desired level, remove the collection tube from the holder. Invert the tubes to allow mixing with the anticoagulant. Do not vigorously shake the tube in order to prevent hemolysis. Place gauze over the site, and remove needle carefully. Put pressure over the site, and then ask patient to put pressure on it. Make sure that the patient does not bend the arm to avoid the occurrence of hematoma. Ensure that the patient keeps his arm extended and raised. Step 13: Remove the needle from holder Remove the needle from holder, and destroy in needle destroyer and discard safely in the sharps container. Step 14: handling of collection tubes Certain tests require special handling of collection tubes. Follow these special handling instructions, like wrapping ice pack, protecting from sunlight, etc. Step 15: Check the patient’s arm and apply bandage Check the patient’s arm and apply bandage over it. Thank the patient for their cooperation. Remove your gloves, discard them in appropriate dustbin and sanitize your hands. Check Your Progress 4 1. What information should you verify before blood collection? ...... 2. How do you prepare a venipuncture site? ...... 13 Technique of Blood Collection 10.5 SPECIAL CRCUMSTANCE

The preparation of children and also elderly for venipunture requires a very careful approach and to seek their corporation. The approach of these special groups is as follows: 10.5.1 Pediatric Patients

Pediatric venipuncture is much more challenging than adult venipuncture due to multiple reasons. Firstly, children have small and underdeveloped veins. These are difficult to fix, and more likely to be injured. Also, injury to the veins in children carries the risk of possible permanent damage. For children younger than 2 years of age, one must limit oneself to superficial veins only.

Dealing with parent/guardian

It is very important to establish a good rapport with the patient’s parent/ guardian. You should work toward gaining their trust by being very warm, understanding, caring and courteous. Try and find out about any prior blood collection experiences the child might have had to make yourself familiar and to prevent any discomfort or complications. In case of younger children, parental presence may be essential. For older children also, you may allow parents to be present to alleviate their fears and anxiety.

Dealing with the child

In case of children, it is very important to establish a friendly rapport with the patient. Try to explain the procedure to the child in a very simple manner that he/he can understand. However, do not lie to the patient and do not tell them it will not hurt at all. It is desirable to offer rewards to children in the form of chocolates, small inexpensive gifts, etc. to ensure cooperation from the child.

Some children may not allow to be pricked with a needle at all due to fear of pain. In these circumstances you may use a topical (cream form) of eutectic mixture of local anesthetics.

Sometimes, it may be necessary to exercise forms of restraint in children who are too young to understand the procedure or cannot otherwise cooperate. In these circumstances, different methods of restraint can be utilized. For infants, you may ask the parent to wrap the infant in a blanket and then hold in their laps. For toddlers as well, ask the parent to hold the child in their lap.

After proper preparation as above, try and collect a minimum amount of blood that can suffice for the test required. Needles used for pediatric venipuncture: smaller diameter needles (0.70 mm or 22 gauze) should be used as children have thin veins. In smaller children, it may be necessary to use a butterfly needle set.

14 Patient Preparation for Venipuncture

Fig. 10.1: Butterfly needle set 10.5.2 Geriatric Patients There are specific challenges for blood collection in older patients. These include skin changes due to loss of collagen that may make it difficult to stabilize and fix veins for venipuncture. It may also take longer for the bleeding to stop in older patients, and it may be necessary to apply pressure on the gauze for a longer while after blood collection. Also, presence of age related diseases can also impair venipuncture in some situations. For example, old patients with severe arthritis may not be able to form a fist efficiently. In patients suffering from Parkinson’s disease and stroke, the patient may have impaired ability to form a fist. Diabetic patients may have impaired circulatory system. Certain safety issues also need to be addressed in case of geriatric patients. For instance, the floors should be non-slippery and clutter free to avoid falls. More space may be needed for patients in wheelchairs and walkers. For wheelchair bound patients, always lock the wheelchair before the procedure. 10..5.3 Patients on Dialysis Patients on dialysis require blood collection very frequently. In these cases, avoid bruised sites from previous venipuncture. Do not use the arm with AV fistula for venipuncture. For hospitalized patients with an IV line, do not use the arm with the IV line for venipuncture. Check Your Progress 5 1. Which groups have thin and difficult veins? ...... 2. What precautions should you take for venipuncture in pediatric patients? ......

...... 15 Technique of Blood Collection 10.6 QUALITY CONTROL

Quality control is an essential part of all laboratory procedures including blood collection. The quality control measures for lab testing are beyond the course of this unit and will not be discussed here. We will briefly discuss the quality control measures for blood collection procedures.

Standard operating procedures (SOPs): SOPs are step by step written protocol to be followed for each lab procedure. There should be detailed SOPs for blood collection in various situations and they should be readily available to all lab staff. Always go through the SOPs. If any new version of SOP has come, read it completely and thoroughly.

Correct patient identification: As described previously, it should be ensured that there is no mistake in correct identification of patient. This can be ensured by checking at various steps and reconfirming with the patient. This is a commonly encountered error in laboratory practice.

Condition of the sample: The condition of the sample should be adequate such that test results are satisfactory. The anticoagulant tube should never be under-filled or overfilled, that will give erroneously wrong result.

Safe practices: Ensure personal protective equipment use to minimize exposure to self during venipuncture. Employ hand hygiene measures. Make sufficient lab supplies available, in order to prevent dangerous practices.

Safe transportation: the sample once collected, should be safely transported to the lab following desired protocol which may vary for different sample types.

Availability of post exposure prophylaxis: Despite being careful, needle injuries may occur. There should be a register to maintain the needle injuries. In case of needle prick injury, you would need to take post prophylaxis treatment.

Check Your Progress 6

1. What are the components of quality control measures for phlebotomy?

......

...... 16 Patient Preparation for 10.7 LET US SUM UP Venipuncture

In this unit, you learned the prerequisites for phlebotomy and the various advance planning measures that you should keep in mind. It is very important to establish a good rapport with the patient at the time of initial encounter. At this point, you should take an informed consent for the procedure after explaining the procedure to the patient. You should also confirm dietary or other such restriction required for a test. For example, whether a patient has followed the 8 hour fasting for a fasting blood sample. You should carefully check and match the patient details on the requisition form, patient record, and on the sample label. Also confirm the same with the patient. In case of an unconscious patient, check the name and record number with wrist band or hospital file. Then appropriately prepare the venipuncture site as described in the unit. Follow personal protective measures. Follow post venipuncture instructions as described previously. This unit also described certain special situations of venipuncture and how to deal with them. Remember that efficient phlebotomy goals include safe procedure with minimum discomfort to the patient and minimum risk to yourself while maintaining politeness and empathy toward the patient.

10.8 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1

1. There are two important aspects. First is the patient’s mental preparation for the needle prick. The second part is actual set up required for the procedure to collect blood.

Check Your Progress 2

1. The prerequisites for a phlebotomy set up include phlebotomy equipment including personal protective equipment, needles, blood collection systems, tourniquets, centrifuge, waste disposal containers, needle destroyer, blood collection trays, label printers etc. in a properly maintained outpatient or inpatient phlebotomy setting with a basin with running water supply.

Check Your Progress 3

1. An informed consent is a consent taken prior to performing any medical procedure, like phlebotomy after thoroughly explaining the procedure, and the risks involved in the procedure.

Check Your Progress 4

1. The following information should be collected before blood collection: whether there is any allergic or reaction history in the patient, whether appropriate dietary and other restrictions have been followed. Etc.

2. Select a venipuncture site. Tie a tourniquet. Identify the most prominent and accessible vein. Untie the tourniquet. Clean the area 17 Technique of Blood Collection with an antiseptic in outward circles. Tie the tourniquet and begin with venipuncture.

Check Your Progress 5

1. Elderly and pediatric patients have difficult veins.

2. Try and collect a minimum amount of blood that can suffice for the test required. Smaller diameter needles (0.70 mm or 22 gauze) should be used as children have thin veins. In smaller children, it may be necessary to use a butterfly needle set.

Check Your Progress 6 1. Correct patient identification, Condition of the sample, Safe practices, and safe transportation.

18 UNIT 11 SITE SELECTIONS AND VENIPUNCTURE Structure 11.0 Objectives 11.1 Introduction 11.2 Proper Site Selection 11.2.1 Attributes of Preferred Vein 11.2.2 Vein selection 11.2.3 Palpating the Vein 11.2.4 Inappropriate Sites for Venipuncture 11.3 Following Standard Precautions 11.4 Let Us Sum Up 11.5 Answers to Check Your Progress 11.0 OBJECTIVES At the end of this unit, you should be able to:

 identify the attributes of a preferred vein;

 describe how to make vein selection;

 describe how to palpate veins;

 identify inappropriate sites for venipuncture; and

 describe the standard precautions while doing site selection 11.1 INTRODUCTION In the previous units, you learnt about the blood collection process and the various equipment required for venipuncture. Site selection is a very crucial aspect of venipuncture. If not done properly it may lead to failed venipuncture. Thus, it is important to learn about vein selection and sites from which venipuncture should not be performed. 11.2 PROPER SITE SELECTION This is a very crucial step in venipuncture as improper site selection is often found to be the underlying cause for failed or repeated venipunctures. As learnt in the previous unit no.7 knowledge of surface anatomy of the limb is very important. The commonly used veins are those that are easily palpable as they are situated quite superficially 11.2.1 Attributes of a Preferred Vein In order to select a vein, it should have the following attributes – i. It should be superficial and easily palpable. This is because if a vein is deeper or palpable with great difficulty then it is more likely 19 Technique of Blood Collection to lead to repeated venipuncture or failed venipuncture. The chances of venipuncture related complications are also much higher in case of deep veins. ii. It should be large enough to provide good blood flow. The vein that is to be selected should be of suitably large caliber. This is because only such large sized veins can provide a good free flow of blood on venipuncture. If the vein selected is of relatively smaller size and venipuncture is attempted from such a vein then it will cause sluggish flow. Such kind of sample is not suitable for laboratory testing as it may lead to erroneous results. This is because of platelet activation and aggregation, clot formation and haemolysis. iii. It should not be very tortuous. Any vein which is straight is a good target for venipuncture. This is because if the vein is tortuous then it is more likely to cause improper penetration of the lumen or puncture of both walls of the vein leading to perforation of the wall and bleeding. This may lead to haematoma formation iv. It should be well anchored and not excessively mobile. If the vein is not well anchored and is very mobile then it will be extremely difficult to puncture the wall of the vein at correct site. Often in such cases the needle passes through either side of the vein without reaching the lumen. This leads to a failed venipuncture. v. There should not be any previous history of venipuncture or IV fluid infusion. If there is prior history of venipuncture then there is often presence of blockade of lumen by the clot which is formed due to the activation of the coagulation cascade by trauma which is induced on the venous wall by venipuncture. Previous IV infusion also has a similar kind of effect on the lumen of the vein. Also, IV infusion lines are often flushed with heparin to keep them patent. This heparin contamination of the blood sample will seriously affect the laboratory test results especially the coagulation tests like Partial Thromboplastin Time (PTT). 11.2.2 Vein Selection The preferred site for venipuncture is the antecubital fossa located anterior and below the bend of the elbow. The cubital fossa or elbow pit is the triangular area on the anterior view of the elbow of a human or other hominid animal. It is also called the antecubital fossa because it lies anteriorly to the elbow (Latin cubitus) when in standard anatomical position. The boundaries of antecubital fossa are as follows -

 superior (proximal) boundary — an imaginary horizontal line connecting the medial epicondyle of the humerus to the lateral epicondyle of the humerus.

 medial (ulnar) boundary — lateral border of Pronator Teres muscle originating from the medial epicondyle of the humerus.

 lateral (radial) boundary — medial border of Brachioradialis muscle 20 originating from the lateral supraepicondylar ridge of the humerus.  apex- it is directed inferiorly, and is formed by the meeting point of Site Selection and the lateral and medial boundaries. Venipuncture

 superficial boundary (roof)- skin, superficial fascia containing the median cubital vein, the lateral cutaneous nerve of the forearm and the medial cutaneous nerve of the forearm, deep fascia reinforced by the bicipital aponeurosis (a sheet of tendon-like material that arises from the tendon of the biceps brachii).

 deep boundary (floor)- brachialis and supinator muscles. The cubital fossa contains four main vertical structures (from lateral to medial):

 The radial nerve is in the vicinity of the cubital fossa, located between brachioradialis and brachialis muscles.

 The biceps brachii tendon.

 The brachial artery. The artery usually bifurcates near the apex (inferior part) of the cubital fossa into the radial artery (superficial) and ulnar artery (deeper).

 The median nerve. The ulnar nerve is also in the area, but is not in the cubital fossa; it occupies a groove on the posterior aspect of the medial epicondyle of the humerus. Several veins are also in the area (for example, the median cubital vein, cephalic vein, and basilic vein) but these are usually considered superficial to the cubital fossa, and not part of its contents. Three major veins—the cephalic, basilic and median cubital—are located in this area and, in most patients, at least one of these veins can be easily located. Cephalic vein is a superficial vein in the arm. It communicates with the basilic vein via the median cubital vein at the elbow and is located in the superficial fascia along the anterolateral surface of the biceps brachii muscle. Near the shoulder, the cephalic vein passes between the deltoid and pectoralis major muscles (deltopectoral groove) and through the deltopectoral triangle, where it empties into the axillary vein. The cephalic vein is often visible through the skin, and its location in the deltopectoral groove is fairly consistent, making this site a good candidate for venous access. Permanent pacemaker leads are often placed in the cephalic vein in the deltopectoral groove. The vein may be used for intravenous access, as large bore cannula may be easily placed. However, the cannulation of a vein as close to the radial nerve as the cephalic vein can sometimes lead to nerve damage. The basilic vein is a large superficial vein of the upper limb that helps drain parts of the hand and forearm. It originates on the medial (ulnar) side of the dorsal venous network of the hand and travels up the base of the forearm, where its course is generally visible through the skin as it travels in the subcutaneous fat and fascia lying superficial to the muscles. 21 Technique of Blood Collection Near the region anterior to the cubital fossa, in the bend of the elbow joint, the basilic vein usually connects with the other large superficial vein of the upper extremity, the cephalic vein, via the median cubital vein (or median basilic vein). The layout of superficial veins in the forearm is highly variable from person to person, and there is a profuse network of unnamed superficial veins that the basilic vein communicates with. As it ascends the medial side of the biceps in the arm proper (between the elbow and shoulder), the basilic vein normally perforates the brachial fascia (deep fascia) above the medial epicondyle, or even as high as mid- arm. There, around the lower border of the teres major muscle, the anterior and posterior circumflex humeral veins feed into it, just before it joins the brachial veins to form the axillary vein. The median cubital vein (or median basilic vein) is a superficial vein of the upper limb. It connects the basilic and cephalic vein and is often used for venipuncture (taking blood), as it lies relatively close to the surface of the arm and becomes prominent when pressure is applied. It lies in the cubital fossa superficial to the bicipital aponeurosis. Vein patterns vary among individuals. The most often seen arrangement of veins in the antecubital fossa are referred to as the “H-shaped” and “M-shaped” patterns (Fig. 11.1 & 11.2). The H pattern includes the cephalic, median cubital, and basilic veins in a pattern that looks like a slanted H. In this pattern the median cubital vein is straight and forms the middle limb of H whereas the two sides are formed by cephalic and basilic veins. The most prominent veins in the M pattern are the cephalic, median cephalic, median basilic, and basilic veins. In this pattern the median cubital vein is not straight and it branches into two vessels. The H-shaped pattern is seen in approximately 70 percent of the population.

Fig. 11.1: H pattern of veins in Fig. 11.2: M pattern of veins in antecubital fossa. antecubital fossa. These veins continue down the forearm to the wrist area; however, in these areas, they become smaller and less well anchored, and punctures are more painful to the patient. Small prominent veins are also located in the back of the hand. When necessary, these veins can be used for venipuncture, but they may require a smaller needle or winged blood collection set. The veins of the lower arm and hand are also the preferred site for administering IV fluids because they allow the patient more arm flexibility. Frequent venipuncture in these veins could make them unsuitable 22 for IV use. Of the three veins located in the antecubital area, the median cubital is the Site Selection and vein of choice because it is large and does not tend to move when the Venipuncture needle is inserted. It is often closer to the surface of the skin, more isolated from underlying structures, and the least painful to puncture as there are fewer nerve endings in this area. The cephalic vein located on the thumb side of the arm is usually more difficult to locate, except possibly in larger patients, and has more tendencies to move. The cephalic vein should be the second choice if the median cubital is inaccessible in both arms. The basilic vein is located on the inner edge of the antecubital fossa near the median nerve and brachial artery. The basilic vein is the least firmly anchored; therefore, it tends to “roll” and hematoma formation is more likely. The basilic vein should be used as the last choice because the median nerve and brachial artery are in close proximity to it, increasing the risk of permanent injury. Care must be taken not to accidentally puncture the brachial artery. Use of the basilic vein is not encouraged; however, if necessary, locate the brachial pulse before accessing the basilic vein. Other sites that may sometimes be used include dorsal metacarpal veins, great saphenous vein and femoral vein. Dorsal metacarpal veins are the three veins that are located on the back of the hand. These veins are made up of the dorsal digital veins, which are the veins that are located on adjacent sides of the second, third, and fourth fingers along the dorsal interossei. The dorsal interossei are muscles located between the metacarpals. The veins drain from the four fingers into the dorsal venous network in the hand. This network also consists of the dorsal digital vein from the radial side of the index finger and the veins of the thumb. Here the network moves upward and becomes the cephalic vein. The vein from the ulnar side of the little finger joins the network on the ulnar side and becomes the basilic vein. The dorsal metacarpal veins are deep veins that run parallel to the arteries and at some angles cross them. Valves are located in the veins that prevent the back flow of blood, ensuring that blood can only flow one way, and that oxygen-rich blood is always flowing through the hand. Although not exactly a common choice, these are commonly used for intravenous infusion. In the event that the antecubital vein is inaccessible, the dorsal metacarpal veins provide a viable alternative. As a policy, however, most hospitals require that Phlebotomy is performed first in the antecubital area, and intravenous line and work on the dorsal metacarpal veins. The great saphenous vein (GSV), alternately “long saphenous vein” is a large, subcutaneous, superficial vein of the leg. It is the longest vein in the body, running along the length of the lower limb, returning blood from the foot, leg and thigh to the deep femoral vein at the femoral triangle. The great saphenous vein originates from where the dorsal vein of the big toe (the Hallux) merges with the dorsal venous arch of the foot. After passing in front of the medial malleolus (where it often can be visualized and palpated), it runs up the medial side of the leg. At the knee, it runs 23 Technique of Blood Collection over the posterior border of the medial epicondyle of the femur bone. In the proximal anterior thigh 3-4 centimeters inferolateral to the pubic tubercle, the great saphenous vein dives down deep through the cribriform fascia of the saphenous opening to join the femoral vein. It forms an arch, the saphenous arch, to join the common femoral vein in the region of the femoral triangle at the sapheno-femoral junction. At the ankle it receives branches from the sole of the foot through the medial marginal vein; in the lower leg it anastomoses freely with the small saphenous vein, communicates by perforator veins (Cockett perforators) with the anterior and posterior tibial veins and receives many cutaneous veins; near the knee it communicates with the popliteal vein by the Boyd perforator, in the thigh it communicates with the femoral vein by perforator veins (Dodd perforator) and receives numerous tributaries; those from the medial and posterior parts of the thigh frequently unite to form a large accessory saphenous vein which joins the main vein near the sapheno- femoral junction. Near the fossa ovalis it is joined by the superficial epigastric, superficial circumflex iliac vein, and superficial external pudendal veins. The thoracoepigastric vein runs along the lateral aspect of the trunk between the superficial epigastric vein below and the lateral thoracic vein above and establishes an important communication between the femoral vein and the axillary vein. Another site is Femoral vein which is not a very common site for phlebotomy. However, in rare circumstances when no other site is accessible then this site may be resorted to. Femoral vein is a blood vessel that accompanies the femoral artery in the femoral sheath. It begins at the adductor canal (also known as Hunter’s canal) and is a continuation of the popliteal vein. It ends at the inferior margin of the inguinal ligament, where it becomes the external iliac vein. The femoral vein bears valves which are mostly bicuspid and whose number is variable between individuals and often between left and right leg. Femoral vein venepuncture is not routinely done. This procedure is indicated in patients with a history of poor venous access as assessed by inability to draw blood from antecubital spaces or other peripheral sites normally used to access veins. It is contraindicated in patients with thrombocytopenia (if platelet count is less than 50,000) or any dyscrasias that can affect clotting time. Also, patients with coagulation defects or those receiving anticoagulant therapy. Therefore, before attempting femoral venepuncture a history of pancytopenia, anticoagulation or aspirin use, renal insufficiency, disseminated intravascular coagulation, or liver dysfunction must be taken. Identify where the femoral vein is and be sure not to access the artery or nerve. The vein is located medial to the artery. (Remember: NAVEL / Nerve-Artery-Vein-Empty-Lymphatic). Identify the pulsation of the femoral artery 1-2 cm below the inguinal 24 ligament. Insert the needle about 1cm medial to the pulsation and aim it towards the head and medially at an angle of 20-30° to the skin. The Site Selection and above measurements are for standard size adults and should be scaled for Venipuncture paediatric patients. In adults, the vein is normally found 2-4cm from the skin. In small children reduce the elevation on the needle to 10-15° since the vein is more superficial. All the veins of the lower limbs mentioned above are shown in Fig.11. 3.

Fig. 11.3: Important veins in the lower limb used for venipuncture. 11.2.3 Palpating the Vein Veins are located by sight and by touch (referred to as palpation). The ability to feel a vein is much more important than the ability to see a vein—an important concept to be kept in mind. Palpation is usually performed using the tip of the index finger of the nondominant hand to probe the antecubital area with a pushing motion rather than a stroking motion. Feel for the vein in both a vertical and horizontal direction. The pressure applied by palpating locates deep veins; distinguishes veins, which feel like spongy, resilient, tube-like structures, from rigid tendon cords; and differentiates veins from arteries, which produce a pulse. The thumb should not be used to palpate because it has a pulse beat. Turning the arm slightly helps distinguish veins from other structures. Select a vein that is easily palpated and large enough to support good blood flow. Once an acceptable vein is located, palpation is used to determine the direction and depth of the vein to aid the phlebotomist during needle insertion. It is often helpful to find a visual reference for the selected vein, such as its location near a mole, freckle, or skin crease, to assist in relocating the vein after cleansing the site. 11.2.4 Inappropriate Sites for Venipuncture There are certain sites from where it is inappropriate to perform venipuncture. These are as follows – 25 Technique of Blood Collection i. Veins on the underside of wrist – The underside of the wrist contains many structures that are lying in close proximity with the vein. These include arteries, nerves, or tendons. If venipuncture is attempted from this site there is a high chance of chance of accidentally puncturing arteries, nerves, or tendons. This will not only cause a failed venipuncture but significant discomfort to the patient and further complications ii. Infected arm – If there is a focus of infection in the arm then venipuncture should not be attempted from this site. It is because venipuncture will further disseminate the infection to other sites leading to further complications in the patient. iii. Arm on side of mastectomy – Mastectomy is often associated with lymphedema in the arm as axillary lymph nodes are also removed as part of the surgical procedure. This lymphedema will cause marked swelling of the arm. In this kind of a situation it will be very difficult to localize the vein properly. This will most likely lead to failed venipuncture. iv. Edematous areas – Edematous areas should never for selected for venipuncture because edema leads to marked swelling of the affected area. Due to this swelling it becomes very difficult to see and palpate veins. Thus, chances of repeated as well as failed venipunctures are increased quite significantly. v. Hematomas – Any area in which there is a hematoma should not be selected for venipuncture. This is because in hematoma there is presence of blood in the soft tissues. Due to this there is swelling also. If venipuncture is attempted in such a scenario then it is highly likely that needle will not enter the vein and may go into the soft tissue area. vi. Arm with blood being transfused – Any arm in which blood is being transfused should never be selected for venipuncture. This because in this limb there is a mixing of donor and recipient blood which is happening. Due to this the results of the laboratory tests will be erroneous. Also, in such a limb there is greater chance of having a blocked vein due to thrombosis. Thus, venipuncture may fail in this situation. vii. Scarred areas – Scarred areas are not a good choice for venipuncture. This is because scarring occurs because of fibrosis which may entrap the veins there by causing their luminal obliteration. This will lead to failure in venipuncture. viii. Arms with fistulas or vascular grafts – Arms which are having fistulas an vascular grafts should never be selected for venipuncture as this may adversely affect them. The venipuncture procedure may cause activation of coagulation cascade thereby leading to blockage of the fistula or vascular graft. ix. Sites above an infusion – Sites that are above an intravenous infusion site should also be never selected for venipuncture. This is 26 because of the fact that the substances that are getting infused may cause erroneous laboratory results. For example, if venipuncture is Site Selection and performed above a site of intravenous infusion of fluids which contain Venipuncture electrolytes like Na+ and K+ will lead to falsely high values in the sample. Also by activating the coagulation cascade proximal to the site of intravenous infusion venipuncture may lead to blockade of the infusion line. Check Your Progress 1 1. Mention what are the attributes of a preferred vein: i) ……………………………………..……… ii) …………………………………………….. iii) ……………………………….……………. iv) ………………………………..…………… 2) A phlebotomist is selecting basilic vein over median cubital vein. Is he/she right in doing so? Yes/No 3) Why venipuncture from basilic vein is associated more commonly with complications? 4) Write briefly the method of vein palpation. 5) List the inappropriate sites of venipuncture and briefly explain the reason for five sites?

11.3 FOLLOWING STANDARD PRECAUTIONS While doing venipuncture it is important to follow certain standard precautions. These are as follows –

 Treat all blood & body fluids as if they were infectious. This makes us follow the universal precautions in all the cases.

 Always wear gloves during vascular access procedures.

 Puncture only the uppermost wall of the vein because puncturing the inner wall will lead to bleeding and haematoma formation.

 Remove the tourniquet before removing the needle. This is done to reduce the pressure in the vein so that after needle removal there is no haemorrhage.

 Use the major superficial veins as the risk of complications is greater with deeper veins.

 Make sure the needle fully penetrates the upper most wall of the vein. (Partial penetration may allow blood to leak into the soft tissue surrounding the vein by way of the needle bevel)

 Apply pressure to the venipuncture site. This is done to prevent any bleeding from the venepuncture site.

 Practice universal precautions: 27 Technique of Blood Collection o Wear gloves and a lab coat or gown when handling blood/body fluids. o Change gloves after each patient or when contaminated. This prevents transmission of infection from one patient to another. o Wash hands frequently. This prevents transmission of infection from one patient to another. Also, it protects the phlebotomist. o Dispose of items in appropriate containers. It is important to do so because all these items constitute bio medical waste. Disposal of these items in separate designated containers allows them to be segregated at source.

 Dispose of needles immediately upon removal from the patient’s vein. Do not bend, break, recap, or resheath needles to avoid accidental needle puncture or splashing of contents.

 Clean up any blood spills with a disinfectant such as freshly made 10% bleach. This is done to protect other patients and the phlebotomist from acquiring any infection.

 Place blood collection equipment away from patients, especially children and psychiatric patients. This is done to protect these individuals from getting needle stick injuries.

 Continuous clenching or pumping of the fist should not be encouraged because it will result in hemo-concentration and alter some test results for example elevated serum potassium levels.

 The tourniquet can only be applied for 1 minute; therefore, after the vein is located, the tourniquet is removed while the site is being cleansed and is reapplied immediately before the venipuncture. Check Your Progress 2 1) While doing phlebotomy, patient should be asked to clench fists continuously. Yes/No 2) List the universal precautions while doing venipuncture...... 11.4 LET US SUM UP In order to do proper site selection, it is essential to know the attributes of a preferred vein. Without this knowledge you are likely to select a site which is not appropriate for venipuncture. The preferred site for venipuncture is the antecubital fossa located anterior and below the bend of the elbow. Three major veins—the median cubital, the cephalic, and the basilic—are located in this area. the median cubital is the vein of choice because it is large and does not tend to move when the needle is inserted. Cephalic vein should be the second choice. Basilic vein should be used as the last choice because the 28 median nerve and brachial artery are in close proximity to it, increasing Site Selection and the risk of injury. Venipuncture The ability to palpate a vein is extremely important. Palpation is usually performed using the tip of the index finger of the non-dominant hand to probe the antecubital area with a pushing motion rather than a stroking motion. There are certain sites which are inappropriate for venipuncture. For example, arm with intravenous infusion, haematomas and oedema. Venipuncture should never be attempted from these sites. While doing venipuncture it is extremely crucial to follow certain standard precautions. These precautions especially the universal safety precautions go a long way in keeping both the patient and phlebotomist safe. 11.5 ANSWERS TO CHECK YOUR PROGRESS Check Your Progress 1 1) i. It should be superficial and easily palpable. ii. It should be large enough to provide good blood flow. iii. It should not be very tortuous. iv. It should be well anchored and not excessively mobile. v. There should not be any previous history of venipuncture or IV fluid infusion. 2) No 3) Venipuncture from basilic vein is associated more commonly with complications because it is the least firmly anchored; therefore, it has a tendency to “roll” and hematoma formation is more likely. The basilic vein should be used as the last choice because the median nerve and brachial artery are in close proximity to it, increasing the risk of permanent injury. Therefore, use of the basilic vein is not encouraged. 4) Vein palpation is usually performed using the tip of the index finger of the non-dominant hand to probe the antecubital area with a pushing motion rather than a stroking motion. Feel for the vein in both a vertical and horizontal direction. The pressure applied by palpating locates deep veins; distinguishes veins, which feel like spongy, resilient, tube-like structures, from rigid tendon cords; and differentiates veins from arteries, which produce a pulse. 5) Inappropriate sites of venipuncture are as follows: i. Veins on the underside of wrist because of the chance of accidentally puncturing arteries, nerves, or tendons. ii. infected arm iii. arm on side of mastectomy iv. edematous areas v. hematomas 29 Technique of Blood Collection vi. arm with blood being transfused vii. scarred areas viii. arms with fistulas or vascular grafts ix. sites above an infusion The reasons for inappropriateness of five sites are as follows - i. Veins on the underside of wrist – The underside of the wrist contains many structures that are lying in close proximity with the vein. These include arteries, nerves, or tendons. If venipuncture is attempted from this site there is a high chance of chance of accidentally puncturing arteries, nerves, or tendons. This will not only cause a failed venipuncture but significant discomfort to the patient and further complications ii. Infected arm – If there is a focus of infection in the arm then venipuncture should not be attempted from this site. It is because venipuncture will further disseminate the infection to other sites leading to further complications in the patient. iii. Arm on side of mastectomy – Mastectomy is often associated with lymphedema in the arm as axillary lymph nodes are also removed as part of the surgical procedure. This lymphedema will cause marked swelling of the arm. In this kind of a situation it will be very difficult to localize the vein properly. This will most likely lead to failed venipuncture. iv. Edematous areas – Edematous areas should never for selected for venipuncture because edema leads to marked swelling of the affected area. Due to this swelling it becomes very difficult to see and palpate veins. Thus, chances of repeated as well as failed venipunctures are increased quite significantly. v. Hematomas – Any area in which there is a hematoma should not be selected for venipuncture. This is because in hematoma there is presence of blood in the soft tissues. Due to this there is swelling also. If venipuncture is attempted in such a scenario then it is highly likely that needle will not enter the vein and may go into the soft tissue area. Check Your Progress 2 1) No 2) The universal precautions while doing venipuncture are as follows: i. Wear gloves and a lab coat or gown when handling blood/body fluids. ii. Change gloves after each patient or when contaminated. This prevents transmission of infection from one patient to another. iii. Wash hands frequently. This prevents transmission of infection from one patient to another. Also, it protects the phlebotomist. iv. Dispose of items in appropriate containers. It is important to do so because all these items constitute bio medical waste. Disposal of these items in separate designated containers allows them to 30 be segregated at source. UNIT 12 TECHNIQUES FOR COLLECTION OF BLOOD SPECIMENS Structure 12.0 Objectives 12.1 Introduction 12.2 Techniques of Blood Collection 12.2.1 Types of Systems for Blood Sampling 12.2.2 Requirements 12.3 Procedure of Phlebotomy 12.3.1 Site Selection 12.3.2 Requirements 12.3.3 Order of draw 12.3.4 Collection 12.3.5 Identification and Labeling 12.3.6 Selection of Vein 12.3.7 Disinfection of Skin 12.3.8 Performing the Venipuncture 12.3.9 Monitoring 12.3.10 Removing the Needle and Collect Sample 12.3.11 Complications 12.4 Quality Assurance in Phlebotomy 12.4.1 Quality Care for Patients 12.4.2 Quality Care for Health Workers 12.5 Let Us Sum Up 12.6 Answers to Check Your Progress

12.0 OBJECTIVES At the end of this chapter you should be able to:

 describe various techniques of blood collection;

 describe appropriate gauge of needles;

 describe the procedure of collection

 describe the order of draw;

 describe the potential complications and how these can be minimized; and

 describe how to ensure quality control for phlebotomy.

12.1 INTRODUCTION In the present day of medical practice, a variety of laboratory tests are available and these have increased the volume of samples to be collected. 31 Technique of Blood Collection Phlebotomy the science of drawing blood has thus become the most common procedure in health care services and a fundamental component in diagnosis and laboratory analysis of a given disorder. Hence, collection of blood samples has become an essential skill for health care workers.

Despite the vital role played by phlebotomy in patient care, there is paucity of resources to ensure that healthcare workers who are involved in phlebotomy are adequately trained in best phlebotomy practices and follow the available guidelines. There is lack of awareness among healthcare providers to understand the outcomes to patients and their own safety from inappropriate sample collection. Hence there is a definite need to standardize the phlebotomy practices and train the healthcare workers in best phlebotomy practices in order to reduce the risks to both patients and healthcare workers and improve blood collection for laboratory tests and from blood donors.

12.2 TECHNIQUES OF BLOOD COLLECTION

Blood is collected from veins for various laboratory tests. In order to obtain accurate and precise results in the laboratory, which will help the clinician to make a correct diagnosis of the patient’s disease; it is of paramount importance to collect the blood sample in a correct manner.

Many blood collection systems are available for phlebotomy. The system used for sampling should be chosen appropriately depending upon the patient condition and availability of resources. 12.2.1 Types of Systems for Blood Sampling

Two broad systems commonly used for blood collection are classified as closed and open systems.

Closed system:

Closed systems are preferred over open systems as they are safer. Amongst the closed systems the following are usually used and preferred.

1. Needle and Syringe: The use of needle and syringe for collection of blood samples is the most common method. In this method it is important to choose the proper gauge of the needle. If the gauge of the needle is not appropriate it can cause complications and invalid results.

2. Vacuum extraction systems: The use of vacuum extraction systems for collection of blood is preferred as it reduces the risk of exposure to blood and makes multiple sample collection from a single patient easier. The use of vacuum extraction systems is safe however it requires training and skill for their use.

Open System:

Open systems include hypodermic needle and syringes, as well as winged steel needles attached to a syringe. 32 12.2.2 Requirements Techniques for Collection of Blood Specimens It is advised to all healthcare workers to follow standard universal precautions while collecting of laboratory specimens as these are always treated as infectious.

 Protective gear including gloves, close shoes and mask

 Hand hygiene

 Adherence to biomedical waste management

 Maintaining clean work environment by disinfection of workstations.

 Use of safety needles and avoiding recapping of used needles

Check Your Progress 1

1. Vacuum extraction system is a

A. Open blood collection system

B. Closed blood collection system

C. Both of the above

D. None of the above

2. Gloves, closed shoes, mask are examples of –

A. Extraction system

B. Protective gear

C. Cleaning supplies

D. None of the above

12.3 PROCEDURE OF PHLEBOTOMY

To ensure accurate results and for proper patient diagnosis and treatment it is important to follow standard guidelines during blood collection. An appropriate blood collection is the first step towards providing the best quality healthcare to patients. 12.3.1 Site Selection

The preferred site for sample collection is antecubital fossa. If the veins in the antecubital fossa are not visible then the blood can be drawn from the veins on the back of hand. An arterial puncture should never be considered as an alternative for venipuncture as it may lead to complications and false results. In case of non-availability of palpable veins at the preferred sites the veins on the palmar surface of wrist and lateral aspect of forearm should not be used for sample collection. In newborns scalp and ankle should not be considered as sites for sample collection as it can lead to serious medical complications. 33 Technique of Blood Collection 12.3.2 Requirements The healthcare worker involved in phlebotomy practices should ensure that all the supplies necessary for blood collection are available and are within easy reach of the healthcare worker. He/ she should ensure that none of the supplies is either defective or expired. The various supplies required before beginning the procedure are:

 Sterile capped needles of various gauges along with disposable syringes: An appropriate needle depending on the volume of the blood to be collected and the size of the vein should be selected.

 Laboratory sample tube: These should be dry and stacked in the rack in an upright position. The tubes should be selected according to the test requisition.

 Well fitting non sterile gloves

 Tourniquet

 Alcohol swab and rub

 Gauze and cotton balls

 Bandages

 Requisition forms

 Puncture resistant sharps container 12.3.3 Order of Draw In order to avoid cross contamination during multi sample collection and to reduce the errors due to additive carryover, the blood should be drawn for various laboratory tests in a particular order. The following order (Table 12.1) of draw is recommended: Table 12.1: Order of Draw S. No. Additive Used Tests to be performed 1. Broth mixture Blood Culture 2. Sodium citrate Coagulation profile 3. Clot activator/ Gel Serology, Immunology, Biochemical tests 4. Heparin ABG, Lithium & Ammonia levels 5. EDTA Hematological investigations 6. Sodium Fluoride Glucose 12.3.4 Collection The healthcare worker going to perform phlebotomy should ensure that before starting the procedure he/she should clean his/her hands thoroughly with soap and water. After cleaning the hands well fitting non-sterile gloves 34 should be donned by him/her. After ensuring the proper supplies and hand hygiene one can progress for blood collection. The collection of blood Techniques for Collection of should be done upto the maximum mark indicated on the tube. Blood Specimens 12.3.5 Identification and Labeling The most important thing to remember while collection of multiple blood samples especially in OPD settings is to ensure correct patient identification. The patient should be identified, the requisition for the tests to be carried out then should be read carefully for that patient in order to select proper tubes. The collection tubes must be labeled in the presence of the patient. The identifiers for the patient including patient’s full name, laboratory or hospital record number and collection date and time should be mentioned on all the collection tubes. In case of bar code labeling the bar code must be applied carefully to the collection tubes so that all the information is clearly visible. In case of manual labeling each tube must be labeled in clear and legible handwriting. 12.3.6 Selection of Vein For collection of blood the following steps should be followed for site selection:

 Extend the patients arm and inspect the antecubital fossa and forearm.

 Look for a good size vein that is clearly visible and straight. The vein should be assessed for vein depth, size, direction and health of the vein. The median cubital vein is preferred for sample collection as the basilic vein has arterial and nerve supply underneath and puncturing here has a risk of damaging the nerve or artery and is also more painful.

 Decide the gauge of the needle depending upon the size of the vein.

 Apply a tourniquet 3-4cm above the intended venipuncture site for blood collection in order to make the veins more prominent. The use of tourniquet should not be exceeding one minute to prevent patient complications and ensure accurate results. Use of tourniquet for a longer period of time can lead to hemo-concentration and may affect the results. 12.3.7 Disinfection of Skin The site of venipuncture must be disinfected in order to avoid microbiological contamination of the sample and patient infection. Except for sample collection for blood cultures for all other investigations the venipuncture site should be cleaned with 70% alcohol for 30 seconds and allowed to dry completely. The complete drying prevents burning sensation and chances of hemolysis of sample during venipuncture. For cleaning the site one should start from the center and move downwards and outwards covering at least a diameter of 2cm around the venipuncture site. The healthcare worker should be cautious not to re-palpate the cleaned area and in case of re-palpation a repeat disinfection is mandatory. 12.3.8 Performing the Venipuncture Collection of blood using syringe:

 The healthcare worker should support the patient’s vein by holding the patient’s arm and placing the thumb below the selected venipuncture site. 35 Technique of Blood Collection  After applying the tourniquet the patient should be asked to clench the fist in order to make the veins prominent.

 Once the vein has been identified, the needle should be inserted in the vein through the skin at an angle of 30° or less keeping the bevel of the needle in upward position.

 Do not allow the patient the pump hand. Instruct patient to open his or her hand if the fist is performed.

 As soon as the blood starts flowing into the syringe release the tourniquet.

 After removing the needle the patient should be instructed not to bend the arm as it may lead to hematoma formation.

Collection of blood using vacuum extraction system:

 The healthcare worker should support the patient’s vein by holding the patient’s arm and placing the thumb below the selected venipuncture site.

 After applying the tourniquet the patient should be asked to clench the fist in order to make the veins prominent.

 Once the vein has been identified, the needle should be inserted in the vein through the skin at an angle of 30° or less keeping the bevel of the needle in upward position.

 The placement of the needle should be maintained while introducing the tube into the stopper of the needle holder. The device should be stabilized until all the tubes are filled appropriately.

 Do not allow the patient the pump hand. Instruct patient to open his or her hand if the fist is performed.

 As soon as the blood starts flowing into the syringe release the tourniquet.

 After removing the needle the patient should be instructed not to bend the arm as it may lead to hematoma formation 12.3.9 Monitoring

After the venipuncture, the site should be monitored for bleeding to stop and also to check if there is any hematoma formation at the site. In case of prolonged bleeding pressure must be applied as long as necessary for stopping the bleeding. After the bleeding has stopped a bandage can be applied to the site of venipuncture and the patient must be instructed to keep the bandage for at least 15 minutes after the procedure. The patient must be instructed to avoid any kind of pressure on the wound site in order to avoid bleeding. 36 12.3.10 Removing the Needle and Collect Sample Techniques for Collection of Blood Specimens The healthcare worker performing the phlebotomy procedure should remove the needle after collection of blood samples. He/she should ensure removal of tourniquet as soon as the blood starts flowing into the tubes and also application of pressure at the site of venipuncture after removal of needle. If needle and syringe is used for blood sample collection, the needle is removed and blood is pushed into the tube through the syringe. Once the indicated maximum volume is achieved in the tube, the tubes should be sealed and inverted slowly for required number times as per the manufacturer’s instructions in order to mix the additive in the tube with the blood sample. A vigorous mixing of the blood with additive should be avoided. 12.3.1 Complications

With every venipuncture there is a possibility for certain adverse reactions as no one can predict how a patient will react to a needle puncture. The healthcare worker should be aware of various complications, which can arise after venipuncture and also should be alert to notice any adverse event occurring during the draw of blood. These adverse reactions should be notified including any exposure to blood and infectious materials. The following are the common complications, which can occur due to venipuncture:

 Hematoma formation

 Accidental arterial puncture

 Dizziness & syncope

 Nausea & Vomiting

 Anxiety & fear

 Excessive bleeding

 Needle injury

The correct method of using vaccum evacuation tube is shown in Fig. 12.1 and 12.2

Fig. 12.1 : Correct way of using vacuum evacuation tube – Accessed from 37 Technique of Blood Collection

Fig. 12.2: Proper insertion of Evacuated Tubes Check Your Progress 2 1. The following order of draw is correct – A. Broth mixture, Heparin, EDTA, Sodium Fluoride, Sodium citrate, Clot activator/ Gel B. EDTA, Sodium Fluoride, Sodium citrate, Broth mixture, Heparin,Clot activator/ Gel C. Broth mixture, Sodium citrate, Clot activator/ Gel, Heparin, EDTA, Sodium Fluoride D. Sodium citrate, Clot activator/ Gel, Broth Mixture, Sodium Fluoride, EDTA, Heparin 2. Hematoma formation, Accidental arterial puncture, Dizziness & syncope are A. Procedure of phlebotomy B. Methodology of phlebotomy C. Complications of phlebotomy D. None of the above

12.4 QUALITY ASSURANCE IN PHLEBOTOMY For following the best practices in phlebotomy in order to minimize and control infection, quality assurance is essential. The most important part of asserting quality assurance is regular trainings and education of the healthcare workers performing phlebotomy. The next important step to maintain quality is preparation of standard operating procedures (SOPs), which should be available to all the personnel working in the blood collection units. SOPs determine the consistency and quality of blood 38 collection thereby influencing the final patient management. Another important element of quality assurance is reporting of any adverse or Techniques for Collection of unwanted event. Blood Specimens 12.4.1 Quality Care for Patients

 The healthcare workers should avoid any use of contaminated equipment like contaminated tourniquets, point of care devices and reusable equipment, which can be a source of infection to the patient.

 All the healthcare workers should be trained in phlebotomy, to prevent unnecessary risk of exposure to blood and to reduce adverse events for patients.

 The involvement and cooperation of patients is of utmost importance in maintenance of quality at any given setting. 12.4.2 Quality Care for Health Workers

 At all times there should be availability of appropriate supplies and protective equipment for the healthcare workers involved in blood collection.

 Regular training of the healthcare workers is mandatory.

 Awareness and availability of post exposure prophylaxis is essential.

 There should be a regular check on the methods of collection and transportation of samples. Check Your Progress 3 1. How can you tell that you are in a vein when using a needle and a syringe? A. There is no way to tell this when you use a needle and syringe. B. You cannot tell until you pull back the plunger and see blood. C. You will normally see blood appear in the hub of the needle. D. None of the above 2. What may happen if you mix a specimen too vigorously? A. Glycolysis B. Hemolysis C. Micro-clot formation D. Analysis

12.5 LET’ US SUM UP

Phlebotomy is a very important and essential procedure. It is required to draw blood samples for variety of investigations including hematology, biochemistry and cultures etc from a single patient and a single venipuncture. Hence it becomes very important to understand the order of draw of blood. The blood sample can be collected through closed system 39 Technique of Blood Collection or open system of sampling. The closed system collection can be done either with the help of syringe and needle or vacuum evacuation tube. It is important to take care of sterilization and possible complication like hematoma, nausea, vomiting, dizziness etc. Quality measures are of prime importance in phlebotomy.

12.6 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1 1. B, Closed Blood Collection System 2. B, Protective Gear

Check Your Progress 2 1. C, Broth mixture, Sodium citrate, Clot activator/ Gel, Heparin, EDTA, Sodium Fluoride 2. C, Complications of phlebotomy Check Your Progress 3 1. C, You will normally see blood appear in the hub of the needle. 2. B, Hemolysis

40 UNITS 13 BLOOD COLLECTION IN SPECIAL CASES AND SITES Structure 13.0 Objectives 13.1 Venipuncture for Blood Donation 13.1.1 The Process of Collection of Blood 13.1.2 Requirements 13.2 Collection of Blood 13.2.1 The Preprocessing 13.2.2 Selection of Vein and Preparation for Veiepuncture 13.2.3 Performing the Venipuncture 13.2.4 Removing the Needle and Collection of Sample 13.2.5 Blood Transfusion and Post Transfusion Care of the Donor 13.2.6 Blood Unit and Samples 13.2.7 Adverse Reaction 13.3 Arterial Blood Sampling 13.3.1 Site Selection 13.3.2 Potential Complications 13.3.3 Precautions to Prevent these Complications 13.3.4 Reasons for an Inaccurate Blood Result 13.3.5 Collection 13.3.6 Procedure for Performing Radial Artery Puncture 13.4 Pediatric and Neonatal Sampling 13.4.1 Venipuncture 13.4.2 Equipment and Supplies for Paediatric Patients 13.4.3 Preparation 13.4.4 Drawing Blood 13.5 Capillary Sampling 13.5.1 Selection of Site and Lancet 13.5.2 Procedure for Capillary Sampling 13.6 Let Us Sum Up 137 Answers to Check Your Progress

13.0 OBJECTIVES At the end of this chapter you should be able to

 explain the circumstances in which blood is to be collected in a different manner from routine phlebotomy;

 describe the sites of collection under these circumstances;

 describe the procedure of collection; and

 describe the potential complications and how these can be minimized. 41 Technique of Blood Collection 13.1 VENIPUNCTURE FOR BLOOD DONATION One of the main objectives of blood banks is to ensure minimal risk of infection to the recipient. Many diseases like HIV, Hepatitis B, Hepatitis C, Syphilis etc are transmitted through blood borne route. Careful screening of donors is therefore of utmost importance. The main guiding principle of a successful blood donation program is to recruit voluntary, unpaid donors with no history of intravenous drug abuse. Though donor blood is routinely screened for the various blood borne diseases, a questionnaire is also administered to the prospective donors to identify those donors who are at an increased risk of infection. Ideally only trained and qualified blood transfusion services personnel should collect blood. 13.1.1 The Process of Collection of Blood The process of collection of blood from donors is similar to that used for blood sampling; but extra precautions are taken to minimize any possible contamination from the skin flora of the donor’s arm. Any skin pathogen that might contaminate the blood unit will multiply on storage, thereby reducing the shelf life of the unit and rendering it unsafe. Usually one step application of a combination of 2% chlorhexidine gluconate and 70% isopropyl alcohol for 30 seconds, followed by 30 seconds drying time is recommended to achieve optimal skin antisepsis. 13.1.2 Requirements Equipment: – Blood pressure equipment, weighing scales, donor chairs, blood collection mixers, blood bag tube sealers, blood transportation boxes and blood bank refrigerators. Regular calibration, maintenance and cleaning of all equipments is required. A closed collection system with a sterile blood collection bag containing anticoagulant and with an integrally attached tube and needle should be used. All glass containers to be disinfected with sodium hypochlorite solution.

13.2 COLLECTION OF BLOOD Blood sample collection procedure plays a vital role in the efficiency of patient treatment in hospitals. You should follow the following steps: First of all it is important to prepare patient, and collect equipment and identify the site as you have already learnt in unit 10 and 11. Hand hygiene is the single most important way to prevent the spread/transmission of infection. Good hand hygiene is critical to reduce the risk of spreading health care-associated infection including multi-drug resistant organisms (MDROs).Evidence showed that use of alcohol-based hand rubs at the point of care (e.g. blood taking trolleys or station, consultation desks, triage station, at bedside) facilitates\, increases compliance and less irritation to hands. Before any procedure you are required to do hand washing as you will learn in detail in Course 2 unit 8. 42 13.2.1 The Preprocessing Blood Collection in Special Cases and Sites Identification and labeling of the blood bag, ensuring that correct patient’s name and unique identifying number is written on the bags and records. 13.2.2 Selection of Vein and Preparation for Venipuncture

 Select a large, firm vein, preferably in the antecubital fossa,

 Examine the site for the presence of any infection or skin lesion.

 Make the vein more prominent by applying a tourniquet or inflating a blood pressure cuff to 40–60 mm Hg.

 Donor may be asked to open and close the fist a few times.

 After vein selection, release the pressure device or tourniquet.

 Disinfect the skin site by one step application of a combination of 2% chlorhexidine gluconate and 70% isopropyl alcohol for 30 seconds, followed by 30 seconds drying time.

 If the site is very dirty, it should first be washed with soap and water, and then dried with single-use towels. Two-step procedure for site disinfection can also be used:

 Step 1 – Apply 70% isopropyl alcohol over the entire area for 30 seconds and let it dry for 30 seconds

 Step 2 – Apply tincture of iodine over the entire area for at least 30 seconds and let it dry for 30 seconds DO NOT touch the venipuncture site once the skin has been disinfected. 13.2.3 Performing the Venipuncture

 Ensure smooth, clean entry into the vein.

 A 16-gauge needle to the blood collection bag is usually used.

 Donor should be asked to continuously open and close the fist slowly every 10–12 seconds during collection.

 Remove the tourniquet or release the pressure when the blood flow is established or after 2 minutes, whichever is earlier. Donor should be carefully monitored for

 Any discomfort

 Signs of fainting like sweating

 Hematoma formation at the site.

 Gentle continuous mixing of the blood (every 30 seconds) of the blood being collected in the bag. 13.2.4 Removing the Needle and Collection of Sample

 Remove the needle gently from the vein. 43 Technique of Blood Collection  Cut off the needle using a sterile pair of scissors.

 Collect blood samples for laboratory testing from the tube. 13.2.5 Blood Transfusion and Post Transfusion Care of the Donor Blood transfusion is the process of transferring blood or blood products into one’s circulation intravenously. Transfusions are used for various medical conditions to replace lost components of the blood. The primary responsibility of a blood transfusion service (BTS) is to provide a safe, sufficient and timely supply of blood and blood products. In fulfilling this responsibility, the BTS should ensure that the act of blood donation is safe and causes no harm to the donor. It should build and maintain a pool of safe, voluntary non-remunerated blood donors and take all necessary steps to ensure that the products derived from donated blood are efficacious for the recipient, with a minimal risk of any infection that could be transmitted through transfusion. All prospective blood donors should therefore be assessed for their suitability to donate blood on each occasion of donation. Donor selection

 History of the donor should be taken to identify high-risk behaviour.

 History of any surgery, including –mastectomy when blood should be taken from the arm opposite the site of surgery.

 History of medications.

 History of Chronic infections or any diagnosed bleeding disorder.

 History of prolonged bleeding history.

 General health check up of the donor should be done.

 The process of blood donation should be informed to the donor who should be properly counseled and an informed consent from the donor must be taken.

 Donor should be offered fluids before donation. Post Transfusion Care of Donor Donor should be instructed to relax on his/her couch for few minutes. Site of venipuncture should be examined for presence of any bleeding and a bandage should be applied once the bleeding has stopped. In case the site is still bleeding, apply pressure in the site to stop bleeding. Offer refreshments to the donor. Make sure that the donor can stand up without feeling dizzy. 13.2.6 Blood Unit and Samples

 Blood unit should be carefully transferred to the designated site.

 The collected blood samples should be sent to the laboratory in properly 44 labeled vials and documentation. 13.2.7 Adverse Reactions Blood Collection in Special Cases and Sites  Hematoma

 Vasovagal attack

 Arterial puncture

 Nerve damage Check Your Progress 1 1. Which of these needles has the smallest bore or diameter? A. 15 gauge B. 23 Gauge C. 20 Gauge D. 22 Gauge 2. Before someone donates whole blood; what test is done? A. Hemoglobin B. HCV and HBV C. HIV D. All of the above

13.3 ARTERIAL BLOOD SAMPLING An arterial blood sample is collected from an artery, primarily to determine arterial blood gases. It should be performed only by trained health professionals. The sample can be obtained either through a catheter placed in an artery, or by using a needle and pre-heparinized syringes to puncture an artery.Precautions must be taken to minimize air exposure which may alter the blood gas values. 13.3.1 Site Selection The arteries which can be chosen are radial, brachial or femoral, but radial artery (Fig. 13.1) is usually preferred for arterial blood sampling as it is more superficial and collaterals are well developed. However because of its small size, expertise is required for radial artery sampling. Illustration – Accessed from

Fig. 13.1: Site for arterial blood sample 45 Technique of Blood Collection 13.3.2 Potential Complications

 Arteriospasm or involuntary contraction of the artery

 Haematoma or excessive bleeding

 Nerve damage

 Fainting or a vasovagal response 13.3.3 Precautions to Prevent these Complications

 Patient should be made comfortable and should lie in supine position.

 Haematoma formation can be prevented by ensuring clean puncture and applying pressure immediately after blood is drawn. 13.3.4 Reasons for an Inaccurate Blood Result

 Presence of air in the sample

 Collection of venous rather than arterial blood

 Inadequate quantity of heparin in the syringe or improper mixing

 Sample transportation delay 13.3.5 Collection

 Equipment and supplies required

 Pre-heparinized syringe

 Needles of different lengths (20, 23 and 25 gauge)

 Bandage

 Local anesthetic 13.3.6 Procedure for Performing Radial Artery Puncture

 Make the patient lie in comfortable supine position.

 Clenching of fist or breath holding should be avoided.

 Allen test maybe performed for localizing radial artery. Both hands can be tried for this test. Allen’s test is a simple bedside test used to assess blood flow to the hand, first described by Edgar B. Allen in 19213. In this test, both radial and ulnar arteries are occluded at the wrist; the subject is then asked to make a firm fist, allowing the palmar surface of the hand to blanch.

 Confirm the site using anatomical landmarks.

 Disinfect the site using complete aseptic precautions.

 Pull the syringe plunger to the required fill level.

 Holding the syringe and needle like a dart, use the index finger to locate the pulse again, and insert the needle at a 45 degree angle, approximately 1 cm distal to (i.e. away from) the index finger, to avoid contaminating 46 the area where the needle enters the skin.  Advance the needle into the radial artery until a blood flashback appears, Blood Collection in Special then allow the syringe to fill to the appropriate level. Cases and Sites

 DO NOT pull back the syringe plunger.

 Withdraw the needle and syringe; place a clean, dry piece of gauze or cotton wool over the site and apply firm pressure for sufficient time to stop the bleeding.

 Check whether bleeding has stopped after 2–3 minutes..

 Expel air bubbles, cap the syringe and roll the specimen between the hands to gently mix it.

 Cap the syringe to prevent contact between the arterial blood sample and the air, and to prevent leaking during transport to the laboratory.

 Label the sample syringe and transport the sample

 Dispose all universal protective equipment and wash hands thoroughly. Check Your Progress 2 1. ABG (Arterial Blood Gas) is A. Analyses test for RBC’s, oxygen, PH and in addition to blood bicarbonate B. Analyses test arterial for WBC’s, carbon dioxide, PH, in addition to blood oxygen C. Analyses arterial blood for oxygen, carbon dioxide, bicarbonate content in addition to blood PH D. Analyses arterial blood for carbon dioxide, glucose, bicarbonate content in addition to blood PH

13.4 PEDIATRIC AND NEONATAL SAMPLING Parents should be contacted for identification of paediatric and neonatal patients,. Name,age and other details should be conformed and matched with the form. 13.4.1 Venipuncture Venipuncture is the preferred method of blood sampling for term neonates, and is less painful than heel-pricks. 13.4.2 Equipment and Supplies for Paediatric Patients

 Winged steel needle, (23 gauge) with an extension tube (a butterfly). Thinner needles should be avoided for the increased chances of hemolysis.

 Use a syringe with a barrel volume of 1–5 ml,

 When using an evacuated tube, choose one that collects a small volume (1 ml or 5 ml) and has a low vacuum. 13.4.3 Preparation

 Give instructions to the parents for proper holding of child. 47  Either another phlebotomist or a parent should immobilize the child. Technique of Blood Collection  The immobilizer should stretch an arm across the table and firmly grasp the wrist of the child

 The grip should be periodically loosened to ensure an adequate flow of blood. Keep the child warm

 Warm the area of puncture with warm cloths to help dilate the blood vessels.

 A trans- illuminator may be used to display the dorsal hand veins and the veins of the antecubital fossa. 13.4.4 Drawing Blood  After mandatory aseptic precautions (DO NOT USE CHLORHEXIDINE IN INFANTS LESS THAN TWO MONTHS OF AGE) and immobilization of the child, puncture the skin 3–5 mm distal to (i.e. away from) the vein.

 If the needle enters alongside the vein rather than into it, withdraw the needle slightly without removing it completely, and angle it into the vessel.

 Draw blood slowly and steadily. Check Your Progress 3 Qs - Tourniquet is A. Constrictive band used for venipuncture, blood aspiration and intravenous injections B. Plastic band that easily breaks, mainly used for patients with blood disease C. Nylon band used to make embolisms, intravenous medicine injections D. Constrictive rubber tied in a knot used for patients needing medical attention Check Your Progress 4 Qs - What is another name for winged infusion set? A. Ladybug B. Buttercup C. Butterfly D. Beetle bug 13.5 CAPILLARY SAMPLING Capillary sampling is required if only very small amount of blood is required for a test or when sample collection is difficult (pediatric age group) 13.5.1 Selection of Site and Lancet  The finger is usually the preferred site for capillary testing in an adult patient.

 The sides of the heel are only used in paediatric and neonatal patients

 Use lancet of appropriate size

 DO NOT use a surgical blade to perform a skin puncture.

 DO NOT puncture the skin more than once with the same lancet 13.5.2 Procedure for Capillary Sampling Adult patients The steps for capitally blood sampling are as under:

48  Prepare the skin by applying alcohol and letting it dry.  Puncture the skin with one quick, continuous and deliberate stroke, to Blood Collection in Special achieve a good flow of blood Cases and Sites

 Wipe away the first drop of blood because it may be contaminated with tissue fluid or debris

 Avoid squeezing the finger or heel too tightly because this dilutes the specimen with tissue fluid (plasma) and increases the probability of haemolysis

 When the procedure is complete, apply firm pressure to the site to stop the bleeding.

 Take laboratory samples in the correct order to minimize erroneous test results. The first sample should be sent to hematology followed by chemistry and blood bank specimens. Paediatric and neonatal patients The choice of site and procedure (venous site, finger-prick or heel-prick) will depend on the volume of blood needed for the procedure and type of laboratory test to be done. Whether select a finger-prick or a bed-prick will depend on the age and weight of a child. Venipuncture is the preferred method of blood sampling for term neonates, and causes loss pain than heel-prick. The steps for capillary blood sampling are as under:

 Immobilize the child and grasp the child’s elbow (i.e. the skin puncture arm)

 Prepare the skin by using alcohol.

 DO NOT use povidone iodine for a capillary skin puncture in paediatric and neonatal patients

 Puncture the skin as described above for adult patients.

 Avoid excessive massaging or squeezing of fingers because this will cause hemolysis.

 Take laboratory samples in the order that prevent cross-contamination of sample tube additives

 Collect all the used items and DO NOT leave anything behind.

 Give follow-up care

Fig. 13.2: Blood sample from infant’s heel 49 Technique of Blood Collection Check Your Progress 5 1. What is the most important thing to remember when doing a capillary puncture? A. PPE, mask, goggle and microscope panes B. Excessively milking the finger during a skin puncture can result in full tubes for testing. Also hemolysis and contamination of the specimen with tissue cells C. Excessively milking the finger during a skin puncture can result in hemolysis and contamination of the specimen with tissue fluids D. Hemolysis and contamination of the specimen with tissue fluids due to not enough excessive milking of the finger 13.6 LET US SUM UP Phlebotomy is a very important task because with its help we take blood samples for establishing diagnosis of various diseases. Besides diseases blood is taken out for blood banking too. In that case the methodology is a little different but basic requirement of equipment and disinfection remain the same. One should also be very alert and aware of the complications which can occur while drawing blood. 13.7 ANSWERS TO CHECK YOUR PROGRESS Check Your Progress 1 1 B 23 Gauge 2 All of the above Check Your Progress 2 1. C, Analyses arterial blood for oxygen, carbon dioxide, bicarbonate content in addition to blood PH Check Your Progress 3 1. A. Constrictive band used for venipuncture, blood aspiration and intravenous injections. Check Your Progress 4 1. B, Butterfly Check Your Progress 5 1. B, Excessively milking the finger during a skin puncture can result in hemolysis and contamination of the specimen with tissue fluids

50 BHTL-011 BASIC PHLEBOTONYASSISTANCE

BLOCK 1 INTRODUCTION TO THE PHLEBOTOMY ASSISTANCE PROGRAMME UNIT 1 Role and Responsibilities of PhlebotomyAssistant UNIT 2 Overview of the Health Care and Hospital System UNIT 3 Ethics and Professional behavior of PhlebotomistAssistant

BLOCK 2 COMMUNICATIONAND EMERGENCY CARE UNIT 4 CommunicationSkills UNIT 5 Basic Emergency Care and Life Support Skills UNIT 6 Disaster Preparedness and Management

BLOCK 3 REQUISITES FOR SAMPLE COLLECTION UNIT 7 Human Body: Structure & Function UNIT 8 Recording and Reporting Formats UNIT 9 Blood Collection Process

BLOCK 4 TECHNIQUE OF BLOOD COLLECTION UNIT 10 Patient Preparation forVenipuncture UNIT 11 Site Selection and Venipuncture UNIT 12 Techniques for Collection of Blood Specimens UNIT 13 Blood Collection in Special Cases and Sites

51 Technique of Blood Collection