BLOOD SAMPLING FROM CENTRAL VENOUS LINES: VACUTAINER METHOD DOCUMENT TYPE: PROCEDURE Purpose Standards and procedure for blood sampling using the syringe method from central venous lines (CVL) including long term and short-term; cuffed/uncuffed external central venous catheters (CVCs), peripherally inserted central catheters and implanted ports. Standards Blood sampling requires a prescriber’s order indicating blood samples to be drawn. Blood may be sampled using the vacutainer method from: External Central Venous Catheters (CVC) Implanted Ports Short-term External Central Venous Catheters Hemodialysis/Apheresis Catheters The push-pull method is the preferred method of blood sampling from a Hemodialysis CVC but other methods can be used. Blood samplsing from a hemodialysis catheter is done only after consultation with a renal unit nurse or nephrologist. Although the vacutainer method is the preferred method for blood sampling from central venous lines for maintaining Blood and Body Fluid precautions, the syringe method is used: For all blood draws from PICC lines If vacutainer method is unsuccessful If small volumes are required for microtubes For drawing blood gas samples For drawing blood cultures Site Applicability Applicable in all BC Children’s Hospital areas where patients with central venous lines are cared for. Practice Level/Competencies Central line care, including blood sampling using syringe method from a CVL is considered a foundational nursing skill and is practiced once the nurse has: o Attended the Vascular Access Workshop, o Practiced the procedure in the lab setting, o Performs at least 3 blood sampling procedures on patients under supervision of a CVL competent RN, and o Has completed the CVL validation tool at the bedside with the appropriate clinical support person Equipment o Requisitions and computerized or addressograph labels for patient o Surface disinfectant wipe o Discard and sample syringes o Chlorhexidine 2% in 70% alcohol swabs x 3 per lumen o Vacutainer 1 per lumen o Appropriate blood collection tubes o Gloves, non-sterile o 10 mL syringe filled with normal saline 1 per lumen (x 2 if implanted port) o Sterile dead-end cap if interrupting infusion 1 per lumen CV.03.05 Published Date: 02-Nov-2018 Page 1 of 6 Review Date: 02-Nov-2021 This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current. BLOOD SAMPLING FROM CENTRAL VENOUS LINES: VACUTAINER METHOD DOCUMENT TYPE: PROCEDURE If heparin locking, add: o 10 mL syringe filled with heparin 10units/mL (x2 if double lumen) o Swabcap™ (x 2 if double lumen) If drawing blood cultures, add: o Three more chlorhexidine 2% in 70% alcohol swabs o Blood culture bottles if required** **NOTE: If drawing blood cultures please refer to Pediatric Blood Culture Guide - note that syringe method is preferred for blood cultures to ensure adequate blood volume is placed into culture bottles. Procedure Steps Rationale 1. REFER to Bloodwork Test and Tubes quick Ensures correct amount of blood collected, reference guide or the Department of Pathology eLab sample placed in correct tube and handled Handbook to determine appropriate blood tubes and correctly. Reduces need to recollect samples. volumes and any special handling instructions. For blood culture instructions, REFER to Blood Culture Collection Protocol and recommended blood volumes for blood cultures chart to determine type of bottles and optimal volume of blood to add to each bottle. 2. IDENTIFY patient by comparing name on requisition Failure to correctly identify patients prior to and labels to patient ID band. If patient does not have procedures may result in errors. ID band (i.e. Ambulatory care patients), ask patient/caregiver for identification information (name, birthdate). Pease refer to Patient Identification Policy 3. EXPLAIN procedure. Evaluates and reinforces understanding of previously taught information and confirms consent for procedure. 4. CLEAN surface with disinfectant wipe. Routine infection control practices. Reduces 5. PERFORM hand hygiene for one minute. transmission of microorganisms. 6. PREPARE equipment using aseptic technique. To reduce risk of contaminating sample. If drawing blood cultures, SCRUB tops of blood culture tubes with chlorhexidine /alcohol wipes for 30 seconds. Allow to dry for 1 minute. 7. CLAMP catheter. If second lumen infusing, CLAMP Both lumens must be clamped to ensure no second lumen. contamination/dilution of blood samples. NOTE: Clamping before or after disconnecting IV infusion lines is appropriate as all neutron caps on CVLs are neutral displacement caps. 8. PAUSE infusion pumps or ACTIVATE the delay By clamping first, then stopping infusion, positive infusion feature if more than 2 minutes is required for pressure is established. blood sampling. 9. PERFORM hand hygiene. DON non-sterile gloves. Routine infection control practices. 10. REMOVE IV tubing and attach sterile dead-end cap to open end to keep covered. SCRUB the needleless connector for 30 seconds with a CV.03.05 Published Date: 02-Nov-2018 Page 2 of 6 Review Date: 02-Nov-2021 This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current. BLOOD SAMPLING FROM CENTRAL VENOUS LINES: VACUTAINER METHOD DOCUMENT TYPE: PROCEDURE chlorhexidine/alcohol wipe. Allow to dry for 1 minute. OR REMOVE Swabcap™ and proceed to next 11. INSERT vacutainer into needleless connector. 12. UNCLAMP catheter and PRESS discard red-top Removes solution from catheter to ensure tube onto vacutainer needle. If experiencing difficulty uncontaminated blood specimen. with blood sampling from other central venous lines refer to Management of a Non-Functioning Central Venous Lines – Policy Ensure appropriate amount of blood for discard: TYPE OF CVL AMOUNT OF DISCARD Cuffed CVC < 10 kgs 1.5 mL Cuffed CVC > 10 kgs 3 mL Short-term CVC 1.5 mL Implanted Port 3 mL PICC and cuffed PICC <10 kg 1.5 mL PICC and cuffed PICC >10 kg 3 mL Hemodialysis/Apheresis 3 mL NOTE: Discard blood can be used in blood culture collection sample if CVL is not ethanol or antibiotic “locked”. May then place culture bottle directly on vacutainer to collect sample and omit discard. 13. CLAMP catheter. REMOVE discard blood tube and DISCARD. 14. PRESS sample blood tubes on to vacutainer To obtain total amount for transferring to needle in the following order: appropriate tubes. blood cultures Na Citrate blue top (coagulation studies) red top heparin green top (chemistries) EDTA tube lavender top (hematology, transfusion medicine) grey top other tubes as required… UNCLAMP catheter and allow each tube to fill up with adequate amount of blood required for lab test. Refer to online eLab handbook for required amounts of blood 15. MIX each tube immediately after drawing blood into Ensures blood cells are mixed with additives in it. GENTLY invert each tube 10 times. the tubes. Do not shake or will cause cell lysis. 16. CLAMP catheter and remove vacutainer. 17. ATTACH normal saline syringe onto needleless Creates positive pressure to maintain connector catheter patency. UNCLAMP catheter and with thumb on plunger of syringe and other hand on clamp, Two quick pushes creates turbulent flow to clear CV.03.05 Published Date: 02-Nov-2018 Page 3 of 6 Review Date: 02-Nov-2021 This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current. BLOOD SAMPLING FROM CENTRAL VENOUS LINES: VACUTAINER METHOD DOCUMENT TYPE: PROCEDURE give two quick pushes, then with continuous catheter and help maintain patency. motion, FLUSH into cap and catheter with remaining normal saline: Type of CVL Saline Flush Cuffed CVC < 10 kgs 3 mL Cuffed CVC > 10 kgs 9 mL Short-term CVC 3 mL Implanted Port 18 mL (use 2 x 10 mL) PICC and cuffed PICC < 10 kgs 3 mL PICC and cuffed PICC > 10 kgs 9 mL Hemodialysis/Apheresis 9 mL 18. RECONNECT infusion set and commence infusion Resumes therapy as ordered. or heparin lock line as ordered. - If second lumen is in use, UNCLAMP second lumen and RECOMMENCE infusion. 19. LABEL specimen tubes at the patient's bedside. Safe blood sampling and transfusion practices. Label must include MRN, first and last name, date of Refer to Transfusion medicine manual. birth, date and time sample drawn and RN initials. May use computerized or addressograph labels if available, except for Group & Screen and Crossmatch.* NOTE *Group & Screen and Crossmatch collection procedure: National Standards for safe transfusion practice require specimen labeling at the bedside Confirm patient identification - name, DOB, MRN on patient ID band matches with the requisition. Resolve any discrepancies prior to collection When possible, ask patient his/her name and DOB Specimen MUST be hand labeled at bedside only by the person who collected the specimen Computer generated labels are not to be used Label must contain patient name, DOB, MRN, date and time of collection and RN initials Sign requisition and record date and time of collection. Signing requisition confirms you have correctly identified the patient. 20. COMPLETE appropriate laboratory requisitions indicating the site where blood sample was obtained, RN initials, and date and time. On the transfusion medicine requisition: sign, date and time the CV.03.05 Published Date: 02-Nov-2018 Page 4 of 6 Review Date: 02-Nov-2021 This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current. BLOOD SAMPLING FROM CENTRAL VENOUS LINES: VACUTAINER METHOD DOCUMENT TYPE: PROCEDURE requisition in the appropriate space. Your signature MUST include full last name, and first name or first initial.