SPECIAL BLOOD COLLECTION and True or False?

POINT-OF-CARE TESTING Always reject a lipemic specimens

PRE-TEST Timed Samples

1. Differentiate stat from ASAP.
2. What is the clinical significance of  Measurement of the body’s ability
OGTT? to metabolize a particular
3. What container will you use for blood substance
culture collection?  Monitoring changes in a patient’s
4. When is arterial puncture performed? condition
5. What is POCT?  Determining blood levels of
medications
Special Blood Collection  Measuring substances that exhibit
• Not part of the routine venipuncture diurnal variation
procedure  Measurement of cardiac markers
• Special techniques involving: following acute myocardial
– Patient preparation infarction
– Timing of sample collection  Monitoring anticoagulant therapy
– Other blood collection techniques
– Sample handling GLUCOSE TOLERANCE TEST

Collection Priorities 2-hour postprandial glucose test

• ROUTINE SAMPLES
 Monitoring • Compares patient’s fasting glucose level with
 Collected during scheduled “sweeps” the glucose level 2 hours after eating a meal
• ASAP SAMPLES with a high carbohydrate content.
 “as soon as possible”
• STAT SAMPLES Classic GTT
 Highest priority
 Done immediately • Patient drinks a standard glucose load and
return for testing on an hourly basis.
Fasting Samples
Guidelines for OGTT
FASTING  Patients should be AMBULATORY
Patient must only have refrained from  Unrestricted diet of 150g
eating and drinking for a certain Carbohydrate/day for 3 days prior to
number of hours. testing
BASAL STATE  Patient should NOT exercise, smoke &
Same conditions as above but patient drink alcohol prior to testing
also must have refrained from exercise.  Fasting for 12 hrs, not more than 16 hrs
Analytes that require fasting samples:  Glucose load for Adults is 75g (WHO
 Glucose standard). Children receive 1.75g/kg of
 Triglycerides body weight
 Lipid profiles
A sample that appears lipemic is an GLUCOSE TOLERANCE TEST
indication that the patient was not fasting  Confirm if patient fasted for 12 hours
and the lipemia may interfere with but not more than 16 hours
laboratory testing.
  Draw a fasting glucose sample DIURNAL VARIATION
(baseline). Primarily affected by diurnal variation
 Patient drinks glucose juice within 5  corticosteroids
minutes  serum iron
 Collect remaining samples at the  glucose
scheduled times.  eosinophils

THERAPEUTIC DRUG MONITORING
Examples of frequently monitored drugs:
 digoxin
 phenobarbital
 lithium
 theophylline
 methotrexate
 various antibiotics

THERAPEUTIC DRUG MONITORING
• Trough levels
– collected immediately before the
drug is to be given
– represent the lowest level in the blood,
ensuring drug is within therapeutic range
GLUCOSE TOLERANCE TEST • Collection for peak levels varies with the
Medications that may interfere: medication and method of administration.
 alcohol
 anticonvulsants Blood Cultures
 aspirin
 birth control pills • Requires strict aseptic technique
 blood pressure medications • Requested on patients with symptoms
 corticosteroids indicating a possible septicemia
 diuretics • Can identify the causative pathogen and
 estrogen-replacement pills determine most effective treatment

What tube is used for GTT blood samples? TIMING OF SAMPLE COLLECTION
a. Gray
b. Gold • Usually ordered stat or as timed collections
c. Red • Samples are collected in sets of two drawn 30
d. All of the above or 60 minutes apart, or just before the patient’s
temperature reaches its highest point.
LACTOSE TOLERANCE TEST • If antibiotics are to be started immediately,
sets are drawn at the same time from different
• Evaluates patient’s ability to digest lactose. sites.
• Principle: Lactose degraded by lactase into
glucose and galactose COLLECTION EQUIPMENT
• Can be used to diagnose lactose intolerance
• Patient drinks a standard lactose solution; • Blood culture tubes containing anticoagulant,
same procedure with GTT sodium polyanethol sulfonate.
• Some blood culture collection systems have SAMPLE COLLECTION
antimicrobial removal devices (ARDs). • Do not repalpate the site without cleansing
• Fastidious antimicrobial neutralization (FAN) the palpating finger in the same manner as the
blood collection system puncture site.
CLEANSING THE SITE • Do not use iodine on disinfecting the
stoppers.
• Increased aseptic preparation of the puncture • Observe proper inoculation.
site • Invert gently the bottle eight times.
• Antiseptics for disinfecting: What is the additive used in blood culture
 2% iodine tincture collection and is its action?
 povidone-iodine
 multiple isopropyl alcohol preps Arterial Blood Collection
 chlorhexidine gluconate
 • Begin with vigorous scrubbing of the • Requested for evaluation of blood gases,
site for 1 minute using alcohol, then lactic acid and ammonia
scrub the site with iodine for another • More uncomfortable and dangerous to the
minute patient
 • From the center of the puncture site • More difficult to perform
progressing outward 3 to 4 inches in • Not a routine duty of phlebotomists
concentric circles
 • Do not repalpate the puncture site Arterial Blood Gases
after disinfection.
• measures the ability of the lungs to provide
SAMPLE COLLECTION oxygen (O2) to the blood and to remove carbon
• Two samples are routinely collected: dioxide (CO2) from the blood and exhale it.
– one incubated aerobically • tested using specialized instrumentation
– another anaerobically designed to measure the pH, PO2 and PCO2,
• Syringe method, anaerobic bottle inoculated and to determine HCO3, ctO2 and O2Sat levels.
first.
• Winged blood collection set, aerobic bottle Arterial Blood Collection
inoculated first.
• Evacuated tube system not recommended. EQUIPMENT
• Blood to media ratio • Syringe
– 1:10 – 20 to 25 gauge
• Overfilling of bottles cause false- positive – 5/8 to 1 ½ inch long
results. • Glass syringes is used when testing cannot be
• Underfilled blood culture bottles may cause done within 30 minutes
false-negative results • Crushed ice, or ice and water, is required for
• Adult blood culture blood maintaining sample integrity
– 8 to 10 mL • Heparin is the anticoagulant of choice for
• Pediatric blood culture bottle ABGs
– 1 to 3 mL
• Pediatric blood volume requirement SITE SELECTION
– Less than 45 kg: 1mL of blood for every 5 kg
of patient weight An artery must be:
– Above 45 kg: treated as that of an adult Large enough to accept at least 25g
– Babies less than 5 kg: 1 mL needle
Located near the skin surface
 Injury to surrounding tissues is not  Insert needle at a 30- to 45-degree
critical angle
Presence of collateral circulation  Allow syringe to fill.
 Remove needle and apply pressure on
SITE SELECTION puncture site.
 Radial artery
 Brachial artery Arterial Blood Collection
 Femoral artery
 Umbilical veins TECHNICAL ERRORS
 Scalp veins  Air bubbles present
 Foot artery  Too much heparin
 Too little heparin/inadequate
mixing
 Delayed analysis
 Venous sample

Arterial Blood Collection

COMPLICATIONS
 Hematoma
 Air embolism
 Tissue necrosis
 Fainting
 Bleeding
 Infection
MODIFIED ALLEN TEST  Deep vein injury
• Done if puncture site is the radial artery
• Performed to determine if the ulnar artery is After two unsuccessful venipuncture, a
capable of providing collateral circulation to phlebotomist must extract blood through
the hand arterial puncture. (True or False)
• Lack of available circulation choose
another site. Blood Bank Phlebotomy

• Used to collect units of blood to provide the

blood bank a supply of blood and blood
components for transfusions
• 1 unit of blood
405 to 495 mL of blood mixed with 63
mL of anticoagulant and preservative
Preservative: CPD or CPDA

Blood Bank Phlebotomy

RESPONSIBILTIES OF A PHLEBOTOMIST
 Donor interview and screening
 Donor identification
 Donor informed consent
PROCEDURE  Venipuncture
 Disinfect puncture site.  Product collection
  Postdonation care
 Complication management PUNCTURE SITE PREPARATION
• Large vein in the antecubital fossa
• Aseptic site preparation
Blood Bank Phlebotomy – Two-step process:
1. Soap or detergent scrub
•The process for collecting blood from donors 2. Iodine or chlorhexidine
is similar to that used for blood sampling; • Do not re-palpate puncture site once
however, a few additional measures are disinfection has been done.
required for collection of donated blood.
•Blood donor collections are performed PROCEDURE
following guidelines established by the 1. Select puncture site and disinfect
American Association of Blood Banks (AABB) accordingly.
and the Food and Drug Administration (FDA) 2. Perform the venipuncture using aseptic
for donor selection and unit collection and technique.
processing. 3. Monitor the donor and the donated
• The measures primarily to ensure patient unit.
safety, but also to minimize contamination of 4. Remove needle and apply pressure to
blood products from the skin flora of the the puncture site.
donor’s arm
• Safe collection ensures that the blood ADVERSE REACTION
products are safe for therapeutic use  Hematoma
throughout their shelf life  Dizziness
 Fainting
Blood Bank Phlebotomy  Arterial puncture
 Nerve damage
EQUIPMENT REQUIREMENTS  Infection

• Sterile, closed systems consisting of one or • If a patient suddenly faints during blood
more plastic bags connected to tubing and a extraction, what will you do?
sterile needle
• Large-gauge needles Special Sample Handling Procedures
– 15 to 16 regular gauge, or
– 17 gauge thin-walled • Cold Agglutinins
• Tourniquet or blood pressure cuff – autoantibodies that react with RBCs at
temperatures below body temperature
– collected samples must be kept warm in an
incubator at 37˚C for 30 minutes
– cryofibrinogen, cryoglobulin

• Chilled Samples

Blood Bank Phlebotomy

• Samples Sensitive to Light  Decreased turnaround time
Bilirubin  Decreased time to treatment
β-carotene  Decreased length of stay
Vitamin A  Fewer follow-up visits or calls
Vitamin B6  Less traumatic sample collection
Vitamin B12  Convenience for both physician/nurse
Folate and patient
Porphyrins  Decreased manpower needs

• Blood Alcohol Samples DISADVANTAGES

– requested for medical reasons, legal reasons,  Significantly more expensive
or as part of employee drug screening  Increased regulatory burden
– must strictly follow the chain of custody  Increased work for clinical staff
(COC) protocol  Maintenance of quality control and
– use benzalkonium chloride to disinfect the quality assurance is difficult
puncture site  Greater potential for preanalytic,
– collected in gray stopper tubes analytic, and postanalytic errors
• Other names: alternate site testing, near-  Results may not correlate with central
patient testing, decentralized testing, bedside laboratory
testing, ancillary testing
REGULATORY REQUIREMENTS
Point-of- Care Testing (POCT) • Clinical Laboratory Improvement Act of 1988
(CLIA 88)
• performance of laboratory tests at the – established standards for all laboratory
patient’s bedside or nearby rather than in a testing to ensure accuracy, reliability, and
central laboratory timeliness of patient test results regardless of
where the test was performed.
Environments Where POCT Might Be
Employed REGULATORY REQUIREMENTS
 Certificate of Waiver
Primary Care  Certificate of Registration
• Home  Certificate for PPMPs
• Health centers  Certificate of Compliance
• Workplace clinic  Certificate of Accreditation
• Diagnostic and treatment center
• Paramedical support vehicle LEVELS OF COMPLEXITY

Secondary and Tertiary Care  Waived Testing

• Emergency room • Requires minimal training and
• Admissions unit education to perform
• Operating room • Erroneous results are likely negligible
• Intensive care unit • Poses no harm when done incorrectly
• Ward • Many POC tests are waived
• OP clinic

Point-of- Care Testing (POCT)  Provider-Performed Microscopy

Procedures
ADVANTAGES
  Moderate-Complexity Testing
 High-Complexity Testing

Point-of- Care Testing (POCT)

TYPES OF POCT ANALYZERS
• Single-use cartridge/strip tests
– Qualitative or semi-quantitative
– Quantitative
• Multiple use
• Subcategory of moderate- complexity – Handheld devices
testing – Bench top devices
• Involve the use of a microscope – Wearable devices
• Performed only by licensed
physicians, dentists, and midlevel

practitioners
• Usually no QC materials available
Point-of- Care Testing (POCT)
CHARACTERISTICS OF A POCT ANALYZER
Release results in a minute or less
Portable instruments with consumable
reagent cartridges
One- or two-step protocol
Capable of performing direct specimen
analysis
Built-in/integrated calibration and
quality control
Low instrument cost