VENIPUNCTURE

RAJESH MOHESS,CLT.
 ORDER OF DRAW

Refers to the order in which blood is

collected when collecting multiple tubes e.g..
Evacuated tube system (ETS)

This also includes blood tubes filled by

syringes
Tubes are filled in order of sterile first then
additional tubes to prevent contamination
 ORDER OF DRAW

Tube order:
1. Sterile tube (blood cultures)
2.Blue top (coagulation)
3.Serum tube (with or without clot
activator/gel)
activator/gel
4.Heparin tubes (with or without plasma
separator)
separator e.g.. Green, royal blue
5.EDTA tubes
6.Glycolytic inhibitor tube
 Rationale for Order of Draw

Blood culture (sterile containers)

Yellow tops, sterile media bottles
Minimizes change of microbial contamination

Coagulation tubes
Light blue
Collected first because all other additives affect
coagulation testing
 Rationale for Order of Draw

Glass nonadditive tubes

Red
Prevents contamination by additives in other tubes

Plastic clot activator

Red
Filled after coagulation tests because silica particles activate
clotting and affect coagulation tests

Serum separator tubes (SST)

Red and gray rubber stopper, Gold plastic caps
Filled after coagulation tests because silica particles activate
clotting and affect coagulation tests
Carryover of silica into subsequent tubes can be overridden by
anticoagulation in them
 Rationale for Order of Draw

Plasma separator tubes (PST) and Heparin Tubes

Green and gray rubber stopper, Light green plastic caps,
Green
Heparin affects coagulation test and interferes in collection of
serum specimen
It causes the least interference in tests other than coagulation
tests, as it occur naturally in body

EDTA, Plasma preparation tubes (PPT)

Lavender, pink, purple, pearl top
Responsible for more carryover problems
It elevates sodium and potassium levels
Chelates and decrease calcium and iron levels
Elevate PT and PTT results
 Rationale for Order of Draw

Oxalates, Fluoride tubes

Gray
Sodium fluoride affects sodium levels
Potassium oxalate affects potassium levels
It is filled after hematology tubes because oxalate
damages cell membranes and causes abnormal
RBC morphology
Oxalate also interfere with enzyme reactions
 Pneumonic To Remember Tubes

Sterile - Stop
Light blue - Light
Red - Red
SST - Stay
PST - Put
Green - Green
Lavender - Light
Gray - Go
 ORDER OF DRAW

If tubes are filled in the wrong order in can lead to

cross contamination resulting in interference in
tests results

Microorganisms, additives/anticoagulants, tissue

thromboplastin can be carried over
Order of draw is implemented to avoid these
problems
 ORDER OF DRAW

Tissue thromboplastin is a substance present in tissue

fluid. It activates the extrinsic coagulation pathway and
can interfere with coagulation tests.
It is usually picked up during venipuncture through the
needle; especially if there is excessive manipulation of
the needle.
Does not have significant effects on PT, PTT
However, if other coagulation tests are required to be
collected, a discard tube should be collected

A discard tube is also needed if using a butterfly and the

first tube is blue top. This is to protect the 9:1 ratio air
in the tubing displace blood in the tube
 ORDER OF DRAW

Microbial contamination
Blood cultures detect organisms in blood
Special cleaning is necessary iodine
It is collected first to avoid contamination
from the non sterile tubes
Most of the time drawn separately
 Carryover/cross contamination

Transfer of additive from one tube to another

It can occur from blood touching the needle or

even when transfer from a syringe

This results in the additive from the previous tube

being transferred to the next tube
 Carryover/cross contamination

Note:
To minimize carryover, make sure that you fill tubes from
bottom up and the contents does not come in contact
with the needle
EDTA tends to have the most carryover problems than
any other additive
Heparin causes the least carryover because it occurs in
the body naturally
If drawing specimen for trace elements (royal blue), it is
recommended to be drawn separately to avoid any
contamination.
If using a syringe system and collecting trace elements
afterwards, the transfer device should be changed
VENIPUNCTURE SITES
 VENIPUNCTURE SITE SELECTION

IV LINES If IV is running on one limb, you should

choose another site to prevent contamination and
hemodilution
EDEMA abnormal fluid accumulation
SCARRING or BURNS difficulty palpating veins;
causes contamination/sepsis. Use alternate site
DIALYSIS Never draw from arm with fistula
MASTECTOMY never draw from the same site;
especially if lymph nodes removed

These are all pre-analytical errors

 DIFFERENT TYPES OF PATIENTS

PEDIATRICS
Increased anxiety both parents and child
Be compassionate and gentle
Take your time and gain the childs trust and confidence
Get help with restraining

ADOLESCENTS
Relax and anticipate anxiety from the patient
Maintain eye contact
May engage in conversation
 DIFFERENT TYPES OF PATIENTS

ADULTS
Be honest and pleasant
Follow HIPAA rules

GERIATRICS
Be patient and pleasant and Treat with dignity and respect
Engage in conversation
May have to speak loud and slow for some patients

COMBATIVE PATIENTS
Some patients may be combative if you think you are in danger and
may get yourself hurt, do not attempt to draw notify your supervisor
 ARTERIAL BLOOD DRAW

Do not perform unless your facility gave you additional

training and authorize you to perform arterial puncture
Mainly used for ABGs
Most common site is Radial artery of non dominant hand
Perform the modified Allen test to confirm collateral
circulation
(open and close fist several time; keep fist clenched; occlude both radial
and ulnar artery; have the patient open hand slowly; release ulnar
artery)
Brachial sites usually difficulty obtaining hemostasis
 VENIPUNCTURE PROCEDURE

1. Review the test requisition/computer order

Should have all information such as: patient's

name, person ordering the test, patients medical
record number, DOB/Age, location of patient, test
to be performed and date to be performed, test
status (STAT, routine), special precaution (e.g..
Allergy, latex sensitivity)
 VENIPUNCTURE PROCEDURE

2. Approach, Identify and Prepare the patient

Be prepared with all information, materials
Identify yourself: name, title and why you are there
Obtain consent ask permission to collect blood
Identify patient by name and date of birth ask patient to
state
Also verify info with ID band (if applicable)
Information for babies that need to be verified: name (if
available) and date of birth, gender, medical record
number, mothers last name
Prepare the patient by explaining the procedure, answer
any questions
 VENIPUNCTURE PROCEDURE

3. Verify diet restrictions and Latex sensitivity

If fasting is required, make sure the patient has been
fasting
If patient is latex allergy, use latex free equipment

4. Sanitize hands
Hands can be washed or used sanitizer follow
facility protocol
 VENIPUNCTURE PROCEDURE

5. Position patient, apply tourniquet and ask patient

to make a fist
Normally inpatients are lying in bed; outpatients will be
sitting in chair
Note: due to possibility of fainting, patient should not be
standing up or seated on high chair/bar stools
If you lower bed rails and forget to raise it back up and
patient falls, you will be liable

6. Locate and select vein to be used

Release tourniquet and ask patient to open fist
Most common vein is in antecubital area of arm where veins
are close to the surface
 VENIPUNCTURE PROCEDURE
Most prominent are the Median cubital, cephalic and
basilic veins in H pattern
Also have median, median cephalic and median basilic
veins in M pattern
 VENIPUNCTURE PROCEDURE

7. Clean and air dry the site

Clean in circular motion, inner to outer, about 2-3 inches in
diameter
If not cleaned, microorganisms can enter the bloodstream
causing infection
Allow to air dry 30-60 seconds
Note: to prevent contamination do not: dry with unsterile
gauze; fan with your hands or blow; touch the site after cleaning

8. Prepare Equipment and put on gloves

Have all equipment handy
Do not remove needle cover yet
ETS (evacuated tube system), Syringe system
Butterfly system same procedure explained in Lab
 VENIPUNCTURE PROCEDURE

9. Reapply tourniquet
Uncap and inspect needle (although rare needle may have
deformities)
Never leave the tourniquet for more than 2 minutes as it can elevate
certain tests, such as: alb, AST, Ca2+, Chol, iron, T. protein, T. bili

10. Ask patient to make a fist

Anchor vein and support arm: thumb 1-2 inches below site of insertion
with other fingers supporting arm below
Insert needle with bevel upwards usually will sense a pop sound
meaning that the needle enter the vein. You may also have less
resistance
Normal angle of needle is 30 degrees; for shallow veins, may need 15
degrees
Angle range from 15-30 degrees depending on depth
 VENIPUNCTURE PROCEDURE

11. Establish blood flow

by penetrating the needle in the tube (ETS). Push with thumb while
grasping the needle holder with index and middle finger
If using a syringe, will see flash blood in hub
If successful venipuncture, blood will flow

Release tourniquet and ask patient to open fist

Tourniquet released with one pull/tug

12. Fill, remove and mix tubes in order of draw

maintain needle position while changing needle
Keep arm in downward position, so blood fills from bottom up
without contact with the needle
Gentle mixing, do not mix vigorously
 VENIPUNCTURE PROCEDURE

13. Place gauze, Remove needle, Activate safety feature and

Apply pressure
Hold gauze lightly in place; do not press down until the needle is
completely out of the vein
Apply pressure for about 3-5 mins or until bleeding has stopped
It is okay to have patient hold pressure while you are labeling tubes
Avoid asking patient to bend arm upwards to keep pressure it
has shown to delay clotting and increase change of bruising

14. Discard collection unit, syringe needle or transfer device

Use red biohazard container (sharps container). Do not break,
cut/crush needle
Never recap needles
 VENIPUNCTURE PROCEDURE

15. Label tubes

Place patient first and last name, DOB, MR #, date and
time of collection and phlebotomist initial; additional
information such as fasting
Labels in hospital already have most of these information
Before leaving, double check label information with
patients wristband and tube label

16. Observe special handling instructions

Tubes may need to be cooled, covered from light, etc
 VENIPUNCTURE PROCEDURE

17. Check patients arm and apply bandage

Instruct patient to leave bandage for at least 15 minutes
Avoid lifting heavy objects for at least one hour

18. Dispose of contaminated materials

Use proper biohazard containers per facility protocol

19.Thank patient, remove gloves and sanitize hands

20. Transport specimen to lab

VENIPUNCTURE PROCEDURE
VENIPUNCTURE EQUIPMENT
VENIPUNCTURE

THE END