PHLEBOTOMY Flashcards
are the components of the
circulatory system that transport blood throughout the human body
blood vessels
Five types of Blood Vessels:
- Arteries
- Arterioles
- Capillaries
- Venules
- Veins
carry the oxygenated blood away
from the heart;
Arteries
small branches of an artery leading into capillaries
arterioles
exchange of water and chemicals between the blood and the tissues occurs
Capillaries
small branches of veins that lead to the
capillaries
venules
carry deoxygenated blood from the
capillaries back towards the heart
Veins
thicker due to the pressure from the heart
pushing away the blood.
Artery
Carry oxygen-rich blood away from the
heart to all of the body’s tissues.
Arteries
Small, thin blood vessels that connect
the arteries and the veins.
Capillaries
Their thin walls allow oxygen, nutrients, carbon dioxide, and other waste products to pass to and from cells
Capillaries
Blood carried by these contains less
oxygen and rich in waste products
Veins (towards the heart)
What is the diameter of the capillary that is same with the RBC?
8 micrometer in diameter
MAIN TYPES OF BLOOD VESSELS
- Artery
- Capillary
- Veins
THE THREE MAJOR LAYERS of the Vein and Capillary
Tunica externa
Tunica media
Tunica intima
Outer layer and the thickest layer in veins.
Tunica externa
Entirely made of connective tissue.
Tunica Externa
Contains nerves that supply the vessel as well as nutrient capillaries (vasa vasorum) in the larger
blood vessels
Tunica externa
What is the nutrient capillaries?
Vasa Vasorum
Thickest layer in the arteries
Tunica Media
Consists of circularly arranged elastic fiber,
connective tissue, polysaccharide substances, the
second and third layer are separated by another
thick elastic band
Tunica Media
The second and the third layer of tunica Media is separated by another thick elastic bond called
External elastic lamina
Innermost and thinnest layer
Tunica intima
Composed of simple squamous epithelial cells (for gas, waste, and nutrients exchange) interlaced with several circularly arranged elastic bands
Tunica intima
The tunica intima interlaced with
several circularly arranged elastic bands called the
internal elastic lamina
what is the vessel size? ranges from?
25 millimeters for aorta to 8 micrometers for capillaries
narrowing of blood vessels
(becoming smaller in cross-sectional area) by
contracting the vascular smooth muscle in the
vessel walls.
Vasoconstriction
similar process mediated by
antagonistically acting mediators
Vasodilation
What is the most prominent vasodilator?
Nitric oxide
TRUE OR FALSE
Increased vessel diameter mean decreased
blood pressure
TRUE
What are the potent vasoconstrictors?
ATP or ADP
cold water
what are the potent vasodilators?
vasopressin
epinephrine
MAJOR ARM & LEG VEINS FOR VENIPUNCTURE
- Anticubital Fossa
- H- Shaped Anticubutal Vein
- M -Shaped Anticubital Vein
- Other arm and hand Veins
- Leg, ankle, and foot Veins
- Arteries
Also known as the elbow pit
Antecubital Fossa
It is where the triangular area on the Anterior of the elbow, which is a site for major veins
Antecubital Fossa
It is the first choice for routine venipuncture since there are several major Veins called antecubutal Veins
Antecubital Fossa
BLOOD FLOW
It is the preferred venipuncture site, easy to access, and least painful for the patient
Median Cubital Vein
It is the second choice
It is harder to palpate, but
It is usually better when drawing blood from an obese patients
Cephalic Vein
It is the last choice vein
Not well anchored
Punctures are more painful
(kay it is near the antebrachial artery)
Basilic Vein
It is the intermediate antebrachial veins, which include the median, median cephalic, median basilic
M-shaped antecubital vein
Intermediate antebrachial Vein
First choice vein
Safest and less painful
Median vein
Intermediate cephalic Vein
2nd choice for venipuncture
less likely to roll
Median Cephalic Vein
Intermediate basilic Vein
Last choice because it is more painful
Median Basilic Vein
It is used only when anticubital veins are not accessible
Other arm and hand veins
Veins at the ____ of the hand can be used but are smaller and more painful
Veins at the BACK of the hand
______ of the wrist is never used as a venipuncture site
UNDERSIDE of the wrist
These are the veins that must not be used for venipuncture without the permission of the physician due to complications such as THROMBOSIS
Leg, ankle, foot Veins
These are not used for routine blood collection and are limited to the collection of arterial blood gas.
Arteries
This requires special training, and procedures are too risky for the patient.
Arteries
What are the Posterior Veins for venipuncture
(Dorsal)
A - accessory cephalic veins
B - basilic Veins
C - cephalic Veins
D - dorsal metatarsal veins; dorsal venous veins
I - intercapitular Veins
What are the basilic veins for venipuncture
(Palmar)
Cephalic Vein
Accessory Cephalic Vein
Intermediate Cephalic Vein
Cephalic Vein
Intermediate antebrachial Vein
Basilic Vein
Intermediate Basilic Vein
Perforating Veins
It comes from the greek word phlebo and tomy
Phlebotomy
Phlebo means ___ and tomy means ___
Phlebo - Vein
Tomy - to make an incision
It is an act of drawing f or removing blood from the circulatory system through a cut or puncture to obtain a sample for analysis and diagnosis
Phlebotomy
Also done as part of patient’s treatment for certain blood disorders
Phlebotomy
They are the first to perform bleeding by scarification document in Ebers Papyrus
Egyptians
He was a prominent Greek physician discovered that arteries as well as Veins had blood. Previously it was thought that arteries were filled with air
Galen of Pergamon
He developed quite a complex system for the quantity of blood which should be removed and from what specific areas of the body
Galen of Pergamon
Often credited as bringing phlebotomy to the United States in the 18th Century
The pilgrims
It was common at this time of use lancets that were fired into Veins at multiple locations, withdrawing up to FOUR PINTS of blood
The pilgrims
It was a popular service for almost one hundred years, although it went out of fashion as many harmful incidents came to life
Bloodletting
In the 18th century,it was a standard treatment
Bleeding
Bleeding was a treatment for in the 18th century?
Treatment doe fever such as putrid fevers (typhus and typhoid fever)
Treatment for hypertension, cases of coma, and drowsy headaches
Recommend for inflammation of lungs according to the amount of pain, the pounding of the pulse and the difficulty breathing.
During the 18th century, how many ounces were bled over a 6-day period?
210 ounces
On December 13, 1799, he was taken l with a cold and mild hoarseness. Who was he?
George Washington
A total of ___ mL of blood was taken over 12 hours
2365 mL
He was an Edinburgh trained physician who offered no explanation about George Washington
James Craik
What happened to Washington’ s blood that it reflected with dehydration and hypovolemia?
Became viscous and flowed slowly
When was the American civil war?
1861 - 1865
During this time, military doctors were unable to cope up with the widespread disease and infection, bled Union soldiers, and civilians like
American Civil War
Early instruments in the American civil war included anything sharps such as?
Hoarded stones
Quills
Thorns or animal teeth
Thumb lancet was introduced in the ______ century
15th
It was a double‐edged instrument, often with ornate handles made out of turtle shells.
Thumb lancet
They proved conclusively that inflammation
resulted from infection and thus was not susceptible to bloodletting.
Louis Pasteur (1822–1895) and Robert Koch
(1843–1910)
They offered a scientifically legitimate way of
thinking about the cause and treatment of the
patient’s illness.
Louis Pasteur (1822–1895) and Robert Koch
(1843–1910)
This theory states that diseases are produced due to unhealthy or polluted vapors rising from the ground.
Miasma Theory
were reported to be
using leeches, primarily to bleed patients as
treatment
Three Kashmiri Hospitals (April 2008)
Three Kashmiri hospitals were reported to be
using leeches, primarily to bleed patients as
treatment for
Heart problems, arthritis, gout, chronic headaches, and Sinusitis
These are for single use to avoid transmission of disease!
Leeches
● It is used every day to diagnose health problems
and introduce medication intravenously.
Phlebotomy today
● It is also used in lifesaving procedures like blood transfusions.
Phlebotomy today
● Today, trained professionals called phlebotomists withdraw blood in clinics and hospitals all over the world
Phlebotomy today
What year was army lancet
1953
Critical areas in quality of phlebotomy:
APCC
Appropriateness of Test request
Patient and Sample Identification
Criteria for accepting or rejecting of specimens
Communicating and interpreting of results
It is the first step in most laboratory analysis
Specimen Collection
Quality depends on how a specimen was ____, ____, and ____
collected, transported, and processed
Quality assessment in phlebotomy includes _____, _____, and ____
PCP
preparation of a patient for any specimens to be collected, collection of valid samples, proper specimen transport
They are the only laboratory staff member that a patient sees
Phlebotomists
they are expected to deliver unexcelled customer satisfaction
Phlebotomists
TRUE OR FALSE
It is important to understand and know the patient’s expectation, manage unrealistic expectations through patient education, and be diplomatic with customer complaints
TRUE
What are the 5 kinds of patients
Conscious in-patients
Sleeping patients
Unconscious or mentally incompetent patients
Infants and Children
Outpatient patient
How to identify conscious in-patients?
Verbally ask for their full name and verify it using the identification bracelet
What is in the identification bracelet?
Patient’s first and last name, hospital or unit number, bed/room and physician’s name
How to identify sleeping patients?
They must be awakened before blood collection
Identify the same as conscious patients
How to identify unconscious or mentally incompetent patients?
Identified by asking the attending nurse or relative; id bracelet
How to identify infants or children?
The nurse or relative may identify the patient or by ID bracelet
How to identify outpatient patient?
Verbally ask for their full name , DOB, and countercheck it with driver’s license or ID with photo. If the patient has ID Card or bracelet, same manner as hospitalised patients
When dealing with them, you need to be gentle and treat them with compassion, empathy, and kindness.
Pediatric patients
When dealing with them, you need to attempt to interact with these patients
Pediatric patients
Acknowledge the parent and the child
Pediatric patients
When dealing with these patients, u need to be friendly, courteous, and responsive
Pediatric patients
You need to allow enough time for the procedure also when dealing with these patients
Pediatric patients
When obtaining a blood specimen from these patients, you need to be RELAXED and be PERCEPTIVE about any anxiety the he/she may have
Adolescent Patients
General interaction techniques include:
Allowing enough time for the procedure
Establishing eye contact
Allowing the patient to maintain a sense of control
You need to treat these patients with DIGNITY and RESPECT
> do nor demean the patient
> address the patient with a more formal title
> they love to talk, so keep a flexible agenda for more enough time
> speak slowly and allow enough time for questions
>they have the right to informed consent
Geriatric Patients
What are the categories of additives used for blood collection?
- Antiglycolytic agent
- Anticoagulant agent
- Clot activator
- Thixotropic gel separator
- Trace element-free tubes
This additive inhibits the use of glucose by blood cells
Antiglycolytic Agent
Examples of Antiglycolytic agents are?
Sodium fluoride and lithium iodoacetate
Generated liquid after centrifugation of antiglycolytic agent is
Plasma
This additive prevents blood from clotting?
Anticoagulant Agent
The mechanism by which clotting is prevented varies with the _____ ?
anticoagulant
EDTA, citrate, and oxalate removes ____ by forming insoluble salts
removes calcium
Heparin prevents conversion of ___ to ___?
prothrombin to thrombin
If you remove the calcium or thrombin is not formed, ____ does not occur
coagulation
What is the general liquid form after centrifugation of the anticoagulant agent?
plasma
It helps to enhance or initiate the clotting mechanism
Clot Activator
These clot activator particles provide increased surface area for platelet activation and clotting factors such as thrombin
glass and silica particles
The generated liquid after centrifugation of clot activator is ?
Serum
an inert material that undergoes a TEMPORARY CHANGE IN VISCOSITY during the centrifugation process, which serves as a SEPARATION BARRIER between the liquid and the cells (serum and plasma)
Thixotropic gel separator
The generated liquid after centrifugation for thixotropic gel separator?
serum
Made up of materials that are free trace element contamination
Trace element-free tubes
It has royal blue stoppers, and it is used for trace element tests, toxicology studies, and nutrient determination
trace element-free tubes
Red
No additive
Orange
Coagulant (coagulate in 5 mins)
Yellow
Coagulant and Separation Gel
Green
Sodium Heparin
Light Green
Lithium Heparin
Purple
EDTA
Light Blue
Sodium Citrate 1:9 (anticoagulant blood) 3.2%
Black
Sodium Citrate 1:4 (anticoagulant blood) 3.8%
Grey
Potassium Oxide Monohydrate and Sodium Flouride
What are the 5 anticoagulants?
(COFEH)
Citrate
Oxalate
Fluoride
Ethylenediaminetetraacitic acid (EDTA)
Heparin
anticoagulant that combines with calcium to form insoluble salt
Oxalate
Combines with calcium in a NON-IONIZED FORM
Citrate
Forms weakly dissociated calcium
Fluoride
Combined with calcium in a process called chelation
EDTA (ethylenediaminetetraacitic acid)
prevents the form of thrombin
Heparin
Glass or Plastic
a.) Red-Top Tube
- no additive
- Glass surface activates clotting sequence
- Do not mix
- SERUM : used for TDM (Therapeutic Drug Monitoring)
Glass Red-Top Tube
Glass or Plastic
a.) Red-Top Tube
- contains additive to activate clotting sequence
- do Invert (5x) to mix additive and initiate clotting sequence
- SERUM
- let the sample rest for 30 MINUTES before centrifugation to GENERATE SERUM
Plastic red-top tube
Blood Clotting Time for Red-Top Tube (how many mins)
60 mins
Also known as plain tube
Red-Top Tube
Its laboratory use are:
1) serum determination in chemistry
2) Routine blood donor screening
3) Diagnostic Testing for infectious disease
Red-Top Tube
- Also known as the Serum Separator Tube
- contains CLOT ACTIVATOR and GEL (SST)
- Invert to mix and initiate clotting sequence
- SERUM
Gold or Mottled-Red-Gray Test tube
What is the blood clotting time for gold or mottled-red-gray tube?
30 mins
Its laboratory use are:
1) serum determination in chemistry
2) blood donor screening
3) serum testing for infectious disease
Gold or mottled-red-gray top tube
Anticoagulant = 3.2% sodium Citrate
Specimen - Plasma
Binds with calcium
Blood: anticoagulant ratio critical (9:1)
Light Blue Top Tube
The inversion needed for light blue-top tube is?
3-4 full gentle inversion
Harsh inversions may generate
microclots
Laboratory use:
1) clot based studies/
2) coagulation studies
Light Blue top tube
- Anticoagulant- heparin
- Three formulations:
1. Lithium Heparin
2. Ammonium Heparin
3. Sodium Heparin - Inhibits Thrombolin
- must be full and on ice to prevent consumption of oxygen, if needed for pH, ionised Ca analysis
Green-Top Tube
Laboratory use: plasma determinations in Chemistry
Green-Top Tube
How many inversions does the green-top tube need?
8 full inversions
- Anticoagulant = glass - liquid K2EDTA
plastic - spray-dried K3EDTA - sample = can be either plasma or whole blood
- binds with calcium
- requires 8 full inversion (10 if the sample rested for long time)
Purple-Top Tube
Laboratory use: hematology determination (CBC), routine immunohematology testing (blood typing), blood donor screening (both red and purple top are used for crossmatching)
Purple-Top Tube
Anticoagulant = Potassium Oxalate
> binds with calcium
> plasma, whole blood
Antiglycolytic = sodium fluoride
> monitors plasma glucose levels
Gray-Top Tube
Laboratory Use: Glucose determination and Lactic acid level determination
Gray-Top Tube
ACD = Acid Citrate Dextrose
• Blood Bank Studies
• HLA Penotyping
• Paternity Testing
• DNA
Yellow Top Tube
SPS = Sodium Polyanethol Sulfonate
• special blood culture studies
• inhibited certain antibiotics
> Both bind calcium ACD and SPS
> PLASMA, Whole blood
Yellow Top Tube
Additive (1) : thrombin-based clot activator with gel for serum separation
Inversion: 5-6 times
Laboratory use: stat serum determination, Inversion ensures mixing or clot activator with blood
Blood Clotting Time: 5 mins
Additive (2): Thrombin-based clot activator
Inversions : 8 times
Laboratory use: stat serum determination, Inversion ensures mixing of clot activator with blood
Clotting Time: 5 mins
Orange-Top Tube
Additive: Clot activator (plastic serum) or K2EDTA (plastic)
Inversions: 8 times
Laboratory Use: trace element, toxicology, and nutritional-chemistry determination
Royal Blue Top Tube
It provides low levels of trace elements
Special stopper formulation
Ensure mixing of either clot activator or anticoagulant (EDTA) with blood
Inversions
Additive: K2EDTA (plastic)
Inversions: 8 times
Laboratory Use: lead determination. This tube is certified to contain less than 0.1 ųg/ml (ppm) lead. Tube inversions prevent clotting.
Tan Test Tube
Additive: K2EDTA and gel for plasma separation
○ Inversions: 8 times
○ Laboratory use: For use in molecular diagnostic
test methods (such as, but not limited to,
polymerase chain reaction [PCR] and/or
branched DNA [bDNA] amplification techniques).
Tube inversions ensure the mixing of
anticoagulant (EDTA) with blood to prevent
clotting.
White Test Tube
Additive: Spray-coated K2EDTA (plastic)
○ Inversions: 8 times
○ Laboratory use: For whole blood hematology
determinations. May be used for routine
immunohematology testing and blood donor
screening. Designed with a special cross-match
label for patient information required by the
AABB. Tube inversions prevent clotting.
Pink Top Tube
ORDER OF DRAW (EVACUATED TUBE)
● Blood Culture or sterile tubes (yellow stopper)
● Coagulation tube (light blue stopper)
● Serum tube with or without clot activator or gel (red,
gold, or red gray marbled)
● Heparin tube (green or light green stopper)
● EDTA tube (lavender stopper)
● Oxalate/fluoride tube (gray stopper)
memory jagger for order of draw
Stop
Light
Red
Stay
Put
Green
Light
Go
Give the inversions of the following tubes:
Blood Gases
Slides and Smears
Lithium heparin
Lithium heparin with gel
separator
Sodium fluoride/
Potassium oxalate
Serum- clot activator
Serum- no additive
Newborn Blood Spot
Card
Blood Gases - rotate between palm to mix
Slides and Smears - 10
Lithium heparin - 10
Lithium heparin with gel separator - 10
Sodium fluoride/Potassium oxalate - 10
Serum- clot activator - 5
Serum- no additive - 0
Newborn Blood Spot Card - recommended to be collected separately
> Rarely collected in adults
Usually performed on INFANTS and YOUNG CHILDREN
CBG specimens are collected from the same sites as routine capillary puncture specimens
warming the site for 5-10 mins is necessary
Capillary Blood Gases
● Done to newborns to detect and monitor
increased bilirubin levels caused by
overproduction or impaired excretion of bilirubin.
● Bilirubin can cross the blood-brain barrier (BBB) of
infants accumulating to toxic levels that can cause
permanent brain damage or even death
● Bilirubin breaks down in the presence of light
● Collection is done quickly by heel puncture,
protected from light during transportation and
handling. Sample is collected in amber-colored
microcollection tubes (alternative is to wrap the tube
with carbon paper/foil).
Neonatal Bilirubin Collection
● Testing of newborns for the presence of certain
genetic, metabolic, hormonal, and functional
disorders that can cause severe mental handicaps
or other serious abnormalities
● Sample collected through blood spot collection
○ Sample is obtained through heel puncture (lateral
side)
○ Blood drops are collected by absorption onto
circles printed on a special type of filter pape
NEWBORN/NEONATAL SCREENING
● failure to mix or inadequate mixing of samples
collected into an additive tube.
● The red cells clump together, making the sample unsuitable for testing
Clotted
This is usually caused by a procedural error such
as using too small of a needle or pulling back too
hard on the plunger of a syringe used for collecting the sample
Hemolysis
● The red cells rupture, resulting in hemoglobin being released into the serum/plasma, making the sample unsuitable for many laboratory tests.
● The serum/plasma will appear red instead of straw color
Hemolysis
● certain additive tubes must be filled completely.
● Incorrect blood-to-additive ratio will adversely affect
the laboratory test results
insufficient sample
Always refer to procedure manual when uncertain.
wrong tube collection for test ordered
certain tests must be collected and placed in ice,
protected from light, or be kept warm after collection
improper storage
● most commonly encountered complication in
obtaining a blood specimen.
● It is caused by leakage of a small amount of fluid around the tissue.
Ecchymosis (bruise)
● second most common complication.
● Before drawing blood, the collector should ask if he/she had prior episodes of fainting
syncope (fainting)
when leakage of a large amount of fluid around
the puncture site causes the area to swell.
● Most commonly occurs when the needle goes
through the vein, bevel is partially inserted in the
vein and if the collector fails to apply enough
pressure after venipuncture
hematoma
due to improper needle positioning
failure to draw blood
small red spots indicating that small amounts of
blood have escaped into the skin epithelium.
petechiae
swelling caused by an abnormal accumulation of
fluid in the intracellular spaces.
edema
veins may be neither readily visible nor easy to
palpate
obesity
is an increased concentration of larger
molecules and analytes (potassium) in the blood
as a result of a shift in water balance.
hemoconcentration
Primary effect is hemoconcentration. The
hydrostatic pressure causes some water and
elements to leave the extracellular space.
prolonged tourniquet application
Burned, damaged, scarred and occluded veins,
seizure and tremors, vomiting and choking, allergies
and mastectomy patients.
Other complications
rupture of red blood cells with the consequent
escape of hemoglobin.
● Can cause the plasma or serum to appear pink or red.
Hemolysis
fluid may dilute the specimen, so collect from
the opposite arm if possible.
IV Therapy
changing from a supine (lying) to a sitting or
standing position results in a shift of body water
from inside the blood vessels to the interstitial
spaces.
Posture
levels of certain hormones such as cortisol and
adrenocorticotropic hormone decreases in the
afternoon. Other test values, such as iron and
eosinophil levels increase in the afternoon.
Diurnal rhythm
anxiety can cause a temporary increase in white
blood cel
Stress
Muscle activity elevates creatine, protein, creatine
kinase, AST (Aspartate Aminotransferase) and LDH
(Lactate Dehydrogenase). Exercise activates
coagulation and fibrinolysis and increases platelet
and white blood cells.
Exercise
if a patient has eaten recently (less than 2 hours
earlier), there will be a temporary increase in
glucose and lipid content in the blood. Serum may
appear cloudy or turbid (take into consideration
the fasting requirements or dietary restrictions)
Diet
Patients who smoke before blood collection may
have increased white blood cell counts and
cortisol levels. Long term smoking can lead to
decrease pulmonary function and result in increased
hemoglobin levels
Smoking
Prolonged application of tourniquet (>1 min)
○ Causes hemoconcentration (affects analytes)
Venous statis
○ Drawing above IV (Dilute sample)
○ Short draw (blood to anticoagulant ratio) (Results
in QNS or dilution)
Hemodilution
○ Traumatic stick
○ Too vigorous mixing
○ Alcohol still wet (always wipe the first drop of
blood)
○ Using too small of needle
○ Forcing blood into syringe
Hemolysis
○ Inadequate mixing
○ Traumatic stick
Clotted Sample
○ Short draw
○ Sodium citrate tube draw volume critical
Partially filled tubes
○ Using incorrect cleanser
○ Alcohol still wet
○ Powder from gloves
○ Drawing above IV
Specimen contamination
○ Exposure to light
○ Pre-chilled tube
○ Body temperature
Specimen Handling
