PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2

College of Allied Health Sciences

Bachelor of Science in Medical Laboratory Science
Second Semester, A.Y. 2022-2023

[TRANS] PMLS UNIT 6: PREANALYTICAL CONSIDERATIONS IN PHLEBOTOMY

beverages containing
OUTLINE caffeine.
Glucose (blood sugar) Increase dramatically
I Preanalytical Considerations in Phlebotomy levels with the ingestion of
II Problem Areas to Avoid and Troubleshooting in Site carbohydrates or sugar-
Selection laden substances
III Vascular Access Devices (VADs) and Sites
IV Complications Associated With Blood Collection
Hgb levels Decrease by drinking
V Procedural Error Risks excessive amounts of
VI Specimen Quality Concerns water and other fluids
VII Troubleshooting Failed Venipuncture Electrolytes Imbalance may occur due
to drinking excessive
amounts of water and
PREANALYTICAL CONSIDERATIONS IN other fluids
PHLEBOTOMY Lipid levels Increase with ingestion of
foods such as butter or
DIURNAL VARIATION margarine, cheese,
cream, and some enteral
Test Effect (tube feeding)
Cortisol Peaks 4–6 AM; lowest 8 preparations
PM–12 AM; 50% lower at 8 Stool Occult Blood test Detects gastrointestinal
PM than at 8 AM; bleeding; may be false
increased with stress positive due to ingestion of
Adrenocorticotropic Lower at night; increased meat, fish, iron, and
hormone horseradish
with stress
Plasma renin activity TAG/TGY, liver enzymes, Are increased due to
Lower at night; higher
liver function tests chronic consumption of
when standing than supine
alcohol
Aldosterone Lower at night
Insulin Lower at night
Growth Hormone and Higher in afternoon and
STRESS
Acid Phosphatase evening  Emotional stress can cause transient (short-lived)
Thyroxin Increases with exercise elevations in WBCs.
Prolactin Higher with stress; higher  Mental and physical stresses induce the production of
levels at 4 and 8 AM and at adrenocorticotropic hormone (ACTH), cortisol, and
8 and 10 PM catecholamines.
Iron Peaks early to late POSTURE
morning; decreases up to  An upright position increases hydrostatic pressure,
30% during the day causing a reduction of plasma volume and increased
concentration of proteins.
EXERCISE  Albumin and calcium levels may become elevated as
 Increase: one changes position from supine to upright.
o Creatine kinase (CK), aspartate  A change in position from lying to standing can cause up
aminotransferase (AST), and lactate to a 15% variation in total and high-density lipoprotein
dehydrogenase (LD) (HDL) cholesterol results.
o Potassium TOURNIQUET APPLICATION
 Mild to moderate exercise – increase by 0.3  May also increase serum enzymes, proteins, and
– 1.2 mmol/L protein-bound substances, including cholesterol,
 Exhaustive exercise – increase by 2-3 calcium, and triglycerides
mmol/L  1 min application:
o Prolactin (in long-distance athletes) o Prolonged application results in:
 Decreased due to exercise:  Venous stasis (hemoconcentration)
o Serum gonadotropins and sex steroid (in long- AGE
distance athletes)  Newborn – much of the Hb is Hb F
DIURNAL VARIATION  Bilirubin concentration rises after birth and peaks at
about 5 days.
Test Effect  Infants have lower glucose level than adults.
Ammonia, urea, and uric May be elevated in  With skeletal growth and muscle development, serum
acid levels patients on high-protein alkaline phosphatase and creatinine levels also
diets increase.
Cortisol and ACTH levels Increase with the  The elderly secrete less triiodothyronine, parathyroid
consumption of hormone, aldosterone, and cortisol.

TETSUYA, KUROKO | SEIRIN HIGH 1

 TRANS: PMLS 2 Unit 4

 After age 50, men experience a decrease in secretion rate  Arterial Line (A-line or Art-line)
and concentration of testosterone and women have an o A catheter that is placed in an artery (radial artery)
increase in pituitary gonadotropins. o Used to provide accurate and continuous
GENDER measurement of a patient’s blood pressure
 After puberty, men have higher alkaline phosphatase, o Used to collect blood gas and other blood
aminotransferase (alanine and aspartate), creatine specimens
kinase, and aldolase levels. o For the administration of drugs
 Women have lower levels of magnesium, calcium, o Never apply tourniquet or perform venipuncture
albumin, Hb, serum iron, and ferritin. on an arm with A-line
COMMON INTERFERENCES: IN VIVO  Arteriovenous Shunt, Fistula, or Graft
 Tobacco smoking o The permanent surgical connection of an artery and
o Smokers have high blood carboxyhemoglobin vein by direct fusion (fistula)
levels o To be used for dialysis
o Chronic effects of smoking: o Has a distinctive buzzing sensation called a
 Increased Hb, RBC Count, Mean Cell Volume “thrill” when palpated
(MCV), and WBC Count o Never apply tourniquet or perform venipuncture
 Increased levels of insulin, epinephrine, and on an arm with a shunt
growth hormones  Blood Sampling Device
 Decreased sperm counts and motility and o A needleless closed blood sampling device is
increased abnormal morphology sometimes connected to an arterial or central
 Hemolysis venous catheter
o Serum/plasma layer is pink or red. o Collecting blood specimens
o Falsely increased in: o Reduce the chance of infection, prevent
 Potassium, magnesium, iron, lactate needlesticks, and minimize waste associated with
dehydrogenase, phosphorus, ammonium, line draws
and total protein o Example is the VAMP® (Venous Arterial blood
o Normally platelets release potassium during Management Protection system) from Edwards
clotting. Lifesciences
o Serum has a slightly higher value of potassium  Heparin or Saline Lock
than plasma. o A catheter or cannula connected to a stopcock or
PROBLEM AREAS TO AVOID AND a cap with a diaphragm (thin rubber-like cover)
o Provides access for administering medication or
TROUBLESHOOTING IN SITE CELECTION
drawing blood
 Burns, Scars, and Tattoos
o Only specially trained personnel
o It is not advisable to choose a site that has burns,
o NOTE: Drawing coagulation specimens from this
scars, or tattoos because veins in the area may be site is not recommended.
difficult to examine and blood circulation may be
 INTRAVENOUS SITES
impaired.
o An IV line is a catheter inserted in a vein to
 Damaged veins
administer fluid
o Aside from being difficult to perform, puncturing o Blood should not be drawn from an arm with IV to
damaged veins may also produce inaccurate avoid contamination
results
o If necessary, the collection site should be below the
o Veins could be:
IV
 Sclerosed o NOTE: Collection of blood from previously
 Hardened known IV sites should be avoided 24 to 48 hours
 Thrombosed
 Central Vascular Access Devices (CVADs)
 Clotted
o Also called an indwelling line
 Edema o Consists of tubing inserted into a main vein or
o “Oedema” artery
o Abnormal swelling caused by the accumulation of
o Are used primarily for administering fluids and
fluid in the tissues
medications, monitoring pressures, and drawing
 Hematoma blood
o A solid swelling or mass of blood in the tissues o Only specially trained personnel should access
caused by the leakage of blood CVADs
o May lead to contamination of sample
TYPES OF CENTRAL VASCULAR ACCESS DEVICES
 Mastectomy
(CVADS)
o Blood drawing from patients who had undergone this
becomes a challenge since the lymph flow is  Central Venous Catheter (CVC) or Central Venous Line
obstructed. There may be swelling and infection o Central line inserted into the large vein(Subclavian)
after the surgery and advanced into the superior vena cava,
o Tourniquet cannot be applied because it can proximal to the right atrium
cause injury o The exit end is surgically tunneled under the skin
o It could change blood composition to a site several inches away in the chest
 Obesity  Implanted Port
o Patients who are obese have veins that are deep o Surgically implanted disk-shaped chamber to the
and difficult to locate indwelling line.
o Surgically implanted under the skin and most
VASCULAR ACCESS DEVICES (VADS) AND
commonly located in the upper chest or arm
SITESBURNS, SCARS, AND TATTOOS
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 TRANS: PMLS 2 Unit 4

o Usually place on the upper chest just below the o Prevent reflux: the patient’s arm must be kept in a
collar bone downward position
 Peripherally Inserted Central Catheter (PICC) o Avoid back-and-forth movement of blood in the
o A flexible tube inserted into the veins of extremities tube
and the central veins  Vein damage
o A line inserted into the peripheral venous system o Numerous punctures in the same area, blind
(veins of the extremities) and threaded into the probing, and improper technique
central venous system (main veins leading to the o This could be avoided by following the proper
heart) technique and avoiding blind probing
o Is typically placed in an antecubital vein just above SPECIMEN QUALITY CONCERNS
or below the antecubital fossa  Hemoconcentration (Venous Stasis)
PROCEDURAL ERROR RISKS o Decrease in the fluid content or plasma volume,
 Hematoma formation usually caused by tourniquet that stagnates the
o Most common complication of venipuncture normal flow of blood leading to the increase in
o Apply cold compress or ice pack to reduce concentration of red blood cells and other non-
swelling filterable large molecules
o The following are conditions that trigger hematoma o Ways to help prevent Hemoconcentration during
 Excessive or blind probing Venipuncture
 Inadvertent arterial puncture  Ask the patient to release the fist upon blood
 The size of the vein is too small flow
 Needle penetration has gone through the  Choose an appropriate patent vein
vein (Through-and-through)  Do not allow the patient to pump the fist
 Tourniquet is still on when the needle was  Do not excessively massage the area in
removed locating a vein
 The pressure is not adequate  Do not probe or redirect the needle multiple
 Iatrogenic anemia times in search of a vein
o Blood loss due to blood draw  Release the tourniquet within 1 minute
o Removing blood on a regular basis or in large  Hemolysis
quantities can lead to iatrogenic anemia in some o Rupture of red blood cells. The hemoglobin is then
patients, especially infants released into the surrounding fluid
o Life is threatened if more than 10% of the patient’s o Serum or Plasma
blood volume is removed at one time or over a  Pink(slight hemolysis),
short period of time  Dark pink to light red (moderate hemolysis),
 Inadvertent arterial puncture to
o Most often associated with deep or blind probing  Dark red (gross hemolysis)
o Rapidly forming hematoma and blood tube fills o Procedural Errors that can cause specimen
very quickly hemolysis
o If arterial puncture is suspected, terminate  Drawing blood through a hematoma or from
venipuncture immediately and apply pressure to a vein with a hematoma
the site for at least 5 minutes  Failure to wipe away the first drop of
 Infection capillary blood, which can contain alcohol
o The risk can be minimized by using proper aseptic residue
technique.  Forceful aspiration of blood during a syringe
 Tapes/bandages are not opened ahead of draw
time  Forcing the blood from a syringe into an
 Needles are not preloaded in the tube holders evacuated tube
 Insertion site of the needle is not touched  Frothing of blood caused by improper fit of
after sterilization the needle on a syringe
 Cap is removed just before venipuncture  Horizontal transport of tubes, which lets the
 Patients are advised to keep the bandage on blood slash back and forth
the site for at least 15 minutes  Mixign additive tubes vigorously, shaking
 Nerve injury them, or inverting them too quickly or
o Causes: forcefully
 Poor site or improper vein selection,  Partially filling a normal-draw sodium
 Inserting the needle too deeply or quickly, fluoride tube
 Movement by the patient as the needle is  Pulling back the plunger too quickly during
inserted, a syringe draw
 Excessive or lateral redirection of the needle  Rough handling during transport
 Blind probing while attempting venipuncture  Squeezing the site during capillary
o NOTE: If the initial attempt is unsuccessful, the specimen collection
phlebotomist should try to redirect the needle by  Syringe transfer delay in which partially
using a slightly forward or backward movement. clotted blood is forced into a tube
The next step is to remove the needle and look for  Using a large-volume tube with a small-
an alternative site. diameter butterfly needle
 Reflux of Additive/Anticoagulant  Using a needle with a diameter that is too
o Blood that has already been drawn flowing back into small for venipuncture
the vein from the collection tube may cause adverse  Partially Filled Tubes (Short Draw)
reaction due to the presence of tube additives
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 TRANS: PMLS 2 Unit 4

o Short-draw serum tubes such as red tops and SSTs

are generally acceptable for testing as long as the
specimen is not hemolyzed and there is
sufficient specimen to perform the test.
o May lead to incorrect blood-to-additive ratio
o Underfilled anticoagulant tubes and most other
additive tubes are NOT acceptable for testing
 Specimen Contamination
o The specimen is compromised due to incorrect
handling, which involves allowing alcohol, powder
or other materials into the sample.
o Getting glove powder or perspiration into films
and specimens
o Using the wrong antiseptic
o Simply not following the proper antiseptic procedure
could interfere with the results
 Wrong or Expired Collection Tube
o Manufacturers of tubes could not warrant the quality
of the seal and pressure after the expiration date
indicated in the tube
TROUBLESHOOTING FAILED VENIPUNCTURE
 Venipuncture could fail due to improper seating of the
tube and failure of the needle to go through the stopper.
 The phlebotomist should be aware and must take measures
to ensure that the proper procedures are followed
o Tube position
o Needle position
o Tube vacuum
 The needle position is critical to the success of the
venipuncture. The phlebotomist should ensure that the
following do not happen:
o Needle not inserted far enough
o Bevel partially out of skin
o Bevel partially into vein
o Bevel partially through vein
o Bevel completely through vein
o Bevel against vein wall
o Needle beside vein
o Undetermined position
COLLAPSED VEINS
 Collapsed Veins
o Usually occur when conditions are less than ideal,
which leads to veins being blocked, resulting in
insufficient blood flow.
o This happens when there is a strong pressure in
the vacuum of the tube or plunger;
o The tourniquet is too close to the site or it is too
tight;
o When the tourniquet has been removed during the
draw.
TUBE VACUUM
 To avoid failure due to loss of vacuum, the phlebotomist
should make sure that the bevel is not partially out of skin
and the tube itself is not damaged.

TETSUYA, KUROKO | SEIRIN HIGH 4