RAJESH MOHESS, CLT. AL.

VENIPUNCTURE

COMPLICATIONS IN BLOOD COLLECTION

Failure to obtain bloodThis is the primary causePossible causes include: bevel on lower wall of vein,

needle inserted too far, needle partially inserted, collapsed vein, needle slipped to side of vein from rolling veins

Simple maneuver will correct the problem; rotate 45 degrees allow blood to flow

COMPLICATIONS IN BLOOD COLLECTION

HematomasCaused by leakage of blood into the tissues around the

venipuncture siteResult in swelling and discolorationMay cause anxiety, discomfort, pain to the patient, and even

nerve injuriesPossible causes are:

Failure to remove the tourniquet prior to remove the needle

Apply inadequate pressure to site after needle removalExcessive probing to obtain bloodInsert needle through the veinBending the arm while applying pressureUsing veins that are too small or fragile

COMPLICATIONS IN BLOOD COLLECTION

Nerve InjuryUsually caused by incorrect technique and site

selectionPossible causes are:

Improper vein selectionUsing jerky movementsInserting the needle too farMovement by the patient while needle is in veinLateral redirection of the needleBlind probing

COMPLICATIONS IN BLOOD COLLECTION

Hemolyzed specimensRed cells are rupturedTests seriously affected: K, LD, AST, CBCTests noticeably affected: Fe, ALT,

Thyroxine (T4)Tests slightly affected: Phosphorus, TP, Alb,

Mg, Calcium, Acid phosphatase

COMPLICATIONS IN BLOOD COLLECTION

Causes of hemolyzed specimens are:

Using too small diameter needle (above 23 gauge)Using small needle with large evacuated tubeUsing improperly attached needle on a syringe,

causing frothing of specimenPulling back plunger of syringe too fastDrawing blood from site that contain hematoma

COMPLICATIONS IN BLOOD COLLECTION

Causes of hemolyzed specimens are:Vigorously missing tubesForcing blood from syringe into evacuated tubeApply tourniquet too close to puncture site or for too

longUsing fragile hand veinsPerform venipuncture before alcohol is driedPartially filled sodium fluoride tubesReadjustment of needle in veins or using occluded

veins

COMPLICATIONS IN BLOOD COLLECTION

Other factors that cause hemolysis are:

Rimming clots

Centrifuge at higher than recommended speed

Elevate or decrease temp of blood

Using pneumatic system without shock absorber

COMPLICATIONS IN BLOOD COLLECTION

Specimen contaminationMay include carryover, draw from edema or hematoma

sites, arms containing IV, site contaminated with alcohol or iodine

Technical problemsProblems with equipment, tubes, syringes, etc

Patient ComplicationsDifficult patient, geriatric population, pediatric

population, obese patientMust use the right equipment – appropriate size needle

OTHER COMPLICATIONS

Vascular – bleeding from site and hematoma formationInfections – introducing bacteria into the blood streamAnemia – as a result of significant blood draw for

testingNeurologic – seizures or painCardiovascular – orthostatic hypotension, syncope,

shock, cardiac arrestDermatologic – localized reaction to iodine or cleaning

agentsGastrointestinal – nausea and vomiting

Quality Assurance in Specimen Collection

Perform QC on all equipment – run controls, maintenance, keep logs

Check all equipment

Follow facility protocol

Quality Assurance Terminology

Quality control – a process that monitors the accuracy and reproducibility of results through the use of control specimens

Control – a specimen with a known value to the analyte/determinant

Standards – highly purified substances of a known composition

Accuracy – closeness of the result to the true valuePrecision – represent how close repeated results

are to each other

POINT OF CARE TESTING

Done at the bedside

Advantages are shorter turn around time, smaller quantity of specimen, convenience for patient, shorter patient care stay and improved patient care management

Disadvantages are higher costs, integrating the results into charts and quality controls

POINT OF CARE TESTING

THINGS TO CONSIDER

Cost of maintenance of competency and training personnel

Labor associated with processing specimen and maintaining the machine/equipment

Reagents, controls, maintenance and depreciation costs

Proficiency testing and any state licensing costs

POINT OF CARE TESTING

REGULATION

All laboratory and sites performing testing are regulated by Clinical Laboratory Improvement Amendments of 1988 (CLIA ‘88)

States and city (government) may enact mandatory regulations which may include the qualification of personnel performing the test

If a site is only performing ‘waived tests’ they must have ‘certificate of waiver’ license. These sites will not be routinely inspected

They must follow the manufacture instructions on performing the tests Agencies such as the Joint commission, College of American

Pathologists and Veteran Administration does not recognize the waive category of testing – as they are not regulated

POINT OF CARE TESTING

CATEGORIES OF POINT OF CARE TESTING

WAIVED TESTSSimple procedures. If performed incorrectly will have little or no negative outcomes

MODERATELY COMPLEX TESTSUsually automated, more complex than waived tests.Example: routine chemistries, blood counts

HIGHLY COMPLEX TESTSUsually manual testing that require considerable judgment for interpretation of resultsExample: microbiology tests and cross match

PROVIDER PERFORMED MICROSCOPY (PPM) TESTSExamination of slides from freshly collected body fluids

POINT OF CARE TESTING

POCT can be automated and non automated

Automated – glucose, electrolytes, PT, PTT, hematocrit, blood gases, urea, cardiac enzymes

Non automated – fecal occult blood, pregnancy tests, rapid strep, HIV

With today’s advance technology (wireless connectivity) the use of handheld POCT is increasing

SPECIAL PROCEDURES

BLOOD BANK SPECIMENS

Strict patient identification and labeling is requiredAny doubt or mislabeling requires a re-drawUndetected errors may result in the patient receiving

incompatible blood or blood products – which could be fatal

Specimens include: type, screen, cross match and donor specimens

SPECIAL PROCEDURES

BLOOD CULTURES

Usually requires two sets which should be drawn 30-60 minutes apart

Must be drawn before antibiotic is given. However, if antibiotics must be given urgently, both sets of blood cultures must be drawn immediately from two different sites

Skin antiseptic is the most critical part of collectionIodine, chlorhexidine and 70% ethyl alcohol are most

commonly used. A 30 -60 seconds friction scrub is most appropriate

SPECIAL PROCEDURES

COAGULATION SPECIMENSRemember the 9:1 ratioDiscard tube if using butterfly and blue top is the

first tube

GLUCOSE TOLERANCE TESTMake sure patient is fasting, except drinking water.

Usually 10-12 hoursCollect fasting, given 100g of glucose, collect 1 hour

and 2 hours post finish drinking glucose drink

SPECIAL PROCEDURES

LACTOSE TOLERANCE TESTSimilar to GTT but uses Lactose instead of glucose

PATERNATY TESTINGRequires chain of custodySpecific identification and fingerprinting may be necessaryUsually include ABO and Rh typing, cheek swab to collect

DNA

DRUG/FORENSIC MONITORINGUrine or bloodChain of custody

THE END