Blood Collection Equipment and Supplies Separate

room to pruvent cortamination

1. Blood-Drawing Station
- Table for supplies
- Sedor redin
Bed or reclining chair
2. Phlebotomy Chair Support e Back rest
Comfortable
Adjustable armrests
3. Handheld phlebotomy equipment carriers & phlebotomy carts
4. Gloves and Glove Liners Later, rubber, sterile e monstente, plastic)
5. Antiseptics Alcohols
- Prevent sepsis (microorganisms or their toxins in the blood)
70% isopropyl alcohol most common for routine blood collection
6. Disinfectants lysol-hom
common
lab
Remove or kill microorganisms on surfaces & instruments- Not safe on human skin
7. Hand Sanitizers
- Alcohol-based rinses, gels, & foams.
- Can replace hand washing if hands are not visibly soiled
8. Gauze Pads/Cotton Balls
- Clean 2-by-2-inch gauze pads folded in fourths are used to hold pressure over site
following blood collection
- Some pads have fluid-proof backing to prevent contamination
- Avoid using cotton balls, as they tend to stick
9. Bandages (Moptionate
Merthionate
Used over blood collection site once bleeding has stopped
10. Glass microscope slides (1- by 3-in.), ink pen, watch check for reaction
11. Needle & sharps disposal containers & biohazard bags
Venipuncture Equipment
1. Vein-Locating Devices see the direction of the veirs
- Transillumination: shine high-intensity LED or infrared light
- Highlight veins in patient's subcutaneous tissue
2. Tourniquet Stop
flow of the blood (rubber, quick release, silicon)
Device applied or tied around patient's arm to restrict blood flow
- Should restrict venous flow to inflate veins, but not arterial flow
- Most common type: stretchable disposable straps.
3. Needles
4. Evacuated Tube System (ETS)
Antiseptics and disinfectants used in venipuncture
1. 70% isopropyl alcohol
chlorsexadine sluconate (chloraprep) for potent alergic to alcohol
2.
3. povidone-iodine
mainly for collection of blood cultures, blood alcohol specimens, or when the patient is
sensitive to alcohol.
**Chloroprep or povidone-iodine with alcohol may not be used for blood alcohol collections
since they both contain alcohol.
Phlebotomy needles
Sterile, disposable, designed for single use only
Types
- Multisample Collect
several tube Lay meedle)
Hypodermic Dr. Alexander Wood
Winged infusion (butterfly): used on children and delicate veins superficial veins
Gauge
Diameter of lumen
Higher the gauge, the smaller the diameter of needle Appropriate range for phlebotomy: 20
to 23 (21 is most common)
Needles color-coded by gauge
Safety features
resheathing, blunting, & retraction devices
Evacuated tube system (ETS) and syringe system components
micro - 101 - 6
て 22、100-9
Collection tubes are categorized according to the blood test that will be performed to prevent
errors in mix-ups. They can come plain, or pre-coated with an additive that will mix with the
extracted blood to complete a particular test.
Micromethods employ the use of smaller volume-collecting devices such as Microtainers,
these are used to draw blood from a skin puncture, such as on the heels or fingers.
Microcollection tubes are used for patients where drawing blood is quite difficult, or those
with difficult veins. But these are only applicable for tests where only small quantities of
blood are needed.
There is also a microcapillary tube that is used to draw an even smaller amount of blood,
most common in hematocrit testing. It is a slim tube with a colored ring or tip to indicate the
presence of an aditive. A red tip indicates a sodium heparin additive, green tip is ammonium
heparin, and the blue tip means the tube is plain or has no additive Systems of Blood
Extraction
1. Closed System lesser chance of contamination
Closed system is a process of extraction in which blood flows through a needle inserted into
a vein & then directly into a collection tube. A vacuum or a negative pressure is created
within the tube so a measured amount of blood will flow easily. Advantages include:
- Prevents exposure to air or outside contaminants
- Allows numerous tubes to be collected with a single venipuncture
Plain red
yellow gel sparen
Blve
Gaten
Traditional components of the evacuated tube system
Multisample Needles (two way needle
- Allow multiple tubes to be collécted in a single venipuncture
- Double-pointed and have threaded part that screws into holder
Tube end of needle has retractable sleeve to prevent leakage
- Available with and without safety features
• If no safety feature: use with safety holder
Tube Holders
- Hubs
- With and without safety features
If no safety feature: use with safety needle
Evacuated Tubes
- Used with both ETS & syringe method
- Available in different sizes & volumes
Size used depends on:
- Age of patient
- Volume of blood needed for test
Size & condition of patient's vein
- Available in glass & plastic (plastic preferred for safety)
- Additive tubes: substance added to tube (e.g., anticoagulant)
Nonadditive tubes: no substance added to tube (rare)
- Stoppers: rubber or rubber with plastic covering
Color coding: color of stopper usually indicates type of additive
- Expiration dates: for additive & vacuum, printed on tube label
2. Open System/ Syringe System
Alternative for patients with small or difficult veins
Needle and Holder Units
Winged Infusion Set (Butterfly) (T)
Effective for small or difficult veins (hands; elderly & pediatric)
Allows more flexibility & precision than a needle & syringe
Components
1/2- to 3/4-in. stainless steel needle, 23- or 25-gauge
5- to 12-in. length of tubing
Luer attachment (syringe) or multisample Luer adapter (ETS)
-
- Plastic extensions ("wings") allow easier manipulation for shallow angle of needle insertion
- Safety devices required to prevent accidental needlesticks
Combination Systems
- Complete system for blood collection
- Blood collection tube & collection apparatus are combined in single unit
- Specimen can be collected by evacuated tube or syringe
Available with regular or butterfly-style needles
Safety devices are available
Categories of additives used in blood collection
Most blood collection tubes contain an additive that either accelerates clotting of the blood
(clot activator) or prevents the blood from clotting (anticoagulant). A tube that contains a clot
activator will produce a serum sample when the blood is separated by centrifugation and a
tube that contains an anticoagulant will produce a plasma sample after centrifugation. Some
tests require the use of serum, some require plasma, and other tests require anticoagulated
whole blood.
A.
Anticoagulants
Substances that prevent blood from clotting
Two methods of preventing clotting:
a.
binding calcium
b.
Inhibiting formation of thrombin
Types (most common types of anticoagulants)
1. Ethylenediaminetetraacetic acid (EDTA) Absorb & bind (calcium, iron) Lovender purple
2. Citrates
3. Heparin
4. Oxalates
ALSorO/
bing
Ethylenediaminetetraacetic acid, widely abbreviated as EDTA is a chelating agent (a
substance whose molecules can form several bonds to a single metal ion). An important use
of EDTA is in the treatment of heavy metal poisoning (lead and mercury) and in the
treatment of excess iron in the blood.
Injected intravenously, once in the bloodstream EDTA traps lead and other metals forming a
compound that the body can eliminate in the urine.
Various forms of EDTA are used as ingredients in cosmetics, pesticides, household
disinfectants, laundry detergent, eye drops and are frequently added to food as a
preservative. In laboratories, EDTA is used extensively in the analysis of blood as an
anticoagulant for blood samples for CBC.
_Most
preffred
K2 EDTA is available in a spray-dried form, which does not introduce dilutional effects on
small sample volumes. It is associated with a less pronounced osmotic effect on blood cells
than K3 EDTA, but it appears to be associated with more complaints regarding blood
clotting. In fact, as K2 EDTA is dispensed as a powder on the inside walls of the vial, primary
tubes containing this additive may need to be properly mixed to allow a complete miscibility
between the blood and the anticoagulant.
While the CLSI US Standard for Venous Blood Collection declines to differentiate between
K2-EDTA and K3-EDTA as separate options for use as an anticoagulant, the International
Council for Standardization in Hematology currently recommends K2 EDTA as the
anticoagulant of choice for hematological testing. This indication has been widely
acknowledged in Europe and Japan, whereas K3 - EDTA is still frequently used in the United
States and the United Kingdom.
EDTA effectively prevents the coagulation cascade and irreversibly prevents blood clotting
so it will always remain in a fluid state by binding to the calcium in blood.
Uses of EDTA (Humatology)
a.
Complete Blood Count (CBC)
b. Hemoglobin estimation
Hematocrit or Packed Cell Volume estimation low much red cell 15%, 250% plasmon
d. ESR by Wintrobe method e.
HbA1C test
f.
Platelet count
g.
Red cell Indices (Morn cell volme)
h. Differential Leukocyte Count
Advantages of EDTA
-. It gives better preservation to the cellular morphology of blood cells when observed even
after 3 hours of blood collection
- It can be used for platelets counting as it inhibits the clumping of platelets
Disadvantages of EDTA
- Excess of EDTA in the blood may lead to shrinkage of RBCs & WBCs. It may cause
degenerative changes in the blood cells (Under collection)
- excess amount of EDTA may cause the decrease in Packed Cell Volume (PCV) & Increase
in MCHC (Mean Cell Hemoglobin Concentration)
- activates naturally occurring anti-platelet auto-antibodies which cause the platelet
adherence to Neutrophils.
Prevent clotting
citrate birds calcium
Sodium citrate is chiefly used as a food additive, usually for flavor or as a preservative. Its E
number (a code for food additives) is E331. Sodium citrate is employed as a tart flavoring
agent in certain varieties of club soda and commercial ready to drink beverages and drink
mixes. Sodium citrate is common as an ingredient in bratwurst, ice-cream, jams, sweets,
milk powder, processed cheeses, carbonated beverages, and wine.
In 1914, the Belgian doctor Albert Hustin and the Argentine physician and researcher Luis
Agote successfully used sodium citrate as an anticoagulant in blood transfusions. It
continues to be used today in blood collection tubes and for the preservation of blood in
blood banks. The citrate ion chelates calcium ions in the blood by forming calcium citrate
complexes, disrupting the blood clotting mechanism.
Uses of Tri-Sodium Citrate
1. ESR estimation by Westergren Method - for 1 volume of citrate, 4 volume of blood is
added
2. Coagulation studies - for 1 volume of citrate, 9 volume of blood is added
Citrated blood cannot be used for Packed Cell Volume (PCV), Hemoglobin (Hb) Estimation,
Total Leukocyte Count TLC, and Differential Leukocyte Count (DLC) because citrate is used
as a solution and it alters the concentration of blood.
Unfractionated heparin and low molecular weight heparin are the most commonly used
antithrombotic and thromboprophylactic agents in hospital practice. It is also used to form an
inner anticoagulant surface on various experimental and medical devices such as test tubes
and renal dialysis machines.
Heparin prevents the formation of clots and extension of existing clots within the blood,
preventing venous thromboembolism. Heparin interferes with the blood clotting process as a
natural inhibitor of thrombin in the body called antithrombin. Heparin binds to antithrombin,
which changes the shape of antithrombin. Heparin is able to bind to antithrombin because of
its structure as one of the most negatively charged molecules in the body. Heparin's
extensive negative charges located on sulfate groups on the molecule are necessary for its
high-affinity binding to antithrombin. Once heparin binds to antithrombin, its new shape
allows it to be more biologically active and bind to thrombin faster, thus inhibiting thrombin
better than without heparin.
The heparinized blood specimen is commonly used to determine the blood gases especially
the Arterial Blood Gas Analysis. It can be used for Erythrocyte Sedimentation Rate (ESR),
Packed Cell Volume (PCV),
Osmotic Fragility Test (OFT), Immunophenotyping and other Hematological tests.
Uses of heparin
1. blood gases especially the Arterial Blood Gas Analysis
2. Erythrocyte Sedimentation Rate (ESR)
3. Packed Cell Volume (PCV)
4. Osmotic Fragility Test (OFT).
5. Immunophemotyping
Oxalates can be used as Single oxalates, Sodium Oxalate, Potassium Oxalate or
Ammonium oxalate but are commonly used as Double Oxalates because when used alone
the Potassium oxalate, when used at a concentration of 2mg/ml of blood causes the
Shrinkage of Red Blood Cells (RBCs) whereas the Ammonium oxalate may cause the
Swelling of Red blood cells when used at concentration of 2mg/ml. It acts as a chelating
agent and binds with the calcium ions present in the blood and forms insoluble precipitates
of Calcium Oxalates.
Uses of Oxalates
a. Blood chemistry
b. Packed cell volume (PCV)
c. Erythrocyte Sedimentation Rate (ESR)
d. Total Leukocyte Count (TLC)
e. Specific gravity
Advantages of Double oxalates
Double oxalate is preferred as it prevents the swelling effect of Ammonium oxalate &
shrinking effect of Potassium oxalate on the RBCs..
Disadvantages of Oxalates
morphology of the White Blood Cells (WBCs) is not preserved well so it is not useful for
making Peripheral Blood Smear
Calcium Oxalate precipitate that forms in the blood is harmful as it is a toxic agent & it is not
used as a preservative in blood banks.
Special-Use Anticoagulants
Acid citrate dextrose (ACD)
Citrate phosphate dextrose (CPD)
Citrate Phosphate Dextrose Adenine-1 (CPDA-1)
- Sodium polyanethol sulfonate (SPS)
Antiglycolytic Agents
- Substances that prevent glycolysis (breakdown of glucose by blood cells)
- Sodium fluoride (most common)
Preserves glucose for up to 3 days & inhibits bacteria growth
- Used with potassium oxalate (anticoagulant) for rapid response
B. Clot Activators
Serum and plasma are both components of the blood; plasma is the liquid in which various
blood cells are suspended, and serum is the fluid without blood clotting factors or blood cells.
There are a few other differences between the two, and this article highlights them.
Serum is the supernatant fluid when clotted blood has been centrifuged. It is the best
specimen for most clinical chemistry laboratory tests because of its specific characteristics.
Here are the reasons why serum is the best specimen.
1. Serum has less protein
When blood clots, fibrinogen takes part in the clotting process thereby removing it from the
serum. The absence of fibrinogen would make the supernatant clearer, while in plasma,
since the blood does not clot, the fibrinogen remains in the supernatant and could add to the
turbidity of the plasma.
2. Serum has no anticoagulant
Since serum does not have an anticoagulant, there are no other substances that could
interact with your test. There are potential interferences coming from anticoagulants with
certain tests. One example is the interference of the anticoagulant EDTA in the laboratory
determination of calcium ions.
EDTA chelates calcium; hence, decreasing inaccurately the concentration of calcium in the
sample.
3. Doesn't dilute specimen
The presence of an anticoagulant could also dilute the specimen and unreliably lower the
concentration of the substance being analyzed.
4. Most reagents are more compatible with serum
The optimum reaction of the reagent with the substance in the blood is very important to
produce reliable results, results that are precise and accurate simultaneously. When a result
is precise, it means that you get almost the same results repeatedly. Accuracy on the other
hand, means obtaining values close to the "true value." When a result or method is reliable,
then you are certain of the results because you know they could be depended on.
Laboratory results are the data that doctors could base their diagnosis on. Together with the
history of the patient, the other diagnostic results, doctors could now come up with a
conclusive diagnosis.
5. Serum can be more stable than plasma with certain substances
Some researches proved that serum is more stable for other substances than plasma. This
is most especially for serum extracted with a separator gel. Gel tubes proved to be stable for
creatinine, potassium, and urea than in plasma. This would specify that gel tubes are more
stable that plain serum tubes.
Types of Activators
1. Substances that provide more surface for platelet activation
a. Glass (silica) particles
b. Inert clays (Celite)
c. Clotting factors (thrombin)
2. Thixotropic Gel Separator
- Has density between that of cells & serum or plasma
- When centrifuged, gel moves between cells & serum or plasma
- Prevents cells from continuing to metabolize substances
3. Trace Element-Free Tubes
- Tubes made of materials free of trace element contamination
- Used for trace element tests, toxicology studies, & nutrient determinations
• Heavy metals: lead, iron, arsenic, mercury, zinc, copper
Feature royal-blue stoppers
Color Coding
Color indicators help the phlebotomist to easily select the tubes in which the blood should be
drawn as per the tests that have to be performed. The additives present in the evacuated
tubes plays the most important role as every additive has a unique function and these are
selected as per the tests to be performed as discussed earlier. The below table shows the
different color codes, additive and its specific use based on Beckton Dickenson (BD)
company:
COLOR CODE
ADDITIVE
COMMON USE

Purple/ Lavender
EDTA
CBC, BLOOD TYPING (Rh Factor & ABO Screening), Cross match, Hb, Red cell Indices,
ESR by Wintrobe's method
Gen. Hema
Light Blue
Tri-Sodium Citrate
(Blood:Anticoagulant ratio is 9:1)
Prothrombin time (PT), Activated
Partial Thromboplastin Time (APTT),
Fibrinogen thrombin time and other blood Coagulation tests
clotting
Light Green
Lithium Heparin
Basic Metabolic Panel (BMP),
Comprehensive metabolic Panel (CMP) and other plasma determination tests
Giucose
Royal Blue
None/ Di-sodium EDTA
Trace Elements like Cu, Zn, etc,
Toxicology and Nutrient determination

Gold (commonly known as Serum

Separator tube)
Polymer Gel and Powdered Glass
Clot activator
BMP, CMP, LFT, KFT, Lipid Profile and other biochemistry assays, Serological tests

Red
Powdered glass Clot Activator
BMP, CMP, Lipid Profile, Serology tests, Therapeutic drug monitoring, blood bank
procedures

Dark green
Sodium Heparin
Arterial blood gas analysis, alpha-TNF,
Lymphocyte Immunotherapy

Gray
Sodium Fluoride
Blood Sugar testing, Toxicology tests
Black
Tri-Sodium Citrate
(Blood:Anticoagulant ratio is 4:1)
ESR by Westergren method

Yellow
ACD (Acid-Citrate Dextrose)
Blood Bank studies, HLA Phenotyping, Paternity testing, Tissue typing

Pink
Dried EDTA
Rh factor, ABO typing, CBC, Blood banking procedures
Order of draw
The order of draw is important especially when collecting multiple samples to avoid inserting
needles every time a blood sample is needed for a different test. This will also prevent
unnecessary carry-over or cross-contamination of additives which may affect the result of
tests to be performed on the sample. In principle this is the order of draw:
1. First - blood culture bottle or tube (yellow or yellow-black top)
Second - coagulation tube (light blue top). If just a routine coagulation assay is the only test
ordered, then a single light blue top tube may be drawn. If there is a concern regarding
contamination by tissue fluids or thromboplastins, then one may draw a non-additive tube
first, and then the light blue top tube
3.
4.
Third - non-additive tube (red top)
Last draw - additive tubes in this order:
a. SST (red-gray or gold top). Contains a gel separator and clot activator b.
Sodium heparin (dark green top)
C.
PST (light green top). Contains lithium heparin anticoagulant and a gel separator.
d. EDTA (lavender top)
e.
ACDA or ACDB (pale yellow top). Contains acid citrate dextrose.
f. Oxalate/fluoride (light gray top)
Following the color codes, the following is the order of draw:
1. Yellow (not used very often)
2. Light blue
3. Red (glass)
4. Red (plastic)
5. Gold (SST, red and gray marbled)
6. Green
7. Light green
8. Lavender
9. Pink
10. Gray
11. Royal or Navy blue
Here are some precautionary measures that are often causing errors in laboratory tests.
Tissue Thromboplastin Contamination
- Tissue thromboplastin, present in tissue fluid:
• Activates extrinsic coagulation pathway
• Can interfere with coagulation tests
- For coagulation tests (other than PT or PTT)
• draw a few ml of blood into a plain red top tube before collecting coagulation specimen
Microbial Contamination
- site cleaning most important
- Microorganisms found on skin can contaminate blood specimens
- Blood cultures are collected first in order of draw, when sterility of site is optimal & to
prevent contamination of needle