Phlebotomy Lesson: A Guide to Equipment and Best Practices

Lesson Overview

• What Is Phlebotomy?
• What Is the Basic Anatomy Relevant to Phlebotomy?
• What Phlebotomy Equipment Is Essential and How Is It Used?
• What Is the Order of Draw and Why Is It Important?
• What Are the Common Risks in Phlebotomy and How Can They Be Mitigated?
• What Is the Role and What Are the Desirable Attributes of a Phlebotomist?
• Conclusion

When a routine blood draw left a patient bruised and anxious, it raised concerns about technique and safety. Such outcomes are preventable with proper training. This lesson on phlebotomy: a guide to equipment and best practices provides essential knowledge on tools, procedures, and protocols to ensure accurate, safe, and professional blood collection.

What Is Phlebotomy?

Phlebotomy is the medical practice of drawing blood from a patient's vein for diagnostic testing, transfusions, research, or donation. Performed by trained professionals called phlebotomists, it involves using sterile equipment-typically needles, tubes, and collection devices-to safely access veins, most commonly in the arm. Phlebotomy is essential in healthcare, as blood tests help diagnose diseases, monitor treatments, and evaluate overall health. Proper technique, hygiene, and patient care are critical to ensure safety and accuracy during the procedure.

Take This Quiz!

What Is the Basic Anatomy Relevant to Phlebotomy?

The circulatory system, also known as the cardiovascular system, is a complex network of blood vessels that transport blood throughout the body. It consists of the heart, arteries, veins, and capillaries. This system is essential for delivering oxygen and nutrients to tissues, removing waste products, and maintaining homeostasis.

Key Components of the Circulatory System:

1. The Heart: The central pump that propels blood through the circulatory system. It has four chambers – the right atrium, right ventricle, left atrium, and left ventricle. The heart pumps oxygenated blood from the lungs to the body and deoxygenated blood from the body to the lungs.
   
2. Arteries: Blood vessels that carry oxygenated blood away from the heart to the body. The largest artery is the aorta, which branches into smaller arteries, arterioles, and finally capillaries, where oxygen and nutrients are exchanged with tissues.
   
3. Veins: Blood vessels that return deoxygenated blood back to the heart. Veins are equipped with valves that prevent backflow and ensure unidirectional blood flow toward the heart. They converge into larger veins, such as the superior and inferior vena cava, which return blood to the heart.
   
4. Capillaries: Microscopic blood vessels that connect arterioles and venules. They facilitate the exchange of oxygen, nutrients, and waste products between blood and tissues.

Focus on Veins and Arteries in Phlebotomy:

In phlebotomy, understanding the structure and function of veins and arteries is crucial for safe and effective blood collection. While arteries carry blood away from the heart under high pressure, veins return blood to the heart at lower pressure, making them more suitable for venipuncture.

Key Differences:

• Walls: Arteries have thick, elastic walls to withstand high pressure, while veins have thinner walls with less elasticity.
• Valves: Veins contain valves to prevent backflow, which are absent in arteries.
• Blood Flow: Blood in arteries flows in pulses due to the heart's contractions, whereas venous blood flow is steady and relies on muscle contractions and the pressure gradient.

Key Veins Used in Phlebotomy: Median Cubital, Cephalic, and Basilic Veins

For blood collection, phlebotomists primarily use veins located in the antecubital fossa, the triangular area on the anterior surface of the elbow. The veins in this area are superficial, making them accessible and relatively easy to puncture.

1. Median Cubital Vein:
   
   • Location: Found in the middle of the antecubital fossa, it connects the cephalic vein on the lateral side of the arm to the basilic vein on the medial side.
     
   • Advantages: The median cubital vein is often the vein of choice for venipuncture due to its prominence, stability, and accessibility. It is typically well-anchored, reducing the likelihood of movement during needle insertion, and is less painful for the patient.
     
   • Considerations: This vein is usually large and superficial, making it easier to locate and puncture. However, care should be taken to avoid the brachial artery and median nerve, which are located nearby.
     
2. Cephalic Vein:
   
   • Location: Runs along the lateral (thumb) side of the forearm and upper arm, extending from the wrist to the shoulder.
     
   • Advantages: The cephalic vein is easily accessible and less prone to movement compared to other veins. It is a good alternative when the median cubital vein is not suitable.
     
   • Considerations: While the cephalic vein is generally easy to palpate, it can be deeper in some patients, particularly those with a higher body mass index (BMI). Proper palpation technique is essential to locate it accurately.
     
3. Basilic Vein:
   
   • Location: Runs along the medial (pinky) side of the forearm and upper arm, extending from the wrist to the axilla (armpit).
     
   • Advantages: The basilic vein is another option for venipuncture, especially if the median cubital and cephalic veins are not suitable. It is often more prominent in individuals with well-developed muscles.
     
   • Considerations: The basilic vein is less stable and tends to roll more than the other veins, making it more challenging to puncture. Additionally, it is located closer to nerves and arteries, requiring greater caution during venipuncture to avoid complications.

Take This Quiz

What Phlebotomy Equipment Is Essential and How Is It Used?

Phlebotomy requires specific tools and equipment to ensure the process is efficient, safe, and minimally invasive. Each piece of equipment has a specific purpose and must be used correctly to maintain the integrity of the blood sample and ensure patient safety.

1. Needles:
   
   • Types: There are various types of needles used in phlebotomy, including straight needles (21-23 gauge) for venipuncture, butterfly needles (winged infusion sets) for smaller or difficult veins, and lancets for capillary blood collection.
     
   • Usage: The appropriate needle is selected based on the vein size, patient age, and the volume of blood needed. Straight needles are commonly used for routine venipuncture, while butterfly needles are preferred for fragile veins or pediatric patients.
     
2. Syringes:
   
   • Types: Syringes come in different sizes (1-10 mL) and are used with needles for drawing blood when a vacuum system is not suitable or when precise control over suction is required.
     
   • Usage: Syringes are often used in situations where veins are prone to collapse, such as in elderly patients or those with low blood pressure. The plunger is pulled back slowly to draw blood without causing vein collapse.
     
3. Vacutainer Tubes:
   
   • Types: Vacutainer tubes are color-coded based on the additives they contain (e.g., EDTA, heparin, citrate) and the tests they are used for. Common colors include red (no additive), blue (citrate), lavender (EDTA), and green (heparin).
     
   • Usage: These tubes create a vacuum that draws blood into the tube when attached to a needle holder. The correct tube is selected based on the type of test ordered. Tubes must be gently inverted after collection to mix the blood with the additives.
     
4. Tourniquets:
   
   • Types: Typically made of elastic material, tourniquets are used to constrict blood flow in the arm, making veins more prominent and easier to puncture.
     
   • Usage: The tourniquet is applied about 3-4 inches above the puncture site. It should not be left on for more than a minute to prevent hemoconcentration and discomfort.
     
5. Alcohol Swabs:
   
   • Types: Pre-packaged pads soaked in 70% isopropyl alcohol.
     
   • Usage: Alcohol swabs are used to clean the puncture site before needle insertion to reduce the risk of infection. The site should be allowed to air dry to ensure maximum antiseptic effect.
     
6. Gloves:
   
   • Types: Disposable gloves made from latex, nitrile, or vinyl.
     
   • Usage: Gloves are worn to protect both the phlebotomist and the patient from potential exposure to bloodborne pathogens. Gloves should be changed between patients and whenever they become contaminated.

Guidelines for Using and Maintaining Phlebotomy Equipment

Proper use and maintenance of phlebotomy equipment are crucial for ensuring patient safety, sample integrity, and the prevention of infections.

1. Needles and Syringes:
   
   • Usage: Always use a new, sterile needle and syringe for each patient. Ensure the needle size is appropriate for the vein and procedure.
     
   • Maintenance: Dispose of used needles and syringes immediately in a designated sharps container to prevent needlestick injuries and contamination. Never reuse needles or syringes.
     
2. Vacutainer Tubes:
   
   • Usage: Select the correct tube based on the test requirements. Attach the tube to the needle holder securely and allow it to fill to the indicated volume.
     
   • Maintenance: Store tubes in a clean, dry environment away from direct sunlight and temperature extremes. Check expiration dates regularly and dispose of expired tubes.
     
3. Tourniquets:
   
   • Usage: Apply the tourniquet snugly but not too tightly. Release the tourniquet as soon as blood flow is established.
     
   • Maintenance: Clean reusable tourniquets regularly with a disinfectant or use single-use disposable tourniquets to prevent cross-contamination.
     
4. Alcohol Swabs:
   
   • Usage: Use a new swab for each puncture site. Clean the site in a circular motion from the center outward.
     
   • Maintenance: Ensure swabs are stored in their original packaging and kept sealed until use to maintain sterility.
     
5. Gloves:
   
   • Usage: Wear gloves for every procedure involving blood or bodily fluids. Choose the appropriate size to ensure a good fit and tactile sensitivity.
     
   • Maintenance: Change gloves between patients and whenever they become visibly soiled or damaged. Dispose of gloves in a biohazard waste container.
     
6. Additional Equipment Maintenance:
   
   • Work Area: Keep the phlebotomy area clean and organized. Regularly disinfect surfaces and equipment.
     
   • Sharps Containers: Use puncture-resistant sharps containers for disposing of needles and other sharp objects. Replace containers before they become overfilled.
     
   • Documentation: Maintain accurate records of equipment use, maintenance, and disposal to ensure compliance with health and safety regulations.

Take This Quiz

What Is the Order of Draw and Why Is It Important?

The "order of draw" refers to the specific sequence in which blood collection tubes should be filled during a venipuncture procedure. This sequence is crucial to prevent cross-contamination between tubes by the additives used in each tube. Cross-contamination can lead to inaccurate test results, which may affect patient diagnosis and treatment.

Each tube in the order of draw contains different additives that serve various purposes, such as anticoagulants, clot activators, or preservatives. When blood is drawn into these tubes, there is a risk that the additives can be transferred from one tube to the next if the correct order is not followed. This contamination can interfere with laboratory tests, causing erroneous results and potentially leading to misdiagnosis or inappropriate treatment.

By adhering to the standardized order of draw, phlebotomists ensure that the integrity of each blood sample is maintained, leading to reliable and accurate laboratory results. This practice is essential for maintaining the quality of patient care and the credibility of diagnostic processes.

Step-By-Step Guide to the Correct Order of Draw

The correct order of draw is based on guidelines established by organizations such as the Clinical and Laboratory Standards Institute (CLSI). The following is a detailed step-by-step guide to the order of draw for venipuncture

1. Blood Culture Tubes (Yellow or Yellow-Black Top)
   
   • Purpose: Used for microbiological studies to detect bacterial or fungal infections in the blood.
     
   • Additives: Contains a nutrient broth that encourages the growth of microorganisms.
     
   • Why First: Prevents contamination from additives in other tubes, which could inhibit the growth of microorganisms and lead to false-negative results.
     
2. Coagulation Tubes (Light Blue Top)
   
   • Purpose: Used for coagulation studies, such as prothrombin time (PT) and activated partial thromboplastin time (aPTT).
     
   • Additives: Contains sodium citrate, an anticoagulant that binds calcium.
     
   • Why Second: The citrate in the blue top tube must be drawn before other additives that could alter coagulation results.
     
3. Serum Tubes (Red Top, Gold Top, or Tiger Top)
   
   • Purpose: Used for chemistry, serology, and immunology tests.
     
   • Additives: Red top tubes have no additives; gold and tiger top tubes contain a clot activator and gel for serum separation.
     
   • Why Third: The absence of anticoagulants in these tubes minimizes the risk of cross-contamination affecting coagulation studies.
     
4. Heparin Tubes (Green Top)
   
   • Purpose: Used for plasma chemistry tests and blood gas analysis.
     
   • Additives: Contains lithium heparin or sodium heparin, which inhibits thrombin to prevent clotting.
     
   • Why Fourth: Heparin can interfere with coagulation and serum studies if drawn out of order.
     
5. EDTA Tubes (Lavender or Purple Top)
   
   • Purpose: Used for hematology tests, such as complete blood count (CBC) and blood smears.
     
   • Additives: Contains ethylenediaminetetraacetic acid (EDTA), which binds calcium to prevent clotting.
     
   • Why Fifth: EDTA has strong anticoagulant properties that can significantly alter results if cross-contamination occurs with other tests.
     
6. Oxalate/Fluoride Tubes (Gray Top)
   
   • Purpose: Used for glucose and lactate testing.
     
   • Additives: Contains potassium oxalate, an anticoagulant, and sodium fluoride, a glycolysis inhibitor.
     
   • Why Sixth: The fluoride preserves glucose levels by inhibiting glycolysis, which can be affected by additives in other tubes.
     
7. Other Tubes (e.g., Royal Blue, Tan, Yellow-Top ACD)
   
   • Purpose: Used for specialized tests such as toxicology, trace metals, and DNA analysis.
     
   • Additives: Various additives depending on the test requirements.
     
   • Why Last: These tubes are drawn last to prevent contamination from the other additives, which could interfere with the specific tests these tubes are designed for.

Take This Quiz

What Are the Common Risks in Phlebotomy and How Can They Be Mitigated?

Phlebotomy, while generally safe, carries several risks that can affect both patients and healthcare providers. Understanding these risks and implementing strategies to mitigate them is crucial for ensuring the safety and efficacy of blood collection procedures. Below is a detailed overview of common risks in phlebotomy and the measures to mitigate them.

1. Needle Stick Injuries

Risks:

• Needle stick injuries can expose healthcare workers to bloodborne pathogens such as HIV, hepatitis B, and hepatitis C.

Mitigation Strategies:

• Use Safety Devices: Employ needles with safety features, such as retractable needles or needle shields.
  
• Proper Disposal: Dispose of needles immediately after use in puncture-resistant sharps containers.
  
• Avoid Recapping: Do not recap needles. If recapping is unavoidable, use a one-handed scoop method or a recapping device.
  
• Training: Regularly train staff on the proper handling and disposal of needles.

2. Hematoma Formation

Risks:

• Hematomas can form if blood leaks into the surrounding tissue during or after the venipuncture.

Mitigation Strategies:

• Proper Technique: Use the correct needle size and ensure the needle is fully inserted into the vein.
  
• Pressure Application: Apply adequate pressure to the puncture site after needle withdrawal to prevent bleeding.
  
• Patient Communication: Advise patients to avoid heavy lifting or strenuous activity with the affected arm for a few hours after the draw.

3. Infection

Risks:

• Infections can occur if the puncture site or equipment is not properly sanitized.

Mitigation Strategies:

• Aseptic Technique: Clean the puncture site with an antiseptic and allow it to air dry before insertion.
  
• Sterile Equipment: Use sterile needles and syringes and avoid touching the needle or puncture site after cleaning.
  
• Hand Hygiene: Perform hand hygiene before and after each patient interaction.

4. Fainting (Syncope)

Risks:

• Some patients may experience fainting during or after a blood draw.

Mitigation Strategies:

• Patient History: Identify patients with a history of fainting and take precautions.
  
• Patient Positioning: Have the patient lie down during the procedure if they feel faint or have a history of syncope.
  
• Observation: Monitor the patient closely during and after the procedure, providing reassurance and support.

5. Vein Damage

Risks:

• Repeated venipunctures can cause damage to veins, making future blood draws more difficult.

Mitigation Strategies:

• Rotating Sites: Avoid using the same puncture site repeatedly by rotating sites.
  
• Proper Technique: Use gentle technique to minimize trauma to the vein.
  
• Hydration: Encourage patients to stay well-hydrated to make veins easier to locate and puncture.

6. Patient Anxiety and Discomfort

Risks:

• Anxiety and discomfort can lead to an unpleasant experience and may cause patients to avoid future necessary blood tests.

Mitigation Strategies:

• Communication: Clearly explain the procedure to the patient and answer any questions they may have.
  
• Comfort Measures: Use smaller needles or a butterfly needle for patients with difficult veins or high anxiety.
  
• Distraction Techniques: Engage the patient in conversation or provide distractions during the procedure.

7. Incorrect Sample Labeling

Risks:

• Mislabeling samples can lead to incorrect diagnosis and treatment.

Mitigation Strategies:

• Immediate Labeling: Label samples immediately at the bedside with the patient's details.
  
• Double-Check: Double-check labels and patient information before sending samples to the lab.
  
• Barcoding Systems: Implement barcoding systems to reduce the risk of human error.

8. Hemolysis

Risks:

• Hemolysis can occur if red blood cells are damaged during the blood draw, which can interfere with test results.

Mitigation Strategies:

• Proper Technique: Use the correct needle size and avoid vigorous shaking of the blood tubes.
  
• Gentle Handling: Handle samples gently and avoid using excessive force when drawing blood into the tube.
  
• Proper Mixing: Invert tubes gently to mix blood with additives, avoiding vigorous shaking.

9. Inadequate Sample Volume

Risks:

• Collecting an insufficient sample volume can result in the need for a repeat draw.

Mitigation Strategies:

• Correct Tube Selection: Use the appropriate size tube for the required tests.
  
• Proper Venipuncture Technique: Ensure proper needle placement and patient preparation to maximize blood flow.
  
• Monitoring: Monitor the blood draw process to ensure adequate volume is collected.

Take This Quiz

[CTA]76572[\CTA]

What Is the Role and What Are the Desirable Attributes of a Phlebotomist?

Role of a Phlebotomist

Phlebotomists are specialized healthcare professionals responsible for drawing blood for various purposes, including laboratory tests, transfusions, donations, and research. Their key duties include:

1. Preparing the Patient: Phlebotomists greet patients warmly, verify their identity, explain the procedure, obtain consent, and address any concerns to alleviate anxiety.
   
2. Selecting Equipment: They choose the appropriate needles, syringes, tubes, and other necessary tools based on the type of blood draw and tests required.
   
3. Performing Blood Draws: Phlebotomists locate suitable veins, clean the puncture site, and draw blood with minimal discomfort to the patient while monitoring for adverse reactions.
   
4. Labeling and Handling Samples: They accurately label samples with patient information and ensure proper storage and transport conditions to maintain sample integrity.
   
5. Post-Procedure Care: Phlebotomists provide post-draw care instructions, apply bandages, and ensure the patient is feeling well before they leave.

Desirable Attributes of a Phlebotomist

1. Attention to Detail: Phlebotomists must ensure procedures are followed accurately and samples are correctly labeled to avoid errors and ensure reliable test results.
   
2. Empathy: They should have a compassionate demeanor to understand and alleviate patients' fears and anxiety, providing a more comfortable experience.
   
3. Communication Skills: Effective communication is essential for clearly explaining procedures, answering questions, and providing post-care instructions to patients.
   
4. Manual Dexterity: Phlebotomists need steady hands and precise movements to perform blood draws smoothly and efficiently, minimizing patient discomfort.
   
5. Professionalism: Maintaining a high level of professionalism is crucial, including adhering to ethical standards, ensuring patient confidentiality, and demonstrating reliability and punctuality.

Conclusion

The practice of phlebotomy is a crucial component of modern healthcare, enabling accurate diagnosis and effective treatment. By mastering the techniques of blood collection, understanding the importance of infection control, and learning to handle equipment properly, you've gained valuable skills that enhance patient care and safety.