Specimen Collection.fm
Contents
1. 8 Blood culture bottles are carried to the laboratory or sent individually through the pneumatic tube system They are brought into the Microbiology Department for entry into the appropriate instrument Additional Information e Greater volume of draw leads to better recovery and sensitivity of the test Please attempt to draw the largest volume appropriate for optimum specimens e The bottles although evacuated are not a controlled draw so volume added must be carefully monitored Adding too much blood may result in a false positive result2. be used when serum is required for Blood Banking procedures cold agglutinin testing and a slight few tests sent out of our laboratory The volume of whole blood needed to perform testing is approximately 2 1 2 times the required volume of serum For example a full 3 5 mL gold top tube will yield approximately 1 4 mL of serum Examples of acceptable tests are e Procalcitonin e Vitamin D 25 Hydroxy e HIV e PSA screening and diagnostic e RA e LDH LH Red Stoppered Glass Non Additive or if Plastic Clot Activator Tube This tube is to be used when serum is needed Serum is the fluid portion of the blood obtained after removal of the fibrin clot and blood cells As a general rule serum is roughly half of the blood content The volume of whole blood needed to perform testing is approximately 2 1 2 times the required volume of serum For example a full 10 mL tube will yield approximately 4 mL of serum Examples of acceptable tests are e Antibody screen type and screen when lavender top only is insufficient e Cold agglutinin e Occasional specimen referral testing Light Green or Dark Green Stoppered Lithium or Sodium Heparin Tube Heparin prevents coagulation by inhibiting the clotting components thrombin and thromboplastin Heparinized blood specimens yield plasma for laboratory testing Heparinized tubes can also include separator gels and can contain heparin in either liquid or powder form Volume requir
3. use for other laboratory work If results obtained with the coagulation specimen indicate that heparin is present a new coagulation specimen should be obtained by venipuncture If this is not possible draw from the line discarding 30 mL of blood Capillary Skin Puncture Blood Collection When collecting blood specimens by skin puncture performing a good puncture is critical to the success of the procedure Skin punctures are particularly useful for both adult when specimen is unattainable by venipuncture and pediatric patients infants and small children when small amounts of blood can be obtained and adequately tested Blood obtained through skin puncture is a mixture of arterial venous and capillary blood along with interstitial and intracellular fluids from the surrounding tissues It contains a higher proportion of arterial blood than venous blood because of the pressure with which the arterial blood enters the capillaries This is especially true if the area has been warmed as warming increases arterial flow into the area Composition of skin puncture blood therefore more closely resembles arterial blood than venous blood obtained by venipuncture 2 If capillary puncture is indicated choose appropriate site e Recommended site for adults and older children is the end segment of third middle or fourth ring fingers e Choose a site that is warm pink and free of scars cuts bruises or rashes e
4. Puncture central fleshy portion of finger slightly to side of center Do not puncture e Side or very tip of finger these areas are half as fleshy as the desired site e Index finger this dominant finger is more sensitive to pain and through use will notice pain longer e Fifth little finger tissue between skin and bone is thinnest in this finger e Fingers of infants and very young children bone injury is likely due to the small amount of tissue between skin and bone e Through previous puncture sites as it may spread infection Warm site for 5 to 10 minutes if indicated Site warming can increase arterial blood flow to the area by 7 fold Warming can be accomplished with by e Commercial warmers e Wrapping site with a diaper or towel that has been run under warm water Cleanse site with a 70 isopropyl alcohol pad e Do not use povidone iodine because it interferes with many tests including bilirubin potassium phosphorus and uric acid e Wipe site dry to remove residual alcohol or allow to air dry Alcohol causes rapid hemolysis of RBCs and will sting if introduced into the puncture Grasp finger firmly and using appropriate automated lancet perform skin puncture Position the site downward and gently massage finger from base to tip to allow a bead of blood to form Excessive massaging can lead to contamination 3 Warm site for 5 to 10 minutes if indicated Site and hemolysis warming can incr
5. Specimen Collection Accuracy of any laboratory test can be no better than the specimen on which the test is performed Instructions for proper patient preparation ie fasting specific specimen requirements and specimen handling are provided in this service manual Only when proper procedures are followed in the area of patient preparation specimen collection and specimen handling will the test results be valid and usable by the physician It is important that patient identification and specimen labeling policies be followed diligently Please refer to these policies in Specimen Labeling in Specimen Identification in General Information Specimen Collection Tubes Blue Stoppered Sodium Citrate Tube Sodium citrate prevents coagulation by binding calcium Testing performed on this tube consists of mainly coagulation studies using plasma Plasma is the whole fluid portion of the blood when cells are removed As with all additive tubes the tube should be inverted gently 4 to 6 times to ensure proper mixing Tubes must be filled completely Clot activator in plastic serum tubes are inappropriate for use before coagulation draws See Correct Order of Draw in Specimen Collection in General Information Examples of acceptable tests are e Prothrombin time PT e Partial thromboplastin time PTT e Fibrinogen e D Dimer Gold Stoppered or Red Black Serum Gel Clot Activator and Gel Separator Tube This tube yields serum It cannot
6. ear Because puncture this patient population has such a small blood volume removing large quantities of blood can lead to anemia e Micro preemie infants as determined by Large quantities removed rapidly can also cause cardiac nursing personnel should warrant the use of the arrest Tenderfoot Preemie depth 0 85 mm length 1 75 mm 1 Choose appropriate site It is important that the e All other heel punctures can be performed with puncture be performed in an area of the heel where the standard Tenderfoot device depth 1 mm there is little risk of puncturing the bone This could length 2 5 mm lead to 6 Position site downward and gently massage heel e Osteomyelitis bone infection intermittently allowing beads of blood to form e Osteochondritis inflammation of the bone Excessive massaging can lead to contamination and cartilage and hemolysis 2 Do not puncture e Wipe away first drop of blood contamination from residual alcohol or interstitial fluids is likely e Deeper than 2 4 mm automated devices to alter laboratory results eliminate this possibility e Collect blood using the tube or device appropriate e Through previous puncture sites as it may for the testing procedure such as spread infection MICROTAINER blood collection tubes or S P e Areas that are cold bruised or edematous Caraway Capillary Tubes for PKU or I Stat e Between boundaries testing e Posterior curvature of the heel e Micro collection tubes fill by capilla
7. ease arterial blood flow to the area by 7 fold Warming can be accomplished with by e Wipe away first drop of blood contamination from residual alcohol or interstitial fluids is likely to alter laboratory results e Collect blood using the tube or device appropriate for the testing procedure such as MICROTAINER blood collection tube e Micro collection tubes fill by capillary action whereby blood flows freely into tube on contact Do not touch device to the wound or scrape skin This activates platelets and can cause hemolysis e Commercial warmers e Wrapping site in a diaper or towel that has been run under warm water 4 Cleanse site with a 70 isopropyl alcohol pad e Do not use povidone iodine because it interferes with many tests including bilirubin potassium phosphorus and uric acid e Wipe site dry to remove residual alcohol or allow to air dry Alcohol causes rapid hemolysis of red blood cells and will sting if introduced into the puncture 7 Gently invert micro collection tube 8 to 10 times to assure proper mixing Lavender top micro collection tube should be continually mixed by gentle tapping during draw 5 Grasp heel firmly but gently as to not bruise the leg Capillary Collection by Heel Puncture ankle or heel Rest appropriate automated heel Heel puncture is the preferred method of obtaining blood incision device flat over intended site Perform skin from newborns and infants no older than y
8. ements are similar to serum specimen tubes and the tube should be inverted 4 to 6 times to ensure proper mixing Examples of acceptable tests are e Chemistry panels Chem8 lytes metabolic LFTs Lipids e Ammonia lactic acid on ice e Troponin e Chromosome analysis sodium heparin only Lavender Stoppered EDTA Tube Ethylenediamine tetra acetic acid EDTA prevents coagulation by binding calcium Testing performed in this tube consists of mainly whole blood studies Tube must be at least half full and should be inverted gently 4 to 6 times to ensure proper mixing Examples of acceptable tests are e Complete blood count CBC e Hemoglobin Alc e BNP e PTH e Type and screen Grey Stoppered Potassium Oxalate Sodium Fluoride Tube Together additives prevent coagulation by binding calcium and also act as an antiglycolitic agent that prohibits metabolism of glucose and destroys many enzymes The 3 mL size tube needs a minimum of mL of blood specimen Examples of acceptable tests are e Ethylene glycol e Legal blood alcohol Special Tube Call CentraCare Laboratory Services at 320 255 5999 or 320 255 5632 for special collection tubes Correct Order of Draw According to the National Committee for Clinical Laboratory Standards NCCLS standards revised in 1998 the following order is recommended to avoid contamination of non additive tubes by additive tubes as well as cross contamination between differ
9. ent types of additive tubes This order is applicable to both evacuated and syringe methods of collection e Blood culture or other sterile tubes bottles Capillary Collection by Finger Puncture e Non additive tubes plain red top tubes contain clot activators 1 e Light blue top 3 2 sodium citrate tubes e Red top red black top serum gel tubes or gold top serum gel tubes e Light or dark green top heparin tubes e Lavender top EDTA tubes e Grey top potassium oxalate sodium fluoride tubes Indwelling Catheters and Coagulation Testing The laboratory discourages obtaining blood coagulation tests indwelling vascular catheters Heparin affects coagulation tests and since heparin is often used to keep indwelling vascular catheter lines open blood obtained from these lines can yield falsely elevated coagulation results for from If blood for coagulation tests must be collected through an indwelling catheter sheath or line blood must be discarded or used for other laboratory tests before the specimen for coagulation testing is obtained The amount of blood to discard is determined by taking 5 times the amount of dwell space in the catheter The more common catheters are listed below Catheter Dwell Waste Arterial sheath 1 5 mL 10 mL Arterial line 0 9 mL 5 mL CVS arterial line 3 mL 15 mL PA catheter prox 1 mL 5 mL Pace port 1 5 mL 10 mL Introducer 2 mL 10 mL Waste or
10. lection in General Information 4 Gold top serum gel tube Micro equivalent to SST but contains no clot activator 5 Red top non additive tube Equivalent to the plain red tube It can also be used for chemistry or utilized when green top tube is not appropriate Blood Culture for the Phlebotomist Routine and Fungal Procedures Background Blood cultures are among the most important cultures performed by the Clinical Microbiology Department Blood cultures are used by physicians to rule out or confirm septicemia and or bacteremia Blood cultures indicate the severity of an infection and identify the causative organism The procedure also determines the antimicrobial susceptibility of the causative organism Normally there should be no organisms of any kind present in a person s blood stream Therefore normal values are negative for growth Proper collection techniques are essential to the accuracy of blood culture results False positive results due to incorrect collection techniques can have serious ramifications for the patient such as inappropriate and potentially risky treatments or prolonged hospitalization False negative results may delay a patient s diagnosis and treatment which may cause their condition to worsen resulting in needless suffering and prolonged hospitalization Supplies e Gloves e Alcohol pads e Chlorhexidine gluconate swab 2 CHG and 70 IPA recommended e Sterile syringe a
11. nd needles e Order containing patient s identification and special instructions e For routine blood cultures e BACTEC Plus Aerobic F and BACTEC Standard Anaerobic F bottles for 1 full set adults e BACTEC Peds Plus F bottle for pediatrics difficult draws e For fungus blood cultures e BBL Septi Chek bottle with Tryptic Soy Broth TSB Media Procedure 1 Identify patient correctly using the order to verify medical record number with patient s wristband 2 Explain procedure to patient specifically that the venipuncture procedure will be performed multiple times over a given time span when applicable 3 Skin antisepsis is a very important part of any blood culture collection procedure Failure to follow sterile technique can introduce skin surface bacteria into the blood culture bottle and interfere with interpretation of results After selecting venipuncture site e Scrub with chlorhexidine swab for 30 seconds using repeated back and forth strokes covering an area of 3 to 4 square inches in diameter e Allow to air dry for at least 30 seconds The scrubbing process as well as the drying process allows time for the antiseptic agent to be effective against skin surface bacteria If chlorhexidine swab is unavailable prepare site using the following procedure e Scrub with 70 isopropyl alcohol pad for 1 minute covering an area of 3 to 4 square inches in diameter to initially cleanse site Scrub with povidone iodine
12. ry action e In area of the arch whereby blood flows freely into tube on contact e Areas of foot other than heel Do not touch device to the wound or scrape skin This activates platelets and can cause hemolysis 7 Gently invert micro collection tube 8 to 10 times to assure proper mixing Lavender top micro collection tube should be continually mixed by gentle tapping during draw Correct Order of Capillary Draw Although today s technology allows many tests to be performed on very small quantities of blood some tests cannot be performed on skin puncture specimens due to volume additive requirements or the nature of the test Included are coagulation tests where tissue thromboplastin interferes chromosome studies and blood cultures where site sterility is a factor These tests are therefore not included in the basic order of capillary draw which is as follows 1 i STAT Testing Caraway Tubes 2 Lavender top EDTA tube Initial specimen is most free flowing and less likely to contain platelet clumping Must be filled past 0 25 mL first line but not over 0 5 mL second line Mix well to avoid micro clotting or platelet clumping 3 Green top lithium heparin and plasma gel tube Chemistry tube of choice for capillary specimens Attention must be given however to those tests that cannot be drawn in a heparinized tube or require sodium heparin see chart under Chemistry Specimen Requirements in Specimen Col
13. swab for 1 minute covering chosen area Scrub with a second povidone iodine swab for 1 minute taking care to begin from the center of site and move outward in concentric circles Allow to air dry for a least 1 minute The scrubbing process as well as the drying process allows time for the antiseptic agent to be effective against skin surface bacteria 4 While the area is drying e Routine blood cultures should be drawn before antibiotic therapy is started The BACTEC Plus bottles e Tops of blood culture bottles are cleansed with contain resins that remove antimicrobials from the alcohol pads leaving pads on the bottle tops blood so that growth of microorganisms will not be until just before inoculation of blood into the inhibited if patient has begun antibiotic therapy bottles occurs e Commonly the first set of blood cultures is ordered and drawn in the hour prior to a fever spike with subsequent sets to follow Bacteria are most likely to be present in the bloodstream in the time frame prior to and just following these fever spikes e The first set of routine blood cultures is typically ordered as a STAT test Subsequent orders are then placed into the computer system in the requested time intervals usually 15 or 30 minutes later If there are any questions about timing or site selection ie e Assemble syringe and needle 5 Venipuncture procedure is performed by laboratory standards with prepared syringe and needle apparatus
14. taking care that nothing touches the prepped area in the process Palpating the site once it has been prepared is notrecommended However if the necessity to repalpate is anticipated the phlebotomist s gloved finger should be cleansed in drawing from indwelling lines vs a peripheral stick the same manner as the venipuncture site please consult patient care staff to clarify physician requests 6 Remove alcohol pads from blood culture bottles e Good standard of care recommends a minimum of 2 and inoculate as follows with aerobic bottles routine blood cultures per 24 hours Numbers should first not exceed 4 sets without consultation from the CCLS Pathology representative e Routine e Fungus blood cultures are incubated and monitored 0 5 to 3 mL BACTEC Peds Plus bottle for 30 days gt 3 to 10 mL BACTEC Plus Aerobic bottle 8 10 mL optimum range gt 10 to 17 mL 6 to 10 mL into BACTEC Plus Aerobic bottle 8 10 mL optimum range or 4 to 7 mL into BACTEC Standard Anaerobic bottle 5 7 mL optimum range e Fungal 1to 10 mL 1 BBL Septi Chek bottle 8 10 mL optimum range 7 Label bottles with patient s name first and last medical record number date and actual time of draw and tech initials or code Sunquest labels may be used provided the time and initials code are added and the labels are placed vertically not horizontally Do not cover any part of the barcode on the blood culture bottles when labeling
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