CHAPTER 42 – HEMOSTASIS SPECIMEN COLLECTION Hemostasis Specimen Collection Rules: Additives
HEMA2-MICO37 The ratio of whole blood to anticoagulant must be 9
Content parts blood to 1 part anticoagulant
I. Patient Management During Hemostasis Specimen Collection tube manufacturers indicate the allowable
Collection
range of collection volume error in package inserts
II. Hemostasis Specimen Collection Tubes
III. Hemostasis Specimen Collection Rules and provide a minimum volume line on each tube
IV. Specimen Collection Using Syringes and Winged-Needle In most cases, the volume of blood collected must be
Sets within 90% of the calibrated volume
V. Selection of Needles for Hemostasis Specimen
VI. Collection of Specimen from Vascular Access Devices Hemostasis Specimen Collection Rules: Short Draw
VII. Specimen Collection Using Capillary Puncture Specimen with a smaller volume than the minimum
VIII. Anticoagulant Used for Hemostasis Specimens
specified by the manufacturer—generates
IX. Other Anticoagulants Used for Hemostasis Specimens
erroneously prolonged clot-based coagulation test
Patient Management During Hemostasis Specimen results because the excess anticoagulant relative to
Collection blood volume neutralizes test reagent calcium
No fasting is required and little special preparation is only Short-draw specimens are consistently discarded,
needed before the collection of hemostasis laboratory and a fresh specimen is collected from the patient.
specimen.
Drugs that affect the outcomes of coagulation tests: Hemostasis Specimen Collection Rules: Winged Needle
Aspirin - suppresses most platelet function Most plastic blue-topped tubes collect 3.0 mL of
Coumadin (warfarin) - reduces the activities of factor whole blood; the smaller the collection tube, the
narrower the tolerance for short draws
II (prothrombin), factor VII, factor IX, factor X, protein
C, protein S, and protein Z and prolongs the When specimens are collected using winged-needle
prothrombin time (PT) test butterfly sets, the phlebotomist must compensate for
The phlebotomist should attempt to record all drugs the the internal volume of the tubing, which is usually 12
patient is currently taking inches long and contains approximately 0.5 mL of air.
Patients should be instructed by their physicians to
discontinue drugs that may interfere with coagulation test Hemostasis Specimen Collection Rules: Clots
results before testing Clotted specimens are useless for hemostasis testing,
If there is a reason to anticipate excessive bleeding—for even if the clot is small. Clotted specimens are
instance, if the patient has multiple bruises or mentions a discarded, and a new specimen is collected from the
tendency to bleed patient.
the phlebotomist should extend the time for observing A few seconds after collection, the phlebotomist must
the venipuncture site from 1 to 5 minutes and should gently invert the specimen at least five times to mix
apply a pressure bandage before dismissing the the blood with the anticoagulant and prevent clot
patient formation
If possible, the medical laboratory practitioner must
Hemostasis Specimen Collection Tubes visually examine for clots just before centrifugation
Most hemostasis laboratory procedures are and testing
performed on venous whole blood collected by
venipuncture and mixed 9:1 with 3.2% (0.105 to 0.109 Hemostasis Specimen Collection Rules: Mixing
mol/L) solution of buffered sodium citrate Excessive specimen agitation causes hemolysis
anticoagulant (RBC rupture), procoagulant activation, and platelet
Tubes of uncoated soda-lime glass are unsuitable activation
because their negative surface charge activates The phlebotomist must never shake the tube. The test
platelets and plasma procoagulants results from visibly hemolyzed specimens are
Siliconized (plastic-coated) glass tubes are available, unreliable, and the speci- men must be recollected
but their use is waning because of concern for
potential breakage, with consequent risk of exposure Hemostasis Specimen Collection Rules: Needle
to bloodborne pathogens Excess needle manipulation may promote the release
of procoagulant substances from the skin and
Hemostasis Specimen Collection Rules: Order of Tubes connective tis- sue, which contaminate the specimen
If the hemostasis specimen is part of a series of tubes and cause clotting factor activation.
to be fillled from a single venipuncture site, it must be Consequently, test results from specimens collected
collected first or immediately after a nonadditive tube. during a traumatic venipuncture may be falsely
The hemostasis tube may not imme- diately follow a shortened and unreliable
tube that contains:
o heparin (green stopper) Hemostasis Specimen Collection Rules: Tourniquet
o ethylenediamine tetraacetic acid (EDTA, During blood collection, the phlebotomist must
lavender stopper) remove
o sodium fluoride (gray stopper) the tourniquet within 1 minute of its application to
o clot-promoting silica particles as contained in avoid blood stasis
plastic red-topped or serum separator (gel) Stasis is a condition in which venous ow is slowed.
tubes Stasis results in the local accumulation of coagulation
factor VIII and von Willebrand factor (VWF), which
may result in false shortening of clot-based
coagulation test results.
***READ TABLE 42.1 PAGE 761*** Collection of Specimen from Vascular Access Devices
Blood specimens may be drawn from heparin or
Specimen Collection Using Syringes and Winged-Needle Sets saline locks, ports in intravenous lines, peripherally
The phlebotomist selects sterile syringes of 20 mL inserted central catheters (PICC tubes), central
capacity or less with nonthreaded Luer-slip hubs venous catheters, or dialysis catheters
The phlebotomist assembles: Vascular access device management requires strict
o Syringes adherence to protocol to ensure sterility, prevent
o winged needle set emboli, and prevent damage to the device.
o tubing clamp Personnel must be trained and must recognize the
o standard venipuncture materials signs of complications and take appropriate action
Institutional protocol may limit vascular access device
The phlebotomist then uses the following protocol: blood collection to physicians and nurses
1. Use standard patient identification and Before blood is collected for hemostasis testing, the
standard blood specimen management line must be flushed with 5 mL of saline, and the first
precautions 5 mL of blood, or six times the volume of the tube,
2. Most syringes are delivered with the plunger must be collected and discarded
withdrawn about 1 mm from the end of the The phlebotomist must not flush with heparin. Blood is
barrel. Move the plunger outward and inward collected into a syringe and transferred to an
within the barrel. Expel all air from the barrel evacuated tube as described in the prior section on
and affix the needle set to the Luer-slip hub. hemostasis specimen collection with syringes and
3. Optional: draw precisely measured winged needle sets
anticoagulant into the syringe prior to
collection Specimen Collection Using Capillary Puncture
4. Cleanse the venipuncture site, affix the Several near-patient testing (point-of-care)
tourniquet, and insert the winged needle. coagulometers generate PT results from a specimen
Immobilize the needle set by loosely taping consisting of 10 to 50 mL of whole blood
the tube to the arm about 2 inches from the These instruments are designed to test either
needle. anticoagulated venous whole blood or capillary
5. Fill the syringe using a gentle, even (finger-stick) blood and represent a significant
pressure. convenience to patients and to anticoagulation clinics.
6. Place the syringe on a clean surface and Many are designed for patient self-testing and
clamp the tubing with a hemostat near the pediatric or neonatal testing, and laboratory
needle hub. practitioners are often charged with training patients
7. Attach a second syringe if needed; release in proper capillary puncture technique
the clamp and fill the second syringe Capillary specimen punctures are made using sterile
8. Replace the clamp, remove the needle set, spring-loaded lancets designed to make a cut of
and immediately activate the needle cover. standard depth and width, while avoiding injury
The phlebotomist or patient selects and cleanses the
Selection of Needles for Hemostasis Specimen
middle or fourth (ring) finger and activates the device
Whether evacuated collection tubes or syringes are so that it produces a puncture that is just off-center of
used, the bore of the needle should be sufficient to the fingertip and perpendicular to the fingerprint lines
prevent hemolysis and activation of platelets and
After wiping away the first drop of blood, which is
plasma procoagulants.
likely to be contaminated by tissue fluid, the
If the overall specimen is 25 mL or less, a 20- or 21- phlebotomist places the collection device directly
gauge thin-walled needle is used adjacent to the free- owing blood and allows the
For a larger specimen, a 19-gauge needle is required. device to fill
A 23-gauge needle is acceptable for pediatric patients The phlebotomist wipes excess blood from the
or patients whose veins are small, but the negative outside of the device and introduces it to the
collection pressure must be reduced coagulometer to complete the assay
All needles provide safety closures that either cover The phlebotomist then presses a gauze pad to the
or blunt the needle immediately after completion of wound and instructs the patient to maintain pressure
the venipuncture until bleeding ceases
The key to accurate PT measurement is a free- owing
puncture
Often it is necessary for the phlebotomist to warm the
patient’s hand to increase blood flow to the fingertips.
Blood collection device distributors provide dry,
disposable warming devices for this purpose
The phlebotomist avoids squeezing (“milking”) the
finger, because this renders the blood specimen
inaccurate by raising the concentration of tissue fluid
relative to blood cells
Anticoagulants Used for Hemostasis Specimens
Sodium Citrate (Primary Hemostasis Anticoagulant)
The anticoagulant used for hemostasis testing is
buffered 3.2% (0.105 to 0.109 M) sodium citrate
o Formula: Na3C6H5O7 ⋅ 2H2O, molecular
weight 294.1 Daltons
Sodium citrate binds calcium ions to prevent
coagulation, and the buffer stabilizes specimen pH as
long as the tube stopper remains in place
The anticoagulant solution is mixed with blood to
produce a 9:1 ratio: 9 parts whole blood to 1 part
anticoagulant
In most cases, 0.3 mL of anticoagulant is mixed with
2.7 mL of whole blood, which are the volumes in the
most commonly used evacuated plastic collection
tubes, but any volumes are valid, provided that the
9:1 ratio is maintained.
The ratio yields a final citrate concentration of 10.5 to
10.9 mmol/L of anticoagulant in whole blood
Some laboratory practitioners prepare specimen
tubes locally for special hemostasis testing
Other Anticoagulants Used for Hemostasis Specimens
Likewise, acid citrate dextrose (ACD, yellow stopper)
and dipotassium EDTA (K2EDTA) with gel (white
stopper) tubes may be used for molecular diagnosis,
as specified by institutional protocol.
Heparinized specimens have never been validated for
use in plasma coagulation testing but may be
necessary in cases of platelet satellitosis (satellitism)
as a substitute for specimens collected in EDTA or
sodium citrate.
Citrate theophylline adenosine dipyridamole (CTAD,
blue stopper) tubes are used to halt in vitro platelet or
coagulation activation for:
o platelet activation markers platelet factor 4
(PF4)
o platelet surface membrane P-selectin
(measured by flow cytometry)
o coagulation activation markers prothrombin
fragment 1+2 and thrombin-antithrombin
complex