Special Collections
and Procedures
Chapter 14
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Learning Objectives
Lesson 14.1: Specimen Types, Therapeutic
Drug Monitoring, and Blood Cultures
(Slide 1 of 2)
1. Define and explain the uses of:
a. Fasting specimens
b. Timed specimens
2. Describe diurnal variation and list the blood
constituents that may be affected by it.
3. Define therapeutic drug monitoring (TDM),
describe the differences among a random level
and peak and trough levels and explain how TDM
samples are collected.
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Learning Objectives
Lesson 14.1: Specimen Types, Therapeutic
Drug Monitoring, and Blood Cultures
(Slide 2 of 2)
4. Define the procedure for performing various
tolerance tests.
5. Describe the reasons and procedures for
collecting blood for culture.
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Factors That Influence
Blood Composition
Age Medication
Alcohol consumption Medical treatment
Altitude Obesity
Dehydration Posture
Diet
Diurnal variation Pregnancy
Exercise Smoking
Gender Stress
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Fasting Specimens
When patient has not had anything to eat or drink
(except water) for 8 hours
If fasting specimen is requested, phlebotomist
must ask patient if he or she has had anything to
eat or drink other than water, or has had any
caffeine or nicotine, within the past 8 hours
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Timed Specimens
Timed specimens are most often used to monitor:
Medication levels
Changes in the patient’s condition
Normal diurnal variation of various substances
throughout the day
Cardiac enzymes, used to diagnose or rule out
myocardial infarction (heart attack); these are tested at
admission and then twice more at 8-hour intervals
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Diurnal Variation
Refers to the normal daily fluctuations in body
chemistry related to hormonal cycles, sleep-wake
cycles, and other regular patterns of change
Many substances in the blood (especially
hormones) show diurnal variation, or regular
changes throughout the day
Cortisol, for instance, is usually twice as high in
the morning as in the late afternoon
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Representative Blood Constituents that
Show Marked Diurnal Variation
Cortisol
Estradiol
Progesterone
Testosterone
Other hormones
Serum iron
Glucose
White blood cells (eosinophils show especially
pronounced variation)
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Therapeutic Drug Monitoring
(Slide 1 of 2)
Patients differ greatly in the rate at which they
metabolize or excrete medications
To maintain constant therapeutic plasma drug
levels and ensure that drug does not reach toxic
levels, a patient may require timed specimens to
measure medication levels
The rate of metabolism is often given in terms of
drug’s half-life
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Therapeutic Drug Monitoring
(Slide 2 of 2)
Collection is usually timed to coincide with either
the trough or the peak serum level
The trough level is the lowest serum level and
occurs immediately before the next dose of
medicine is given
The peak level, or highest serum level, occurs
sometime after the dose is given; exactly when
depends on the characteristics of the drug, the
patient’s own metabolism, and the method of
administration
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Diabetes Testing
Four types of diabetes:
Type 1
Type 2
Gestational
Diabetes caused by other causes
Diagnoses of diabetes or prediabetes relies on
results of four tests:
Glycated hemoglobin (A1C)
Fasting glucose
Random glucose
Oral glucose tolerance test (OGTT)
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Oral Glucose Tolerance Test
(Slide 1 of 2)
Tests for both diabetes and other disorders of
carbohydrate metabolism
Measures change in blood glucose after drinking
very sweet solution
Fallen out of use for the diagnosis of diabetes;
been replaced by either hemoglobin A1C or
fasting glucose sample
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Oral Glucose Tolerance Test
(Slide 2 of 2)
Glucose testing is still widely
used in pregnant woman to
diagnose gestational diabetes
2-hr glucose tolerance test
(GTT)
Fasting, 1 hr, and 2 hr
3-hr GTT
Fasting, 1 hr, 2 hr, and 3 hr
5-hr GTT
Fasting, 1 hr, 2 hr, 3 hr, 4 hr,
and 5 hr
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Other Tolerance Tests
The lactose tolerance test (LTT) determines
whether the lactose-digesting enzyme lactase is
present in the gut
Stool acidity test may be ordered for patients and
children who are unable to undergo other tests
Lactic acid and other acids from undigested
lactose can be detected in a stool, or fecal, sample
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Blood Cultures
A blood culture (BC) is ordered to detect the
presence of microorganisms in the blood, a
potentially life-threatening situation
Such microorganisms include bacteria, fungi, and
protozoa
Bacteremia refers specifically to the presence of
bacteria in the blood
Septicemia is a life-threatening infection caused
by rapid multiplication of pathogens in the
bloodstream
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Types of Collection Containers
There are three basic types of containers for
collecting BCs
A long-necked bottle, which accepts a BD Vacutainer
needle and tube holder
A shorter bottle, which accepts a winged infusion
device, such as a BD Bactec, using a special adapter
A standard evacuated tube with sodium polyanethole
sulfonate (SPS) anticoagulant
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Site Preparation with Antiseptics
Proper antiseptic preparation of skin reduces
presence of normal skin flora contaminants in the
BC sample
Reducing risk of false positive
Alcoholic preparations of iodine, povidone-iodine,
or chlorohexide gluconate (CHG): preferred
antiseptics
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Timing
The number of organisms in the bloodstream is
often highest just before a spike in the patient’s
temperature
By frequently recording the temperature, these
spikes can often be predicted and collection
scheduled accordingly
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Multiple Sites
Contamination of the sample by skin bacteria is a
frequent complication of BC collection
However, distinguishing contaminants from true
pathogens can be difficult because some
contaminants can grow on indwelling devices,
causing infection in the patient
To reduce errors caused by this contamination, a
known skin contaminant must be cultured from at
least two different sites to be considered a blood
pathogen
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Blood Culture Collection
(Slide 1 of 2)
Prepare the site
After identifying the site, scrub it vigorously with
alcohol to clean 1½ to 2 inches beyond the intended
puncture site
Scrub vigorously with 2% iodine or a povidone–iodine
swab stick
Avoid touching the site once it has been cleaned
Prepare your collection equipment
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Blood Culture Collection
(Slide 2 of 2)
Collect the sample
Reapply the tourniquet, and perform the venipuncture
Attend to the patient
After collection, remove the iodine from the patient’s
arm with alcohol
Check the puncture site to be sure bleeding has stopped
Apply a bandage, using a fresh adhesive bandage or
placing adhesive tape over the gauze square
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Learning Objectives
Lesson 14.2: Blood Donor
Collection and Blood Smears
(Slide 1 of 2)
6. Explain the steps in collecting blood from donors for
transfusion.
7. Define and explain the uses of autologous donation
and therapeutic phlebotomy.
8. Explain how samples to be tested for or suspected of
containing cold agglutinins, cryofibrinogen, or
cryoglobulin should be handled.
9. List samples that should be chilled until tested.
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Learning Objectives
Lesson 14.2: Blood Donor
Collection and Blood Smears
(Slide 2 of 2)
10. List samples that are light sensitive, and explain how
they should be handled.
11. Describe the precautions to be taken when collecting
legal or forensic specimens.
12. List samples that are time sensitive, and explain how
they should be handled.
13. Explain how to prepare blood smears, describe features
of unacceptable smears, and list the possible causes.
14. Explain how to prepare smears to be examined for
malaria.
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Blood Donor Collection
(Slide 1 of 2)
Blood donation is a vital link in the healthcare
system, and the phlebotomist plays a central role
in the collection of donated blood
Blood banks collect and store donated blood for
use in both emergency and scheduled transfusions
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Blood Donor Collection
(Slide 2 of 2)
Potential donors must be screened to ensure that
the donation is not harmful to the donor or the
recipient
Screening involves the following:
Registration
Interview and medical history
Physical examination
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Collection Procedure
Blood is collected by the unit, whose volume is 400
to 500 mL, or approximately 0.5 L
It is collected directly into a sterile plastic bag,
which hangs below the collection site and fills by
gravity
The weight of the filled bag triggers a clamp that
stops the collection
A 16- to 18-gauge needle is used for collection
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Autologous Donation
An autologous donation is blood donated by a
patient for his or her own use later
Patients planning surgery often make autologous
donations before the procedure
Because multiple units might be needed during
surgery, patients may need to donate several times
A patient can donate as often as every 72 hours,
assuming that his or her health is good
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Therapeutic Phlebotomy
Therapeutic phlebotomy is the removal of blood
from a patient’s system as part of the treatment for
a disorder
The principal disorders treated by therapeutic
phlebotomy are polycythemia, a disease
characterized by excessive production of red
blood cells (RBCs), and hemochromatosis, an
excess of iron in the blood
In both cases, periodic removal of a unit of blood
may be part of the treatment program
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Cold Agglutinins
Cold agglutinins are antibodies often formed in
response to infection with Mycoplasma
pneumoniae, a cause of atypical pneumonia
The antibodies created by the immune system
during the infection may also react with RBCs at
temperatures below body temperature, causing
them to stick together, hence cold agglutinins
(agglutination is the process of sticking together)
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Cryofibrinogen and Cryoglobulin
Warm collection and storage are required for two
other types of samples: cryofibrinogen (an
abnormal type of fibrinogen) and cryoglobulin (an
abnormal serum protein)
These samples should be collected and handled in
the same manner as a cold agglutinin sample
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Chilled Specimens
A number of tests require that the specimen be
chilled immediately after collection
Chilling is used to prevent chemical changes that
would alter test results
The sample should be placed in crushed ice or in
an ice and water mixture and immediately
delivered to the laboratory
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Light-Sensitive Specimens
Exposure to light can break down or alter certain
blood constituents
Specimens to be tested for these constituents must
be protected from light after collection
This is done by wrapping the tube in aluminum
foil immediately after collection
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Legal and Forensic Specimens
(Slide 1 of 2)
Blood specimens may be collected for use as
evidence in legal proceedings, including alcohol
and drug testing, deoxyribonucleic acid (DNA)
analysis, or paternity or parentage testing
The most important concept in handling forensic
specimens is the chain of custody (COC), a
protocol that ensures that the sample is always in
the custody of a person legally entrusted to be in
control of it
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Legal and Forensic Specimens
(Slide 2 of 2)
The purpose and procedure of the test must be
explained to the patient
The patient must sign a consent form
The patient must present picture identification
The specimen must be labeled appropriately to
establish a COC
The specimen must be sealed in such a way that any
tampering can be identified
The specimen must be placed in a locked container
before transport to the testing site
The recipient must sign for delivery of specimen
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Legal Alcohol Collection
Important features of alcohol testing include the
following:
The site must not be cleaned with alcohol, as this would
falsely elevate the result
Tubes must be filled as full as the vacuum allows to
minimize the escape of alcohol from the specimen into
the space above
Note on the requisition form that the site was cleansed
with soap and water or another a nonalcoholic solution
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Time-Sensitive Blood Constituents
Adrenocorticotropic hormone (ACTH)
Ammonia
Brain natriuretic peptide
Lactate
Platelet aggregation
Prostatic acid phosphatase
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Blood Smears
Blood smears are made to allow microscopic
examination of the blood cells
The blood smear is used for determining the
proportion of the various blood cell types, called a
differential count; counting reticulocytes; and
performing special staining procedures
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Blood Smear Preparation
(Slide 1 of 2)
Prepare the smears
Place one drop of blood on a clean slide, ½ to 1 inch
from the end, centered between the two sides
Place the edge of a second slide, the “spreader,” onto
the first slide in front of the blood at a 25- to 30-degree
angle, and draw it back to just contact the drop
Move the spreader slide forward, away from the drop,
in one continuous movement to the end of the slide
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Blood Smear Preparation
(Slide 2 of 2)
Examine the smears
An acceptable smear
must have a feathered
edge, meaning that the
cells appear to thin out
farther from the
original drop
At the far end, you
should see a very thin
transparent layer
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Unacceptable Smears
and Their Causes
(Slide 1 of 2)
Holes in the smear
Dirty slide
Smear that is too thick and long
Drop that is too large
Drop that is not placed close enough to far edge of slide
Spreader slide that is lifted before it reaches end of
sample slide
Smear that is too thick and long
Drop of blood that is too big
Angle of spreader slide > 30 degrees
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Unacceptable Smears
and Their Causes
(Slide 2 of 2)
Smear that is too thin and short
Drop of blood that is too small
Angle of spreader slide <25 degrees
Streaks in the feathered edge
Chipped or dirty spreader slide
Spreader slide that is not placed flush against smear
slide
Drop of blood that is in front of spreader slide
Uneven distribution of blood
Uneven pressure on spreader slide
Uneven movement of the spreader slide
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Malaria Smears
(Slide 1 of 2)
Malaria is caused by blood-borne protozoa of the
genus Plasmodium
A patient with malaria has cycles of fever and
chills that coincide with the life cycle of the
parasite in the bloodstream
Malaria is diagnosed with a blood smear, drawn as
a stat or timed collection just before the onset of
fever or chills
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Malaria Smears
(Slide 2 of 2)
To make the thick smear, use a larger drop of blood, and
spread it out to only about the size of a dime
Sample must be allowed to dry for at least 2 hours; then
stained to reveal parasites
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Questions?
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