Chp#12 Blood Collection in Special Populations

Types of VAD's #1 Central Venous Catheter (CVC)

aka central line, is a long, thin, flexible tube used to give medicines, fluids, nutrients, or blood products over a long period of time, usually several weeks or more. A catheter is often inserted in the arm or chest through the skin into a large vein.

Anesthetics

the most common used is the EMLA cream (2.5% lidocaine, 2.5% prilocaine) in reducing distress, anxiety, and pain associated with phlebotomy in pediatric outpatients. When applied for a minimum of 45 to 60 minutes, extensive evidence supports reduction of pain. DO NOT use for PKU testing.

Precautions When Selecting a Puncture Site on the Heel

The puncture should NOT be done in a previous puncture site because of the possibility of infection. Do not do punctures in the central arch area of the foot. Puncture in this area may result in damage to nerves, tendons, and cartilage and offers no advantage over a heel puncture.

Pediatric collection

Collecting specimens from pediatric patients involves attention to different issues and using alternative procedures to obtain samples safely and with sensitivity. Use small needles and small tubes for children. (23g needle) capillary draws are best for patients younger than 2 yrs old. Butterfly needles are a good choice because the tubing allows for flexibility if the patient is struggling.

Newborn Screening

The Newborn Metabolic Screening Programme screens for rare but potentially serious disorders such as phenylketonuria (PKU), cystic fibrosis, and congenital hypothyroidism. A blood sample is taken from your baby's heel at or as soon as possible after 48 hours of age (the 'heel prick) aka: 'Guthrie' test. Newborn blood testing identifies almost all cases of phenylketonuria. All 50 states in the United States require newborns to be screened for PKU. Collected by capillary heel stick (dermal puncture)

#2 Broviac

A "HICKMAN"® catheter or "BROVIAC"® catheter is a long, hollow tube made of soft, rubber-like material called silicone, with an opening called a lumen. This catheter is commonly referred to as a central venous catheter because it is inserted into the large vein leading directly into the heart.

#3 Groshong

A Groshong line is a type of both tunneled or non-tunneled intravenous catheter used for central venous access. Groshongs may be left in place for extended periods and are used when long-term intravenous therapy is needed, such as for chemotherapy.

#4 Hickman

A Hickman line is a central venous catheter most often used for the administration of chemotherapy or other medications, as well as for the withdrawal of blood for analysis. Some types are used mainly for the purpose of apheresis or dialysis.

Peripherally inserted Central catheter (PICC)

A PICC line is a thin, soft, long catheter (tube) that is inserted into a vein in your arm, leg or neck. The tip of the catheter is positioned in a large vein that carries blood into the heart. The PICC line is used for long-term intravenous (IV) antibiotics, nutrition or medications, and for blood draws.

Neonatal Bilirubin test (Bili test)

A bilirubin test is a diagnostic blood test performed to measure levels of bile pigment in an individual's blood serum and to help evaluate liver function. If untreated can lead to brain damage and a condition called kernicterus. Collected by capillary heel puncture (dermal puncture). Bili test needs to be protected by light.

Dermal procedure for Infants

After identifying the newborn 1. Put on gloves 2. Warm and clean the heel with 70% alcohol 3. Allow to dry 4. Lance the appropriate side of the heel no more the 2.0mm 5. Wipe away the first drop of blood and wait for blood to flow again 6. Apply gentile pressure with thumb to form full drops of blood. 7. Collect blood using a micro tube (pedi tube). For dermal puncture follow only steps 1-7 for and 10. Newborn Screening test follow 1-10 8. Touch blood drops to printed side of filter paper and fill circles completely with one application 9. Keep the blood drops within the circles and fill the circles completely. 10. when completing the test apply pressure on the dermal puncture area and apply band-aid when the bleeding has stop.

Galactosemia

Babies with galactosemia lack the enzyme that converts galactose (one of two sugars found in lactose) into glucose, the major source of energy for the body's cells. For a baby with galactosemia, milk (including breast milk) and other dairy products must be removed from the diet. Otherwise, galactose can build up in the body and damage cells and organs, leading to blindness, severe intellectual disability, growth deficiency, and even death.

Immobilization

Children can be immobilized during a draw by wrapping newborns or infants in receiving blankets, Older children need to be restrained. They may be seated in the lap of a parent or assistant who hugs the child's body and holds it arm not being used in the draw, or they may be lying down with the parent or assistant leaning over the child, holding the unused arm securely.

Common Disorders

Common disorders affecting the elderly population includes hearing loss, stroke, arthritis, and tremors, all of which can make blood collection difficult. Extra care should be taken appropriate to each condition

Restraining a child

Don't ever think you won't need someone to help with a child. Be prepared for anything. Children can be very strong and may hit, kick, scream, bite and pinch if they don't want to have blood drawn. Ask a parent to help you hold the child.

Parents and guardians

Earn their trust. You must be calm, confident and caring. Offer the option to stay in the room or wait outside while you perform the draw. Some parents do not handle very well seeing their child get stuck, so they might be better off staying away from the draw area.

Site selection

For children younger than 2, limit your choice of site to superficial veins—those not deep or hard to find. Venipuncture takes less time than a finger stick and usually produces a better specimen. For children younger than 1 and who are not walking or standing on their feet, a heel puncture can be performed.(Depth of heel puncture no more than 2.0mm)

Older children: <10 years of age

Gain their trust by being patient and friendly. Never tell them the stick won't hurt. Explain the importance of holding still. It may be helpful to give the child a job, such as holding the gauze or bandage. Offer a reward for being as brave as they can

Phenylketonuria (PKU)

Phenylketonuria (PKU) is a condition in which the body cannot break down one of the amino acids found in proteins. PKU is considered an amino acid condition because people with PKU cannot break down the amino acid called phenylalanine. If left untreated, PKU can cause brain damage or even death. However, if the condition is detected early and treatment is begun, individuals with PKU can lead healthy lives.

Pediatric (Children)

Phlebotomy for a child can be a very frightening experience. Special considerations must always be taken when performing pediatric phlebotomy. The patient's comfort should be the primary importance.

physical changes in a geriatric patient

Physical changes the elderly undergo include skin that is less elastic and thinner, a tendency to bruise more easily, longer healing times, more fragile, less elastic, and narrower blood vessels, loss of supporting connective tissue, leading to loose skin, loss of muscle tissue, allowing veins to move from their usual locations, and arteries that are closer to the surface.

#5 Triple Lumen VAD

The number of lumens within an MLC varies from two to four. For example, an MLC with three separate tubes (lumens) combined into one catheter is called a triple-lumen catheter. The multiple ports allow for administration of medications, blood infusions, blood sampling, fluid replacement, and pressure monitoring.

Congenital Hypothyroidism

The thyroid, a gland at the front of the neck, releases special chemicals called hormones that control metabolism and growth. These hormones control how fast the body uses up energy and are also key factors in helping kids grow. Babies with congenital hypothryoidism don't have enough thyroid hormone. The condition can cause slow growth and brain development. If congenital hypothryoidism is detected early, a baby can be treated with oral doses of thyroid hormone.

Special considerations for blood collection

To preform a draw on an elderly patent, be especially careful with patient identification; be aware of the frequency of blood draws; be especially gentle; do not apply the tourniquet as tightly; place the arm on a pillow and have the patient grip a washcloth wile the arm is supported by rolled towels, do not slap the arm to find a vein; anchor the vein firmly; and apply pressure longer to ensure bleeding has stopped.

psychological complications

a child may experience a fear of the unknown and a fear of pain. As a phlebotomist, you must explain the procedure in detail to the child, using words the child understands. The phlebotomist should speak to the child during the entire procedure, letting the child know how much longer the procedure will last. prolong crying affects the white blood cells (WBC) count and PH level of blood.

Maple Syrup Urine Disease (MSUD)

urine disease (MSUD) are missing an enzyme needed to process three amino acids needed for the body's normal growth. When these amino acids aren't processed correctly, they can build up in the body. If not detected and treated early, MSUD can cause intellectual disability, physical disability, and even death.

Heparin lock or saline lock

A device attached to an intravenous catheter to prevent it from clotting. It is used for intermittent administration of fluids or medication then flushed with saline, and then capped off for later use.

IV line

A peripheral IV line (PVC or PIV) consists of a short catheter (a few centimeters long) inserted through the skin into a peripheral vein. Phlebotomist should draw blood from the opposite arm or hand or below IV line. If drawn from that vein, the specimen may be contaminated and diluted by the IV fluid; the blood test results could then be erroneous.

Biotinidase Deficiency

Babies with biotinidase deficiency don't have enough biotinidase, an enzyme that recycles biotin (a B vitamin) in the body. Biotinidase deficiency may cause seizures, poor muscle control, problems with the immune system, hearing loss, intellectual disability, coma, and even death.

Vascular Access Device (VAD)

It is a tube that is inserted into either a vein or an artery and is used to administer fluids or medications, monitor blood pressure, or draw blood.

Dermal Puncture

aka skin puncture or capillary blood collection involves puncturing the dermis layer of the skin to access the capillary beds which run through the subcutaneous layer of the skin. ... Capillary blood collection is the preferred method of blood specimen collection for newborns and infants. For adults due a finger-stick s of the non dominant hand , 3rd(middle) and 4th (ring) finger. Do NOT use the index fingers as more nerve endings. Lancet should never penetrate more than 3.0mm

Site selection dermal puncture

an appropriate site for skin puncture should appear warm and pink. Avoid areas which have scars, cuts, bruises or rashes. Do not choose a site that is cold, cyanotic or edematous. The heel is the recommended site for collection of skin puncture specimens on infants less than 1 year old. Heel sticks must not exceed 2.0 mm. Massage with your thumb and forefinger or gentle squeezing.

Sickle Cell Disease

is a blood disorder that's inherited (meaning it's passed down from parents to their children). It affects a protein in red blood cells called hemoglobin that helps carry oxygen throughout the body. Red blood cells with normal hemoglobin move easily through the bloodstream because of their rounded shape and flexibility. But sickle cell disease makes red blood cells form into a curved, sickle shape. These cells also become sticky, stiff, and more fragile. This makes it hard for them to move through the bloodstream.

Congenital Adrenal Hyperplasia (CAH)

is a group of disorders involving hormones produced by the adrenal gland. CAH can affect both boys and girls. It causes the adrenal glands to make excess androgens (male steroid hormones) and, in some cases, not enough of the hormones that regulate the body's salt balance.

Arterial line

is a thin catheter inserted into an artery. It is most commonly used in intensive care medicine and anesthesia to monitor blood pressure directly and in real-time (rather than by intermittent and indirect measurement) and to obtain samples for arterial blood gas analysis.

Jaundice

is a yellow tint to a newborn's skin and the white part of the eyes. It is a sign that there's too much bilirubin in the baby's blood. The word for having too much bilirubin in the blood is hyperbilirubinemia. Collected by capillary heel stick.