Phlebotomy & Donor Reactions Phlebotomy What is Phlebotomy

Phlebotomy & Donor Reactions Phlebotomy What is Phlebotomy

Phlebotomy & Donor Reactions Phlebotomy What is Phlebotomy Greek words phleba-, meaning "vein and -tomy, meaning "to make an incision of"

Done by a trained phlebotomist. Indications for blood sampling and blood collection Laboratory tests for clinical management and health assessment. Arterial blood gases for patients on mechanical ventilation, to monitor blood oxygenation; Neonatal and paediatric blood sampling heel-prick (i.e. capillary sampling);

scalp veins in paediatrics Capillary sampling (i.e. finger or heel-pricks or, rarely, an ear lobe puncture) e.g - testing of Hemoglobin levels before blood donation, - blood glucose monitoring, and - rapid tests for HIV, malaria and syphilis. Blood collection - Routine Blood Donation - Therapeutic Phlebotomy

Preliminary Steps Phlebotomist should introduce him/herself to the donor in a cheerful manner Responsibility of the phlebotomist to make certain that all blood unit numbers on the donor record, collection bags, and specimen tubes match and are applied properly Donor identification is the single most important process of the

phlebotomy procedure Site of Phlebotomy Usually cubital fossa is chosen as the vein as it is palpable and required volume of blood can be easily drawn from this vein Examination of the area chosen for the Venipuncture Should have no local infections Site examination

Check the site as professional donors/drug abusers will have multiple punctures Collection is a sterile process so surgical environment should be maintained Both the phlebotomist and the donor should follow the hand washing procedures Vein Selection

Often the best veins to use are not the ones seen most easily. Differences in the anatomy of arms among donors may cause problems in proper vein selection. Vein location may differ from donor to donor. It is essential for the phlebotomist to know the general anatomy of the arm. Differences b/w Artery and Vein Donor care

Before, during and after donation Donating blood should be a pleasant experience The venue must be a safe place for the donor The venue must be comfortable - temperature, surroundings

Staff must be trained in interpersonal skills Adverse reactions Facilities to deal with any reactions before, during or after donation Pre- Donation Checks of Equipment All equipment and materials must be Correct Clean

Calibrated Checked for performance Ready for use Equipments & Material Required in Donation Room

Donor Couch Blood Bags Blood collection mixer Needle destroyer

Tube sealer Alcohol Swabs Stripper Spirit & iodine BP instruments Donor Identification Correct identification of the donor At reception

Immediately before venipuncture Cross- check the donor with available records Name, address, date of birth Re-check the donors identity Phlebotomy To be performed by a trained person Usually cubital fossa is chosen as the vein is palpable and required volume of blood can be easily drawn from this vein

Examination of the area chosen for the venipuncture Should have no local infections Preparation of the area BP cuff should be tied and pressure maintained at 40-60 mm Hg Tourniquet should be used carefully, as the pressure applied cannot be gauged. No local anaesthetic drug need to be administered

Donor Arm Cleaning Important to minimise risk of bacterial contamination during vene puncture Follow the SOP for Methodology and selection of cleansing agent Trained staff Assessment of Compliance and effectiveness Cleaning the area

Deflate the cuff and clean the area selected Spirit /alcohol swab and iodine should be used to do this Savlon etc. is not recommended.

Clean 4-5cms area in a concentric centrifugal pattern Do not touch the cleaned area after preparation. Procedure Apply tourniquet or blood pressure cuff at 60 mm Hg to upper arm.

Have donor open and close fist several times, holding gripper tightly Remove needle protector Using thumb of free hand placed well below prepared area - pull skin taut. - inform donor that you are ready to perform venipuncture. Holding needle at a 30- to 45-degree angle, pierce skin with a quick thrust. When bevel is completely under skin, lower angle of needle to 10-15 and advance into vein Release clamp to let blood flow

Instruct donor to relax hand and give gripper a slow, firm squeeze every 5-10 seconds. Secure needle and tubing by placing tape Loosen tourniquet or lower blood pressure cuff to 40-60 mm Hg. Record necessary information on bag and donor records according to facility policies and procedures The procedure takes about 5-10minutes Donor should not be left unattended

Bag should be periodically mixed so that uniform mixing of anticoagulant with blood occurs 1ml of blood=1.05gm 350ml=367gms+weight of the bag Monitoring Blood Collection

Constant monitoring during donation Smooth Blood flow Gentle mixing of blood Collection time -5-10 min Appropriate Volume collected = 10 % of desired volume Sample collection

-Identity checks -Correct handling -Labeling After the procedure

Deflate the cuff once the procedure is over Clamp the tubing Place the sterile swab and withdraw the needle Apply pressure and let the donor lie down for 5 minutes Do not recap the needle Stripping of tubings should be done to mix the blood in tubing with anticoagulated blood in the bag Collect Pilot samples for serology & grouping

Seal tube at least 5 segments Post Donation Care Donor should be constantly observed Apply medicated adhesive when oozing stops

Check for any haematoma Check for any hypovolemic signs Post Donation Care (contd) Make them rest for 8-10 minutes before they go to refreshment area It is mandatory to provide light refreshments to the donors They should be observed for another 10 minutes while in refreshment area. Make sure they are completely alright

Post-donation instructions Instructions to the donor after the donation 1.Drink more fluids than usual in the next 4 hours. Do not remain hungry. 2.Do not smoke for half an hour. 3.Do not take alcoholic drinks for atleast 6 hours. 4.If there is bleeding from phlebotomy site, raise the arm and apply pressure. 5. If there is feeling of faintness or dizziness, donor should be in lie-down

position or sit with head between knees. If symptoms persist, ask for help, return to the bloodbank or consult a doctor. 6. Remove the bandage/band-aid after 5-6 hours ADVERSE DONOR REACTIONS Donor Reaction Localized Reaction

1. 2. 3. 4. 5. Bruise or Hematoma Phlebitis and Cellulitis Nerve Injury Puncture of artery

Upper extremity Deep Vein Thrombosis Systemic Reaction 1. Vasovagal Attack 2. Tetany 3. Air Embolism Bruise or Hematoma

One of the most common complications May be immediate of or Delayed Majority of cases restricted to small area in antecubital fossa Bruise or Hematoma ManagementImmediate Case-

1. Deflate blood pressure cuff. Withdraw the needle from the vein if enlarging hematoma. 2. Place 3-4 gauze pieces over the hematoma apply digital pressure for 7-10 mins keeping donors arm above heart level. 3. Apply ice to the area for 5mins. Delayed- 4. Ice compression and analgesic if necessary 5. Keeping hand in rest. Avoid working by affected hand. 6. Observation and informing donor regarding compartment syndrome & refer if necessary

OutcomeGenerally resolve completely within 7-14 days and do not prevent donors from donating again Phlebitis and Cellulitis Incidence- 1 in 50000 to 1 in 100000 Mild phlebitis at the venepuncture site is common, self-limited and usually of little consequence. PresentationMild discomfort, small swelling, pain, local linear or surrounding erythema

ComplicationDespite a seemingly benign appearance, it may extend to local abscess formation or septic phlebitis Phlebitis and Cellulitis Management Warm Compression Oral Analgesic and anti inflammatory agents Administration of oral antibiotics Nerve Injury

Incidence- Approx. 2/10,000 donations Cutaneous branches of the medial and ulnar nerves are injured occasionally by large bore phlebotomy needle. Direct nerve damage from the phlebotomy needle is not very common. Injuries are generally transient and rarely a source of donor distress. Nerve Injury Presentation- Immediate severe shooting and radiating pain

(earliest presentation), paraesthesias, sensory changes in forearm, wrist, hand. rarely loss of arm strength Outcome- 70% of nerve injury usually disappear within a month, almost all resolve within one year. Rare cases of complex regional pain syndrome (Reflex sympathetic dystrophy) has been reported. Prevention- To reduce the risk of direct nerve injury need should be inserted only once and no further manipulation or attempt ( single prick

strategy) Puncture of Artery Incidence- 1/10,000 donations More common among inexperienced phlebotomists than those with experience. Presence of bright red blood, rapid collection (within seconds), and a pulsating needle suggest arterial puncture are indicators of arterial puncture

Puncture of Artery ManagementNeedle should be taken out early and local pressure should me applied for an extended period. ComplicationsHematomas, compartment syndrome, delayed nerve injury may happen Most donors recover quickly and completely. Follow upShould be evaluated for pseudoaneurysm by ultrasound and doppler studies. Upper Extremity Deep Vein Thrombosis Very rare delayed type of complication

Symptoms- Pain in the upper limb Swelling of the arm Prominent palpable, cord like thickening of the thrombosed vein Investigation- Ultrasonography doppler study should be used as an screening tool Upper Extremity Deep Vein Thrombosis Management- Thrombolysis is done by

unfractionated heparin. Anticoagulants is used like Dabigatran, Rivaroxaban, Apixaban, Wafarin in uncomplicated cases. Systemic Reactions Vasovagal Reaction Most common systemic reaction Incidence- 250/10000 donations

Predisposing factors- First time donors Donors with low weight H/o previous adverse reaction Donor in Fasting state > 4hours Inadequate sleep last night Symptoms Chills or cold extremities,

Feeling of warmth Light- Headedness Nausea Pallor Weakness Hyperventilation Declaration of nervousness ( Anxiety) Sweating Signs

Hypotension Tachycardia or Bradycardia Syncope Seizure Activity ( Tonic- Clonic Convulsion)

Twiching 3 types according to severity1. Mild 2. Moderate 3. Severe Mild vasovagal reaction Present with one or more

Nausea, dizziness, hyperventilation, vomiting, twitching and muscle spasm, sweating etc. Usually brought about by the sight of blood or needle. Management-

Remove tourniquet and withdraw needle Raise Donors leg above the level of head of Head Loosen tight clothing and secure airway Monitor vital signs Cold compress to the neck or forehead Moderate vasovagal reaction Mild vasovagal reaction + loss of consciousness May be associated with decreased pulse rate, may hyperventilate, may exhibit a

fall in systolic pressure to 60mm Hg. Management Check Vital signs frequently Raise Donors leg above the

level of head of Head Administer 95% oxygen and 5% carbon-di-oxide Severe vasovagal reaction A donor experiencing convulsion defines a severe reaction. May be caused by-

1. Cerebral Ischemia, 2. Marked hyperventilation, 3. Epilepsy May be associated with vasovagal syncope, reduced blood flow to brain owing to shock symptoms. Management-

Prevention of further injury due to fall Ensure an adequate airway Use anticonvulsant to manage Seizure Administer 95% oxygen and 5% carbon di oxide Monitoring vitals

In case of Cardiac and respiratory difficulties perform CPR Tetany Occasionally observed in blood donors Incidence- 1/1000 donors

Predominantly seen in nervous subjects Thought to be due to hyperventilation which causes excited donor to lose excess of carbon dioxide. Presents with twitching, muscular spasm, carpopedal spasm, laryngismus, stridulus and positive Chvosteks sign. Management- Make the donor as comfortable as possible

Rebreathing in a proper bag which brings prompt relief Inhaling 5% carbon dioxide from a cylinder Ask the donor to breath slowly and shallow Air Embolism Rare incident now-a-days When blood is taken into plastic bags that contain no air, no possibility if air embolism When blood is taken into glass bottle air embolism may happen.

It may happen in some instruments of Apheresis. Prime cause of air embolism in this circumstance is obstruction to the air vent of the bottle. Allergic Reaction Donor may be hypersensitive to sterilizers specially ethylene oxide, ethly alcohol etc. Symptoms and signs- Hives, difficulty in breathing, wheezing, hypotension or hypertension, tachycardia or bradycardia, facial swelling or flushing, burning eyes, angioedema etc. Even anaphylaxis may happen.

ManagementInj. Promethzine ( Any antihistaminic) Inj. Hydrocortisone if necessary Citrate Induced Hypocalcemia Citrate anticoagulants, used in apheresis donor collections, exerts effect by binding to calcium avoid clotting of blood. Symptoms- 1. 2.

3. 4. 5. 6. Perioral or peripheral paresthesias or both, Unusual taste, Transient nausea, Light-headedness, Muscle Cramps

Dysphagia Citrate Induced Hypocalcemia Signs1. 2. 3. 4. 5. 6. 7.

Carpopedal Spasm, Tetany ( May be present if associated with hyperkalamia) Change in pulse, Tremor, Chvosteks sign, Seizure ( Grand mal, Petit mal) Laryngospasm Management Reducing citrate infusion rate

Administering calcium tablets for mild to moderate cases For severe cases termination of collection and Shifting the donor to Emergency Department Vitals monitoring, ECG Electrolyte monitoring Calcium gluconate injection if necessary (Inj Calcium Gluconate 10% IV over 10 to

15mins) Prevention of Donor Reaction Post Donation Care

Pressure should be applied on the venepuncture site for sometime Venepuncture dressing should be kept for 24 hours Strenuous exercise should be avoided for next 24hours

Plenty of fluids to be taken Heavy weights should not be lifted using the venepuncture arm Prolonged standing should be avoided for rest of the day Any illness within 2 weeks to be reported at the Transfusion medicine department Avoid smoking and alcohol Refrain from works specially pilots, drivers, police and surgeon If feeling faint or vertigo Donor should sit down and lower his head Some strategies can be taken-

Predonation Education- specially among first time donors by motivational audio-visual aids regarding need for blood in the community Drive set up and environment- A well planned, adequately staffed and organized lay out of blood donation area or donation camp. Staff supervision & phlebotomist skill- An experienced phlebotomy staff and adequate supervision is important to reduce adverse incidents. Distraction- Fear and

associated anxiety is an important factor associated with donor reaction. Distraction techniques have shown to reduce the no of donor reactions. Water Ingestion 350-500ml drinking water 30minutes before whole blood donation

The mechanism related to increased gastric distension which increases sympathetic tone and overall peripheral resistance, BP and cerebral Blood flow. Applied Muscle Tension (AMT)- AMT in combination with water hydration is a fairly new concept in preventing presyncopal and syncopal reactions.

AMT involves Repetitive contraction of major muscle groups of the arms and legs and there by promoting venous return and cardiac output which affects cerebral blood flow. Salty Snacks- The amount of salt we consume daily affects the volume of our extracellular

fluid. Increased dietary Sodium improves orthostatic tolerance in blood donors. The addition of salty snacks before and immediately after donation is a low cost attractive approach to prevent donor reaction.

DONOR HAEMOVIGILANCE Haemovigilance Programme of India has been formed jointly by National Institute of Biologicals & Indian Pharmacopoeia Commission Collaboration on 10th December, 2012 and Donor Hemovigilance was started on 14th June 2015. Every blood bank have to keep records of donor reaction in their own registry and in every month they have to register it in Blood Donor Vigilance Programme Of India maintained by National Institute of

Biologicals. References WHO guidelines on drawing blood: best practices in phlebotomy

Technical Manual- 18th Edition, AABB publication Transfusion Medicine And Hemostasis, 2nd Edition, Beth H. Shaz, Christopher D. Hillyer, Elsivier Publication Rossis Principles of transfusion Medicine- 5th Edition, Wiley Blackwell Publication Mollisons Blood Transfusion in Clinical Practice- 12th Edition, Harvey G. Klein, David J.Anstee, Wiley Blackwell Publication Transfusion Medicine Technical Manual,Directorate General of Health Sciences Immunohematology and Transfusion Medicine, Mark T. Friedman, Kamille A. West, Springer Publication Modern Blood Banking and Transfusion Practices- 6th Edition, Demise M. Harmening, F.A Davis Company

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