Phlebotomy

Phlebotomy is the process of making a puncture in a vein, usually in the arm, with a cannula for the purpose of drawing blood.[1] The procedure itself is known as a venipuncture, which is also used for intravenous therapy. A person who performs a phlebotomy is called a phlebotomist, although most doctors, nurses, and other technicians can also carry out a phlebotomy.[2] In contrast, phlebectomy is the removal of a vein.

Phlebotomy
Students practising phlebotomy
ICD-9-CM38.99
MeSHD018962

Phlebotomies that are carried out in the treatment of some blood disorders are known as therapeutic phlebotomies.[3] The average volume of whole blood drawn in a therapeutic phlebotomy to an adult is 1 unit (450-500 ml) weekly to once every several months, as needed.[4]

Etymology

From Ancient Greek: φλεβοτομία (phlebotomia – phleb 'blood vessel, vein' + tomia 'cutting'), via Old French: flebothomie (modern French phlébotomie).

Phlebotomies

Phlebotomies are carried out by phlebotomists – people trained to draw blood mostly from veins for clinical or medical testing, transfusions, donations, or research. Blood is collected primarily by performing venipunctures, or by using capillary blood sampling with[5] fingersticks or a heel stick in infants for the collection of minute quantities of blood.[6] The duties of a phlebotomist may include interpreting the tests requested, drawing blood into the correct tubes with the proper additives, accurately explaining the procedure to the person and preparing them accordingly, practicing the required forms of asepsis, practicing standard and universal precautions, restoring hemostasis of the puncture site, giving instructions on post-puncture care, affixing tubes with electronically printed labels, and delivering specimens to a laboratory.[7] Some countries, states, or districts require that phlebotomists be licensed or registered.

A therapeutic phlebotomy may be carried out in the treatment of some blood disorders (example: Hemochromatosis, polycythemia vera, porphyria cutanea tarda), and chronic hives (in research).[8][9]

Australia

In Australia, there are a number of courses in phlebotomy offered by educational institutions, but training is typically provided on the job. The minimum primary qualification for phlebotomists in Australia is a Certificate III in Pathology Collection (HLT37215) from an approved educational institution.[10]

United Kingdom

In the UK there is no requirement for holding a formal qualification or certification prior to becoming a phlebotomist as training is usually provided on the job. The NHS offers training with formal certification upon completion.[11]

United States

Special state certification in the United States is required only in four states: California, Washington, Nevada, and Louisiana. A phlebotomist can become nationally certified through many different organizations. However, California currently only accepts national certificates from six agencies. These include the American Certification Agency (ACA), American Medical Technologists (AMT), American Society for Clinical Pathology (ASCP), National Center for Competency Testing/Multi-skilled Medical Certification Institute (NCCT/MMCI), National Credentialing Agency (NCA), National Healthcareer Association (NHA), and the National Phlebotomy Certification Examination (NPCE).[12] These and other agencies such as the American Society of Phlebotomy Technicians also certify phlebotomists outside the state of California. To qualify to sit for an examination, candidates must complete a full phlebotomy course and provide documentation of clinical or laboratory experience.

South Africa

In South Africa learnerships to qualify as a Phlebotomy Technician are offered by many public and private educational institutions as well as by private academies owned up by pathology laboratories (such as Ampath Laboratories, Lancet, PathCare) and healthcare service providers (such as Netcare, South African National Blood Service). Some of the larger retail pharmacy chains offering in-store clinical services (such as Clicks, Dis-Chem) also provide training for aspirant phlebotomists. Certification can be obtained from a number of examination and testing institutions. To work as a phlebotomist in South Africa, registration with the Health Professions Council of South Africa (HPCSA) is required.

Sample-tube-types
Vacutainer/sample tube types for venipuncture/phlebotomy  
Tube cap color or type in order of drawAdditiveUsage and comments
Blood culture bottleSodium polyanethol sulfonate (anticoagulant) and growth media for microorganismsUsually drawn first for minimal risk of contamination.[13] Two bottles are typically collected in one blood draw; one for aerobic organisms and one for anaerobic organisms.[14]
Blue

("light blue")

 Sodium citrate

(weak calcium chelator/anticoagulant)

Coagulation tests such as prothrombin time (PT) and partial thromboplastin time (PTT) and thrombin time (TT). Tube must be filled 100%.
Plain red No additiveSerum: Total complement activity, cryoglobulins
Gold (sometimes red and grey "tiger top"[15]) Clot activator and serum separating gel[16]Serum-separating tube (SST): Tube inversions promote clotting. Most chemistry, endocrine and serology tests, including hepatitis and HIV.
Orange Clot activator and serum separating gel[17]Rapid serum-separating tube (RST).
Dark green Sodium heparin (anticoagulant)Chromosome testing, HLA typing, ammonia, lactate
Light green Lithium heparin (anticoagulant)

Plasma separator gel

 Plasma. Tube inversions prevent clotting
Lavender ("purple") EDTA (chelator / anticoagulant)Whole blood: CBC, ESR, Coombs test, platelet antibodies, flow cytometry, blood levels of tacrolimus and cyclosporin
Pink K2 EDTA (chelator / anticoagulant)Blood typing and cross-matching, direct Coombs test, HIV viral load
Royal blue

("navy")

 EDTA (chelator / anticoagulant)Trace elements, heavy metals, most drug levels, toxicology
Tan Sodium EDTA (chelator / anticoagulant)Lead
Gray

Fluoride Oxalate

 Glucose, lactate[19]
Yellow Acid-citrate-dextrose A (anticoagulant)Tissue typing, DNA studies, HIV cultures
Pearlescent ("white") Separating gel and (K2)EDTAPCR for adenovirus, toxoplasma and HHV-6
Black Sodium CitratePaediatric ESR
QuantiFERON

Grey, Green, Yellow, Purple

 QuantiFERON

1. Grey (nil) tube 2. Green (TB1 antigen) tube 3. Yellow (TB2 antigen) tube 4. Purple (mitogen) tube

Tuberculosis

History
Main article: Bloodletting

Early phlebotomists used techniques such as leeches and incision to extract blood from the body. Bloodletting was used as a therapeutic as well as a prophylactic process, thought to remove toxins from the body and to balance the humors. While physicians did perform bloodletting, it was a specialty of barber surgeons, the primary provider of health care to most people in the medieval and early modern eras.

See also

References
  1.  This article incorporates text available under the CC BY 4.0 license. Betts, J Gordon; Desaix, Peter; Johnson, Eddie; Johnson, Jody E; Korol, Oksana; Kruse, Dean; Poe, Brandon; Wise, James; Womble, Mark D; Young, Kelly A (July 28, 2023). Anatomy & Physiology. Houston: OpenStax CNX. 18.1 An overview of blood. ISBN 978-1-947172-04-3.
  2. "FAQ". National Association of Phlebotomists. Archived from the original on 28 December 2014. Retrieved 28 December 2014.
  3. Kim, KH; Oh, KY (2016). "Clinical applications of therapeutic phlebotomy". Journal of Blood Medicine. 7: 139–44. doi:10.2147/JBM.S108479. PMC 4957680. PMID 27486346.
  4. Retrieved 17 February 2022.
  5. Krleza, Jasna Lenicek; Dorotic, Adrijana; Grzunov, Ana; Maradin, Miljenka (2015-10-15). "Capillary blood sampling: national recommendations on behalf of the Croatian Society of Medical Biochemistry and Laboratory Medicine". Biochemia Medica. 25 (3): 335–358. doi:10.11613/BM.2015.034. ISSN 1330-0962. PMC 4622200. PMID 26524965.
  6. Jeon BR, Seo M, Lee YW, Shin HB, Lee SH, Lee YK (2011). "Improving the blood collection process using the active-phlebotomist phlebotomy system". Clinical Laboratory. 57 (1–2): 21–7. PMID 21391461.
  7. "Best practices in phlebotomy". WHO Guidelines on Drawing Blood. World Health Organization. 2010.
  8. Cook, Lynda S. (2010). "Therapeutic Phlebotomy". Journal of Infusion Nursing. 33 (2): 81–88. doi:10.1097/nan.0b013e3181d00010. PMID 20228645.
  9. Yao, Q; Zhang, X; Mu, Y; Liu, Y; An, Y; Zhao, B (2019). "Bloodletting Therapy for Patients with Chronic Urticaria: A Systematic Review and Meta-Analysis". BioMed Research International. 2019: 8650398. doi:10.1155/2019/8650398. PMC 6500668. PMID 31139656.
  10. "Certificate III in Pathology Collection". Australian Government. Archived from the original on 14 January 2018. Retrieved 14 January 2018.
  11. "Phlebotomist". NHS Careers. Archived from the original on 29 September 2014. Retrieved 15 September 2014.
  12. "Archived copy" (PDF). Archived from the original (PDF) on 2016-03-23. Retrieved 2016-03-16.{{cite web}}: CS1 maint: archived copy as title (link)
  13. Pagana, KD; Pagana, TJ; Pagana, TN (19 September 2014). Mosby's Diagnostic and Laboratory Test Reference - E-Book. Elsevier Health Sciences. p. xiii. ISBN 978-0-323-22592-2.
  14. "Chapter 3.4.1: Blood cultures; general detection and interpretation". Clinical Microbiology Procedures Handbook. Wiley. 6 August 2020. ISBN 978-1-55581-881-4.
  15. "Test Tube Guide and Order of Draw" (PDF). Guthrie Laboratory Services. June 2019.
  16. "Specimen requirements/containers". Pathology & Laboratory Medicine, UCI School of Medicine. Retrieved 2020-09-10.
  17. "Proper Order of Draw" (PDF). Memorial Lab Services. Retrieved 2023-06-15.
  18. Castellini MA, Castellini JM, Kirby VL (1992). "Effects of standard anticoagulants and storage procedures on plasma glucose values in seals". J Am Vet Med Assoc. 201 (1): 145–8. PMID 1644639.
  19. Amitava Dasgupta; Jorge L. Sepulveda (20 July 2019). Accurate Results in the Clinical Laboratory: A Guide to Error Detection and Correction. Elsevier Science. p. 131. ISBN 978-0-12-813777-2.
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