Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Transfusion Medicine and Blood Bank 8 Plebotomy And Donor Reaction PPT-Powerpoint Presentations and lecture notes
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
col ection
? 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
? Capil ary 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 col ection
- 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 donor's 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 wel 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 Col ection
? Constant monitoring during donation
? Smooth Blood flow
? Gentle mixing of blood
? Col ection time -5-10 min
? Appropriate Volume col ected = ?10 % of desired volume
? Sample col ection
-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
Systemic
Reaction
Reaction
1. Bruise or Hematoma
1. Vasovagal Attack
2. Phlebitis and Cellulitis
2. Tetany
3. Nerve Injury
3. Air Embolism
4. Puncture of artery
5. Upper extremity Deep
Vein Thrombosis
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
Management-
Immediate 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-
1. Ice compression and analgesic if necessary
2. Keeping hand in rest. Avoid working by affected hand.
3. Observation and informing donor regarding compartment syndrome & refer if necessary
Outcome-
General y resolve completely within 7-14 days and do not prevent
donors from donating again
Phlebitis and Cel ulitis
? Incidence- 1 in 50000 to 1 in 100000
? Mild phlebitis at the venepuncture site is common, self-limited and usually of little
consequence.
? Presentation-
Mild discomfort, small swelling, pain, local linear or surrounding erythema
? Complication-
Despite a seemingly benign appearance, it may extend to local abscess formation or septic phlebitis
Phlebitis and Cel ulitis
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
Management-
Needle should be taken out early and local pressure should me applied for an extended period.
Complications-
Hematomas, compartment syndrome, delayed nerve injury may happen
? Most donors recover quickly and completely.
Fol ow up-
Should 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
? Swel ing 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
? Chil s or cold extremities,
? Feeling of warmth
? Light- Headedness
? Nausea
? Pal or
? Weakness
? Hyperventilation
? Declaration of nervousness ( Anxiety)
? Sweating
Signs
? Hypotension
? Tachycardia or Bradycardia
? Syncope
? Seizure Activity ( Tonic- Clonic Convulsion)
? Twiching
? 3 types according to severity-
1. Mild
2. Moderate
3. Severe
Mild vasovagal reaction
Present with one or more
Nausea, dizziness, hyperventilation, vomiting, twitching and muscle spasm, sweating etc.
? Usual y brought about by the sight of blood or needle.
Management-
? Remove tourniquet and withdraw needle
? Raise Donor's 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
fal in systolic pressure to 60mm Hg.
Management
? Check Vital signs frequently
? Raise Donor's 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 fal
? 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 Chvostek's 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 shal ow
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.
Al ergic Reaction
? Donor may be hypersensitive to sterilizers special y ethylene oxide, ethly alcohol
etc.
Symptoms and signs- Hives, difficulty in breathing, wheezing, hypotension or
hypertension, tachycardia or bradycardia, facial swel ing or flushing, burning eyes,
angioedema etc. Even anaphylaxis may happen.
Management-
Inj. 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. Perioral or peripheral paresthesias or both,
2. Unusual taste,
3. Transient nausea,
4. Light-headedness,
5. Muscle Cramps
6. Dysphagia
Citrate Induced Hypocalcemia
Signs-
1. Carpopedal Spasm,
2. Tetany ( May be present if associated with hyperkalamia)
3. Change in pulse,
4. Tremor,
5. Chvostek's sign,
6. Seizure ( Grand mal, Petit mal)
7. Laryngospasm
? Management-
? Reducing citrate infusion rate
? Administering calcium tablets for mild to moderate cases
? For severe cases termination of col ection 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 il ness within 2 weeks to be reported at the Transfusion medicine department
? Avoid smoking and alcohol
? Refrain from works special y 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- specialy among first time donors by
motivational audio-visual aids regarding need for blood in the community
? Drive set up and environment- A wel planned, adequately staffed
and organized lay out of blood donation area or donation camp.
? Staff supervision & phlebotomist skil - 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
overal 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
? Rossi's Principles of transfusion Medicine- 5th Edition, Wiley Blackwell Publication
? Mollison's 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
This post was last modified on 08 April 2022