BLOOD SAMPLING FROM AN INDWELLING LINE

Ensure that patient and health care provider safety standards are met during this procedure including:

  • Risk assessment and appropriate PPE
  • 4 Moments of Hand Hygiene
  • Procedural Safety Pause is performed
  • Two patient identification
  • Safe patient handling practices
  • Biomedical waste disposal policies
  • Sharps handling
  1. Order Tests
  2. Assemble Equipment
  3. Prepare Equipment and Environment
  4. Connect Blood Sampling Device
  5. Draw Blood from Arterial Line
  6. Draw Blood from Venous Line
  7. Prevent Contamination of Sample
  8. Flush Catheter
  9. Flush Sampling Port
  10. Label Specimens
  11. Document

PROCEDURE

 1.

Obtain Order

  • Verify there is an order, protcol or medical directive to support the collection of blood. 
  • Order laboratory tests in PowerChart and obtain labels.
  • Check labels with patient's armband at bedside to verify patient, test and label is correct.
  • Blood drawing from indwelling arterial or central venous lines is done through a stopcock with a needleless access device on the sampling port.

Change the ethanol Swab Cap(TM) cap after each access. Draw blood sample through the needless access cap.  Change this cap if if is contaminated or has residual blood.

Note: 

The needless system reduces the risk for stopcock contamination and needlestick injuries.

Collection of backflush solution into a disposable blood tube reduces exposure of health care providers to blood products. Backflushing reduces potential to introduce pathogens.  Arterial lines are frequently the source for blood stream infection include central line associated blood stream infections.

 2.

Obtain Equipment

Perform hand hygiene before donning non-sterile gloves.

Assess risk for need of a face shield

Collect necessary equipment:

  • Vacutainer with luer lock adapter and needle
  • New ethanol based access cap
  • Blood collection tubes as required for ordered lab tests
  • Blood gas syringe if required
  • Two additional DISCARD blood collection tubes. One will be used to collect the discard sample and the other will be used to collect backflush.
  • Order labels from Powerchart

 

 
Discard

Note: If you are not collecting any blood into vacuum tubes (i.e, blood gases, glucometer samples or point-of-care testing), a syringe can be used to collect the discard sample and to back flush.

 3.

Prepare Equipment and Environment

  1. Explain procedure to patient/family.
  2. Assemble vacuntainer with access needle, sample tubes and/or blood gas syringe
  3. Press the alarm silence to reduce nuisance alarms during blood sampling.

Blood sampling from an arterial line reduces patient discomfort from needle sticks, however, patients should be advised that they may feel a warm sensation in their extremity during line fllushing.

 4.

Connect Blood Drawing System

  1. Remove antiseptic.  If no access camp present, scrub the hub with 70% alcohol and 2% chlorhexidine swab. Wait 30 seconds dry time before acccesing port. 

The Centre for Disease Control (CDC) recommends 70% alcohol or an or an iodophor for cleansing injection sites. Chlorhexidine adheres to provide prolonged gm positive antimicrobial properties.

2. Connect vactainer with sampling needle to luerlock sampling port as shown in Figure 1.01.

3.  Begin with 3-way stopcock positioned with prong toward the sampling port (this is off to sampling port).

Blood Sampling Equipment
Figure: 1.01 Stopcock off to sampling port with vacutainer connected.

 5.

Collect Discard Sample (Artrial Lines) 

  1. Insert one of the DISCARD tubes into the vaccutainer. Be careful to use tubes that will not be confused with actual blood samples.
  2. Depress the blood tube to activate the vacuum.
  3. Open up the flow of blood by turning the stopcock 90 degrees toward the flush system. This is open between the patient and sampling port. 
  4. Allow a minimum of 3 mL discard to be drawn from the arterial line.
  5. Quickly turn the stopcock to 45 degrees (half-way between the patient and sampling port) when sufficient blood volume has been collected to avoid excess blood removal.
  6. Remove the tube to release the vaccum and discard into the sharps container.

Note: If you are not collecting any blood tubes, you can collect discard sample into an extra syringe.

 

Tubes3
Figure 1.02: Position of stopcock for withdrawal of blood.

 

6.

Collect Discard Sample (Venous Samples)

  1. Assess all IVs that are running distal to the catheter during sampling.
  2. All IVs that are running into any lumen of a multilumen or PICC catheter (including an introducer) must be off for blood sampling (except for blood gases).
  3. A minimum discard sample of 5 ml is required when drawing blood samples from  central venous lines due to longer lumen volume.
  4. Peripheral IVs should not be used for blood sampling due to the high risk for hemolysis.
  5. If IVs cannot be temporarily stopped, the patient should have an arterial line for lab sampling.


Infusions from distal peripheral lines or from any other port of a multilumen PICC or temporary venous catheter can dilute or contaminate a lab sample. These IVs should be turned off prior to sampling. If an infusion cannot be safely stopped during blood sampling, an alternative method for blood sampling is recommended.

Consider IV contamination for any patient with unusual electrolyte or lab values.  TPN can signficantly contaminate blood samples.

7.

Collect Blood Samples to Prevent Dilution or Contamination with IV Fluids or Vaccum Tube Contents

Order of Draw

When drawing blood from an indwelling line, the INR/PTT should be drawn AFTER blood gases to prevent contamination of the PTT from the heparinized blood gas syringe. 

Although we do not routineliy heparinize our hemodynamic circuits anymore, any PTT drawn from a heparinized line should be drawn after at least a 5 ml discard.

The recommended order of blood tube collection is shown in Figure 1.03.

Order of Draw
Figure 1.03: Recommended order of draw. When drawing from indwelling line, adjustments may need to be made if sample is drawn from a heparinized line or blood gases are being collected.

 

Position Stopcock to 45 Degees Between All Samples/Tube Changes

  1. Turn the white stopcock to a position half-way between the patient line and the sampling port (45 degree position) between each tube change. This posiiton ensures that the stopcock is off in all directions.
  2. Turn the stopcock to 45 degrees before removing the tube from the vacutainer to prevent back spash of blood when the vaccum is released.
  3. Do not turn the stopcock directly toward the sampling port during blood sampling (this would leave the circuit open between the flush and the patient).  This position can allow saline from the flush system to contaminate the sample.
  4. If your are drawing blood from a heparinized line (saline without heparin is our standard setup), draw the blue top tubes for INR/PTT last, but BEFORE blood gas sample.

8.

Flush the Patient Catheter

  1. When all of the desired specimens have been collected, turn the white prong on the stopcock toward the sampling port at 90 degrees (open to the patient and flush system).
  2. Pull the flush device located below the transducer to activate the fast flush mechanism.
  3. Flush until there is no visible evidence of blood.
  4. Evaluate the waveform to ensure it has been restored.

 

9.

Backflush the Stopcock

  1. Connect the second extra syringe or blood tube to the sampling port.
  2. Turn the stopcock so that the white prong points toward the patient's catheter. This is open beween the flush and discard syringe.
  3. Activate the flush device and back flush saline into the DISCARD tube or syringe.
  4. Ensure all blood is cleared from the needlesless access device. 
  5. Replace the needleless access device if residual blood remains after flushing
  6. Connect a new luer lock antiseptic cap on the needleless access port.
  7. Remove non-sterile gloves, perform hand hygiene.

 

tube
Figure 1.04: Position of stopcock to backflush the stopcock.

10.

Label Specimens

  1. Place labels on specimens at the bedside.
  2. Verify that the label name and patient are correct.
  3. Send blood samples to the lab in a biohazardous bag.

11.

Document

  1. Document the reason that the sample was drawn if collected as part of a PRN protocol or medical directive. 
  2. Monitor for results to be posted.
  3. Review signficant findings with physician and document discussion/plan. Signficant findings include abnormal results, return to normal following treatment or normal results that may rule out issues of concern.

References:

http://www.cdc.gov/ncidod/hip

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm

http://www.cdc.gov/niosh/topics/bbp/sharps.html


Gillies D, O’Riordan L, Wallen M, et al. Optimal timing for intravenous administration set replacement. Cochrane Database Syst Rev 2005;(4):CD003588.

http://www.cdc.gov/mmwr/preview/mmw.htm/rr5110a1.htm

Luebke, M., et al. (1998). Am J Infection Control, 26: pp. 437-441.

Plott, R., Wagner, R., Tyring, S. (1990). Archive Dermatology, 126: pp 1441-1444.

Salzman, M., Isenberg, H., Rubin, L. (1993). Journal of Clinical. Microbiology, 31: pp. 475-479

Developed by: Brenda Morgan, CNS, CCTC 1988

Revised: June 30, 2016, Revised January 29, 2020