Lining and labs/ hemolyzed specimens - page 5
So it was decided by our hospital that it is no longer "acceptable" to draw labs when starting an IV--i.e. they have to be peripherally stuck for blood in addition to the stick for the IV start. The... Read More
Sep 9, '14 by e102587Thank you for pointing out the importance of hemolysis in lab tests. Outpatient centers do usually arrange for their own recollects. The story you tell of all the patients with critical (6.4) potassiums you see come into ER is really different. Lab informs physician potassium is critical, but, hemolyzed which can contribute to falsley elevated potassium. Physician sends patient to ER- better safe than sorry. You write "not always true," and very few things in life are always true.
Sep 10, '14 by RN_rescue_ninjaThis is ridiculous. it is counterproductive, a waste of time, causing unneeded pain for the pt to name a few. Wouldn't the logical first step to resolve this issue be to have an in-service for the nurses/techs (if applicable) on how to prevent hemolyzed samples from IV starts? BTW, the colored bags are supposed to be the "stat" ones; the ones the lab treats with priority. Another issue with hemolyzed specimins is that it could be from the samples sitting for longer than needed, as you pointed out, also because they are often drawn and the order for tests for them is not put in immediately, so they sit in the lab. The way to avoid this as much as possible is with the nurses putting in as many protocols as they can, to speed things up and not let the sample sit in the lab any longer than what they should. As for pulling the phlebs, this is silly as the ED, being and EMERGENCY department, should have priority, although I can see the argument that nurses can do the sticks, too. I have only been a nurse for a little over 3 months, but I already hate when the "high-up" admin make decisions for the whole hospital that affect the ED, when in reality, the ED is so different (and has to be) that you really cannot apply these principals and make them work in the best interest of the patients. Also, no phelbs on night? What's up with that? Nights are just as busy as days.
Your director and charge nurses should be pulling together with some arguments and facts to bring to whomever made this decision, to come up with an alternative.
Sep 10, '14 by RN_rescue_ninja[QUOTE=icuRNmaggie;8106753]Quote from Bobmo88Yes! All this is definitely true. One thing I have noticed (when I have time to stop and think about these things long enough ) is that when the catheter flushes,but does not draw back, it is because the catheter is not an optimal size (i.e. too big). It presses against the wall of the vein tight enough where it creates a vacuum effect and blood either will not come out or is hemolyzed, even if you "fiddle" with the catheter. It's also hard for venous blood to get around the catheter, if it is that tight of a fit. There's articles that are well researched about this, too.I work as a Tech in the ER and we have had a lot of issues with our lab. I usually don't get very many recollects which is why I am furious every time my specimens get recollected unless I know it wasn't a very good draw. There are many reasons why labs can get hemolyzed but some of the main ones I see from the nurses/phlebotomists end are:
Leaving the tourniquet on for too long; when using a syringe, using either too big a syringe on a small vein or pulling forcefully on the syringe; shaking the tubes instead of inverting them gently.
just curious, how would a lab tech hemolyze the specimen.
I have been called about hemolyzed specimens when I knew what I sent to lab was a perfectly good specimen.
Sep 10, '14 by ♪♫ in my ♥Quote from e102587Fifty percent? Absurd. I draw nearly all of my labs through patent IVs and it's rare that I have hemolyzed samples... And this is true of the other 120 nurses in my department.The big reason the tubes drawn with an IV start are hemolyzed better than fifty percent of the timethe lumens are designed to introduce liquid fluid into the body NOT to TAKE IT OUT.As healthcare providers, we need to consolidate correct drawing procedure and stick with it. We owe this to our patients!
Drawing blood through IV catheters is not a problem.
This is just one of those "urban legends" that persist in nursing.
Sep 10, '14 by e102587Have you ever heard of the Journal of Emergency Nursing? They published a study in 2012 addressing the high rates of hemolysis occurring when obtaining labs during IV placement.
Sep 10, '14 by e102587
"This is just one of those "urban legends" that persist in nursing."
Plus see Clinical Biochemistry (2012) 45 1012-1032[COLOR=#2f2777],
One of the countless published studies addressing hemolysis in ED's IV lab draws worldwide.
The Journal of Emergency Nursing has the IV lab draw hemolysis rate at around 32% and the Clinical Biochemistry study has the value between 40 and 70% citing different studies. A far cry from an "urban legend."
"Oh, in what way is that? X"
The hemolysis occurs during IV lab draws in ER due to the tubing, hub size, pressure applied to syringe, proximity of IV set bevel to interior of vein and overall difficulty of obtaining the draw.
"We owe to our patients to minimize the number of times that we stick needles in them..."
If a patient is in ER and may be having an MI, correctly drawn blood samples are very, very important. Foolish concern over an additional needle stick lab draw can needlessly prolong treatment time.
Last edit by e102587 on Sep 10, '14 : Reason: Clarity
Sep 10, '14 by Sassy5dI don't use a syringe. I attach my vaccutainer directly to my fitted j-loop.
The order in which you draw your rainbow can ruin your entire draw.
Sep 10, '14 by icuRNmaggie, BSN, RNI occasionally have hemolysis drawing from a 20g, but never or hardly ever with a new 18g. Anyone else notice this?
Sep 12, '14 by psu_213, BSN, RNQuote from e102587If the pt is having a STEMI, he/she will (should) be in the cath lab long before any chemistry results are back from the lab.If a patient is in ER and may be having an MI, correctly drawn blood samples are very, very important. Foolish concern over an additional needle stick lab draw can needlessly prolong treatment time.
Sep 12, '14 by MunoRNI think there's a common misconception that high hemolysis rates off of PIV draws are due to the use of the IV for drawing, when actually the research shows stronger connection to technique when drawing off PIV's than it does to the PIV itself. We can see this in studies where we compare hemolysis rates when drawing off of IV's using different techniques and pre-education/post-comparison studies. The exception is with 22 gauge and smaller IV's where hemolysis is often due to the IV rather than technique.
The general rule is that facilities should monitor their hemolysis rates and intervene, typically with education, if their rates are above the standard range, if that fails then they should switch to hard-needle draws only.
At my facility we routinely draw initial labs with the IV start, our hemolysis rate for those draws is 4% which good for even hard-needle draws. We also place IV's solely for drawing blood in some patients, but it has to be a 20g or larger in the AC.
Sep 12, '14 by ♪♫ in my ♥It's pretty rare that I place 22g in adults but on occasion I do and generally, I'm able to pull labs off of them for the next few hours.
This debate starts to sound like the dogmatic declarations that contrast studies can only be successfully executed through a 20g or larger placed in the AC... which is simply not an absolute truth.
Just last week I had an elderly patient on whom the best line I could secure without ultrasound was a 22ga in the forearm. It coughed up serial crits and admit labs as well as permitting successful CTcon studies of the abdomen, pelvis, and chest.
Sep 12, '14 by psu_213, BSN, RNQuote from ♪♫ in my ♥Don't even get me started on how different CT techs will accept different IV gauges/placements for CTAs.This debate starts to sound like the dogmatic declarations that contrast studies can only be successfully executed through a 20g or larger placed in the AC... which is simply not an absolute truth.
Sep 13, '14 by Pixie.RN, MSN, RN, EMT-P Senior ModeratorI have drawn acceptable/non-hemolyzed specimens from adults using 22g or even 24g IV catheters in the thumb/knuckle/inner wrist/wherever I can get it. I just draw very gently using a 3cc syringe. I rarely have any specimens hemolyze (until now, when the IV Gods will no doubt slap me for my hubris with a week-long hemolysis-fest, haha).