Lining and labs/ hemolyzed specimens - page 3

by psu_213 7,529 Views | 64 Comments

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 supposed reasoning behind... Read More


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    @music in my heart:

    I can understand your reasoning ; however, those slow draws I would really be leary of. Our stat lab (ED lab) is just around the corner and if I have had a slow draw, I literally walk it over in 5 minutes and they are calling me to tell me that it is clotted or hemolyzed. I always have that fear, especially in the older population who are very dehydrated. If I see that it is slow, I always notify the physician first and get the ok to call the phlebotomist to come draw the patient. 99.9% of the time the physician gives the okay. If not, the physician comes to the bedside with ultrasound and starts the IV or places a central line depending on patient acuity.
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    My old ER was pushing this double stick policy on us and I think its a violation of a nurse's ethical values. Double sticking people for labs does not produce significantly different lab results. For example, a big deal is made of out of elevated potassiums due to hemolysis so I went and looked it up. The MOST a potassium ever really changes is 1 due to lysis and as a physician pointed out to me when I went and argued with the nursing director, 1 is not a significant change in the patient's condition to cause any real harm.

    Example: You get a reading of 6.0 so you treat it. If cells were lysed, it might have been 5.0 BUT treating K at 5.0 will only drop it to 4 so no real significant different is made in patient condition even you are wrong. If its a critical value, say like 7.7 in a non dialyzer, you can redraw specimen.

    This double stick thing is stereotypical of the "a little knowledge can be so dangerous" in people who are undereducated and illprepared to understand what is really going on with the patient's health and IT DRIVES ME CRAZY! Can't see the forest for the trees!

    Frankly, I agree with Esme. If you draw straight from the hub with no cap on it, you reduce hemolysis anyway. Our lab definitely knew who collected labs because the phleb collected her in the lab computer for them which we couldn't do and you bet they drew from lines and got fewer hemolyzed results.

    For my money, I go in there, educate the patient about the potential dangers of double sticking and variations of lab results. If they refuse, and they always do, I would tell the director that the patient refused. Period. End of story.
    Last edit by VICEDRN on Jan 17, '13
    canoehead, icuRNmaggie, psu_213, and 1 other like this.
  3. 0
    I have worked in many ERs and in almost all of them we draw from the IV start. In drawing thousands of labs this way I have had maybe 10 come back hemolyzed. You do have to be careful about how fast you draw back on the syringe and you do have to draw from the hub of IV for best results. But most labs were drawn from the J-loop. some times we just let the hub drip into the tube if needed. When I worked at one ER that had a dedicated lab I would sometimes go get her and together we would decide on a good vein and we had great success doing this. For more info you might look up the Infusion nurses association and check out their info.
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    Using a syringe with a soft/slow "pull" can work quite well, especially if you let the inherent vacuum of the tube draw the sample from the syringe. Using a direct (catheter to tube) adapter is probably stillthe best method, if at all possible. After all this, promptly send the samples to the lab, and there should be no problem.
  5. 1
    Quote from Overland1
    After all this, promptly send the samples to the lab, and there should be no problem.
    Well, that is assuming the lab processes the received sample right away...and we all know what happens when you assume.
    One1 likes this.
  6. 2
    I just get upset when they tell me all my tubes need redrawn. Especially when the poor pt was such a hard poke.
    I can usually tell when it came out waaaay to fast or slow, but I have a hard time believing sometimes that every tube was bad. Call me back and tell me a color
    icuRNmaggie and psu_213 like this.
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    In my opinion it depends on who is working in the lab as far as how many times we get the call that the blood is hemolyzed. So lets say they do call and say it is. We go back in stick the patient again, send it to the lab and guess what? It's hemolyzed again. I've gotten where I just keep extra tubes when I start an IV and send them up if they do call, most of the time, they aren't hemolyzed. Depending on where you work and the labs policies you can use pedi tubes which seem to not be as bad to me.
    One1 likes this.
  8. 1
    Oh yeah and sometimes I just pop the top off the tube and let the blood just flow into the tube with no suction at all. I do this if I'm in a vein but can't get the catheter to advance but it has great blood return and the vein isn't blowing.
    canoehead likes this.
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    Quote from LilgirlRN
    Oh yeah and sometimes I just pop the top off the tube and let the blood just flow into the tube with no suction at all. I do this if I'm in a vein but can't get the catheter to advance but it has great blood return and the vein isn't blowing.
    Be careful with this practice as the vacuum on certain colors of tubes is set to allow a certain volume of blood into the tube to mix with the additive in a specific ratio. If that tube is over or under filled your labs will be off and will have to be repeated.
  10. 0
    I'm not an ER nurse, but I think I can give some perspective here. Before becoming an RN, I was a lab tech. You know, the one who actually runs the tests. I think every hospital has a communication barrier between lab and nursing, and it can be difficult to understand exactly why it is the way it is.

    First, as for not having enough blood to run a test, it most certainly has nothing to do with the lab staff. Certain machines need certain amounts of blood. If the machine rejects the specimen, it can not be "made" to run the test. Depending on the test, the lab tech might be able to run it manually, which takes a LOT longer, and if there wasn't enough for the machine, you're not likely to get very accurate results manually either.

    10mls of blood for a culture provides the most accurate results. If the patient is able to give up that much, they should. Just because other cultures have shown positive with less specimen doesn't mean that all cultures will show up with less. If your lab tech is sick to death of fighting with the nursing staff, or the patient is too young to give up all that blood, they can do the test, but again, less accurate.

    It would be a pretty twisted lab tech who would treat specimens drawn by nursing any differently than ones the phlebotomist drew. Also, leaving a CBC sit for a few hours will not cause it to hemolyze. CBCs can be done off of blood up to 48 hours old in either a lavender or green tube, depending on the instrument doing it.

    I've never met a lab tech who really wants to have a patient restuck. Yes, I worked with some nasty people, but no one who ever tried to punish nurses by tormenting patients. We in the lab didn't want to make those phone calls any more than the units wanted to hear from us. Being on the other side, I can see how it is a frustrating system to everyone involved.


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