Lining and labs/ hemolyzed specimens

[psu_213]

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 this is that too many blood specimens were hemolyzed when drawn during an IV start, especially compared with the hemolysis rate for phlebotomists drawing on the floor.

So, we were 'provided' with a phlebotomist and it apparently showed or hemolysis rate went down when they drew blood. What I find interesting is that they were doing such a great job that, yet they went from working in the ER from 11a-11p to now just working 11a-7p. In addition, we are the first place from which a phlebotomist is pulled if they are short staffed (so that they cover the whole house). A coworker also make an interesting observation. When the phlebotomist draws blood they send it to the lab in a colored biohazard bag, while the biohazard bag that we have in stock is clear plastic with the biohazard logo on it. The coworker suggested that if the specimen shows up in the colored bag, the lab treats it differently so that it does not come back hemolyzed or the ignore minor hemolysis on these specimens, yet they always report even the smallest amount of hemolysis drawn on samples drawn by ER staff. Not sure if I buy into the conspiracy theory, but it is an interesting thought.

I have been told by several ER docs and residents that this is a foolish policy and that they line/lab (all in one stick) "everywhere." One doc, who happens to run the residency program for the hospital system asked me "who came up with such an inane policy?"

Anyway, just looking for comments from other ER nurses. Anyone else have to deal with something so silly?

[psu_213, BSN, RN]

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.

If 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.

[MunoRN, RN]

I 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.

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.

[psu_213, BSN, RN]

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.

Don't even get me started on how different CT techs will accept different IV gauges/placements for CTAs.

[Lunah, MSN, RN]

I 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).

[e102587]

ENA, the Emergency Nurses Association in Des Plaines Illinois, revised a TIP's sheet publishing in late 2013 that is aimed at reducing hemolysis in peripherally drawn blood samples. In the Supporting Rationale section the first listing reads "Multiple studies have shown that significantly higher hemolysis occurs when blood is drawn through an IV catheter." There are ten (10) research articles referenced as supporting this statement.

[e102587]

No labs will be forthcoming if the sample is grossly hemolyzed. Regardless if the patient is sent to cath lab or not.

[Guest219794]

I understand how going through a huber, or using a syringe to draw can hemolyze blood. But, how can any iv catheter be more inclined to hemolyze blood if a vaccutainer is used? What is the difference between that and a lab draw?

Also-

When possible, 18 in the AC, no tourniquet for the draw. since startnig that, no bad specimens.

[Ozzy84]

I 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).

How safe is to draw blood on running IV cath?? I know some people does and than all results come high/low and not accure , due dilated w iv fluid.

Is this really right practice to draw a blood from iv cath ? (Not central or PICC)

[Lunah, MSN, RN]

How safe is to draw blood on running IV cath?? I know some people does and than all results come high/low and not accure , due dilated w iv fluid.

Is this really right practice to draw a blood from iv cath ? (Not central or PICC)

Check your facility policy, but it can be done if you discontinue the fluids for a bit.

[Altra, BSN, RN]

How safe is to draw blood on running IV cath?? I know some people does and than all results come high/low and not accure , due dilated w iv fluid.

Is this really right practice to draw a blood from iv cath ? (Not central or PICC)

Note that this thread is in the Emergency Nursing section. In the ER, the majority of patients have IVs (saline locks) inserted ... doesn't mean that there is anything infusing. Also ... in most instances blood specimens are drawn immediately after inserting the line - nothing has been infused yet.