Nurses can't draw blood, its always hemolyzed

[HiThisIsStatLabCLICK]

Okay, now that I've gotten your attention, I didn't really mean it...or did I =)

First and foremost I am not a nurse, I'm a technologist in the stat lab with a whopping 1 month of experience. Now, there's been some bad blood brewing recently between the lab and the ER. The issue, hemolyzed blood specimens. For the past 4 days, it seems as if EVERY single specimen sent from the ER is hemolyzed. We call because we need a restick, the ER gets ******, we get the tubes, its still hemolyzed, we get ******, we call again, they get more ******, we get the tubes, we get more ****** etc. etc. Its gotten to the point where the clerks won't even document a hemolyzed specimen and we have to speak to the Doctor directly. I'm just curious as to why all these specimens drawn from the lines are hemolyzed. Enlighten me.

P.S. Feel free to rant off about the lab and I'll try my best to shed some light upon your qualms.

[JRD2002]

Is it the lab leaving them laying around for 1-2 hours....ooooh that might be it! At least if you work in my facility....

Leaving a tube laying around will not cause hemolysis. I worked for 5+ years in a lab before becoming an RN. It was common practice to draw an extra clot tube. These extra tubes would sit in a rack by my computer and would get used if additional tests were ordered during the day. I have spun down tubes that are 8+ hours old and they were fine.

I agree that the high rate of hemolysis seen in ERs is due to collecting samples from peripheral IV sites. In the last few years our techs have started doing most of the IVs and collecting blood samples, which I am totally against. In addition to probably not being adequately trained I feel like that is asking them to do too much. Not to mention that most patients would probably prefer and feel safer with a nurse performing the procedure.

Whenever the ER would call us back saying that they could not get anymore blood on the patient and several nurses had tried, I would usually be the one that had to go down there. Whenever I walked into the room and saw no dressings on the patients arm I would ask the patient how many times they had been stuck and usally they would reply that they hadn't been stuck after their IV had been started. If the patient had a huge vein...and I am talking about one that I could see as I was walking through the doorway, I would usually go find the nurse and tell them where they could stick him at to get a blood sample. Of course I would only do this when they weren't getting slammed. If they refused I would pull them aside and tell them that if they did not go and at least try to stick the patient that I would write them up for unprofessional conduct.

[HiThisIsStatLabCLICK]

If I had wanted to draw blood I would have gone to school to be a lab tech.

Hehehe. The irony here is that lab techs of today (raises hand) don't even know how to draw blood as its no longer part of our curriculum. The old geezers, which describes approximately 98.9% of the laboratory population do though, but heck, they haven't drawn blood in years.

[rnmi2004]

I've never had an ER patient with a hemolyzed specimen, and they send most of their samples off of the IV starts, even a 22-gauge. They place angiocaths, which have a stiffer catheter & less likely to collapse as you're drawing blood out. I work on the floor, where we use insytes, which are more likely to hemolyze if you pull back forcefully on the plunger. You have to have great blood return & basically move the plunger out of the way as the blood is freely flowing into the syringe. I won't bother trying to draw blood off of an IV start that isn't really bloody.

[blondy2061h, MSN, RN]

I understand your irritation...for some reason other floors believe that ICU nurses are great at starting IV's (which makes you wonder, since almost everyone in ICU has a central line or PICC:imbar). There is nothing more irritating to me that to be called to assist with a "hard stick"...you get there and notice that the patient doesn't have any punture sites...:angryfire

ICU nurses are good from all their practice running around the hospital doing everyone else's sticks Floor nurses half the time would rather run 12 things on one 14 gauge IV then try and start a new IV. At least I would.

[RhiaRN75, RN]

We had the same problem at our facility, and there are a few things that have helped tremendously. Out night lab girls are awesome, so we have a good working relationship. If I have the lab standing beside me and waiting for the tubes, they can tell just by how the blood is flowing if there's going to be a problem. We almost always try to draw blood then we insert an IV. I think it's a good policy, because if you can get everything in one stick, it's worth the try.

We've stopped using syringes. When in a hurry, it's easy to pull back to hard when the blood's flowing easily. We started using vacutube adapters, made specifically to attach to the end of an angiocath, and it's made a big difference. After the initial 'I'm not used to it this way', it's really easier. The adapter is easier to hold, so there's less accidental loss of the IV site w/ movement during the draw.

We also now recognize as nurses, that if we have a difficult stick, we need to draw two chem tubes, just in case. We can also tell that if it's flowing two slow, we need two chems. All my kids get two chems just because- if possible. We tell the pts upfront that we're going to try to get blood when we start the IV, but that sometimes the lab may need more.

We also make sure we draw the blood in the proper order. Proper order not only helps w/ chems, it makes sure the coags are accurate as well.

After these changes, we almost never have hemolyzed blood anymore.

[underabus]

Could it be that you, the lab, are not letting the sst coag before you spin? You have to wait atleast 20 minutes, preferably 30 before you put it in the 'fuge. If the RN's are drawing from the IV lines, they could be causing it to occur then, but you can't say Hemolysis can only occur during the draw or as a result of the draw. If anyone is being too rough with the sample, shaking, bumping, dropping, etc.

As a side note, I most often use is a blue butterly and I have NEVER had my draws come back hemolyzed. So, it's not the needle as much as it is the technique when using the needle. Someone in the comments said they used an 18g. WHY? And yeah, it came back hemolyzed. The bore was too big, it caused the blood to flow to rapidly into the tube, slamming against the bottom and breaking up the cells! Why on earth would you use an 18 to draw blood? SMH. I've never heard of such a thing. But then maybe what you do requires it.

[Wishinonastar, BSN]

We were taught by the lab when we learned to draw blood (at the lab, nurses did not learn this in school then) that a bigger size gauge minimized shearing force on the poor little RBCs as they whisked through to the tube. No shearing force, no hemolysis. Bigger is better they said. Now you say the poor cells are slammed into the tube and burst that way. Yikes! There is no solution then?

[MAISY, RN-ER, BSN, RN]

While I agree that drawing blood from a large bore needle causes turbulance, we often don't use our first tube and those are ones I rarely have a problem with hemolyzation!

How can the coag tube be clotted? I never use an iv line as I have seen our phlebotomists do for samples, I always obtain a fresh sample and truly-as for sitting around....the only labs I have "hemolyzed" are the ones called back after 2+ hours-you'll excuse me if I consider that as a possible connection.

I don't mind drawing blood, no big deal-we do it all day long! Our floors are now drawing blood on a regular basis in an effort to slash costs and jobs. I believe the time factor matters....our CVA and STEMI labs are processed immediately and they are never hemolyzed! That says it all to me....especially when the draw is not only rushed but the group and rh is part of it! (through the hub, and iv catheter)

As always my experiences and my opinions.....

M

[underabus]

"The use of a large bore needle may result in a much faster and more forceful flow of blood through the needle, resulting hemolysis."

Once again, like someone else did, I'm going to direct you to:

http://www.bd.com/vacutainer/pdfs/techtalk/TechTalk_Jan2004_VS7167.pdf

[TorsadesDePointesRN]

I had absolutely no idea peripheral IV sites could be used to draw blood and I've been doing blood draws as an aide for 3 years at my hospital before I became an RN. Doesn't it blow the IV site? Is this a routine thing in other hospitals to use peripheral IVs for blood draws? I am utterly shocked about this!

[suanna]

I can tell you exactly why- Nurses need to start an IV- they stick- then draw the labs from the jelco (angiocath)before they start the fluid or flush the J-loop. Patients don't understand why they would have to be stuck twice- once for an IV and again for labs. A needle is a needle to them. Angiocaths are famous for causing hemolysis. The bore is smaller, it has a longer way travel, with more twists and turns, to get to the specimine tube. An angiocath isn't designed to allow blood to be drawn with the force of suction present in a specimine tube. It colapses the lumen and squishes the blood. Then the specimine must draw through a half flat plastic tube, then through a j-loop before it gets to the lab tube. You can draw from an angiocath- the trick is low flow/low suction. Slowly draw the blood into a syringe and then transfer to the appropriate tubes using a short, large bore needle.

[iluvivt, BSN, RN]

It is perfectly acceptable practice to draw blood from a new peripheral IV site just after it is inserted.....after that it is not acceptable to do so. With that said it is not always possible to get a good draw from a new PIV...and that means the blood can be withdrawn in a smooth and steady fashion. If the flow becomes sluggish and you are pulling hard on the syringe..it will probably hemolyze...if you are pulling so hard the syringe vibrates..you will most likely have a hemolyzed specimen. I never want to lose my new IV site to get a draw and will just perform a traditional venipunture to obtain a sample. Yes many possible causes but I tend to see this one a lot