Use of butterfly needles to draw blood is independently associated with marked reduction in hemolysis compared to intravenous catheter

Recommendations for blood sampling in emergency departments from the European Society for Emergency Medicine (EUSEM), European Society for Emergency Nursing (EuSEN), and European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for the Preanalytical Phase. Executive summary

AIM

Blood Sampling Guidelines have been developed to target European emergency medicine-related professionals involved in the blood sampling process (e.g. physicians, nurses, phlebotomists working in the ED), as well as laboratory physicians and other related professionals. The guidelines population focus on adult patients. The development of these blood sampling guidelines for the ED setting is based on the collaboration of three European scientific societies that have a role to play in the preanalytical phase process: EuSEN, EFLM, and EUSEM. The elaboration of the questions was done using the PICO procedure, literature search and appraisal was based on the GRADE methodology. The final recommendations were reviewed by an international multidisciplinary external review group.

RESULTS

The document includes the elaborated recommendations for the selected sixteen questions. Three in pre-sampling, eight regarding sampling, three post-sampling, and two focus on quality assurance. In general, the quality of the evidence is very low, and the strength of the recommendation in all the questions has been rated as weak. The working group in four questions elaborate the recommendations, based mainly on group experience, rating as good practice.

CONCLUSIONS

The multidisciplinary working group was considered one of the major contributors to this guideline. The lack of quality information highlights the need for research in this area of the patient care process. The peculiarities of the emergency medical areas need specific considerations to minimise the possibility of errors in the preanalytical phase.

Comparison of Clinical, Economic, and Humanistic Outcomes Between Blood Collection Approaches: A Systematic Literature Review

BACKGROUND

A systematic literature review was performed to understand the prevalence, advantages, and disadvantages of blood collection using different approaches (direct venipuncture or vascular access devices), and interventions used to mitigate the disadvantages.

METHODS

The review included a broad range of study designs and outcomes. Database searches (Embase, MEDLINE, Cochrane library, and Centre for Reviews and Dissemination) were conducted in March 2021 and supplemented by hand searching.

RESULTS

One hundred forty-one publications were included. The data indicate that blood sampling from vascular access devices is common in emergency departments, trauma centers, and intensive care units. Studies showed that hemolysis and sample contamination place a considerable economic burden on hospitals. Significant cost savings could be made through enforcing strict aseptic technique, or using the initial specimen diversion technique.

CONCLUSIONS

Hemolysis and sample contamination are far from inevitable in vascular access device-collected or venipuncture samples; both can be reduced through adherence to strict blood sampling protocols and utilization of the initial specimen diversion technique. Needle-free blood collection devices offer further hope for reducing hemolysis. No publication focused on the difficult venous access population; insertion success rates are likely to be lower (and the benefits of vascular access devices higher) in these patients.

Effect of pre-analytical variables on Raman and FTIR spectral content of lymphocytes

The use of Fourier transform infrared (FTIR) and Raman spectroscopy (RS) for the analysis of lymphocytes in clinical applications is increasing in the field of biomedicine. The pre-analytical phase, which is the most vulnerable stage of the testing process, is where most errors and sample variance occur; however, it is unclear how pre-analytical variables affect the FTIR and Raman spectra of lymphocytes. In this study, we evaluated how pre-analytical procedures undertaken before spectroscopic analysis influence the spectral integrity of lymphocytes purified from the peripheral blood of male volunteers (n = 3). Pre-analytical variables investigated were associated with (i) sample preparation, (blood collection systems, anticoagulant, needle gauges), (ii) sample storage (fresh or frozen), and (iii) sample processing (inter-operator variability, time to lymphocyte isolation). Although many of these procedural pre-analytical variables did not alter the spectral signature of the lymphocytes, evidence of spectral effects due to the freeze-thaw cycle, in vitro culture inter-operator variability and the time to lymphocyte isolation was observed. Although FTIR and RS possess clinical potential, their translation into a clinical environment is impeded by a lack of standardisation and harmonisation of protocols related to the preparation, storage, and processing of samples, which hinders uniform, accurate, and reproducible analysis. Therefore, further development of protocols is required to successfully integrate these techniques into current clinical workflows.

Development of circulating microRNA-based biomarkers for medical decision-making: a friendly reminder of what should NOT be done

Circulating cell-free microRNAs (miRNAs) represent a major reservoir for biomarker discovery. Unfortunately, their implementation in clinical practice is limited due to a profound lack of reproducibility. The great technical variability linked to major pre-analytical and analytical caveats makes the interpretation of circulating cell-free miRNA data challenging and leads to inconsistent findings. Additional efforts directed to standardization are fundamental. Several well-established protocols are currently used by independent groups worldwide. Nonetheless, there are some specific aspects in specimen collection and processing, sample handling, miRNA quantification, and data analysis that should be considered to ensure reproducibility of results. Here, we have addressed this challenge using an alternative approach. We have highlighted and discussed common pitfalls that negatively impact the robustness of circulating miRNA quantification and their application for clinical decision-making. Furthermore, we provide a checklist usable by investigators to facilitate and ensure the control of the whole miRNA quantification and analytical process. We expect that these recommendations improve the reproducibility of findings, and ultimately, facilitate the incorporation of circulating miRNA profiles into clinical practice as the next generation of disease biomarkers.

A Single-Center Prospective Study of the Effects of Different Methods of Phlebotomy in the Emergency Department on Blood Sample Hemolysis Rates

INTRODUCTION

Hemolysis is more commonly seen in the emergency department and causes delays in diagnosis, hospitalization, discharge, and treatment of patients. The aim of this study was to determine the most appropriate phlebotomy method and device to reduce blood sample hemolysis in the emergency department.

METHODS

This prospective, comparative descriptive study involved patients who presented to the emergency department with any medical condition and required blood sampling. Patients were divided into 6 groups according to the method of phlebotomy and the device used for phlebotomy. Data were analyzed with logistic regression.

RESULTS

A total of 715 patients participated in the study. The blood sample hemolysis rate in the emergency department was 25.7%. When the hemolysis rates were compared with a steel straight needle or intravenous catheter, it was found that the use of steel straight needle significantly reduced hemolysis. Blood drawing through a 20 G intravenous catheter with Luer-Lock access device reduces the risk of hemolysis. Male sex and difficult blood collection also have been shown to increase the risk of hemolysis.

DISCUSSION

Blood should be drawn with a steel straight needle instead of an intravenous catheter. However, when that is not possible, we recommend the use of a 20 G intravenous catheter with Luer-Lock access device if a blood sample is to be drawn from intravenous line.

Reverse pseudohyperkalemia is more than leukocytosis: a retrospective study

BACKGROUND

Hyperkalemia is a potentially life-threatening electrolyte abnormality that often requires urgent treatment. Clinicians should distinguish true hyperkalemia from pseudohyperkalemia and reverse pseudohyperkalemia (RPK). RPK has exclusively been described in case reports of patients with hematologic malignancies (HMs) and extreme leukocytosis [white blood cell (WBC) count >200 × 103/mL].

METHODS

This single-center retrospective study analyzed laboratory data from the Mount Sinai Data Warehouse between 1 January 2010 and 31 December 2016 for plasma potassium and serum potassium samples drawn within 1 h of each other, with plasma potassium ≥1 mEq/L of the serum potassium. Only plasma potassium ≥5 mEq/L were included. Samples that were documented to be hemolyzed or contaminated were excluded. Clinical history and laboratory data were collected from the identified cases.

RESULTS

After applying the inclusion/exclusion criteria to 485 potential cases, the final cohort included 45 cases from 41 patients. There were 24 men and 17 women with a mean age of 52 years. The median plasma potassium was 6.1 mEq/L and serum potassium was 4.4 mEq/L. The median WBC count was 9.35 × 103/mL (interquartile range 6.5-19.7 × 103/mL). Only 44% of the samples had leukocytosis, defined as WBC >11 × 103/mL.Seven patients had a HM and comprised 11 of the cases (24%) with a median WBC of 181.8 × 103µL. There was no difference in their plasma and serum potassium levels when compared with the total cohort, despite a higher median WBC count. Thirty-eight percent of the cases required medical management.

CONCLUSIONS

The literature on RPK is limited to case reports and series associated with extreme leukocytosis. This is the first study characterizing RPK predominantly associated with normal leukocyte counts. Further investigation is required to more precisely characterize factors associated with RPK and to elucidate RPK mechanisms.

The impact of blood sampling technique, including the use of peripheral intravenous cannula, on haemolysis rates: A cohort study

AIMS

To explore the relationship between blood sampling techniques and haemolysis.

BACKGROUND

Haemolysis rates of blood samples have been thought to be influenced by the method of collection. There is a lack of research evidence available to clearly show the comparative risk of haemolysis across different blood sampling methods, including venepuncture and use of peripheral intravenous cannulas.

DESIGN

A prospective cohort study. Reporting followed the STROBE checklist.

METHODS

A trained observer was used to record blood sampling techniques over a 10-week period between April and June 2019. These records were then linked to pathology haemolysis results. Multivariable logistic regression was used to model patient and blood draw characteristics affecting haemolysis.

RESULTS

Most of the blood samples were not haemolysed (n = 324, 87.1%). Multivariable analysis showed haemolysis was associated with increased tourniquet duration and if the level of tube was less than half full. Univariable analysis showed haemolysis was associated with increased age of the patient, the difficulty of cannulation/ venepuncture and increased number of attempts. No difference was found in the haemolysis rate related to the qualification of the blood collector.

CONCLUSION

There was no significant difference in haemolysis rates associated with sampling blood from a PIVC compared with venepuncture. Research should be undertaken to determine whether education on the factors influencing haemolysis is useful in decreasing haemolysis rates.

RELEVANCE TO CLINICAL PRACTICE

There was no association with increased haemolysis rates when drawing blood via venepuncture compared with a peripheral intravenous cannula. Haemolysis of blood samples was associated with increased tourniquet duration, if level of the tube was less than half-filled, increased age of the patient and difficulty of blood draw. Awareness of the risk of haemolysis associated with specific blood sampling methods may assist clinicians to improve care.

Errors within the total laboratory testing process, from test selection to medical decision-making - A review of causes, consequences, surveillance and solutions

Laboratory analyses are crucial for diagnosis, follow-up and treatment decisions. Since mistakes in every step of the total testing process may potentially affect patient safety, a broad knowledge and systematic assessment of laboratory errors is essential for future improvement. In this review, we aim to discuss the types and frequencies of potential errors in the total testing process, quality management options, as well as tentative solutions for improvement. Unlike most currently available reviews on this topic, we also include errors in test-selection, reporting and interpretation/action of test results. We believe that laboratory specialists will need to refocus on many process steps belonging to the extra-analytical phases, intensifying collaborations with clinicians and supporting test selection and interpretation. This would hopefully lead to substantial improvements in these activities, but may also bring more value to the role of laboratory specialists within the health care setting.

The Impact of Undetected In Vitro Hemolysis or Sample Contamination on Patient Care and Outcomes in Point-of-Care Testing: A Retrospective Study

BACKGROUND

Point-of-care (POC) testing is an integral diagnostic component in clinical settings like the emergency department (ED). However, most POC testing devices are unable to detect endogenous interferents such as hemolysis, which typically occurs during sample collection and handling and can falsely increase measured potassium (pseudohyperkalemia), a phenomenon we hypothesized may significantly impact patient care.

METHODS

In this retrospective study, we evaluated 100 unique admissions to the Oregon Health & Science University ED, presenting with elevated potassium measured at the POC. To evaluate whether in vitro hemolysis had occurred, POC test results were compared to repeat testing of the original specimen, or other specimens tested within 90 minutes in the Core laboratory. Review of associated Electronic Health Records determined whether elevated potassium initially measured using the POC analyzer was real, or due to in vitro hemolysis or contamination, and whether pseudohyperkalemia impacted patient management or care.

RESULTS

Of the 100 admissions with hyperkalemia measured using a POC analyzer, 40% were found to have pseudohyperkalemia due to hemolysis or contamination. Of these 40 patients, 6 experienced repeated testing, and an additional 5 were noted to have altered patient management, specifically due to pseudohyperkalemia.

CONCLUSIONS

This study demonstrates the incidence of in vitro hemolysis, which is unknown to the POC operator, is high in patients who show an elevated potassium as measured at the POC. Furthermore, in vitro hemolysis can significantly impact patient management, suggesting that minimizing the incidence of unrecognized hemolysis will benefit hospital efficiency, decrease waste, and improve patient care.

Underfilling of vacuum blood collection tubes leads to increased lactate dehydrogenase activity in serum and heparin plasma samples

Background Lactate dehydrogenase (LD) activity is routinely monitored for therapeutic risk stratification of malignant diseases, but is also prone to preanalytical influences. Methods We systematically analyzed the impact of defined preanalytical conditions on the hemolysis-susceptible parameters LD, potassium (K) and hemolysis index in vacuum blood collection tubes (serum [SE], heparin plasma [HP]). Blood was collected by venipuncture from healthy volunteers. Tubes were either filled or underfilled to approximately 50%, then processed directly or stored at room temperature for 4 h. Potassium (K), sodium (Na), chloride (Cl), LD, creatine kinase (CK), total cholesterol, and indices for hemolysis, icterus, and lipemia were analyzed. Filling velocity was determined in a subset of tubes. Findings in healthy volunteers were reconfirmed in an in-patient cohort (n = 74,751) that was analyzed for plasma yield and LD data distribution. Results LD activity was higher in HP compared to SE. Underfilling led to higher LD values (SE: +21.6%; HP: +28.3%), K (SE: +4.2%; HP: +5.3%), and hemolysis index (SE: +260.8%; HP: +210.0%), while other analytes remained largely unchanged. Filling velocity of tubes was approximately 3-fold higher in the first half compared to the second half in both HP and SE collection tubes. Importantly, plasma yield also inversely correlated with LD in routine patients. By calculating reference limits, the lowest plasma yield quartile of the patient cohort displayed LD values clearly exceeding current reference recommendations. Conclusions Underfilling of tubes leads to a higher proportion of blood aspirated with high velocity and relevant elevations in LD. This finding should be considered in cases of clinically implausible elevated LD activities.

Drawing blood from peripheral intravenous cannula compared with venepuncture: A systematic review and meta-analysis

AIMS

To synthesize the evidence evaluating if blood samples are similar when obtained from peripheral intravenous cannula compared with venepuncture.

DESIGN

A systematic review and meta-analysis was undertaken.

DATA SOURCES

Searches were conducted in databases for English language studies between January 2000-December 2018.

REVIEW METHODS

The search adhered to the Meta-analysis of Observational Studies in Epidemiology guidelines. The methodological quality of studies was assessed using Joanna Briggs critical appraisal instruments. The overall quality of the evidence was assessed using the GRADE.

RESULTS

Sixteen studies were identified. Findings suggest haemolysis rates are higher in blood sampled from peripheral intravenous cannula. However, haemolysis rates may be lower if a peripheral intravenous cannula blood sampling protocol is followed. For equivalence of blood test results, even though some results were outside the laboratory, allowable error and were outside the Bland-Altman Level of Agreement, none of these values would have required clinical intervention. With regard to the contamination rates of blood cultures, the results were equivocal.

CONCLUSION

Further research is required to inform the evidence for best practice recommendations, including, if a protocol for drawing blood from a peripheral cannula is of benefit for specific patient populations and in other settings.

IMPACT

Venepuncture can provoke pain, anxiety and cause trauma to patients. Guidelines recommend blood samples from peripheral intravenous cannula be taken only on insertion. Anecdotal evidence suggests drawing blood from existing cannulas may be a common practice. Further research is required to resolve this issue.

ACVIM consensus statement on the diagnosis of immune-mediated hemolytic anemia in dogs and cats

Immune-mediated hemolytic anemia (IMHA) is an important cause of morbidity and mortality in dogs. IMHA also occurs in cats, although less commonly. IMHA is considered secondary when it can be attributed to an underlying disease, and as primary (idiopathic) if no cause is found. Eliminating diseases that cause IMHA may attenuate or stop immune-mediated erythrocyte destruction, and adverse consequences of long-term immunosuppressive treatment can be avoided. Infections, cancer, drugs, vaccines, and inflammatory processes may be underlying causes of IMHA. Evidence for these comorbidities has not been systematically evaluated, rendering evidence-based decisions difficult. We identified and extracted data from studies published in the veterinary literature and developed a novel tool for evaluation of evidence quality, using it to assess study design, diagnostic criteria for IMHA, comorbidities, and causality. Succinct evidence summary statements were written, along with screening recommendations. Statements were refined by conducting 3 iterations of Delphi review with panel and task force members. Commentary was solicited from several professional bodies to maximize clinical applicability before the recommendations were submitted. The resulting document is intended to provide clinical guidelines for diagnosis of, and underlying disease screening for, IMHA in dogs and cats. These should be implemented with consideration of animal, owner, and geographical factors.

The effect of blood sampling and preanalytical processing on human N-glycome

Glycome modulations have been described in the onset and progression of many diseases. Thus, many studies have proposed glycans from blood glycoproteins as disease markers. Astonishingly, little effort has been given unraveling preanalytical conditions potentially influencing glycan analysis prior to blood biomarker studies. In this work, we evaluate for the first time the effect of hemolysis, storage and blood collection, but also influence of various times and temperatures between individual processing steps on the total N-glycome and on a glycan-biomarker score. Venous blood was collected from 10 healthy donors in 11 blood collection tubes with different additives, processed variously to obtain 16 preanalytical variables and N-glycans released from serum or plasma were analyzed by MALDI-TOF-MS and capillary electrophoresis coupled with fluorescence detection (CE-LIF) for the first time. Long time storage of deep frozen samples at -20°C or -80°C exerted only a minor influence on the glycome as demonstrated by CE-LIF. The N-glycome was very stable evidenced by MALDI-TOF when stored at 4°C for at least 48 hours and blood collected in tubes devoid of additives. The glycome was stable upon storage after centrifugation and aliquoting, which is an important information considering future diagnostic applications. Hemolysis, however, negatively correlated with an established glycan score for ovarian cancer, when evaluated by MALDI-TOF-MS measurement by affecting relative intensities of certain glycans, which could lead to false negative / positive results in glycan biomarker studies.

Evaluation of a new venous catheter blood draw device and its impact on specimen hemolysis rates

OBJECTIVES

Blood collections from peripheral intravenous catheters offer several benefits to patients, including reduced needle punctures and patient discomfort, but they risk reducing the quality of blood specimens analyzed by the laboratory. In an effort to balance analytical quality of test results with patient-centered care initiatives, a needle-less blood collection device called PIVO™ was evaluated at two institutions. The primary objective of this study was to assess the ability of the PIVO™ device to provide high-quality blood specimens for laboratory testing compared to current blood collection methods.

METHODS

Blood specimens drawn using the PIVO™ device were prospectively flagged. A retrospective review was performed comparing the degree and rate of hemolysis for PIVO™ blood collections to both concurrent and historical hemolysis rates for other collection methods.

RESULTS

Approximately 7600 PIVO™ blood draws were performed across the two institutions. The hemolysis rates of samples collected with PIVO™ were evaluated using 2380 flagged collections, containing approximately 1200 test orders requiring hemolysis index measurements. The hemolysis rate of PIVO™-flagged samples (1.8%) was statistically superior to the venipuncture and central line blood collection methods (3.3%), reducing the risk of hemolysis during a venous blood draw by 39%.

CONCLUSIONS

PIVO™ collections facilitated improvement in the rate and degree of sample hemolysis when compared to venipuncture and central line blood collections. These findings suggest that PIVO™ is capable of delivering samples that are superior to current blood collection methods in terms of hemolysis rate as well as reducing the number of invasive venipunctures required for laboratory testing.

Effect of peripheral IV based blood collection on catheter dwell time, blood collection, and patient response

AIM

To evaluate the effect of daily PIV-based phlebotomy using the PIVO device on PIVC dwell times and replacement rates, as well as the reliability of blood sample collection, and patient response to this method of blood collection.

BACKGROUND

Blood draws which are also known as phlebotomy for laboratory analyses are one of the most common experiences for hospitalized patients. When performed by venipuncture, they are often associated with pain and anxiety for patients. Most hospitals avoid phlebotomy from peripheral IV catheters due to sample hemolysis, sample dilution by fluids in PIVC line or infused medications, PIVC dislodgement or infiltration, and increased rates of phlebitis.

METHODS

A prospective, randomized- controlled study of 160 GI surgery patients was enrolled. Patients were randomized to either control evaluation of PIVC dwell or to receive daily PIVO blood collections in addition to evaluation of PIVC dwell.

RESULTS

Daily PIVO blood collections did not negatively affect PIVC dwell or replacement rates. Overall 81% of blood collection attempts were successful and the likelihood of success was strongly associated with PIVC condition. Patients reported 0.7/10 pain for PIVO blood collection on a 0-10 pain scale and a 9.1/10 preference for PIVO on a 0 (strongly prefer needle) to 10 (strongly prefer PIVO) preference scale. Results suggest that use of a PIV based blood collection was a reliable and valid approach and was superior to routine phlebotomy in self-reported responses from patients.

Repeated Blood Collection from Tail Vein of Non-Anesthetized Rats with a Vacuum Blood Collection System

Blood can be collected from rats in a number of sampling locations. For instance, the tail vein is a superior location for blood sampling. However, the tail vein is thin so that it is sometimes hard to puncture. In addition, the tail vein has low blood flow and requires a long sampling time to get sufficient blood. The present report describes a simple blood sampling method, the vacuum blood collection method, which is usually used to obtain blood samples from patients, here used for non-anesthetized rats. The 22 G butterfly needle tip was inserted into one of the lateral tail veins approximately 2-3 cm from the tip of the tail at an angle of approximately 20°, and blood was collected in the vacuum collection tube by inserting the rubber end of the butterfly needle into the vacuum blood collection tube. The present experimental results show that the success rate was 95% in the experimental group and 90% in the beginner group. The success rate and puncture times were similar between two groups. The sampling duration was significantly shorter in the experimental group compared to beginner group. In conclusion, this vacuum blood collection method for sequential blood sampling from the tail vein of non- anesthetized rats is feasible and easy-to-learn, which might serve as a reliable alternative to other conventionally used blood sampling techniques for rats.

Making sense of a haemolysis monitoring and reporting system: a nationwide longitudinal multimethod study of 68 Australian laboratory participant organisations

Background:

The key incident monitoring and management systems (KIMMS) quality assurance program monitors incidents in the pre- and postanalytical phases of testing in medical laboratories. Haemolysed specimens have been found to be the most frequent preanalytical error and have major implications for patient care. The aims of this study were to assess the suitability of KIMMS for quality reporting of haemolysis and to devise a meaningful method for reporting and monitoring haemolysis.

Methods:

A structured survey of 68 Australian KIMMS laboratory participant organisations was undertaken. Quarterly haemolysis reports (2011–2014) were analysed.

Results:

Among 110 million accessions reported, haemolysis rates varied according to the reporting methods that participants used for assigning accessions (16% of participants reported haemolysis by specimen and 83% reported by episode) and counting haemolysis rejections (61% by specimen, 35% by episode and 3% by test). More than half of the participants (56%) assigned accessions by episode and counted rejections by specimen. For this group, the average haemolysis rate per 100,000 episodes was 177 rejected specimens with the average rate varying from 100 to 233 over time. The majority of participants (91%) determined rejections using the haemolysis index. Two thirds of participants (66%) recorded the haemolysis manually in laboratory information systems.

Conclusions:

KIMMS maintains the largest longitudinal haemolysis database in the world. However, as a means of advancing improvements in the quality of the preanalytical laboratory process, there is a need to standardise reporting methods to enable robust comparison of haemolysis rejection rates across participant laboratories.

The relationship between vacuum and hemolysis during catheter blood collection: a retrospective analysis of six large cohorts

Background:

Blood collection through intravenous (IV) catheters is a common practice at emergency departments (EDs). This technique is associated with higher in vitro hemolysis rates and may even be amplified by the use of vacuum collection tubes. Our aim was to investigate the association of five different vacuum tubes with hemolysis rates in comparison to an aspiration system under real-life conditions and to propose an equation to estimate the amount of hemolysis, depending on the vacuum collection tube type.

Methods:

We retrospectively evaluated hemolysis data of plasma samples from our ED, where blood is drawn through IV catheters. Over the past 5 years, we compared 19,001 hemolysis index values amongst each other and against the respective vacuum pressure (Pv) of the collection tubes, which were used within the six observational periods.

Results:

The highest hemolysis rates were associated with full-draw evacuated tubes. Significantly reduced hemolysis was observed for two kinds of partial-draw tubes. The hemolysis rate of one partial-draw blood collection tube was comparable to those of the aspiration system. Regression analysis of Pv and mean free hemoglobin (fHb) values yielded the formula fHb (g/L)=0.0082*Pv2–0.1143*Pv+ 0.5314 with an R2 of 0.99.

Conclusions:

If IV catheters are used for blood collection, hemolysis rates directly correlate with the vacuum within the tubes and can be estimated by the proposed formula. By the use of partial-draw vacuum blood collection tubes, hemolysis rates in IV catheter collections can be reduced to levels comparable with collections performed by aspiration systems.

pH-Sensitive N-doped carbon dots–heparin and doxorubicin drug delivery system: preparation and anticancer research

In this study, doxorubicin (DOX) hydrochloride as a model drug, N-doped carbon dots as a drug carrier, and heparin as an auxiliary medicine were selected to design and prepare a multi-functional drug delivery system with pH-triggered drug release.

Key factors influencing the incidence of hemolysis: A critical appraisal of current evidence

Hemolysis is a leading cause of pre-analytical laboratory errors. The identification of contributing factors is an important step towards the development of effective practices to reduce and prevent hemolysis. We performed a review of PUBMED, Embase, Medline and CINAHL to identify articles published between January 2000 and August 2016 that identified factors influencing in vitro hemolysis rates. The 40 studies included in this review provide excellent evidence that hemolysis rates are higher in Emergency Departments (EDs), for non-antecubital draws, for specimens drawn using an intravenous catheter compared to venipuncture and for samples transported by pneumatic tube compared to by hand. There is also good evidence that hemolysis rates are higher when specimens are not collected by professional phlebotomists, larger volume specimen tubes are used, specimen tubes are filled less than halfway and tourniquet time is greater than one minute. The results of this review suggest that hospitals and clinical laboratories should consider deploying phlebotomists in EDs, drawing all blood through a venipuncture, using the antecubital region as the optimum blood collection site and transporting specimens by laboratory assistant/other personnel, or if this in not practical, ensuring that pneumatic transport systems are validated, maintained and monitored. Studies also recommend making hemolysis a hospital-wide issue and ensuring high-quality staff training and adherence to standard operating procedures to reduce hemolysis rates. Awareness of the factors that influence hemolysis rates, and adoption of strategies to mitigate these risk factors, is an important step towards creating quality practices to reduce hemolysis rates and improve the quality of patient care.

Phlebotomy, a bridge between laboratory and patient

The evidence-based paradigm has changed and evolved medical practice. Phlebotomy, which dates back to the age of ancient Greece, has gained experience through the evolution of medicine becoming a fundamental diagnostic tool. Nowadays it connects the patient with the clinical laboratory dimension building up a bridge. However, more often there is a gap between laboratory and phlebotomist that causes misunderstandings and burdens on patient safety. Therefore, the scope of this review is delivering a view of modern phlebotomy to "bridge" patient and laboratory. In this regard the paper describes devices, tools and procedures in the light of the most recent scientific findings, also discussing their impact on both quality of blood testing and patient safety. It also addresses the issues concerning medical aspect of venipuncture, like the practical approach to the superficial veins anatomy, as well as the management of the patient's compliance with the blood draw. Thereby, the clinical, technical and practical issues are treated with the same relevance throughout the entire paper.

Generalizability and Effectiveness of Butterfly Phlebotomy in Reducing Hemolysis

OBJECTIVES

The objective was to test the hypothesis that exclusive use of butterfly needles for phlebotomy, compared with sample collection via intravenous (IV) catheter, will reduce rates of sample hemolysis.

METHODS

This was an observational study of hemolysis rates before and after implementation of a "butterfly-only" phlebotomy protocol. Weekly hemolysis rates, generated by the central laboratory, were collected and the proportion of hemolyzed specimens before and after protocol implementation were compared.

RESULTS

Prior to institution of the butterfly-only protocol, 11.3% of specimens sent from the emergency department were reported as hemolyzed. During the postintervention period, only 4.3% of specimens were hemolyzed for a proportionate decrease of 62% and an absolute decrease of 7.0% (95% confidence interval = 6.6% to 7.3%).

CONCLUSIONS

Use of a butterfly-only phlebotomy protocol cuts hemolysis rates by more than half when compared with IV catheter phlebotomy.