This procedure is used when blood is removed for treatment of a patient. The usual indication for phlebotomy is an abnormally high hematocrit (primary or secondary polycythemia). Another indication for phlebotomy is iron overload from hemachromatosis, chronic iron overdose or long term transfusion of chronic anemias.
II. Clinical Significance: N.A.
III. Specimen: N.A.
1. Blood pressure cuff
3. Blood collection bag (Baxter #4R0012P)
Note: When pouches are opened secure the open end of the foil pouch to prevent possible loss of moisture to unused collection bags.
4. 2 x 2 Gauze squares (Fisher #22362178)
5. Allegiance Providone-Iodine prep pad (CardinalHealth #40000020)
6. Scale suitable to weigh blood (Ohaus #8004-110)
7. Surgical paper tape (CardinalHealth #M1535-1)
8. DonorCare Needle Guard (Teruma Medical Corp #8-A100100)
9. Hand Sealer Clips (Baxter-Fenwal #4R4418)
10. Hand Sealer (Baxter-Fenwal #BS-4)
V. Reagents: N.A.
VI. Standardization: N.A.
A. Staff physician's written order specifying amount of blood to be collected.
Note: If withdrawal of more than one unit is ordered, notify a pathologist before proceeding.
B. Hemoglobin/hematocrit (HGB/HCT) done at a UCL site within the last 48 hours along with a history and indication for phlebotomy.
Note: If a HGB/HCT has not been run in the last 48 hours, collect and run one prior to performing the phlebotomy. Charge the patient for the HGB/HCT and venipuncture fee.
Note: HGB/HCT performed by Dubuque Internal Medicine Laboratory and Medical Associates Laboratory are acceptable.
C. Before proceeding with the procedure:
a. Mercy: The patient must read and sign the “My Request and Consent to Admission and Agreement to Conditions of Admission” form. The hospital provides this form.
Finley: The patient must read and sign the “Consent for Surgery or Procedure” form. The hospital provides this form.
b. Time Out:
D. Therapeutic phlebotomies do not typically require a pathologist’s approval.
If the order is for the first phlebotomy on a patient, the doctor must provide a diagnosis and also state the hemoglobin level below which a phlebotomy will not be performed. This information must be transcribed to the Patient Phlebotomy Card and transferred to a subsequent card if the number of phlebotomies exceeds the number of spaces on the original card.
E. Only qualified personnel may perform therapeutic phlebotomies. (See Therapeutic Bleeding Qualification sheet at the MMC-DBQ site and the Orientation Checklist at the Finley site and MMC-DV site.)
A. The procedure is performed:
a. Finley site: in the emergency room on outpatients and in the assigned patient room on inpatients.
b. MMC-DBQ site: in the Same Day Surgery Suite on outpatients and in the assigned patient room on inpatients.
c. MMC-DV site: in an available patient room on outpatients and in the assigned patient room on inpatients.
B. Instruct the attending nurse to take and record the patient's weight, blood pressure, pulse and temperature. Acceptable limits are as follows:
a. Pulse rate and rhythm:
1. Pulse rate: 50 to 100 beats per minute
2. Rhythm: regular
b. Blood pressure:
1. Systolic pressure: 90 to 180 mm of mercury
2. Diastolic pressure: 50 to 100 mm of mercury
110 lb (50 kg) or more.
oral temperature must not exceed 37.5° C (99.6° F)
Note: If the patient fails to meet any of these criteria the attending nurse must notify the laboratory and a pathologist will contact the attending physician for further orders.
C. Tear open the foil pouch and remove the collection bag.
D. Inspect the blood collection bag for defects. The anticoagulant solution must be clear.
E. Suspend the collection bag from the scale. Keep the bag lower than the venipuncture site. Make sure no kinks are formed in the tubing.
Note: One ml of blood weighs 1.06 gm. The final container should weigh 425 to
520 gm plus the weight of the container with its anticoagulant. (The collection bag with anticoagulant weighs approximately 85 gm.) If a Fenwal scale is used, set it at 565 to withdraw the usual amount for one unit of blood from the patient.
F. Orientate a DonorCare needle guard by ensuring that the arrow is pointing to the needle hub. Clip the guard over the tubing making sure that all three lock points click fully into place. The DonorCare guard can be slid over the needle hub and stabilized with tape or can be left behind the needle hub during the blood collection.
G. Apply the blood pressure cuff and inflate it to 40 to 50 mm of mercury.
H. Select a large firm vein in an area of the antecubital fossa that is free of skin lesions.
I. Prepare the skin for venipuncture by wiping a 2 inch area with betadine. Allow the area to dry before proceeding with the venipuncture.
Note: If provodone-iodine prep pad cannot be used, use alcohol prep pad.
J. Apply the hemostat to the tubing attached to the collection bag, perform the venipuncture following the "Venipuncture” procedure.
K. After the venipuncture has been performed, release the hemostat from the tubing and tape the needle in place on the patients arm.
L. Instruct the patient to open and close their hand slowly and continuously during the entire collection.
M. Monitor the volume of the blood being collected.
N. After the collection is completed, once again apply the hemostat to the tubing attached to the collection bag. Deflate the blood pressure cuff; remove the needle from the patient's arm. Apply pressure with a gauze pad until the bleeding has stopped. Stabilize the needle guard with one hand and pull the tubing back until the needle is locked into the DonorCare guard. Confirm the needle lock by listening for the “click” as the needle is drawn into the guard and by ensuring that the tubing cannot be pulled through the guard.
O. Inform nursing personnel that you are finished. Instruct the nurse to observe the patient and, at 15 minutes from the conclusion of the phlebotomy, to take the patient's blood pressure and pulse. On outpatients, if the blood pressure and pulse are within the previously stated limits and the patient is free of adverse symptoms, he/she may be released contingent upon approval of the attending physician.
P. After the phlebotomy is completed:
a. Record the amount of blood withdrawn on the requisition.
b. Enter the quantity of blood withdrawn (in units), as recorded on the requisition, in CLICS for the specific accession number and configuration code.
Q. Use clips available in the blood bank to seal the unit after returning to the laboratory. Remove the hemostat after sealing the unit. Discard the unit of blood and needle according to "Waste and Sharps Disposal" section of the Engineering and Work Practices Control protocol in the Laboratory Exposure Control Plan.
R. File the patient's Therapeutic Phlebotomy Card appropriately.
VIII. Limitations: N.A.
IX. Results Derivation: N.A.
X. Expected Result(s) and/or Critical Values: N.A.
XI. Quality Control: N.A.
1. AABB Committee on Technical Manual, AABB Technical Manual, 10th Ed., 1990, pp 11 - 15.
2. Fenwal Blood Pack Unit package insert.
3. United Clinical Laboratories, Inc. "Venipuncture Procedure", 1993.
4. United Clinical Laboratories, Inc. "Laboratory Exposure Control Plan", 1993.
i. 11-22-77 S. Pfaff
ii. 6-29-93 R. Maiers (Revised: Format, Sec:VII.1.B. and E., 2.H., L.,N. and O.)
iii. 3-1-94 J. Wiederholt (Revised: VII.1.D.E., 2.A.d.; Include LMH)
iv. 1-12-2001 J. O’Connor, MD and S. Raymond; VII,1.D. and VII, 2.M. Discontinued practice of requiring pathologist approval for routine phlebotomies. Modified card to include diagnosis and lower limit Hgb.
v. October 2004 R. Schaefer (Revised: IV.8.; VII.2.C&M.; DonorCare needle guard)
vi. January 2007 A. McCrea (Revised: VII.1.C.Finley)
vii. February 2007 J. Mueller (Revised: VII.2.O.)
viii. October 2009 S. Rodriguez, R. Maiers (Revised: VII.C. and forms)
July 2010 M. Lewis (Revised: IV.3., 8.; VII.1.C.a-b., 2.C-D.)
September 2011 R. Shireman (Revised: IV.4-10.; VII.2.I.note, M., P.b.; list)
The following are trained to perform therapeutic phlebotomy and complete annual Competency Review of the procedure.
Example of therapeutic phlebotomy file card
THERAPEUTIC PHLEBOTOMY RECORD
Pt Name & MR#:
Do NOT phlebotomize if Hgb is less than:________ date:________