blood sample collection in children
TRANSCRIPT
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Blood sample collection in children Do’s and Don'ts
Dr Swati Bhave
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Preparation of Pediatric Patients
• Find out –Is it the first time for the child?
Find out about past experience. How did the child react ? How did the parents react ?
• Explain – To parent and child about procedure (if possible with dolls or puppets)Explain need of second attempt if required
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Parental co-operation
•Assess - Parental ability to participate or assist you
•Decide - Whether parent should be present or not
• If present - Decide how will they assist : physical restrain, distraction, emotional support , explanation
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How to relieve Anxiety & Fear
• Collect blood away from other patients in a special room. Never in the hospital bed. This is a comfort zone
• Area should be child friendly. Uniforms should be colourful
• Keep equipment out of site • Ask child’s preference of hand • Allow child to select comfort object• Stop procedure if child combative • Try later or another person
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Minimizing PAIN
• Topical anesthetic like AMETOP, EMLA • Cost, time ( 10-60min)• More than one site tried, allergy • Sucrose or pacifier
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Selection of Site • Very important to get adequate volume • Will be decided by
– Age of the child: heel or finger stick, IV – Whether arterial or venous blood required – Equipment available eg neonate capillary
tubes, vacutainers, routine needle & syringe etc
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Infants and Neonates HEEL stick puncture
• Lateral plantar bottom surface • 3 - 5 min Pre-Warming > blood flow (arterializes)• Pediatric lancet New born 2.5mm L /1mm D,
Preterm o.75 mm L / 0 .85 mm D• Depth of major BV is 0.03 mm to 1.6 mm from
skin to calcaneous• > 2.4 mm depth injury: Osteomyelitis
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Infants and Neonates HEEL stick puncture
• Do not use anteromedial area or posterior curve of C
• Do not use alcohol swabs to stop bleeding : stinging; Use sterile gauze for pressure
• Do not use adhesive tapes :maceration and bruising of skin
• Do not squeeze or milk excessively : hemolysis or dilutes blood with tissue and interstitial fluid : erroneous results
• Discard first drop • Complications cellulitis, abscess, scarring, tissue
loss, calcified nodules
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Older child : > one yr age finger prick
• Damaged veins, arm in cast or bandaged • Do not use if edema, infection, < circulation• Skin to BV depth 1.5 -2.4 mm• Should not go >2.4 mm deep• Pediatric lancet sizes 1.75/1.25/0.85 mm
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Intravenous blood collection• Site selection • Tourniquet not excessively tight
• Special precautions when– Heparin lock or – IV line collection
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What is required from the sample
• Does the test require : whole blood , serum or plasma.
• How much is the volume required : 2, 4, 5, ml etc. Pre-term 10 ml may be 5 % of total volume
• What are the special bulbs or ready made tubes required : e.g. fluoride bulb for sugar, chemistry bulb for urea , EDTA for hematology etc
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In What to collect blood ?
BULB FUNCTION USED FOR
EDTA Chelates Ca preserves cellular elements
CBC,Reticulocytes, ESR,G6PD, Hb electrophoresis
Trisodium citrate
Converts Ca into non-ionized form
PT, APTT, TT Fibrinogen etc
Flouride Enzyme poison. Inhibits Glycolysis In RBC (Glucose destroyed at 5% / hr)
Glucose
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ORDER of drawing
• This is important - so that additives in one tube will not contaminate specimen in subsequent tubes
• Blood culture • Non Additive tube • Coagulation tube • Non Additive tube
• If using syringes minimize clotting by filling additive tubes before non additive
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When & How to get Serum & Plasma
• Serum sample – blood collected without
any anti-coagulant and centrifuged
– clear supernatant fluid devoid of any fibrin products
• Plain bulb– Most enzymes,– Biochemical LFT,KFT, – S Electro.– Serological :Widal,
VDRL
• Plasma sample – blood collected & mixed
with anticoagulant and centrifuged
– clear supernatant fluid with thrombosis inhibited. Most satisfactory sample. No changes occur in blood
• Heparinized bulb– PH, NH4, RBC levels,
Plasma cortisol, testosterone, globin,cholinesterase
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For Special Testing
• PCR, Genetic, ammonia, blood gases, drug, antibiotic & hormone levels etc.
• Before collection of sample ascertain that you know everything about the sample collection
• Confirm from lab how much volume, what bulb, procedure, timing etc
• Recollection of blood is distressing for everyone: Child-parent- doctor & adds to cost
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HEMOLYSIS OF SAMPLES
• Contact with water • Excessive heat or cold • Rigorous mechanical injury to RBS
( thin gauge ) • Prolonged storage • Hemolyzed samples will give
erroneous results
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PREVENTION OF HEMOLYSIS
• Equipment used to collect : absolutely dry
• Minimum constriction of limb• Use correct gauge • Collect slowly and steadily • Remove needle and put
immediately into the bulb• Easier if collection in Vacutainer
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Important steps before collection
• Identification of the patient • Labeling correctly: very very important • Re-checking which test is required• Keeping ready all the necessary equipment :
drawing of blood and bulbs for collection• Clean up the area before and after
collection
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Following safety precautions
• Do no harm to your patient – Ensure use of safe and sterile equipment
• Do no harm to yourself – Follow universal precautions – Avoid needle stick injuries and splashing of
blood into your eyes, skin or mucous membrane
• Do no harm to the community – Ensure that you have safely and correctly
disposed all equipment so that no other person can get exposure
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Transport & Storage of samples • Ideally the sample should be collected
in the laboratory and immediately into the processing
• If it cannot be sent immediately one should follow instructions carefully for
Storage • where should it be kept ? : room temp,
cold storage-what temp Transport • What are the precautions during
transport
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Summary
• Blood collection in children is a traumatic and invasive procedure
• All efforts should be made to reduce the discomfort
• Care should be taken to avoid need for repeat puncture