ENA’s T I P Reducing Hemolysis of Peripherally Drawn Blood Samples

ENA’s Translation Into Practice
Reducing Hemolysis of Peripherally Drawn Blood Samples
Hemolysis is the rupture of blood cells, which interferes with the accuracy of blood sample results and
clinical diagnosis and affects emergency department throughput.
Applies to the adult and geriatric population.
Translation Into Practice: TIPs for Reducing Hemolysis of Peripherally Drawn Blood Samples
Recommended Clinical Practice
Hemolysis is less likely when blood is drawn from the antecubital fossa. 1-3 [Level B Recommendation]
Direct venipuncture with straight needles is less likely to cause hemolysis than blood collection through intravenous
catheters.1,3-7 [Level B Recommendation]
Drawing blood through needless connectors does not increase hemolysis.8,9 [Level B Recommendation]
Low (partial) vacuum tubes result in less hemolysis. 3,10 [Level B Recommendation]
Reducing Hemolysis of Peripherally Drawn Blood Samples
Choose the appropriate site for blood draw 11,12
Preferred: Draw blood via antecubital site with a straight needle and blood collection system that draws
blood directly into the tube 13,14
Ensure all connections are tight 11
Cleanse skin with an antiseptic per manufacturer’s recommendations. Allow area to air dry without assistance. 11-14
Do not fan to dry area
Instruct patient not to pump fist during blood draws 12
Apply tourniquet 3-4 inches above site. Release tourniquet when blood is flowing.12 The tourniquet should be
applied for no more than one minute.7,12
Match needle size to vein size
Adults: Use of a 21 gauge needle is recommended 13
Ensure connections are secure 11
Fill tubes until the vacuum is depleted and blood stops flowing
Follow the Clinical & Laboratory Standards Institute Guidelines for order of the blood sample draw:
Order of the Draw for Full-Sized Tubes
1. Blood culture tubes or non-additive waste tube
2. Coagulation tube
3. Serum tubes with and without clot activator and with and without gel separator
4. Heparin tubes with or without plasma separator
5. EDTA tube with or without gel separator
6. Glycolytic inhibitor (fluoride, iodoacetate) tubes
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December 2012; Revised October 8, 2013
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ENA’s Translation Into Practice
Reducing Hemolysis of Peripherally Drawn Blood Samples
TIP: Reducing Hemolysis of Peripherally Drawn Blood Samples - continued
Reducing Hemolysis of Peripherally Drawn Blood Samples
Order of the Draw for Microtainer Tubes
1. Blood gases
2. Slides/smears
3. EDTA tube
4. Other additive tubes
5. Serum tubes
Gently rotate filled tubes back and forth (180°) the number of times recommended by the tube manufacturer – do
not shake 11-12
Label tubes before leaving patient’s side15
Send specimens for analysis as soon as possible 11-12
Adequately pad specimen(s) when sending by pneumatic tube system 16,17
Syringe draw (Note: Not recommended; see statement in Supporting Evidence section)11,13
Before using, expel all air and ensure the plunger moves easily within the barrel 11-12
Use a transfer device to place blood into tubes 11,18
Allow vacuum to fill tube - do not force blood into tube 12
Reducing Hemolysis of Peripherally Drawn Blood Samples
Supporting Rationale: Reducing Hemolysis of Peripherally Drawn Blood Samples
Multiple studies have shown that significantly higher hemolysis occurs when blood is drawn through an IV
catheter. 1,11,13,16,19-24
The median antecubital vein site is easily accessible, stable, closer to the surface and located away from nerves
and arteries and is typically less painful for the patient. 12
Loose connections allow air into the system leading to frothing and hemolysis. 11
Residual wet antiseptic on the skin may cause red blood cell breakage. 11-14
Clenching and unclenching of the fist is no longer recommended because it changes certain analytes in the
blood. 12,16 An analyte is the part of the sample that the test is designed to find or measure.26
Tourniquets left on for longer than 1 minute cause blood stasis resulting in falsely higher values for protein
based analytes, packed cell volume, and other cellular contents. 12
Match needle size to vein size to reduce hemolysis: 11-13
When the needle is too small, blood is pushed through a smaller opening with greater pressure 11,14
When the needle is too large, blood flows into the tube faster and more forcefully
Under filled blood tubes disrupt the additive/blood mix and can lead to hemolysis. 11
Emergency Nurses Association • 915 Lee Street • Des Plaines, IL 60016-6569 • 847-460-4000
December 2012; Revised October 8, 2013
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ENA’s Translation Into Practice
Reducing Hemolysis of Peripherally Drawn Blood Samples
Supporting Rationale: Reducing Hemolysis of Peripherally Drawn Blood Samples - continued
The order of the blood draw is designed to prevent additive carryover resulting in analysis errors. 12
The labeling of all specimens is a risk-reduction activity consistent with safe medication management.15
Blood specimens sent via unpadded pneumatic tube carriers are subjected to the acceleration and deceleration
forces that can damage red blood cells. 11,17
Syringe draw: The smooth, solid inner lumen surface of the transfer device decreases turbulence and hemolysis
and is safer than using a needle to transfer blood. 11,14,18
Berger-Achituv, S., Budde-Schwartzman, B., Ellis, M. H., Shenkman, Z., & Erez, I. (2010). Blood sampling through peripheral venous catheters is reliable for selected basic analytes in
children. Pediatrics, 126(1), 179-186. doi: 10.1542/peds.2009-2920
Bush, R.A., Mueller, T., Sumwalt, B., Cox, S.A., and Hilfiker, M.L. (2010). Assessing pediatric trauma specimen integrity. Clinical Laboratory Science, 23, 219-222.
Dwyer, D. G., Fry, M., Somerville, A., & Holdgate, A. (2006). Randomized, single blinded control trial comparing haemolysis rate between two cannula aspiration techniques.
Emergency Medicine Australasia, 18, 484-488. doi:10.1111/j.1742-6723.2006.00895.x
Fang, L., Fang, S., Chung, Y., & Chien, S. (2008). Collecting factors related to the haemolysis of blood specimens. Journal of Clinical Nursing, 17, 2343-2351. doi: 10.1111/j.13652702.2006.02057.x
Heyer, N.J., Derzon, J. H., Winges, L., Shaw, C. Mass, D. Snyder, S.R., Epner, P., Nichols, J.H., Gayken, J.A., Ernst, D., & Liebow, E., B. (2012). Effectiveness of practices to reduce blood
sample hemolysis in EDs: a laboratory medicine best practices systematic review and meta-analysis. Clinical Biochemistry, 45(13-14), 1012-1032.
Ong, M.E.H., Chan, Y. H., & Lim, C. S. (2009). Reducing blood sample hemolysis at a tertiary hospital emergency department. The American Journal of Medicine, 122(11), 1054.e11054.e6. doi:10.1016/j.amjmed.2009.04.024
Saleem, S., Mani, V., Chadwick, M.A., Creanor, S., & Ayling R. M. (2009). A prospective study of causes of haemolysis during venipuncture: tourniquet time should be kept to a
minimum. Annals of Clinical Biochemistry, 46, 244-246.
Schwarzer, B. A., McWilliams, L., Devine, K., & Sesok-Pizzini, D. A. (2001). Increased number of hemolyzed specimens from the emergency department and labor and delivery with use
of IV safety catheters. Transfusion, 41, 138S-139S.
Sharp, M. K. & Mohammand, S. F. (2003). Hemolysis in needleless connectors for phlebotomy. American Society for Artificial Internal Organs Journal, 49(1), 128-130. doi: 10.1097/01.
Tanabe, P., Kyriacou, D, N., & Garland, F. (2003). Factors affecting risk of blood bank specimen hemolysis. Academic Emergency Medicine, 10(8), 897-900.
Bush, V., & Mangan, L. (2003). The hemolyzed specimen: Causes, effects, and reduction. Preanalytical Solutions Lab Notes, BD Vacutainer Systems, 13(1), 1-5.
Clinical Laboratory Standards Institute (2007). Procedures for the collection of diagnostic blood specimens by venipuncture, 6th edition. Clinical and Laboratory Standards
Institute, 27(26), 2-20.
Bowen, R. A. R., Hortin, G.L., Csako, G., Otanez, O. H., & Remaley, A. T. (2010). Impact of blood collection devices on clinical chemical assays. Clinical Biochemistry, 43, 425.
Halm, M. A., & Gleaves, M. (2009). Obtaining blood from peripheral intravenous catheters: Best practice? American Journal of Critical Care, 18 (5), 474-478.
The Joint Commission. (2012). Hospital Accreditation Standards. Oakbrook Terrace, IL: Joint Commission Resources.
Lippi, G., Salvagno, G. L., Favalaro, E. J., & Guidi, G. C. (2009). Survey on the prevalence of hemolytic specimens in an academic hospital according to collection facility:
Opportunities for quality improvement. Clinical Chemistry & Laboratory Medicine, 47(5), 616-618.
Streichert, T., Otto, B., Schnabel, C., Nordholt, G., Haddad, M., Maric, M., Petersmann, A., Jung, R., & Wagener, C. (2011). Determination of hemolysis thresholds by the
use of data loggers in pneumatic tube systems. Clinical Chemistry, 57(10), 1390-1397.
Carraro, P., Servidio, G., & Plebani, M. (2000). Hemolyzed specimens: A reason for rejection of a clinical challenge? Clinical Chemistry, 46(2), 306-307.
Dugan, L., Leech, L., Speroni, K.G., & Corriher, J. (2005). Factors affecting hemolysis rates in blood samples drawn from newly placed IV sites in the emergency department.
Journal of Emergency Nursing, 31(4), 338-345.
Grant, M. S. (2003).The effect of blood drawing techniques and equipment on the hemolysis of ED laboratory blood samples. Journal of Emergency Nursing, 29(2), 116121.
Lowe, G., Stike, R., Pollack, M., Bosley, J., O’Brien, P., Hake, et al. (2008). Nursing blood specimen collection techniques and hemolysis rates in the emergency department:
Analysis of veniinsertion versus catheter collection techniques. Journal of Emergency Nursing, 34(1), 26-32.
Seeman, S., & Reinhardt, A. (2000). Blood sample collection from a peripheral catheter system compared with phlebotomy. Journal of IV Nursing, 23(5), 290-297.
Stauss, M., Sherman, B., Pugh, L., Parone, D., Looby-Rodriquez, K., Bell, A., & Reed, C. (2012). Hemolysis of coagulation specimens: A comparative study of IV draw
methods. Journal of Emergency Nursing,38(1), 15-21.
Straszewski, S.M., Sanchez, L., McGillicuddy, D., Boyd, K., DuFresne, J., Joyce, N. …Mottley, J.L. (2011). Use of separate venipuncture for IV access and laboratory studies
decreases hemolysis rates. Intern Emergency Medicine, 6, 357-359.
Munnix, I.C.A., Schellart, M., Gorissen, C., & Kleinveld, H. A. (2011). Factors reducing hemolysis rates in blood samples from the emergency department. Clinical Chemistry
& Laboratory Medicine, 49(1), 157-158.
U.S. Food and Drug Administration (FDA). (2009). Medical devices: Glossary. Retrieved from
Emergency Nurses Association • 915 Lee Street • Des Plaines, IL 60016-6569 • 847-460-4000
December 2012; Revised October 8, 2013
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ENA’s Translation Into Practice
Reducing Hemolysis of Peripherally Drawn Blood Samples
Key for Level of Evidence Recommendation
This document, including the information and recommendations set forth herein (i) reflects ENA’s current position with respect to the subject matter discussed herein based
on current knowledge at the time of publication; (ii) is only current as of the publication date; (iii) is subject to change without notice as new information and advances
emerge; and (iv) does not necessarily represent each individual member’s personal opinion. The information and recommendations discussed herein are not codified into law
or regulations. Variations in practice and practitioner’s best nursing judgment may warrant an approach that differs from the recommendations herein. ENA does not
approve or endorse any specific sources of information referenced. ENA assumes no liability for any injury and/or damage to persons or property arising from the use of the
information in this document.
Authored by the 2012 ENA Clinical Practice Committee:
Mary Stauss, MSN, RN, CEN
Estrella Evangelista-Hoffman, DNP, MEd, BSN, RN, CNL
Janis Farnholtz-Provinse, MS, RN, CNS, CEN
Kristie Gallagher, MSN, RN, CEN, NREMT-P
Catherine Harris, MSN, RN, CEN, CPEN
2012 ENA Board of Directors Liaison:
Kathleen Carlson, MSN, RN, CEN, FAEN
ENA Staff Liaisons:
Kathy Szumanski, MSN, RN, NE-BC
Jessica Gacki-Smith, MPH
Emergency Nurses Association • 915 Lee Street • Des Plaines, IL 60016-6569 • 847-460-4000
December 2012; Revised October 8, 2013
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