Elsevier

Clinical Biochemistry

Prevention of hemolysis in blood samples collected from intravenous catheters

Abstract

Objectives

Samples drawn through intravenous catheters are frequently hemolyzed. We planned a prospective, randomized study to establish whether hemolysis in samples drawn from intravenous catheters may exist reduced using S-Monovette® tubes collected by manual aspiration as compared with standard vacuum tubes.

Design and Methods

We studied 52 consecutive patients admitted to the ED. Blood was drawn through a 20-gauge intravenous catheter. A 5.0   mL, Becton Dickinson Vacutainer® SST II Plus serum tube was collected and discarded. In the odd group of patients (i.eastward., due north. i, 3, v, etc.), a 2d SST Ii tube was fatigued with vacuum ("BD-V"), followed by a five.5   mL Southward-Monovette® serum tube collected with manual aspiration ("SD-A") and an identical S-Monovette collected by vacuum ("SD-V"). In the pair group of patients (i.e., n. 2, 4, 6, etc.), the sequence was modified to "SD-A", "SD-5" and "BD-V". Serum was separated and tested for lactate dehydrogenase (LDH), potassium and cell-free hemoglobin.

Results

The mean concentration of potassium (+   2.7% in BD-Five and +   one.7% in SD-V, respectively), LDH (+   15% in BD-5 and +   7% in SD-V, respectively) and cell-free hemoglobin was significantly increased when samples were collected with vacuum tubes every bit compared with manual aspiration. No significant differences were observed betwixt SD-V and BD-V. The frequency of hemolyzed samples was higher when blood was collected with the vacuum as compared with SD-A (i.due east., 2%), just did not differ betwixt BD-5 and SD-V (i.e., 29 versus 31%; p   =   0.70).

Conclusion

S-Monovette tin be used with vacuum or aspiration collection. This latter arroyo allows claret drawing with limited shear stress and less likelihood of generating spuriously hemolysis.

Highlights

► Samples drawn through intravenous catheters are oftentimes hemolyzed. ► Hemolysis was college in vacuum tubes than in S-Monovette collected in manual mode. ► S-Monovette tin be used with vacuum or aspiration collection ► This arroyo allows express shear stress and less likelihood of spurious hemolysis

Introduction

Laboratory diagnostics is an essential role of the clinical decision making, provided that a loftier degree of quality is established throughout the total testing process [ane]. Several lines of evidence attest that the manually intensive activities of the preanalytical stage are more prone to uncertainties and errors than those belonging to the analytical and post-analytical phases [2], [3]. This inherent vulnerability is mostly attributable to inappropriate, wrong or mishandled procedures used for obtaining blood specimens. Among the various preanalytical problems, spurious hemolysis largely prevails in terms of prevalence, especially in samples referred from specific hospital wards such equally the emergency department (ED), where their frequency can be as high as ten to xxx% of all claret samples being referred to the central laboratory for diagnostic testing [four], [5], [6]. Although artifactual (in vitro) hemolysis recognizes several patient- and operator-dependent causes that accept been comprehensively reviewed elsewhere [7], several lines of evidence consistently attest that collection of blood tubes using intravenous catheters may be associated with a high likelihood to generate erythrocyte injury [vi], [viii], [9], [x]. All the same, the use of intravenous catheters is almost unavoidable in the ED and other brusk stay or procedural units, wherein nurses often draw the blood from newly established intravenous lines considering this practice is faster and more convenient than searching for another venipuncture site. In a contempo critical review of the literature, Halm and Gleaves reported that spurious hemolysis occurs in three.3 to 77% of blood samples obtained through intravenous catheters, whereas the frequency is nearly xx times lower when blood specimens are drawn by direct venipuncture [ix]. Even more interestingly, artifactual hemolysis can be every bit high as 77% when intravenous catheters and vacuum tubes are combined, while the use of syringe draw is constructive to decrease the rate of hemolyzed specimens by nearly half [9]. Regardless of the specific cause, the generation of catheter-related hemolysis generates a diverseness of clinical, organizational and economic issues, which are mainly owing to specimen rejection and/or recollection, suppression of those tests most sensitive to artifactual hemolysis, delayed diagnosis and overcrowding due to increasing length of stay of patients in ED, also as frequent inquiring between the ED and laboratory personnel [10].

The drove of blood through a syringe and subsequent transferral of blood into primary blood collection tubes [6], equally well equally the utilize of depression book vacuum tubes [11], [12] take both been proposed as potential approaches to prevent catheter-related hemolysis. However, neither solution appears suitable to completely prevent hemolysis. The employ of primary tubes adjusted for drawing blood from intravenous line would hence represent a breakthrough for decreasing the rate of hemolyzed samples and lowering healthcare costs and patient discomfort. A prospective, randomized study was thereby planned to establish whether spurious hemolysis in samples nerveless in the ED from intravenous catheters may be reduced using the Southward-Monovette® serum tubes nerveless by manual aspiration as compared with the use of standard vacuum serum tubes.

Department snippets

Materials and Methods

This investigation was settled in a large urban ED, averaging ~   90,000 visits per yr. The study population consisted in all sequent patients admitted to the ED from 8:00   AM to 2:00   PM of a single working twenty-four hours, who required blood collection for diagnostics purposes, including assessment of potassium and lactate dehydrogenase (LDH). According to our experimental blueprint, blood was drawn by the nurse in duty at the ED through a i.0   ×   3.two   mm, xx-gauge catheter (Neo DELTA VEN, Viadana, MN, Italy; ref.

Results

The final report population consisted in 52 consecutive patients (21 males and 31 females; hateful age 69   ±   3   years, 95% CI from 63 to 75   years). The reasons for ED admission were equally follows: dyspnea (n. 12), intestinal pain (n. eleven), syncope (n. v), arrhythmias (north. 4), renal or biliary colic (n. 3), chest pain (n. 3), cerebrovascular disease (northward. 3), low dorsum pain (n. ii), vertigo (n. 2), epilepsy (n. ane), hypertensive crisis (n. 1), trauma (n. i), epistaxis (n. one), diabetes (n. i), drug poisoning (due north. i)

Discussion

Claret collection is the about vulnerable footstep throughout the testing procedure [16]. Although sample collection via venipuncture rather than through intravenous catheters should be considered as a standard of care throughout the healthcare [17], the latter procedure is near unavoidable in procedural or short-stay units such as the ED or the cardiac intensive intendance unit. Several explanations have been offered to support the hemolytic propensity of intravenous catheters, including the presence

Author Contributions

All authors confirmed that they have contributed to the intellectual content of this newspaper and accept met the following 3 requirements: (a) significant contributions to the conception and design, conquering of data, or analysis and interpretation of data; (b) drafting or revising the article for intellectual content; and (c) final approving of the published commodity.

Acknowledgments

The authors acknowledge the nurses Catia Caleffi, Caterina Colombo and Davide Caputo for the skill assistance during blood collection in the emergency department.

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  • Causes, consequences and management of sample hemolysis in the clinical laboratory

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    Lippi et al. as well investigated the frequency of in vitro hemolysis in samples obtained via intravenous catheters by manual aspiration compared to standard vacuum tubes [23]. The mean levels of M, LDH and free Hb were significantly lower when the sample was aspirated manually as compared to the vacuum technique [23]. A subsequent study demonstrated that the introduction of Sarstedt S-monovette® blood tubes reduced the rate of hemolysis in the emergency department (ED) compared to the previously used BD Vacutainer® SST Ii Plus plastic serum tubes [24].

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    Show also recommends the use of primary tubes adapted for cartoon blood from 4 lines,13 whereby the use of an access device with the vacuum tubes enables direct collection into blood tube from the intravenous catheter.fourteen The use of a syringe to draw blood is non recommended considering it may create a college take a chance of needle-stick injury and blood contamination and also may be associated with additional erythrocyte injury and identification errors, because the syringe cannot be equipped with labels or other patient identifiers.fifteen Allowing nurses to draw claret will reduce the number of venipunctures when using these primary tube adaptors.

  • Blood venous sample collection: Recommendations overview and a checklist to improve quality

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    Unlike these options, blood drawing through intravenous catheters should exist usually discouraged, since this exercise may atomic number 82 to a significantly higher take chances of spurious hemolysis compared with standard blood collections using direct needles [17]. Interestingly, it has been reported that reducing the negative pressure level for aspirating claret from catheters by ways of ho-hum manual aspiration or low vacuum tubes [xviii] can be effective to limit the burden of spurious hemolysis from intravenous catheters [19], and this may therefore be seen as a potential opportunity in brusk stay units (due east.g., emergency departments) or other healthcare settings (due east.grand., oncology or hematology wards), where the number of patients bearing these devices is considerably high. The employ of unsuitable containers cannot be easily identified by the laboratory.

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