Order of Draw and Additives | Blood Collection

[Music] you all right well welcome everybody to another video lesson from ICU advantage in this lesson we're going to talk about something that is extremely important and the care that we provide to our patients specifically when we talk about blood sampling or phlebotomy and even more specifically to the order of draw there are some very important key takeaways when we look at the order in which we fill the blood tubes from the samples that we draw and in this lesson I'm gonna fully break that down for you and so my name is Eddie Watson and

I'm gonna be presenting this lesson for you today and so before we begin in order to stay up to date on our videos as we release them make sure and subscribe to our channel below and don't forget to hit that Bell icon in order to be notified as the new lessons become available alright so for this lesson I'm actually gonna start this out a little bit different than I normally do and I'm gonna start things off with a question and really this question is to kind of check your knowledge and see where you're at at

the beginning of this lesson and it's something that you can come back to at the very end and check and see how close were you and so that question then is do you know the proper order of draw and so in the comment section below tell us what you think is the proper order of draw and when we reach the end of this video let's check and see how close you were alright so as we talk about the proper order of draw like I said it's something that's extremely important to the care that we provide

to our patients drawing blood and sending sending samples down to the lab to check a whole host of various different things that are going on with your patient is something that we do on a daily basis and really the effects of doing this properly can have a profound impact on our patients and the care that they receive and so it's really important that we maintain that proper order of draw essentially that the proper filling of the blood tubes in the correct order because if that order of draw is not followed then what can happen is

the additives that are in some of the tubes can actually be transferred from one tube to another and this can cause inaccurate results cross contamination and really those inaccurate results can lead to a misdiagnosis in your patient and it can prevent them from receiving the correct treatment so like I said it's a but most important that we get this right and so what I'm gonna do is I'm gonna start off and go through each of the different types of sampling tubes and bottles that that we use and talk about what they are what's in them

as far as the additives what we use them for and then at the very end of this lesson is when I'll actually break it down and show you the proper order of draw as well as give you a handy little acronym in order to help you remember this all right so the first of these that we're going to begin to talk about are our blood cultures and for these we can really think about these as our sterile collection and so here is an example of one type of blood culture bottle now these bottles can vary

from facility to facility in fact even some facilities use tubes that look very similar to the typical lab collection tubes that we normally use but for the purposes of this lesson this is the example that I have here and so with our blood cultures we're really looking at two things we're looking at our aerobic and our anaerobic now again depending which manufacturer you use these can have different colored tops on the bottles but if you look at the label all the labels are gonna tell you which type of tube it is that you're working with

and so the most important thing to remember with our blood cultures is you actually want to do these ones first and the reason for that is it's really important that we reduce that risk of contamination and so if we look at our blood culture bottle there's a couple things that it contains that really help this process of being able to grow the bacteria and properly identify things the first is there's a little bit of film typically across the bottom and this is primarily used to help identify growth that's taking place and then inside there's going

to be some sort of level of a nutrient broth and this is again gonna help in and growing that bacteria and helping it to proliferate also inside of there there's going to be some sort of anticoagulant and even more importantly there's a another chemical that's in here and the sole purpose of this chemical is to reduce the natural bacterial seidel action that's normally present in the blood itself and so it does this by stopping complement and this slows down the phagocytosis and really prevents the the killing of the bacteria by the blood and so when

it comes to drawing our blood cultures there's really a recommended order to do this although it's not required and the first is that you want to start off with your aerobic Bobble and the reason for this is sometimes there's a little bit of air that's in the syringe and so if you start off with the aerobic bottle if that air goes into the bottle it really doesn't affect your results and so after you've filled up your aerobic bottle then next is when you would move on to your anaerobic bottle and so really the last thing

that I'm going to talk about with the blood culture bottles is again going back to the basics of this is it's really important that you maintain that sterility because this truly can affect or have an impact on the treatment that your patient receives all right so now moving on to our actual lab blood collection tubes and so the first of these that we're going to talk about is the light blue tube and this light blue tube we really can think about as our coagulation tube and so not to list out all of the tests that

you can do with this tube but some of the more common ones that you would expect to see would be things like your PT your INR you'd also be looking for your PTT your anti 10a if your facility does this and also check your fibrinogen your d-dimer as well as your tag studies and so one really important thing to know with the like blue tube as these tubes actually contain a set amount of sodium citrate and so what this sodium citrate does is it actually binds with calcium which plays an important role in the clotting

cascade and therefore it helps to prevent the formation of a clot but the most important thing to know about this is that it is truly a defined ratio of sodium citrate to blood and so more so than in almost any other tube there's a line that it must be filled to in order to have that proper ratio and if you use the vacuum containers those have a predefined vacuum in there that if you just let the blood flow in it will typically fill right up to that line and again it's really important that you have

this right amount so that you have the proper mixing of the sodium citrate with the blood because when they go to actually run the test all they have to do is provide a reagent that has calcium in it and then they can begin the whole clotting cascade process and test the coagulation of the blood all right and so moving on the next tube that we're going to be talking about is our red top tube really there's a whole slew of tests that we can do with this tube but if you think about this is really

just one option available if we need to run some sort of chemistry panel but this isn't the common one that facilities will use for chemistry panels they're typically for certain types of tests in particular if you need serum which is basically the liquid portion of the blood after a clot is formed and so often times you'll find these tubes with no gel or additive in there but sometimes you may find them that they have what they call a silica clot activator and essentially what this does is it just helps to form a clot inside of

the tube in order to give them the serum that they're looking for and again this isn't a very common tube typically you're not going to use this one all that often but there are certain tests that they do ask for the sample to be drawn in the red top tube alright and so on to our next tube and so this tube is gonna be our gold or what we sometimes call our SST and in case you ever wondered the SS T stands for serum separator tube in some facilities you may also find this in what

we call a tiger top and really you can think of this as a red and black stripe top tube but essentially these are the same thing and again this tube can be used for a whole host of different chemistry's but again this isn't the common tube that we typically will use and more often than not these are going to be our send out tubes and typically here they're checking for the antigen antibody and one of the things that this tube has it's a little bit different as it has a gel in here and what this

gel does is it helps to separate the cells from the serum of the blood and it does this just naturally with the gel and so you know the serum is the portion of the blood that's like the plasma but without any of the clotting factors in there and so sometimes you will find some of these tubes that do have a clot activator to help that process along but again this gel works to separate the cells from that serum inside of the tube and again this is not a very regular tube that you'll you'll often use

but it is something that you will see fairly regularly but again not the primary tube that we're gonna use for typical chemistry's within the hospital alright and so we've talked about it enough at this point and so now we're gonna move on and talk about our green top tube and again this is going to be a wide range of chemistry's but unlike the red and the gold SST tube this is going to be the one that we typically are using to to run these tests in the hospital and like I said there's a whole slew

of tests that can be run with this but it's also important to note that in addition to the chemistry's this is typically going to be what we draw our cardiac markers such as our troponin and so with these tests typically you would just draw the sample into the tube and send down but there are a couple tests that it's important that the tube actually ends up on ice immediately and then sent down to the lab and the point of having it on ice is so that it helps to preserve the value of whatever we're checking

at the time the blood is drawn throughout the time it takes to get down to the lab and actually run the tests and so a couple of these tests that we would be looking at would be things like our ammonia levels also our ionized calcium and while not typical for most facilities as we do have another tube specifically for this purpose you can also draw your lactate levels again ensuring that as soon as the sample is drawn and labeled that it ends up in a bag with ice in order to be sent down to the

lab to get those proper results now the green tubes you may sometimes hear them referred to as a PST which is essentially a plasma separating tube and the reason for this is you'll find a gel down here in the bottom similar to the SST but in these PS T's they actually contain fiber nogen and what it does is it separates out the plasma from the specimen and so as we talked about the way this differs from the serum is that the plasma actually contains all those clotting factors now in addition to that plasma separating gel

you're also gonna find heparin which is used as an anticoagulant and helps to keep the blood from clotting all right and so moving right along the next of the tubes that we're going to talk about is the purple top and we can think of the purple top as our hematology tube and so again not to list out everything that you can do with this tube but these are gonna be things like our CBC which will tell us our white count our haemoglobin our platelets can check our ESR or what we refer to as our sed

rate or we can also check our a1c which will give us an indication of how our patient is maintaining their blood sugars and so when we look at our purple top there's actually something very important that we need to know these tubes actually comes sprayed right along the inside of the tube with a chemical that we call EDTA and I'm not even gonna try and tell you what that stands for because I probably would pronounce it wrong but essentially what this does is a couple things first it preserves the natural cell morphology so if they

need to look at the the blood specimen under microscope the cells maintain that that shape and morphology that they had when they were inside the body but in addition to that it also works by inhibiting the clotting cascade by binding calcium again not allowing that to be available and preventing a clot within the specimen but the important thing to know about EDTA is that it's very high in potassium and so we'll talk about this more in a little bit here but just start to think about some of the issues that can come up if you

start to cross contaminate the additives from one tube into another and how that might actually skew your results alright so on to our next tube and for this tube this is gonna be our pink top and really the pink top is identical to the purple top hematology tube except before we use it for a specific purpose and this specific purpose that we use it for is our blood type sample and so once again this tube is again coated with that EDTA which means it's also gonna have a high potassium and so again typically these tubes

are are just used when you're sending a specimen down to blood bank but again they're identical to the purple top tube alright and so now we're gonna move on to the last tube that we're going to talk about and that tube is gonna be our grade top and for the gray top there's really not a type to go along with this there's just a handful of select tests that will typically be run on this and those tests are going to be things like checking our lactate level or a lactic acid you also can use this

tube to check an ethanol level or if your patient needs to have a fasting glucose check you would use this tube as well and so for the gray tube there's actually two different additives that are in there that achieve different things the first of these is going to be what is typically sodium fluoride and so what the sodium fluoride does is it actually stops glycolysis and by preventing the glycolysis this is going to help to preserve some of those results and findings that you're looking to get from this tube now it also will work to

prevent bacterial growth again working to help preserve those results that you're looking for now in addition to the sodium fluoride you're also going to find what we call potassium oxalate and what potassium oxalate does is again this is another one that is going to bind our calcium which is going to prevent clotting and so with all of these additives and chemicals it's really not important that you know what they are but that you understand some of the implications that some of these additives can have if they end up in the wrong tube one important thing

that I do want to add is since these tubes do have those additives in there is that you do want to quickly invert them three to five times for each tube you don't want to shake them but you just want to gently mix them by inverting repeatedly and the point is to ensure that we have proper mixing of whatever that reagent or additive is that's in the tube all right and so we have covered all of the different tubes that you will typically be drawing for your patients and so now let's go ahead and talk

about what the actual proper order of draw is and if you haven't figured it out yet well surprise the order is we actually just went through everything in the proper order but just to refresh you I'll bring it up here again and one handy place so the first thing that we want to draw are those blood cultures and again think of these as our sterile and then next is going to be our light blue again think our coagulation studies next will be our red top tube is there are not so commonly used chemistry tubes in

addition to our cold SST tubes again not so common chemistry tubes typically used for our send out tests and then from there we have our green top which is going to be our common chemistry tube then next is going to be the purple top and this is going to be those hematology studies coming near the end we have our pink top which is our blood type studies and finally our gray top - some of those tests like the lactic acid fasting glucose and ethanol and so like I said this order of draw here really kind

of matters it's important that we have our blood cultures being drawn first because we don't want to risk contaminating those by filling up some of these other tubes and then putting blood into the blood culture bottles but then if you look at really the the first actual blood collection tube we do as the light blue tube which is those hematology studies because it has that defined ratio of that sodium citrate and so that we can get an accurate assessment of a patient's coagulation factors and clotting times and if we get some of these other additives

such as the Green heparin that gets in here then that's gonna throw off the results of your coagulation studies also in addition to that if you remember our pink and our purple tubes have that EDTA which if you think about is high in potassium but then also binds calcium if you were to draw that first and that were to end up in let's say your green top tube this is going to skew the results of your potassium in your calcium so you could either end up with high or critically high levels of potassium or if

your patient is actually low in potassium you couldn't mask that by having a abnormally normal result when your patient is actually hypokalemic so again like I said at the very beginning it's absolutely vital that you you draw these in the proper order and so it's important that you memorize this order and be able to draw it quickly without having to think about it so like I said I'm gonna give you a quick little acronym that hopefully will help you to be able to remember the proper order in which to draw lees and so I'm gonna

list it out here first and that'll be s L R s g p l g and so there's a stupid little mnemonic but maybe it will help you memorize this and it's gonna be stoplight red stay green power light go and so if you think about it the essence top is gonna be the same as our sterile that Ellen light is going to be for our light blue the R is gonna be for the R in red the essence day is going to be for the SST or the gold top the G in green is

gonna just match up with the green the P and power is for a purple the Ellen light is really for our if we think about a light pink and the G and go is gonna be for gray and so hopefully this silly little acronym mnemonic will help you to memorize this and be able to keep them in order and eventually as you do them enough you'll you'll learn what goes before what but for me it's always been helpful to think about not only the the what of what I'm trying to do but the why behind

it so that I understand it and I'm able to implement it easier alright and so that is gonna conclude this lesson and as always I do want to thank you for watching this video and I really hope that this lesson was informative for you if you did like this video and you found it useful make sure and hit the like button below as it really does help to get the word out about our channel and so once again down in the comments below tell us your favorite part of this video and also let us know

how you did on your guests from the beginning of the video and so finally once again I do invite you to subscribe to our channel in order to stay up to date on our videos as well as check out a couple of our other great series that we have on hemodynamics and Schock and with that said you guys have a great day and we'll see you in the next video