Capillary Puncture Equipment and Procedures: Topic 7

Topic 7

CAPILLARY PUNCTURE
EQUIPMENT AND PROCEDURES
MLS 1204 | Principles of Medical Laboratory Science 2 (Clinical Laboratory Assistance and Phlebotomy)
Learning Outcomes
At the end of lesson, the student must be able to:

1. describe completely the various types of equipment needed for

capillary specimen collection.
2. discuss comprehensively the composition of capillary blood
specimen and the tests and reference values.
3. identify correctly indications for performing capillary puncture on
adults, children, and infants.
4. list systematically the order of draw for collecting capillary
specimens.
5. describe accurately the proper procedure for selecting the
puncture site and collecting capillary specimens from adults,
infants and children.
6. describe properly how both routine and thick blood smears are
made and the reasons for making them at collection site.
7. explain correctly the clinical significance of capillary blood gas,
neonatal bilirubin, and newborn screening tests and describe
how specimens for these tests are collected.
Capillary Puncture
• Also skin/dermal puncture and
Microsample technique
• Method of choice for collecting blood for

<2 years old patients
• Blood collected (microsamples) comes

from the capillaries, arterioles, and venules.
Dermal Puncture may be
required in…
1. Burned or scarred patients
2. Patients receiving chemotherapy
3. Patients with thrombotic tendencies
4. Geriatric or other patients with very fragile
veins
5. Patients with inaccessible veins
6. Obese patients
7. Apprehensive patients
8. Patients requiring home glucose monitoring
and POCT
Capillary Blood Specimen
• Composition: Potassium,
total
• Mixture of capillary, protein,
arterial and venous calcium
blood
• Small amounts of
interstitial and
intracellular fluids. Glucose
• More closely
resembles arterial If dermal punctures are performed,
blood. it should be documented
Capillary Puncture
Equipment
A. Dermal Puncture Devices
B. Microsample Containers
1. Capillary Tubes
2. Microcollection Tubes
C. Additional Supplies
1. Alcohol pads
2. Gauze
3. Sharps containers
4. Glass slides
5. Heel warmer
Dermal
Puncture
Devices BDMicrotainerContact-
ActivatedLancet
QuikHeellancet
• Also lancets
• Depth: should
not exceed 2.0
mm Tenderfoot Tenderlett
• Incision widths:
needle stabs to
2.5 mm.
Unistik 2
Capillary Tubes
• Also Microhematocrit tubes
 75 mm long
 Bore of about 1mm
 Holds 50-75 uL of blood
• Color coded:
A. RED
• Heparinized
• For use with non-anticoagulated WB
B. BLUE
• Plain
• To be used when using anticoagulated blood
Capillary
Clay Sealer
used to seal the
end of glass
capillary tubes
used for
microhematocrit
tests.
Microcollection
Tubes Microtainers
Microtainers with
Microgard Closure
• Microtainer tubes
(BD) can hold 600
μL of blood
MiniCollect Microvette/Multivette
• Color-coded to
match evacuated
tube colors
Safe-T-Fill
Heel
Warmer
• Packet containing
sodium thiosulfate
and glycerin
• Produces heat
when the
chemicals are
mixed together
by gentle
squeezing of the
packet
Warm washcloths or
towels can also be
used
SKIN PUNCTURE TECHNIQUE
1 Patient identification and

preparation
2
Patient position
Patient seated or lying down, hand
supported on a firm surface, palm up
and fingers pointed downwards.
For infants, lying on the back with heel
in downward position.
Select an appropriate puncture site.
3 Do not use/puncture:
a. Thumb and fifth finger
b. Callused, scarred, bruised, edematous,
cold, cyanotic and infected areas
c. Previous puncture site
d. Side of mastectomy
e. Fingers in infants <12 years
For infants For infants >12 months,

<12 months old children, and adults
Palmar
Lateral or surface of
medial the last digit
plantar heel of the third
surface. or fourth
finger
4
Cleanse the puncture site with 70%
aqueous isopropanol solution.
a. Allow the area to dry.
b. Do not touch the swabbed area with
any nonsterile object.
c. Povidone-iodine is Residual alcohol causes rapid
not recommended hemolysis that can alter test
results for certain analytes.
5
Warm site if necessary.
Moistening a towel with warm water (42°C)
or activating a commercial heel warmer
and covering the site for 3 to 5 minutes
effectively warms the site.
Make the puncture with a sterile
6 lancet or other skin-puncturing device,
a. Single deliberate motion nearly
perpendicular to the skin surface.
b. Heel puncture – hold the heel with the
forefinger at the arch and the thumb
proximal to the puncture site at the ankle.
c. Finger puncture – hold finger between
nondominant thumb and index finger
d. Do not indent skin when placing lancet
on puncture site.
One firm puncture is less painful than

two “mini” punctures.
Dispose puncture device
7 in sharps container.
A new puncture device must be used if an
additional puncture is required.
Wipe first drop of blood with a

8 sterile pad. Regulate further blood
flow by gentle thumb pressure.
a. Do not milk the site (may cause hemolysis
and introduce excess tissue fluid).
b. Alternately applying pressure to the area
and releasing it will produce the most
satisfactory blood flow.
Applying pressure about 1/2 inch away from the puncture site frequently
produces better blood flow than pressure very close to the site.
Collect specimen in
9 suitable containers by capillary
action.
a. Capillary tubes
• Hold tubes horizontally
• Maintain tube to the drop of
blood
• Seal with clay or plastic caps
b. Microcollection tubes
• Hold tubes in slanting position
• Allow blood to run through
“scoop” and down the side of
the tube
• Mix the specimen as necessary.
ORDER OF DRAW
1. Capillary blood gases
2. Blood smear
3. EDTA tubes
4. Other anticoagulated tubes
5. Serum tubes
Apply pressure
10 and put bandage.
Bandages are not used
for children younger than
2 years.
Label the sample

11 with date and time of
collection and patient
demographics. For
transport, capillary
pipettes are placed in a
large tube.
Take Note!
• "Skin puncture" should be noted on test
requisition
• Skin puncture specimen composition differs

most from venous blood.
1. RBC count, Hct, Hb and APC are lower
2. Glucose is normally higher
3. Ca++, K+, and total protein are lower.
 Squeezing the site falsely elevates K+ levels
Special Dermal Puncture
1. Collection of Newborn Bilirubin
2. Newborn Screening
3. Capillary Blood Gases
4. Preparation of Blood Smears
5. Bleeding Time
6. POCT
Collection of Newborn
Bilirubin
• Bilirubin decrease as much as 50% if blood
sample is exposed to light for 2 hours.
• Filled tubes should be shielded from light.
Amber-colored
microcollection tubes
are available for
collecting bilirubin
Newborn
Screening
• Testing of newborn
babies for genetic,
metabolic, hormonal,
and functional
disorders that can
cause physical
disabilities, mental
retardation, or even
death, if not detected
and treated early.
• Blood is collected
between 24 and 72
hours after birth
Newborn Screening Blood
Collection
Touch the filter Evenly fill the circle Only one large
paper to a large on one side of the free-falling drop
drop of blood. filter paper, should be used to
allowing the blood fill a circle
to soak through the Fill all required
paper to be visible circles correctly.
on the other side.
Causes for Invalid Newborn Screening Samples
INVALID SAMPLE POSSIBLE CAUSES
Quantity Filter paper is removed before blood has completely filled
insufficient for circle or before blood has soaked through to other side
testing Filter paper touches gloves, powder, or lotion
Appears Blood applied with capillary pipette
scratched
Not dry before Sample mailed before drying a minimum of 3 hours
mailing
Appears Excess blood applied to filter paper using an alternate
supersaturated device Blood applied to both sides of filter paper
Appears diluted, “Milking” area surrounding puncture site
discolored, or Filter paper contaminated with powder, alcohol, formula,
contaminated water, lotion Blood spots exposed to direct heat
Exhibits serum Alcohol not dry before puncture
rings Filter paper contaminated with powder, alcohol, formula,
water, lotion “Milking” the puncture site
Sample dried improperly
Appears clotted Several drops of blood used to fill the circle
or layered Blood applied to both sides of filter paper
Capillary Blood Gases
• Essential to warm the collection site
Hold the capillary Completely fill Immediately seal Mix the sample
pipette horizontal the pipette both ends of the with the heparin
to the drop of without any air capillary pipette. by moving the
blood and fill the spaces. magnet up and
capillary pipette down the tube
in less than 30 several times.
seconds.
Preparation of Blood Smears
• For microscopic examination of blood cells
• Dermal puncture
• Smears should be collected before other
samples to avoid platelet clumping.
• Venipuncture
• Smears made from EDTA tube within 1 hour of
collection
Wedge Smear Procedure
1. Place a drop of blood:
• 2-3mm in diameter, 0.25
inch from the end or
frosted area of a glass
slide.
2. Position spreader slide
(30-45°) to the
stationary slide and
bring it back into the
drop of blood
3. Allow blood drop to
spread along the back
edge of the spreader
slide and push forward
with a smooth and
rapid stroke.
4. Air dry rapidly
(manually or with an
electric fan/cool air
blower).
5. Label on frosted end
of slide or in the thicker
end after it has dried.
Automated
Instrument
• Wedge (Push)
Type
• Stimulates the
manual
spreader-type
technique
Characteristics of a Proper
Wedge Smear
1. Covers approximately one-
half to two- thirds of the slide,
2. Narrower than the slide; should
not occupy the lateral edge
of the slide.
3. Gradual transition from thick to
feathery edge.
4. No waves, streaks, holes (oily
areas) or bubbles.
5. Should terminate in a straight
feathered end.
UNACCEPTABLE PERIPHERAL
BLOOD FILMS.
A. Chipped or rough edge on

spreader slide.
B. Hesitation in forward motion of
spreader slide.
C. Spreader slide pushed too
quickly.
D. Drop of blood too small.
E. Drop of blood not allowed to
spread across the width of the
slide.
F. Dirt or grease on the slide; may
also be due to elevated lipids in
the blood specimen.
G. Uneven pressure on the
spreader slide.
H. Time delay; drop of blood began
to dry.
Thick and Thin Blood Film
• Used when looking for blood
parasites (e.g. malaria)
1. THICK smear: Detection
2. THIN smear: Identification
• Use the corner of a slide to

spread blood the size of a dime
• Thickness: newspaper print is
visible through the blood
• Air dry @ least 2-4 hours @ RT, or
preferably overnight
Plasmodium
falciparum
Ring-form
trophozoites in
thin blood
smear.
www.mcdinternational.org
Bleeding Time
• Time it takes for a standard
wound to stop bleeding
• Screening test
• Evaluates platelet number,
platelet function and BV
integrity
• Drug therapy is the most

common cause of
prolonged BT
• Aspirin, NSAIDs, herbs
Bleeding Time Procedure
1. Identify patient.
• Ask about medications.
2. Assemble materials.
3. Wash hands and put on
gloves.
4. Place patients arm on a 1. Gloves
steady surface, volar surface 2. 70% alcohol pad
facing up. 3. Automated
bleeding time
5. Place BP cuff on upper arm. incision device
6. Select site 4. BP cuff
5. Filter paper (No. 1
• 5 cm below antecubital crease Whatman)
• Middle of arm 6. Stopwatch
• Free of veins, scars, bruises and 7. Butterfly bandage
edema 8. Bandages
7. Cleanse the area with
alcohol and allow it to dry.
8. Inflate BP cuff to 40 mm Hg
9. Make incision (within 30-60
seconds of inflation) and
start stopwatch.
10. After 30 seconds blot/wick
blood using filter paper.
11. Remove blood from incision
every 30 seconds until
bleeding stops.
12. Record time to the nearest
30 seconds.
Point-of-Care testing (POCT)
• Dermal punctures are performed usually by
routine dermal puncture
• Follow all manufacturer recommendations

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Topic 7

1. describe completely the various types of equipment needed for

• Method of choice for collecting blood for

• Blood collected (microsamples) comes

1 Patient identification and

For infants For infants >12 months,

One firm puncture is less painful than

Wipe first drop of blood with a

Label the sample

• Skin puncture specimen composition differs

• Filled tubes should be shielded from light.

A. Chipped or rough edge on

• Use the corner of a slide to

• Drug therapy is the most

• Follow all manufacturer recommendations

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