# Order of Blood Draw



## MikeC (Apr 27, 2017)

I know phlebotomy requires a particular "order of draw" for drawing blood via venipuncture. Here is the order from top to bottom according to one source.






I believe EMS uses only 5 or 6 for blood draws.

*Could anyone clarify which ones are utilized for the blood draw kits in EMS, and confirm which order they are to be drawn in?*


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## Summit (Apr 27, 2017)

I think you should try to explain:
What tests and information could each tube offer?
When it is appropriate to draw each tube?
Why one might consider a particular order of draw?


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## DesertMedic66 (Apr 27, 2017)

We have different colored blood tubes here. For us there was no order that we drew them in.


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## MikeC (Apr 27, 2017)

Summit said:


> I think you should try to explain:
> What tests and information could each tube offer?
> When it is appropriate to draw each tube?
> Why one might consider a particular order of draw?


 
I'm actually asking this question for Paramedics. The primary question being what colors are in most blood draw kits so I can research what they are used for and what order ideally they should be drawn in, at least according to phlebotomists.


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## Summit (Apr 27, 2017)

The order of draw is all about what information is a priority in that patient if you are worried that you may not be able to draw enough blood for all tubes.

My practice, if not doing cultures (which I'd always do first because they are contamination sensitive and the most volume demanding), is to draw into an empty syringe and then use a transfer device (or needle) to fill tubes based on how much I get.

Most of the time one gets enough volume that the order does not matter.

Otherwise, I'll usually fill citrate tube first (coags) if I need one because it needs a very specific volume while the other tubes simply have minimums (although some tests need multiple full tubes). After the citrate, I prioritize by the information I need based on the patient... what do I need most? BMP? CBC? VBG? Lactate? Type and Cross?

I usually know what I need (whether it is a rainbow draw or a specified set of tubes) and how much blood is required and draw accordingly... when you have anemic patients getting serial labs for days, being efficient with draws can make a difference in the h/h.


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## MikeC (Apr 27, 2017)

Summit said:


> The order of draw is all about what information is a priority in that patient if you are worried that you may not be able to draw enough blood for all tubes.
> 
> My practice, if not doing cultures (which I'd always do first because they are contamination sensitive and the most volume demanding), is to draw into an empty syringe and then use a transfer device (or needle) to fill tubes based on how much I get.
> 
> ...


 
So you basically follow the order that is proposed by phlebotomists then it sounds like.


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## Summit (Apr 27, 2017)

MikeC said:


> So you basically follow the order that is proposed by phlebotomists then it sounds like.


Not really...

What I propose:
1. Cultures, aerobic first (if needed)
2. Citrate (if needed)
3. Whatever else is needed in order of a particular patient's needs

What that actually looks like is:
1. Cultures (if needed)
2. Figure out how many mL I need otherwise. Grab appropriate sized syringe, fill it, if less than needed, then worry about fill order based on that patient's priorities. If I have enough for all tests, who cares about the fill order.

And I also disagree with the chart you posted because almost none of those tubes "must be full" and the citrate tube must be filled exactly to the fill line, not less AND not over.

You should speak to your CLIA certified lab personnel.


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## GMCmedic (Apr 27, 2017)

The only one that really matters is with cultures. If drawing off a line draw aerobic first and aenerobic second as aerobic tolerates oxygen better. Reverse if filling from a syringe. 

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## Summit (Apr 27, 2017)

GMCmedic said:


> If drawing off a line draw aerobic first and aenerobic second as aerobic tolerates oxygen better. Reverse if filling from a syringe.


"aerobic first" was only part of that statement that was correct...

The reason we fill the aerobic first is because higher blood volume into the culture bottle increases the likelihood of capturing/culturing an in-vivo pathogen.
So if we have less than the 10mL per bottle we want we want to put a full 10mL in one place than that place is the aerobic bottle because 98% of septicemia is caused by aerobic bacteria (or aerobic tolerant anaerobes)

You do not reverse if filling from a syringe.

And don't draw off of a line unless it was a fresh stick and you were extremely diligent in your aseptic technique (or if drawing an extra set off of a central line). And remember, "two is one, none is one," applies to blood cultures.


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## GMCmedic (Apr 27, 2017)

Summit said:


> "aerobic first" was only part of that statement that was correct...
> 
> The reason we fill the aerobic first is because higher blood volume into the culture bottle increases the likelihood of capturing/culturing an in-vivo pathogen.
> So if we have less than the 10mL per bottle we want we want to put a full 10mL in one place than that place is the aerobic bottle because 98% of septicemia is caused by aerobic bacteria (or aerobic tolerant anaerobes)
> ...


Apologies. Just posting what my medical director and lab said. Thanks for the explanation. 

Also, i kind of just made the assumption that people would know that if youre drawing cultures of a line it was prepped for cultures. 

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## Summit (Apr 27, 2017)

GMCmedic said:


> Apologies. Just posting what my medical director and lab said. Thanks for the explanation.
> 
> Also, i kind of just made the assumption that people would know that if youre drawing cultures of a line it was prepped for cultures.
> 
> Sent from my SAMSUNG-SM-G920A using Tapatalk


You'd be shocked... even in the hospital sometimes people have to be reminded that old lines are a no-go unless drawing an extra set off of a central.


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## Bullets (Apr 27, 2017)

I dont think there is an order. We really dont draw blood as a medic here. Only time i do is trauma activation ill draw 2 reds because the trauma team has asked if we could. 

As far as order, during clinicals the nurses said cultures first but otherwise no order of the standard rainbow draw


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## Tigger (Apr 28, 2017)

Can drawing the citrate second actually contaminate the sample?


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## kev54 (Apr 29, 2017)

There is a proper order of draw! I also used to teach phlebotomy and am certified nationally as well. Some hospitals may make some changes to the above or use slightly different color tubes but I will say they will have the same additive. The order that Mike C posted in general is considered an accepted standard. Each hospital may tweak it ever so slightly. Blood cultures are first then light blue, gold, red, light green, green, lavender, pink, then grey which needs to go on ice. Green is for stat tests. Red is good because it takes roughly 30 minutes to an hour for it to fully clot so they can run tests when you get to the ER. If you had an I-Stat that might be helpful in a more rural setting. Additives speed up that process either by inhibiting the coagulation cascade or by encouraging the clotting process at various points. 

The light blue top tube is required to have a specific ratio of 9:1 or your PT/INR numbers are going to be way off. It also has to be a full draw and between the line. Tubes come in various sizes as well so at minimum for light blue is 2.7 ml. 

I will draw off a line when I start an IV. It also means I just started the line so it's no different than if I had just stuck them with a butterfly. Your blood culture bottles change in your order of draw under only two circumstances. A butterfly with evac due to oxygen being in the tubing the aerobic goes first because you can grow most bacteria and the aerobic likes oxygen so were getting rid of it before inoculating the anaerobic. Lets say we made a mistake and accidentally forgot to do that and put our light blue tube first we would not get a full draw on your light blue tube so our ratio would be off since the oxygen in the tubing just filled up part of the light blue tube. Our PT/INR results will be off and now a patient might get a treatment they don't need.  

You cant just put the tubes where you them. The lavender top tube has EDTA in it and it also causes the majority of contamination in samples as well. Lets say EDTA somehow has a reflux issue and the order of draw is incorrect then that could cause factitious hyperkalaemia, hypocalcaemia and hypomagnesaemia and now were giving a patient a treatment to correct something that they may not exist and then we cause an iatrogenic issue with the patient.

Tigger to prevent contamination which is a concern keep the arm flat don't lift it above there head. MD's and people much smarter than me have worked on the order of draw for many years. In the 90's the syringe method had a separate order of draw. Today it's well researched and standardized. I posted some resources below for additional reading. 

https://www.ncbi.nlm.nih.gov/pubmed/19624792

https://www.eflm.eu/files/efcc/3. CCLM 2016 WG-PRE.pdf


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