Past and present of

1. Past and present of Phlebotomy Dr. Jose F. Gomez

2. History: 3500 Years Ago Greek physicians maintained that good health depended on maintaining a balance of the bodily humors (fluids) comprised of phlegm, yellow bile, black bile, and blood. In order to restore health, doctors would drain "excess" humors by purging the digestive tract or draining blood.

3. Bloodletting • Bloodletting, or Phlebotomy is the longest-running tradition in medicine. • It originated in the ancient civilizations of Egypt and Greece, persisted through the second Industrial Revolution. • The practice continued for 2,500 years until it was replaced by the techniques of modern medicine. • Doctors bled patients for pneumonia and fevers, back pain and rheumatism, headaches and depression, even to treat a sore throat, bone fractures and other wounds. • Yet there never was any evidence that this practice did any good.

4. Bloodletting3500years ago Greeks

5. Bloodletting Egyptians

6. Early Practice • Bleeding was as trusted and popular in ancient days as aspirin is today. • It wasn't until well into the 19th century that people began to question the value of bloodletting. • Scientists such as Louis Pasteur, Joseph Lister, and Robert Koch showed that germs, not humors, were responsible for disease. Eventually the practice died, although it continued in some parts of rural America into the 1920s. • Bloodletting is almost never used anymore, except for certain rare conditions such as hemochromatosis (a genetic condition affecting 600,000 to 1,000,000 Americans in which the body stores too much iron). One way to treat this is to periodically drain some of their iron-rich blood, which restores the mineral's proper balance.

7. Bloodletting Instruments

8. Bloodletting Instruments

9. The Barber Surgeon • During the Middle Ages a new category of medical practitioner emerged. • The Pope had banned the clergy from performing bloodletting (although they were welcome to receive it), and physicians were discouraged by the fact that feudal lords could have them executed in cases of malpractice. • So bloodletting and other minor procedures moved into the hands of barber-surgeons. • They advertised with a symbol that endures to this day a red and white striped pole. The pole represents the what patients would grab while being phlebotomized • The white stripes represent the bandages • The red stripes represents the blood.

10. The Barber, Surgeon, and bloodletter

11. Bloodletting using Leeches • Most people today regard leeches as loathsome, but for centuries these blood-sucking creatures were a mainstay of medical care. • Derived from the Anglo-Saxon word loece, to heal (Medieval doctors called themselves leeches), the leech was used as an adjunct to bloodletting, in places too sensitive or confined for the lancet or other blood-letting instruments. • Physicians applied leeches to areas such as "the gums, lips, nose, fingers," or even "the mouth of the womb," according to a medical text from 1634. The common medicinal leech, Hirudo medicinals, produces natural anti-coagulants and anesthetics in its saliva, so patients bleed readily and generally feel nothing during the procedure. • Traditionally used in a minority of cases, leeches became popular in the 19th century so much so that the species became endangered in Europe. • In 1833 alone, French doctors imported 41,500,000 leeches. Eventually the procedure was largely abandoned, along with other forms of bloodletting. • Today leeches have found renewed utility in certain surgical procedures, particularly after microsurgery. Doctors sometimes find it helpful, for example, to use leeches to restore circulation to a re-attached finger, or to portions of the skin following plastic surgery.

12. Bloodletting Leech Set

13. Bloodletting with Leeches

14. George Washington First President of the United States died after a bloodletter drew approximately 9 pints of blood in a 24 hour period this was performed to cure a sore throat

15. The new generation of Bloodletting The PHLEBOTOMIST

16. The New Equipment Evacuated Tubes Syringes Lancets Butterflies (winged infusion sets)

17. Evacuated Tubes • An evacuated tube is a tube made of glass or plastic whose air has been extracted creating a vacuum effect (negative pressure) the negative pressure in the tube will pull the blood in to the tube filling the tube in a few seconds. • The color of the top of an evacuated tube determines the type of additive it has therefore the phlebotomist knows what test can be performed with this particular tube.

18. Evacuated Tubes and Color Tops

19. Additives • Chemicals are added to evacuated and non evacuated tubes and in turn will have a certain effect on the sample. Additives added are categorized as: • Coagulants • Anticoagulants • Preservers

20. Additives: • EDTA – (Etilene-diamino-tetra-acetic-acid) – An Anticoagulantthat binds calcium ions in order to block the coagulation cascade, making sure blood does not clot. • Heparin - An Anticoagulant (Sodium H, Lithium H, and Ammonium H) activates anti thrombin's, blocking the clotting cascade. • Sodium Citrate - an Anticoagulant that binds with Calcium required for the coagulation cascade.

21. Additives: • Sodium Fluoride – is an Anti-glycoticand glucose stabilizer. • Potassium Oxalate - prevents glycolysis. • Thrombin - An coagulant that increases the binding of the fibrin clot and promotes platelet activation (fast coagulation for STAT testing) • Acid Citrate Dextrose – An Anticoagulant that preserves blood specimens for further testing.

22. Evacuated and Non Evacuated Tubes

23. Evacuated Tube Sizes • 2 ml • 3 ml • 5 ml • 7 ml • 10 ml • 15 ml

24. Non-Evacuated Tube Sizes • Capillary Tubes hold approximately .5 mm of blood • Microtainers hold approximately .5 ml

25. Routes of Capillary Punctures • Finger stick, Dermal puncture, or capillary puncture. • Performed on the finger • Performed on the heal of a newborn • Performed using a lancet no more than 2.5 mm • And blood will be collected with a capillary tube or a Microtainertube

26. Lancets

27. Capillary Tubes A capillary tube holds approximately .5mm of blood when full.

28. Microtainer Tubes

29. Finger stick

30. Limits for a Heelstick

31. Application of the Tourniquet Tourniquetneeds to be applied 2 to 3 inches above the area to be punctured.

32. Removal of a Tourniquet The tourniquet is to be removed before taking out the needle from the vein to prevent a hematoma due to the increase intravenous pressure.

33. Tourniquets

34. Hematomas

35. Veins of the Arm

36. Looking for a vein • Put your gloves on. • Perform a general observation of both arms. • Select the arm that seems to be the best one. • Place the tourniquet in place ( 3 inches above the puncture site ) . • Allow the vein to be visible and palpable by keeping the tourniquet in place for a few seconds. • Then feel the vein size, direction, and depth. • When you have selected a vein proceed to perform the venipuncture.

37. Performing a Venipuncture • Greet and identify the patient. • When identifying the patient never presume their identity. Always ask the questions such as name, DOB, address. (Check wrist band/ID band for identification). • Collect the Laboratory Request Form from the patient. • See the test requested by the institution or Physician. • Gather the necessary equipment to collect the sample needed to perform the test.

38. Performing a Venipuncture • Place the tourniquet in the proper place and give your self a few seconds allowing the vein to pop-up. • Wipe the site using alcohol at a 70% concentration and in a circular motion not coming back to the clean area. Repeat this one more time. • Let the site “air dry”. DO NOTblow on it or fan to speed the process. • In the mean time assemble the equipment. • Proceed with introducing the needle into the vein in a steady and rapid push.

39. Performing a Venipuncture • Start to collect the samples using the appropriate tubes until complete. • Remove the tourniquet. • Remove the last evacuated tube. • Remove the needle from the vein. • Discard the equipment into a sharps container. • Place a gauze on top of the site. • Instruct the patient to keep the arm straight and apply pressure for no less than 3 minutes. • Place a band-aid. • Label all tubes and samples and place them in a laboratory bag with the Laboratory Request Form.

40. Performing a Venipuncture • Thank the patient. • Clean your work area. (Disinfect) • Take your gloves off. • Wash and sanitize your hands. • Get your next patient and repeat the procedure.

41. THE END