BRIEF SCIENTIFIC REPORTS
Vol. 79 • No. I
References
1. Bodansky O: Acid phosphatase. Adv Clin Chem 1972:15:43-147.
2. Cooper GH, Glashan R. Robinson MRG, et al: The evaluation
of a new enzyme immunoassay for the measurement of prostatic acid phosphatase. Clin Chim Acta 1981; 113:27-34
3. David GS, Wang R, Bartholomew R, et al: The hybridoma—An
immunochemical laser. Clin Chem 1981; 27:1580-1585
4. Farnsworth WE, Gonder MH, Cartagena R, Steinbach JJ: Comparative performance of three radioimmunoassays for prostatic
acid phosphatase. Urology 1980; 16:165-167
5. Foti AG, Cooper JF, Herschman H, Malvaez RR: Detection of
prostate cancer by solid-phase radioimmunoassay of serum
prostatic acid phosphatase. N Engl J Med 1977; 297:13571361
6. Galen RS, Gambino SR: Beyond Normality: The Predictive Value
and Efficiency of Medical Diagnoses. New York, John Wiley
and Sons, 1975
119
7. Griffiths JC, Rippe DF, Panfili PR: Comparison of enzyme-linked
immunosorbent assay and radioimmunoassay for prostate-specific acid phosphatase in prostatic disease. Clin Chem 1982;
28:183-186
8. Gutman AB, Gutman EB: An acid phosphatase occurring in the
serum of patients with metastasizing carcinoma of the prostate
gland. J Clin Invest 1938: 17:473-478
9. Kohler G, Milstein C: Continuous cultures of fused cells secreting
antibody of predefined specificity. Nature 1975; 265:495-497
10. Sevier ED, David GS, Martinis J, et al: Monoclonal antibodies
in clinical immunology. Clin Chem 1981: 27:1797-1806
11. Shaw LM. Yang N, Brooks JJ, et al: Immunochemical evaluation
of the organ specificity of prostatic acid phosphatase. Clin
Chem 1981; 27:1505-1512
12. Whitmore WF Jr: Hormone therapy in prostatic cancer. Am J
Med 1956; 21:697-713
Data Regarding Blood Drawing Sites in Patients Receiving
Intravenous Fluids
KENNETH R. WATSON, DO., RICHARD T. O'KELL, M.D., AND JEFFREY T. JOYCE, M.D.
Intravenous fluids were infused into the forearms of 18 volunteers. Baseline hematologic and serum biochemical profiles
were obtained from each volunteer prior to starting the IV.
After the intravenous fluids had infused for 30 minutes, blood
was drawn from the opposite arm, and above and below the
IV in the same arm. The intravenous fluids were then stopped,
and after waiting two minutes, another blood sample was drawn
from the IV needle. The deviation from the baseline value was
determined for each analyte by sampling site for each volunteer
and the mean deviation was calculated for each analyte from
each sample site. Drawing blood from above the infusing IV
line resulted in a dilutional effect for most of the analytes.
Most analytes were not affected when blood was drawn from
the other sites. Serum glucose and phosphorus had mean deviations greater than two standard deviations from the baseline,
regardless of where they were drawn. Serum glucose was the
only analyte with values higher than the baseline values. We
recommend that serum biochemical and hematologic profiles
not be drawn above an infusing IV, but should be drawn from
the opposite arm or below the IV while it is infusing or out
of the IV needle after the intravenous fluids have been stopped
for two minutes. (Key words: Serum biochemical and hematologic profiles; Intravenous fluids) Am J Clin Pathol 1983;
79:119-121
WHERE SHOULD BLOOD be drawn when a patient
is receiving intravenous fluids? Can blood be drawn
Received May 13, 1980; accepted for publication August 18, 1980.
Address reprint requests to Dr. Watson: Department of Pathology,
St. Luke's Hospital, Kansas City, Missouri 64111.
Departments of Pathology and Anesthesiology, St. Luke's
Hospital, Kansas City, Missouri
from above the IV without altering the results?1 These
become important questions when blood cannot be
drawn from the opposite arm in cases of recent mastectomy, amputation or when the opposite arm has no
patent vein or is covered with bandages. We undertook
a study to evaluate this problem using 18 healthy volunteers.
Materials and Methods
Intravenous fluids were infused into the forearm of
18 volunteers, 10 women and eight men, ages 20 to 45
years using an 18-gauge, l'A-inch Jelco® needle. All the
volunteers believed themselves to be healthy. Blood for
baseline hematologic and serum biochemical profiles
was drawn from the IV needle prior to starting the intravenous fluids. Nine patients received 5% dextrose in
water (D5W) and nine received 5% dextrose in Vi normal
saline solution (D5W in Vi NS). The rate of intravenous
fluid flow was approximately 125 mL/hour. After intravenous fluids were infused for 30 minutes and while the
IV was still infusing, blood was drawn from the opposite
arm, and above and below the IV in the same arm with
0002-9173/83/0100/0119 $00.95 © American Society of Clinical Pathologists
WATSON, O'KELL, AND JOYCE
120
A.J.C.P. • January 1983
Table 1. Mean Deviation for Analytes at Each Site
Mean Deviation*
Bun
Calcium
Phosphorus
Uric acid
Cholesterol
Albumin
Total protein
Bilirubin
AP
LDH
AST
Glucose
Creatinine
Sodium
Potassium
Chloride
co 2
WBC
RBC
Hb
Hct
Units
Baseline
Mean
Opposite
Arm
Above
IV
Below
IV
Out of IV Needle
After Stopped
Per Cent Volunteers
with >2 SD
Deviation when
Drawn Above IV
mg/dL
mg/dL
mg/dL
mg/dL
mg/dL
g/dL
g/dL
mg/dL
MIU/mL
MIU/mL
MIU/mL
mg/dL
mg/dL
mEq/L
mEq/L
mEq/L
mEq/L3
th/mm
106/mm3
g/dL
Vol%
13
9.5
3.25
5.5
207
4.9
7.2
0.6
66
158
24
99
1.0
140
4.0
101
26
6.4
4.79
14.3
41.8
0
0.3
0.3
0.1
10
0.2
0.4
0
4
13
2
27.5
0
1
0
0
0
0.39
0.11
0.3
1
1.7f
1.0
0.5
0.4
27
0.6
0.9
0.2
8
22.5
6.0f
253
0
7
0.3
3
1
0.55
0.28
1.1
2.5
0
0.2
0.2
0
7
0.2
0.3
0
3
9
1
37
0
1
0.1
1
1
0.34
0.13
0.4
1
0
0.2
0.2
0
10
0.2
0.3
0
3
7
2
28
0
0.5
0.1
1
1
0.20
0.13
0.4
1
33
61
78
67
78
61
83
27
22
55
56
100
05
83
56
50
22
22
44
61
11
• All mean deviations are below baseline values except for glucose.
a 21-gauge 1'/2-inch needle and a 12-mL plastic syringe.
The intravenous fluids were then stopped, and after
waiting two minutes, another blood sample was drawn
from the IV needle. The blood was transferred to two
vacuum tubes (Vacutainers®), one 15-mL tube for
serum biochemical profiles and one 4-mL EDTA tube
for hematologic profiles.
Serum biochemical profiles (urea nitrogen, calcium,
phosphorus, uric acid, cholesterol, albumin, total protein, bilirubin, alkaline phosphatase (AP), lactate dehydrogenase (LD), aspartate aminotransferase (AST),
glucose, creatinine, sodium, potassium, chloride, and
C0 2 ) were done using a SMA II (Technicon Instruments
Corporation, Tarrytown, NY 10591). Hematologic profiles (red blood cell count, white blood cell count, hemoglobin, and hematocrit) were done using the Coulter
Model S. (Coulter Electronics, Incorporated, Hialeah,
FL 33014). Our laboratories' standard deviation of quality control using commercial serum for each analyte is
shown in the last column of Table 1. All specimens from
the same individual were analyzed in the same batch.
The deviation from the baseline value was determined
for each analyte by sampling site (opposite arm, above
the IV, below the IV, and out of the IV needle after the
intravenous fluids were stopped) for each volunteer. The
mean deviation from the baseline was then calculated
for each analyte from each sample site.
Results
The mean baseline values for 17 serum analytes and
four hematologic constituents are shown in Table 1.
Standard Deviation
of Quality Control
0.648
0.186
0.056
0.072
5.535
0.167
0.147
0.075
5.124
7.752
2.348
4.334
0.036
1.061
0.060
1.459
1.50
0.70
0.15
0.3
2
t Mean deviation for D,W in 1/2 NS volunteers only.
Also shown are the mean deviations from the baseline
for samples drawn from the opposite arm, above the IV,
below the IV, and from the IV needle after the intravenous fluids had been stopped for two minutes. In all
cases except glucose, the mean deviation is below the
baseline value. Also included are the percentage of volunteers for each analyte that fell greater than two standard deviations (SD) from the baseline for only those
specimens drawn above the IV. The last column shows
our laboratories' SD of quality control for each analyte.
Calcium, uric acid, cholesterol, albumin, total protein, bilirubin, LD, sodium, potassium, chloride, and
hemoglobin all had a mean deviation greater than 2 SD
below the baseline when drawn above the IV. The mean
deviation was less than 2 SD for samples drawn from
the opposite arm, below the IV, and out of the IV needle
after the IV was stopped for two minutes. All the analytes mentioned above varied greater than 2 SD below
the baseline when drawn above the IV regardless of
whether the intravenous fluids were D 5 W or D 5 W in Vi
NS. With the exception of serum sodium and chloride,
all of the analytes showed a greater variation with D 5 W
in '/2 NS than with D 5 W.
The mean deviation for serum glucose and phosphorus determinations were greater than 2 SD from the
baseline, regardless of where the blood was drawn. Urea
nitrogen and AST levels were greater than 2 SD below
the baseline only when drawn above the IV in volunteers
receiving D 5 W in lh NS solution. The mean deviation
for AP, creatinine, C 0 2 , white blood cell count, red
blood cell count, and hematocrit from all sites was less
Vol. 79 • No. I
BRIEF SCIENTIFIC REPORTS
than 2 SD below the baseline. However, as listed in
Table 1, a small percentage of samples for each of these
analytes drawn above the IV still showed values greater
than 2 SD below the baseline.
There was considerable difficulty in drawing blood
from the IV needle after the intravenous fluids were
stopped in volunteers #4 and #13. Test results for some
of the analytes from these two volunteers from this site
showed considerable variation from the baseline that
could not be accounted for by the infusion of intravenous fluids. These were not included in calculating the
mean deviation.
Discussion
Drawing blood from above an infusing IV will alter
serum levels of a number of analytes. Most of the analytes showed a dilutional effect with results falling
greater than 2 SD below baseline levels. Only serum
glucose showed values higher than the baseline. It appears that most analytes are not affected when blood is
drawn below the IV, from the opposite arm, or from the
IV needle after the IV has been stopped for at least two
minutes. Only serum glucose and phosphorus levels varied more than 2 SD from the baseline when drawn from
sites other than above the IV. Ong and co-workers2 also
demonstrated that serum glucose would vary greatly re-
121
gardless of the site where it was drawn. No explanation
can be found for the variation of phosphorus levels at
sites other than above the IV. Ong and colleagues2 also
demonstrated that blood could be drawn distal to the
IV site with a tourniquet in between without altering
serum biochemical and hematologic profiles except glucose.
In two patients in our study where difficulty was encountered drawing the blood, the analytes showed great
variation from the baseline that could not be accounted
for by the intravenous fluids and were not consistent
with variations seen in the other volunteers.
Serum biochemical and hematologic profiles should
not be drawn above an infusing IV. Blood may be drawn
from the opposite arm or below the IV while it is infusing
or from the IV needle after stopping the intravenous
fluids for two minutes, for all analytes except glucose
and phosphorus. We would also suggest that when there
is difficulty with phlebotomy, test results may show great
variation and should be reviewed with care.
References
1. Baer DM: Tips on technology. Medical Laboratory Observer 1979;
11:132-133
2. Ong YY, Boykin SF, Barnett RN: You can draw blood from the
"IV arm" below the intravenous needle if you put a tourniquet
in between. Am J Clin Pathol 1979; 72:101-102