Phlebotomy Exam Units: Order of Draw Fundamentals
Understanding the CLSI Standard H3-PS-1
The Clinical and Laboratory Standards Institute (CLSI) establishes the gold standard for clinical laboratory procedures globally. The specific document, GP41 (formerly H3-A6), dictates the CLSI order of draw to ensure that additives from one tube do not affect the results of subsequent tubes. On the exam, you will likely encounter questions regarding why this standard exists. The protocol is rooted in the prevention of biochemical interference. For example, if a tube containing a clot activator is drawn before a coagulation tube, the activator could initiate the clotting cascade in the second tube, rendering the Prothrombin Time (PT) or Activated Partial Thromboplastin Time (aPTT) results clinically useless. The exam expects you to recognize that these standards are revised periodically to reflect changes in tube technology and manufacturing, such as the transition from glass to plastic tubes, which necessitated changes in how serum activators are handled.
The Consequences of Additive Carryover
Additive cross-contamination occurs when the needle used to puncture the stopper of one tube carries a trace amount of that tube's chemical additive into the next tube in the sequence. This is a high-yield exam topic because it directly impacts patient safety. A classic example involves Ethylenediaminetetraacetic acid (EDTA). EDTA works by chelating (binding) calcium to prevent clotting. If an EDTA tube is drawn before a serum tube intended for electrolyte testing, the carryover of EDTA will artificially decrease the measured calcium levels and, more critically, may cause a massive false elevation in potassium levels if Potassium EDTA is used. In a clinical setting, a falsely elevated potassium (pseudohyperkalemia) could lead to unnecessary and dangerous medical interventions. The exam will test your ability to identify which specific tests are compromised by specific sequence errors.
Core Tube Types, Additives, and Tests
To master the blood collection tube sequence, you must link the stopper color to its specific additive and the department it serves. The exam frequently asks you to categorize tubes based on their function: anticoagulants, clot activators, or glycolytic inhibitors. Anticoagulants like Sodium Heparin, Lithium Heparin, and EDTA prevent clotting so that whole blood or plasma can be analyzed. Conversely, Serum Separator Tubes (SST) contain silica particles to promote clotting and a thixotropic gel to create a physical barrier between the cells and the serum during centrifugation. You must know that a "Red Top" tube typically contains no additive (in glass) or a clot activator (in plastic) and is used for chemistry, serology, and blood bank. Understanding the chemical mechanism—such as how Sodium Citrate preserves coagulation factors by binding calcium reversibly—is essential for answering "why" questions on the certification test.
A Step-by-Step Breakdown of the Tube Sequence
Blood Culture Bottles and SPS Tubes
Blood cultures always come first in the sequence to maintain strict sterility. Whether using a syringe or an evacuated tube system, the primary concern is preventing skin flora or additives from other tubes from entering the culture media. These containers often contain Sodium Polyanethol Sulfonate (SPS), which aids in bacterial growth by inhibiting complement, phagocytosis, and certain antibiotics. On the exam, you may be asked about the specific collection requirements for blood cultures, such as the need for aerobic and anaerobic bottles. If you are performing a butterfly draw, the aerobic bottle must be filled first because the air in the tubing will be displaced into the first container. Failure to follow this specific sub-rule can inhibit the growth of anaerobic organisms, leading to a false-negative result and a significant loss of points on the assessment.
Sodium Citrate (Light Blue) for Coagulation
The light blue stopper tube, containing 3.2% Sodium Citrate, follows blood cultures. This tube is used for coagulation studies, such as the International Normalized Ratio (INR). A critical rule for the exam is the 9:1 ratio of blood to anticoagulant. Because the liquid citrate dilutes the blood, the tube must be filled to the marked line (at least 90% capacity) to ensure accurate results. If the tube is underfilled, the excess citrate will bind too much calcium in the test environment, artificially prolonging clotting times. You should also be aware of the "discard tube" rule: if using a wing-infused set (butterfly), a discard tube must be used first to prime the tubing and remove the "dead space" air, ensuring the blue tube reaches its required volume. This procedural nuance is a favorite for examiners looking to distinguish between novice and expert technicians.
Serum Tubes: Red, SST, and Serum Separators
Serum tubes are drawn after coagulation tubes. These include the plain Red Top and the Gold or "Tiger" Top (SST). These tubes are designed to allow the blood to clot completely, which typically takes 30 to 60 minutes at room temperature. The SST contains a thixotropic gel that, when centrifuged, moves to the interface between the heavy blood cells and the lighter serum. This prevents the cells from metabolizing analytes in the serum, such as glucose. On the exam, you must distinguish between the "Red" glass tube (no additive) and the "Red" plastic tube (clot activator). While glass naturally initiates the intrinsic clotting pathway, plastic is too smooth and requires the addition of silica or celite to trigger the process. Missing this distinction can lead to errors when the exam asks about "plain" versus "activated" serum collection.
Completing the Draw: Heparin, EDTA, and Specialty Tubes
Heparin Tubes (Green) for Chemistry
Green-top tubes contain Heparin, which acts by inhibiting thrombin in the coagulation cascade. There are three formulations: Lithium Heparin, Sodium Heparin, and Ammonium Heparin. Lithium Heparin is the most common for general chemistry panels because it does not interfere with electrolyte measurements. The exam will often present a scenario where a technician must choose between an SST and a Green-top tube for a "STAT" chemistry test. The correct answer is the Green-top (Plasma Separator Tube or PST) because it does not require the 30-minute waiting period for clotting, allowing for a faster Turnaround Time (TAT). Understanding the difference between plasma (the liquid portion of anticoagulated blood) and serum (the liquid portion of clotted blood) is a fundamental requirement for passing the phlebotomy certification.
EDTA Tubes (Lavender/Pink) for Hematology
Lavender or purple-top tubes contain EDTA and are primarily used for the Complete Blood Count (CBC) and blood smears. EDTA is the preferred anticoagulant for hematology because it preserves the morphology (shape and structure) of the blood cells better than other chemicals. Pink-top tubes also contain EDTA but are specifically labeled for Blood Bank (Immunohematology) to meet stringent labeling requirements for cross-matching. Because EDTA is high in potassium and binds calcium, it must never be drawn before tubes intended for electrolyte or calcium testing. On the exam, you might see a question about "micro-clots"; these occur if the EDTA tube is not inverted immediately 8–10 times after collection, leading to a rejected specimen and the need for a redraw.
Glycolytic Inhibitors (Gray) and Other Specialties
The Gray-top tube is usually the final tube in the standard sequence. It contains two main additives: Sodium Fluoride, which acts as an antiglycolytic agent to prevent the breakdown of glucose by red blood cells, and Potassium Oxalate, an anticoagulant. This tube is used for glucose tolerance tests (GTT) and lactic acid measurements. If a gray tube is drawn out of order—specifically before a green or lavender tube—the potassium oxalate can damage the cell membranes of the red blood cells, causing hemolysis and invalidating hematology results. Other specialty tubes, such as the Royal Blue (for trace elements) or Tan (for lead), have specific placements depending on whether they contain EDTA or no additive, but for the general exam, the Gray tube marks the conclusion of the standard draw.
Order of Draw Exceptions and Special Scenarios
Butterfly Needles and Short Draws
Using a Winged Infusion Set (butterfly needle) introduces a specific challenge: the air trapped in the 7-to-12-inch tubing. If the first tube drawn is a light blue sodium citrate tube, this air will displace the blood, resulting in a "short draw" and an incorrect blood-to-additive ratio. To prevent this, a "discard tube" (either a plain red or another light blue tube) must be used to purge the air from the line. The discard tube does not need to be filled completely; it only needs to show the blood reaching the hub of the tube. This is a critical safety step often tested in "What is the next step?" style exam questions. Note that the discard tube is only necessary for the first tube in the sequence if that tube is a volume-sensitive coagulation tube.
Pediatric and Geriatric Phlebotomy
In pediatric and geriatric populations, where veins are fragile and blood volume is limited, the order of draw for capillary punctures (skin punctures) differs from the venous order. When performing a fingerstick or heelstick, the EDTA tube is collected first, followed by other additive tubes, and serum tubes last. This is the exact opposite of the venous sequence. The rationale is that the skin puncture triggers the clotting process immediately; therefore, the hematology tube must be collected first to prevent micro-clots from forming in the specimen. On the phlebotomy exam, you must pay close attention to whether the question specifies a "venipuncture" or a "skin puncture," as the correct answer for the sequence will change based on that single word.
Blood Bank Specimens and Cold Agglutinins
Specialized testing often requires deviations or additional steps in the collection process. For example, Cold Agglutinins are antibodies that react at low temperatures. These specimens must be collected in tubes pre-warmed to 37 degrees Celsius and kept warm until they reach the laboratory. While the order of draw remains the same, the handling of the tube is the priority. Similarly, for Blood Bank specimens (Pink or Red tops), the exam emphasizes the Positive Identification (PID) process. Because a transfusion error can be fatal, the sequence is less likely to be the focus than the labeling requirements. However, you must still know that a Pink EDTA tube follows the same sequence rules as a Lavender EDTA tube to avoid contaminating chemistry samples drawn earlier.
Memory Techniques and Exam Strategy
Effective Mnemonics and Visual Aids
To master the phlebotomy tube colors and tests, most students rely on order of draw memorization tricks. A widely accepted mnemonic is: Be (Blood Culture) Loving (Light Blue) Respectful (Red) Stay (SST) Gracious (Green) Lovely (Lavender) Gray (Gray). Another variation is "Boys Love Ravishing Girls Like Gravy." While these are helpful, the exam will try to trick you by using the additive names instead of colors. Therefore, your study strategy should involve "stacking" the information: associate the color with the additive, then the additive with the department, and finally the department with the mnemonic. Visualizing the "rainbow" of tubes in your tray from left to right can also help solidify the sequence during the high-pressure environment of the testing center.
Practice Questions Focusing on Rationale
Exam questions rarely just ask for the list; they provide scenarios. For example: "A technician draws a Lavender tube before a Green tube. Which test result is most likely to be affected?" To answer this, you must know that Lavender contains EDTA (which has potassium) and Green is often used for electrolytes. The answer would be a falsely elevated potassium. Another common question type involves a list of four tests (e.g., PT, CBC, Glucose, Electrolytes) and asks you to sequence them. You must first translate the tests to their tubes: PT (Blue), CBC (Lavender), Glucose (Gray), Electrolytes (Green or SST). Then, apply the CLSI order of draw to arrange them: Blue, SST, Green, Lavender, Gray. Practicing this multi-step reasoning is the most effective way to prepare for the advanced logic used in modern certification exams.
Common Order of Draw Exam Pitfalls
One of the most frequent mistakes on the phlebotomy exam is confusing the order for syringe draws versus evacuated tubes. While the order of draw is now generally the same for both, historically there were differences that some older exam banks might still reference. Always follow the current CLSI guideline: Cultures, Citrate, Serum, Heparin, EDTA, Fluoride. Another pitfall is the "Transfer Device" scenario. If you draw blood into a syringe and then transfer it to evacuated tubes, you must use the same order of draw as a standard venipuncture to prevent carryover from the transfer needle. Finally, watch out for questions regarding "Trace Element-Free" tubes (Royal Blue). These are drawn separately or at the very beginning to prevent any contamination, though their position can vary based on whether they contain an anticoagulant. Precise reading of the question's "site" and "equipment" is your best defense against these common traps.