BSMLS - 1202 | PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2

Unit 7: Pre-Analytical Considerations in Phlebotomy

2nd SEMESTER | S.Y 2021 – 2022 BACHELOR OF SCIENCE IN MEDICAL LABORATORY SCIENCE
LECTURER: MS. MICHELLE T. MABASA TRANSCRIBED BY: MANYLL REIGNE A. MAGANA

THE ENTIRE TESTING PROCESS A reference range (normal values or NV) is used as basis for a
normal range within a population. Example: An individual’s
1. Pre-analytical (Pre-examination Phase) normal glucose level should be < 100 mg/dl; if the patient has
The pre-analytical phase includes any actions of factors a glucose level of 150 mg/dl, then the patient could be
involved in acquiring, handling, transporting, and processing a suffering from hyperglycemia or increase of blood sugar.
patient specimen prior to the actual analysis.
PATIENT FACTORS
Comprised of:
• interview of patient Variable Effects On
• taking of notes RBC, WBC, Creatinine Clearance
• blood extraction
Some analytes are normally higher in one
Pre-analytical phase only ends when the sample is tested, and age bracket than another.
Age
phlebotomy belongs to the pre-analytical phase of the testing
process. RBC and WBC are higher in value among
newborns and creatine values are lower
Errors can be encountered during this phase. Once there are among elderly.
errors, your results can be considered as invalid. If the invalid RBC
test could be released to the patient’s physician, it could be
erroneous: a wrong prescription or treatment could be given. In high altitude areas, oxygen values are
Altitude low, thus the body releases more RBC to
2. Analytical (Examination Phase) compensate the low value of oxygen in the
The analytical phase includes all factors relation to the test surroundings. Individuals living in high
platform and to the testing process itself. areas have higher values of RBC.
Hemoconcentration, RBC, Enzymes, Fe,
3. Post-analytical (Post-examination Phase) Ca, Na
The post-analytical phase refers to the interpretation of the
test results considering our expertise as physicians to Dehydration is a pathologic patient factor
formulate a diagnosis (or differential diagnosis) to guide because it originates from one’s illness,
patient management. such as: diarrhea or severe vomiting.

Comprised of: Hemoconcentration happens during

• results dehydration because it causes the water
Dehydration
• releasing of the results and other fluids to leak out of the blood
vessels, leaving the formed elements
PRE-ANALYTICAL VARIABLES inside, increasing their concentration and
other enzymes to increase too.
1. Patient Factors
It is divided into two: pathologic factor (e.g., a patient having a This causes a false increase in blood
fever or diarrhea) and physiologic factor (not illness related, chemistry and makes the patient’s vein
what a patient inertly has e.g., age, sex, race) hard to locate (thin and does not
protrude).
2. Sample Handling Glucose, Lipids, Electrolytes
This pre-analytic variable refers to how you take care or handle
the sample. An example of this would be how the sample is The patient is required to fast to break
transported. their diet. The prescribed fasting is set at
Diet
12 (hours) and should be done at night to
3. Sample Collection eliminate the effects done by the diet. It is
This variable is focused on the actual drawing of blood. A not ideal to draw blood when the patient
phlebotomist should take not of common errors that could fasts during the day because the patient’s
reoccur.

MANYLL REIGNE A. MAGANA

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 BSMLS - 1202 | PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2
Unit 7: Pre-Analytical Considerations in Phlebotomy
2nd SEMESTER | S.Y 2021 – 2022 BACHELOR OF SCIENCE IN MEDICAL LABORATORY SCIENCE
LECTURER: MS. MICHELLE T. MABASA TRANSCRIBED BY: MANYLL REIGNE A. MAGANA

body is at work and is prone to using up Basically, most drugs affect the liver
protein, carbohydrates, and electrolytes. because the liver stabilizes the products.

If their diet is high in carbohydrates and There are medicines that are hepatotoxic,
sweets, it increases their glucose and even though it has cured a disease, it
insulin levels. And if their diet is high in causes damage to the liver.
protein, their body’s breakdown products pH, PCO₂, CK, LDH, Glucose
are ammonia, uric acid, urea.
Muscle enzymes (specifically CK) are
Fruits such as pineapple and banana greatly affected, especially when the
increases uric acid and mangoes increase exercise done is weight lifting which
blood sugar (having high fructose content). focuses on muscle mass.

Alcohol can destroy the liver’s cells and The increase in muscle mass increases the
pose an increase in liver enzymes (AST, value of muscle enzymes.
ALT, LTH).
After an intramuscular injection, the
Fat-rich foods increase triglycerides, lipids, Exercise or patient should rest for 1 hour at most
cholesterol. Intramuscular before drawing blood.
TSH, Cortisol, Fe Injection
Muscle enzymes also fluctuate depending
Diurnal variation (a variation that is on what exercise is done and its duration,
synchronized within a morning or evening which could cause a low value in pH and
cycle) and circadian variation or rhythm (a PCO₂ value and increase glucose (for
Diurnal 24-hour variation) are changes throughout energy), creatinine, insulin, and even
Variation the day. Example: There are analytes that Potassium – however, the effects are only
or Circadian vary in value depending on the time of the transient.
day.
During blood extraction, it is not advisable
Thus, it is important that during blood for the patient to pump their first because
extraction, the phlebotomist should take it falsely increase Potassium within cells.
note of time of collection. Hormones, Cortisol
Enzymes, Hormones
The high temperature in the body affects
Fever
There are medicines that pose an effect on the body’s hormone and cortisol due to
the patient. the shift in the balance between acid-base
(pH).
Examples: Chemo toxic drugs that kill RBC, Hgb, Hct
cancer but also the body’s natural cells,
decreasing WBC and platelets. There are some analytes that are naturally
higher and lower which vary between
Drug Therapy Contraceptives also increase the ESR of the genders.
Gender
(Medicine) patient but decrease the Vitamin B12. Thus,
it is not allowed to continuously use these. In Males: Higher – muscle enzymes,
creatine, CK (because males have higher
Morphine also affects the liver, increasing muscle) and iron (because males do not
the liver enzymes (AST, ALT, LDH), menstruate monthly)
including the pancreatic enzymes. Yellow Color Interferes
Jaundice
Steroids and diuretics also increase a The patient who suffers with liver
patient’s pancreatic enzymes (amylase problems tend to have blood samples that
and lipase).
MANYLL REIGNE A. MAGANA
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 BSMLS - 1202 | PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2
Unit 7: Pre-Analytical Considerations in Phlebotomy
2nd SEMESTER | S.Y 2021 – 2022 BACHELOR OF SCIENCE IN MEDICAL LABORATORY SCIENCE
LECTURER: MS. MICHELLE T. MABASA TRANSCRIBED BY: MANYLL REIGNE A. MAGANA

are very dark yellow in color (icteric), or it stop the patient to smoke) to prevent their
could be slightly green (jaundice). increase.

The phlebotomist can decline blood

collection when the patient is caught to be
smoking.
WBC, Fe, ACTH, Catecholamine, Cortisol

Anxiety, fear, trauma, or shock is a

pathologic factor that transiently increase
WBC.
Stress
When doing blood collection in infants,
The phlebotomist cannot repeat collection make sure that the infant is not crying
because it will still be the same color. (stressed) to prevent a false reading for
increased WBC.
However, it could cause color interference Hemoconcentration
during analyzation because the chemical
analysis of these analytes is colorimetric, In high temperature, a sweating patient
making the result unreliable. could lead to hemoconcentration due to
Temperature leakage of water from blood vessels to
Thus, the phlebotomist should dilute the and Humidity compensate the body’s loss of water.
serum or plasma for proper analyzation.
In humid temperature, there is low oxygen
The phlebotomist should also take note in the environment and the body increase
that the sample is icteric (or jaundice) to RBC to compensate.
inform the physician during the release of
results. Factor Examples of Analytes Affected
Protein, K Albumin, Alkaline Phosphate (ALP) high in
Age
Elderly, Phosphorus (P), Cholesterol
A shift of body fluids happens when the High in Males: Albumin, ALP, Creatine, Ca²+,
patient changes their position, causing a Uric Acid, Creatinine Kinase (CK), Aspartate
shift in analytes. Aminotransferase (AST), Phosphate (PO4),
Gender
BUN, Mg2+, Bilirubin, Cholesterol
Position Patients, especially out-patients should be
given time to rest for a while before blood High in Females: Fe, Cholesterol,
collection for the shift of body fluids to set. High in AM: Adrenocorticotropic Hormone
(ACTH), Cortisol, Fe, Aldosterone
Example: When testing for cholesterol, the Diurnal
patient should be seated for at least 5 Variation High in PM: Acid Phosphatase, Growth
minutes before drawing blood. Hormone, Parathyroid Hormone (PTH),
RBC Thyroid-Stimulation Hormone (TSH)
Pregnancy About 20% or Greater Than for Alanine
RBC levels and other specific hormones are Day-to-day
Aminotransferase (ALT), Bilirubin, Fe, TSH,
increased during pregnancy. Variation
Triglycerides
Cholesterol, Cortisol, Glucose, GH, High: Glucose, Insulin, Triglycerides,
Triglyceride, WBC Gastrin, Ionized Ca²+
Recent Food
Smoking Ingestion
When smoking, specific analytes are Low: Chloride, Phosphorus, Potassium,
affected, but their effects are only Amylase, ALP
transient. Thus, fasting is done (advising to

MANYLL REIGNE A. MAGANA

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 BSMLS - 1202 | PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2
Unit 7: Pre-Analytical Considerations in Phlebotomy
2nd SEMESTER | S.Y 2021 – 2022 BACHELOR OF SCIENCE IN MEDICAL LABORATORY SCIENCE
LECTURER: MS. MICHELLE T. MABASA TRANSCRIBED BY: MANYLL REIGNE A. MAGANA

High when Standing: Albumin, Cholesterol, Hemoglobin Lower at night

Posture
Aldosterone, Ca²+ Potassium Lower at night
High in Ambulatory Patients: CK Testosterone Lower at night
RBC Lower at night
High with Exercise: Lactic Acid, Creatine,
Activity Protein, CK, AST, Lactate Dehydrogenase SAMPLE COLLECTION
(LD)
1. Misidentification of Patient
Low with Exercise: Cholesterol, Triglycerides Misidentification commonly happens when the phlebotomist
Stress High: ACTH, Cortisol, Catecholamines personally asks the name of the patient instead of making
High in Black: Total Protein (TP) them say their name for confirmation.
Low in Black: Albumin
Correct Identification: The patient should be the one to state
White Male vs Black Male their full name (including suffixes) and their birthdate for
High in Black: IgG 40% and IgA 20% confirmation, which should be match with the patient’s ID
band and requisition form before blood extraction.
Race High in Black Males: CK/LD
2. Mislabeling of Specimen
High in White (greater than 40 years old): Labeling of the tubes should be done after blood extraction
Cholesterol and Triglycerides and in front of the patient, while asking their name again to
double check.
Asian, Black, Native American, Hispanic:
Glucose-incidence Diabetes When writing, the tube should be in a horizontal position for
Fasting Blood Sugar, Glucose Tolerance your handwriting to be readable, writing the patient’s full
Require
Test, Triglycerides, Lipid Panel, Gastrin, name, patient ID number, date and time of extraction, and
Fasting
Insulin, Aldosterone or Renin initials of the phlebotomist.
Require ICE
Lactic Acid, Ammonia, Blood Gas (if not
(Immediate Some laboratories have a
cooled = low: pH and PO2)
Cooling) Laboratory Information System
High: K+, Ammonia, PO4, Fe, Mg2+, ALT, AST, (LIS) that is uses a bar code. A
Hemolysis LD, ALP, Catecholamines, CK (marked sticker with the bar code is stick on
hemolysis) the tube directly under the cap.
The sticker contains: patient
Tests Affected by Diurnal Variation, Posture, and Stress name, patient ID number, and bar
Cortisol Peaks 4-5 AM; Lowest 8PM – 12 PM; code (which contains all
50% lower at 8PM than at 8AM; information such as the patient’s
Increased with stress age, gender, and tests taken). The
Adrenocorticotropic Lower at night, increased with stress phlebotomist should leave a
Hormone visible window to monitor the
Plasma Renin Lower at night; Higher standing than sample.
Activity supine
Aldosterone Lower at night 3. Short Draws or Wrong Anticoagulants – Blood Ratio
Insulin Lower at night All tubes contain their own pre-determined vacuums. The
Growth Hormone Higher in afternoon and evening phlebotomist should not remove the cap to keep the vacuum
Acid Phosphatase Higher in afternoon and evening inside the tube.
Thyroxine Increases with exercise
The phlebotomist should make sure that the tube to be used
Prolactin Higher with stress; Higher levels at 4
are not expired. An expired tube that has lost it vacuum causes
and 8AM and at 8 and 10PM
short draws.
Iron Peaks early to late morning;
Decreases up to 30% during the day
In using syringe system, when transferring blood to the tube,
Calcium 4% decrease supine the blood should be filled until the stated mark. Do not
MANYLL REIGNE A. MAGANA
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 BSMLS - 1202 | PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2
Unit 7: Pre-Analytical Considerations in Phlebotomy
2nd SEMESTER | S.Y 2021 – 2022 BACHELOR OF SCIENCE IN MEDICAL LABORATORY SCIENCE
LECTURER: MS. MICHELLE T. MABASA TRANSCRIBED BY: MANYLL REIGNE A. MAGANA

overfill or underfill the tube to prevent incorrect anticoagulant Yellow

Serum Whole Blood
– blood ratio. An underfill could cause dilution (too much Top ACD or SPS
Tube Determination
anticoagulant), causing the RBC to shrink. An overfill could also Tube
cause a too concentrated sample. Orange
Thrombin Chemical
Top Thrombin
4. Mixing Problems or Clots Tube Testing
Tube
Right after the tube is filed, the tube should immediately be Contains a Clot
inverted to mix the blood and anticoagulant. Gel Various
Serum Activator and
Yellow Laboratory
Gel Tube Serum Gel
The inversion of tubes depends on the type Tube Tests
Separator
of anticoagulant inside, but most tubes
require 8 inversions. The proper 1 inversion
is: top à bottom à top. 6. Hemolysis or Lipemia

A red top with clot activator is the only red

top that should be inverted (5 times).
Regular top tubes (no additive) are not
allowed to be inverted because the RBC
could lyse causing the sample to be
hemolyzed.

The SST (Yellow Top) should be inverted for only 5 times, while
tubes with Sodium Citrate should be inverted for only 3 – 4 Regardless of hemolysis (could be mild or severe), if the sample
times and the rest of the tube follow the standard 8 times is hemolyzed, the phlebotomist should repeat collection. A
inversion. Inversion is done to prevent micro clots. hemolyzed sample will greatly affect the reading of results.

5. Wrong Tubes or Wrong Anticoagulants Potassium is present in RBC. When RBC is lysed, Potassium is
The phlebotomist should know which tube should be used and released unto the sample which causes a false increase during
the correct order of draw. the reading of the hemolyzed sample.

Order of Stopper Laboratory Possible Reasons of Hemolysis:

Additives
Draw Color Use • puncturing when the alcohol used for disinfection has
Plain Red Top Drug Levels, not yet dried up
N/A
Tube Tube Blood Bank • tying the tourniquet too tight
Lavender • collection within site with hematoma
EDTA
Top EDTA (K2 or K3) CBC, HbA1c • pulling the plunger too quickly during blood
Tube
Tube extraction
Plasma • incorrect transfer of blood from syringe to tube
Green
Heparin Chemistry,
Top Sodium Heparin
Tube Ammonia Lipemic sample happens when the serum is milky in color, this
Tube
Level would mean that the sample is high in lipids, specifically:
Black Westergren triglyceride and cholesterol.
ESR Tube Top Sodium Citrate Sedimentation A lipemic sample usually happens when extraction is done
Tube Rate right after the patient is done eating. A lipemic sample can be
Glucose eliminated through fasting.
Glucose Grey Top Tolerance
Sodium Fluoride
Tube Tube Testing, However, some patients really have naturally lipemic samples.
Alcohol Level The phlebotomist should note that the collected blood
Light specimen is lipemic.
PT Tube Blue Top Sodium Citrate PT, PTT
Tube

MANYLL REIGNE A. MAGANA

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 BSMLS - 1202 | PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2
Unit 7: Pre-Analytical Considerations in Phlebotomy
2nd SEMESTER | S.Y 2021 – 2022 BACHELOR OF SCIENCE IN MEDICAL LABORATORY SCIENCE
LECTURER: MS. MICHELLE T. MABASA TRANSCRIBED BY: MANYLL REIGNE A. MAGANA

7. Hemoconcentration from Prolonged Tourniquet Phlebotomist should also

Time avoid sites with edema
An increased tourniquet time also causes hemoconcentration. because the analytes within
The tourniquet should be used for only less than or exactly 1 the area are too diluted
minute. because of the build-up of
fluid.
A prolonged tourniquet time causes the water to leak out of
the blood vessels which causes a concentration of elements
inside the blood vessel, resulting to a false increase. Hematoma is the swelling
or a mass of blood that has
Fist pumping should also be avoided because it could also leaked out of the blood
cause hemoconcentration. vessel walls during
venipuncture and should
The phlebotomist can release the tourniquet as soon as they also be avoided because
are able to establish a blood flow, do not wait until the tube is these sites could
filled. contaminate the blood
sample or obstruct the patient’s blood flow. The phlebotomist
SAMPLE HANDLING should also advise the patient with hematoma to use cold or
hot compress to lessen the swelling.
1. Agitation or Centrifugation
2. Storage The site of mastectomy (removal of breast) should be avoided,
3. Transport Condition especially when lymph nodes are affected because there will
4. Delays in Transport to the Laboratory be an accumulation of lymph fluids. The area or the arm in the
same side of the mastectomy should not be taken samples
PROBLEM SITES from for about 3 to 5 years.

Problem sites are areas within the range of the site of An obese patient’s vein is hard to locate. The phlebotomist
venipuncture that should be avoided. should have great skills in locating the vein to successfully draw
blood.
Burns are fresh wounds and thus,
would hurt the patient when IV lines, VAD’s, or
blood is taken from burn sites. A Cannula should be
burn also results to skin’s scarring avoided because the
and should also be avoided fluid from these can
because these have impaired dilute the blood. The
circulations which could cause an phlebotomist can take
erroneous result. Areas that also sample from the other
have tattoos should be avoided arm which does not
because the dye used for the have the dextrose attached. However, when both arms are
tattoo could mix with the blood used, the phlebotomist can extract blood below the IV line.
sample.
Patient’s arm with a cannula used for chemotherapy) and
Damaged veins such patient’s arm with VAD’s (vascular access devices) which are
as sclerosed permanent fusion of vein and artery (for access of dialysis)
(hardened blood should also be avoided for blood collection.
vessel wall due to
frequent blood PATIENT COMPLICATION
drawing on the same
area) and thrombosed A patient could have an allergic reaction from latex (due to
(not totally dissolved using tourniquet and gloves), antiseptics (povidone iodine),
blood clot) should be and adhesive (plaster). It is important to interview the patient
avoided because these also have impaired circulations. regarding their allergies to avoid any complication.
MANYLL REIGNE A. MAGANA
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 BSMLS - 1202 | PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2
Unit 7: Pre-Analytical Considerations in Phlebotomy
2nd SEMESTER | S.Y 2021 – 2022 BACHELOR OF SCIENCE IN MEDICAL LABORATORY SCIENCE
LECTURER: MS. MICHELLE T. MABASA TRANSCRIBED BY: MANYLL REIGNE A. MAGANA

Ask permission and explain Avoids misinterpretation

There are also patients who undergo excessive bleeding, what you are doing if it is of actions that are
which are common with patients having prolonged clotting necessary to loosen a tight standard protocol to
time due to medication that dilutes blood or they could be collar or tie. hasten recovery.
naturally bleed a lot. Apply a cold compress or wet Part of the standard of
washcloth to the forehead and care.
The phlebotomist should only apply plaster when they have back of the neck.
made sure that the bleeding has stopped. Only use gauze Have someone stay with the Prevents patients from
(preferred) or cotton to check if the bleeding has stopped, ask patient until recover is getting up too soon and
the patient to apply pressure about 5 minutes before sealing it complete. possibly causing self-
with plaster. The patient is not advised to fold the arm right injury.
after extraction because it could lead to hematoma. Call first aid personnel if the Emergency medicine is
patient does not respond. not in the phlebotomist’s
Some patients could also feel nausea or even vomit before scope of practice.
venipuncture. Do not disregard the patient and make sure that Document the incident Legal issues could arise,
they are feeling calm and relaxed to prevent fainting (syncope) according to facility protocol. and further
or further complications during blood extraction. documentation is
essential at that time.
Petechiae could also be evident in the patient’s skin, also
considered as micro clots. These are tiny red spots that are PROCEDURAL ERROR RISKS
usually evident after tying a tourniquet. Petechiae are signs
that the patient is a “bleeder” or has prolonged clotting time. Hematoma (bruising) are cause by the needle piercing through
and through the blood vessel, causing pokes.
If the patient ever vomits, feels pain, has a seizure
(convulsion), or faints (syncope) during venipuncture, Iatrogenic Anemia could happen due to successive blood
immediately stop. extraction. However, this type of anemia has a transient effect
since once extraction is stopped, blood is then normalized.
Steps to Follow if a Patient Starts to Faint During
Venipuncture Inadvertent Arterial Puncture happens when the needle
Steps Explanation or Rationale passes through the blood vessel and hits a nerve (nerve injury)
Release the tourniquet and Discounting the draw and or artery.
remove and discard the discarding the needle
needle as quickly as possible. protects the phlebotomist Infection could happen due to dirty or bad practices during
and patient from injury venipuncture, introducing an agent of infection towards the
should be done when the patient.
patient faints.
Apply pressure to the site Pressure must be applied A phlebotomist should never:
while having the patient lower to prevent bleeding or • remove the cap of the needle prior to venipuncture,
the head and breathe deeply. bruising. Lowering the exposing the needle
head and breathing • pre-loot the needle in the tube holder
deeply helps get • touch the needle
oxygenated blood to the • touch the site of venipuncture after disinfection
brain. • prepare the gauze or cotton, exposing to infection
Talk to the patient. Diverts patient’s
attention, helps keep the Reflux of anticoagulant could happen because of the position
patient alert, and aids in of the patient. The ideal position should be lower so that the
assessing the patient’s tube is placed properly (15 to 30 degree), preventing the
responsiveness. anticoagulant to slip through the needle and enter the
Physically support the patient. Prevents injury in cause of bloodstream of the patient.
collapse.

MANYLL REIGNE A. MAGANA

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 BSMLS - 1202 | PRINCIPLES OF MEDICAL LABORATORY SCIENCE 2
Unit 7: Pre-Analytical Considerations in Phlebotomy
2nd SEMESTER | S.Y 2021 – 2022 BACHELOR OF SCIENCE IN MEDICAL LABORATORY SCIENCE
LECTURER: MS. MICHELLE T. MABASA TRANSCRIBED BY: MANYLL REIGNE A. MAGANA

Vein damage is also encountered during successive blood blood vessel. To

extraction within the same vein, resulting to a build-up of scar troubleshoot, move your
tissue. needle backwards.

TROUBLESHOOT

1. Tube Position
The phlebotomist should make sure that the tube is in the The needle is beveled up
correct position. When using evacuated tube system, it is but has hit the wall of the
essential to make sure that the tube is penetrated in the blood vessel.
stopper.

2. Needle Position
The phlebotomist should make sure that the needle is in the
correct position. The needle is beveled
down.
Position Description
Correct:

The needle is inside the The blood vessel has rolled

blood vessel, the correct during venipuncture. The
position of the needle. phlebotomist should make
sure that the chosen blood
vessel does not roll. To
anchor a blood vessel, a
The needle did not reach
thumb or forefinger is
the blood vessel, only up
placed below the puncture
until the skin. To
troubleshoot, move the site.
needle forward.

The needle is exposed The blood vessel has

outside the skin. When tube collapsed.
is inserted on the ETS, the
vacuum of the tube will be
released and introducing air
inside the tube.
3. Collapsed Vein
The needle is only pierced A collapsed vein is common among elderly due to a shut off in
halfway through the blood blood flow because of too much pressure from the tube, the
vessel. The blood will leak tourniquet tied too tight, or the tourniquet is removed too
through the blood vessel, early.
causing hematoma.
4. Tube Vacuum
The needle is pierced A loss in tube vacuum is due to improper insertion of bevel
through the other end of inside the blood vessel or an expired tube.
the blood vessel,
puncturing it, which causes
hematoma. It could possibly
hit an artery or a nerve.
The needle is pierced
through and through the
MANYLL REIGNE A. MAGANA
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