Jump to ContentJump to Main Navigation
Show Summary Details
More options …


Official Journal of the Society to Improve Diagnosis in Medicine (SIDM)

Editor-in-Chief: Graber, Mark L. / Plebani, Mario

Ed. by Argy, Nicolas / Epner, Paul L. / Lippi, Giuseppe / Singhal, Geeta / McDonald, Kathryn / Singh, Hardeep / Newman-Toker, David

Editorial Board: Basso , Daniela / Crock, Carmel / Croskerry, Pat / Dhaliwal, Gurpreet / Ely, John / Giannitsis, Evangelos / Katus, Hugo A. / Laposata, Michael / Lyratzopoulos, Yoryos / Maude, Jason / Sittig, Dean F. / Sonntag, Oswald / Zwaan, Laura

CiteScore 2018: 0.69

SCImago Journal Rank (SJR) 2018: 0.359
Source Normalized Impact per Paper (SNIP) 2018: 0.424

See all formats and pricing
More options …

Routine coagulation testing in Vacutainer® Citrate Plus tubes filled at minimum or optimal volume

Fiamma Balboni / Stefania Barbui / Marco Gallo / Margherita Berardi / Marco Vezzosi / Giuseppe Lippi
  • Corresponding author
  • Section of Clinical Biochemistry, University Hospital of Verona, Piazzale LA Scuro, 37134 Verona, Italy
  • Email
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
Published Online: 2019-08-17 | DOI: https://doi.org/10.1515/dx-2019-0052



Filling of citrate tubes with appropriate amount of blood is essential for obtaining reliable results of coagulation testing. This study aimed to verify whether results of routine coagulation tests are comparable when the new Becton Dickinson Vacutainer® Citrate Plus tubes are filled at minimum or optimal volume.


The study population consisted of 133 patients (40 on oral anticoagulant therapy), who had blood collected for routine coagulation testing. Two sequential Vacutainer® Citrate Plus tubes of the same type and lot were drawn. The first tube was collected after a butterfly needle was inserted into the vein, so that the air in the tubing was aspirated into the tube before blood (minimum fill volume), whilst the second was drawn at optimal fill volume. Experiments were repeated using 2.7-mL (n = 86) and 1.8-mL (n = 47) tubes.


Prothrombin time (PT) and fibrinogen values were slightly but significantly decreased in tubes with minimum than in those with optimal fill volume. The activated partial thromboplastin time (APTT) was slightly prolonged in tubes with minimum than in those with optimal fill volume, but the difference was not statistically significant. An identical trend was noted in separate analyses for the 2.7-mL and 1.8-mL tubes. Spearman’s correlations between the two fill volumes were always >0.94 and bias was always within the quality specifications.


Blood drawing into Vacutainer® Citrate Plus tubes at minimum fill volume does not clinically bias routine coagulation testing.

Keywords: anticoagulant; blood tubes; coagulation; hemostasis


  • 1.

    Sciacovelli L, Lippi G, Sumarac Z, West J, Garcia Del Pino Castro I, Furtado Vieira K, et al. Quality Indicators in Laboratory Medicine: the status of the progress of IFCC Working Group “Laboratory Errors and Patient Safety” project. Clin Chem Lab Med 2017;55:348–57.Web of ScienceGoogle Scholar

  • 2.

    Lippi G, von Meyer A, Cadamuro J, Simundic AM. Blood sample quality. Diagnosis (Berl) 2019;6:25–31.PubMedGoogle Scholar

  • 3.

    Lippi G, Adcock D, Favaloro EJ. Understanding the “philosophy” of laboratory hemostasis. Diagnosis (Berl) 2018. doi: 10.1515/dx-2018-0099 [Epub ahead of print].Google Scholar

  • 4.

    Favaloro EJ, Lippi G. Recent advances in mainstream hemostasis diagnostics and coagulation testing. Semin Thromb Hemost 2019;45:228–46.PubMedWeb of ScienceCrossrefGoogle Scholar

  • 5.

    Preston FE, Lippi G, Favaloro EJ, Jayandharan GR, Edison ES, Srivastava A. Quality issues in laboratory haemostasis. Haemophilia 2010;16(Suppl 5):93–9.CrossrefPubMedWeb of ScienceGoogle Scholar

  • 6.

    Favaloro EJ, Funk-Adcock DM, Lippi G. Pre-analytical variables in coagulation testing associated with diagnostic errors in hemostasis. Lab Med 2012;43:1–10.Google Scholar

  • 7.

    Marlar RA, Rollins-Raval MA. Sources and solutions for spurious test results in coagulation. Int J Lab Hematol 2019;41(Suppl 1):162–9.Web of ScienceCrossrefPubMedGoogle Scholar

  • 8.

    Lippi G, Favaloro EJ. Preanalytical issues in hemostasis and thrombosis testing. Methods Mol Biol 2017;1646:29–42.CrossrefPubMedGoogle Scholar

  • 9.

    Adcock DM, Kressin DC, Marlar RA. Minimum specimen volume requirements for routine coagulation testing: dependence on citrate concentration. Am J Clin Pathol 1998;109:595–9.PubMedCrossrefGoogle Scholar

  • 10.

    Reneke J, Etzell J, Leslie S, Ng VL, Gottfried EL. Prolonged prothrombin time and activated partial thromboplastin time due to underfilled specimen tubes with 109 mmol/L (3.2%) citrate anticoagulant. Am J Clin Pathol 1998;109:754–7.PubMedCrossrefGoogle Scholar

  • 11.

    Chuang J, Sadler MA, Witt DM. Impact of evacuated collection tube fill volume and mixing on routine coagulation testing using 2.5-ml (pediatric) tubes. Chest 2004;126:1262–6.CrossrefPubMedGoogle Scholar

  • 12.

    Ver Elst K, Vermeiren S, Schouwers S, Callebaut V, Thomson W, Weekx S. Validation of the minimal citrate tube fill volume for routine coagulation tests on ACL TOP 500 CTS®. Int J Lab Hematol 2013;35:614–9.PubMedCrossrefWeb of ScienceGoogle Scholar

  • 13.

    Adcock DM, Hoefner DM, Kottke-Marchant K, Marlar RA, Szamosi DI, Warunek DJ. Collection, transport, and processing of blood specimens for testing plasma-based coagulation assays and molecular hemostasis assays: approved guideline – fifth edition; CLSI document H21-A5. Wayne, PA: Clinical Laboratory Standards Institute, 2008.Google Scholar

  • 14.

    Lippi G, Salvagno GL, Montagnana M, Lima-Oliveira G, Guidi GC, Favaloro EJ. Quality standards for sample collection in coagulation testing. Semin Thromb Hemost 2012;38:565–75.CrossrefPubMedWeb of ScienceGoogle Scholar

  • 15.

    Favaloro EJ, Lippi G, Adcock DM. Preanalytical and postanalytical variables: the leading causes of diagnostic error in hemostasis? Semin Thromb Hemost 2008;34:612–34.PubMedWeb of ScienceCrossrefGoogle Scholar

  • 16.

    Lippi G, Salvagno GL, Radišić Biljak V, Kralj AK, Kuktić I, Gelati M, et al. Filling accuracy and imprecision of commercial evacuated sodium citrate coagulation tubes. Scand J Clin Lab Invest 2019;79:276–9.CrossrefPubMedWeb of ScienceGoogle Scholar

  • 17.

    Lippi G, Cornes MP, Grankvist K, Nybo M, Simundic AM. EFLM WG-Preanalytical phase opinion paper: local validation of blood collection tubes in clinical laboratories. Clin Chem Lab Med 2016;54:755–60.PubMedWeb of ScienceGoogle Scholar

  • 18.

    Milos M, Herak D, Kuric L, Horvat I, Zadro R. Evaluation and performance characteristics of the coagulation system: ACL TOP analyzer – HemosIL reagents. Int J Lab Hematol 2009;31:26–35.PubMedWeb of ScienceCrossrefGoogle Scholar

  • 19.

    Ricos C, Alvarez V, Cava F, Garcia-Lario JV, Hernandez A, Jimenez CV, et al. Current databases on biologic variation: pros, cons and progress. Scand J Clin Lab Invest 1999;59:491–500.CrossrefGoogle Scholar

  • 20.

    Falay M, Senes M, Korkmaz S, Turhan T, Okay M, Öztürk BA, et al. Biological variation estimates of prothrombin time, activated partial thromboplastin time, and fibrinogen in 28 healthy individuals. Int J Lab Hematol 2018;40:721–5.CrossrefWeb of SciencePubMedGoogle Scholar

  • 21.

    Simundic AM, Bölenius K, Cadamuro J, Church S, Cornes MP, van Dongen-Lases EC, et al. Joint EFLM-COLABIOCLI Recommendation for venous blood sampling. Clin Chem Lab Med 2018;56:2015–38.CrossrefPubMedWeb of ScienceGoogle Scholar

  • 22.

    Seligsohn U, Zivelin A, Bar-Shani S. Cold-promoted activation of factor VII: is it a problem under blood bank conditions? Haemostasis 1983;13:186–91.PubMedGoogle Scholar

  • 23.

    Raijmakers MT, Menting CH, Vader HL, van der Graaf F. Collection of blood specimens by venipuncture for plasma-based coagulation assays: necessity of a discard tube. Am J Clin Pathol 2010;133:331–5.CrossrefPubMedWeb of ScienceGoogle Scholar

  • 24.

    Lippi G, Funk DM, Favaloro EJ. Discard tube for coagulation testing: the debate continues. Blood Coagul Fibrinolysis 2012;23:572–3.CrossrefPubMedWeb of ScienceGoogle Scholar

About the article

Corresponding author: Prof. Giuseppe Lippi, Section of Clinical Biochemistry, University Hospital of Verona, Piazzale LA Scuro, 37134 Verona, Italy

Received: 2019-07-04

Accepted: 2019-07-31

Published Online: 2019-08-17

Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

Research funding: None declared.

Employment or leadership: None declared.

Honorarium: None declared.

Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.

Citation Information: Diagnosis, 20190052, ISSN (Online) 2194-802X, ISSN (Print) 2194-8011, DOI: https://doi.org/10.1515/dx-2019-0052.

Export Citation

©2019 Walter de Gruyter GmbH, Berlin/Boston.Get Permission

Comments (0)

Please log in or register to comment.
Log in