| Discussion A phlebotomist should never use an arm with restricted usage for the venipuncture. Even if no sign is posted, the patient may tell you not to use a particular arm for various reasons, i.e. previous mastectomy, history of phlebitis, active AV fistula, etc. Do not draw blood above an IV line. If blood is taken from a vein above an IV line it might be diluted by the IV fluid, which could cause incorrect test results. In this case, Bobby should choose a vein on the dorsum of Mrs. Grayson’s hand, below the IV. A butterfly needle would facilitate drawing blood from these small hand veins.Relevant topics:Alternate sites, Sites to avoid, Signs, Arms to avoid
| View Page |
| Discussion Hemolysis can easily be caused by improper phlebotomy techniques. Hemolysis occurs when RBCs are broken up and hemoglobin is released into the plasma, causing it to become pink rather than its natural straw color. Hemolysis can occur by using too small a needle, pulling a syringe plunger too rapidly, expelling blood vigorously into a tube, or shaking a tube of blood too hard. Hemolysis can cause falsely increased potassium, magnesium, iron, and ammonia levels, and other aberrant lab results.In this case, Marcie did not properly wipe the site with gauze after cleaning it with alcohol, and alcohol contacting the blood could have caused RBCs to break up or hemolyze. Marcie also squeezed the baby’s foot too hard, causing hemolysis.Relevant topics:Site selection and preparation, Heelstick: Puncture, Hemolysis, Causes of hemolysis | View Page |
| Case Julie Smith, a newly certified phlebotomist at Northlake Hospital, entered a patient’s room on the third floor for a routine blood draw. The patient was an elderly woman who had very small fragile veins. Julie therefore decided to use a safety butterfly needle attached to a Vacutainer tube in order to draw the blood. When Julie was finished with the venipuncture, she detached the butterfly needle from the Vacutainer, and approached the Biohazard needle disposal box. She noticed that the disposal box was full , but decided to try to fit the butterfly into the box anyway. Holding the butterfly by the tubing, she tried to push the butterfly into the box. The needle suddenly recoiled and stuck Julie’s finger. Julie left the patient’s room in a panic and headed back to the lab to report the needle stick injury. | View Page |
| What should Julie have done to prevent the needle stick? | View Page |
| Discussion All biohazard needle disposal containers are marked with a “full” line at about ¾ of the box’s volume. Therefore, needles should never be sticking out of the top of the container. Julie should never have attempted to put the needle into an overly full container. The needlestick safety and prevention act requires the use of butterflies with built in safety devices. However, they are only effective if properly activated. When disposing of a butterfly needle, hold its “wings” with one hand, and the hub at the opposite end of the tubing with your other hand to prevent the needle from recoiling. Butterflies should be used with extra caution since they are the number one cause of needle stick injuries.Relevant topics:Needle disposal, Sharps disposal containers, Butterfly needles with safety 1, Butterfly needles with safety 2, Needle-stick injuries, Built-in safety features, Angel Wing™ safety butterfly, Punctur-Guard™ safety butterfly | View Page |
| Discussion Insufficient blood volume may cause erroneous test results, and specimen rejection. When blood flow stops, it can mean several things:The bevel of the needle may be pressed against the wall of the blood vessel. If this is the case, moving the needle slightly may cause blood to begin flowing again.The vein may have collapsed due to the vacuum of the tube. If moving the needle slightly does not re-establish blood flow, you will have to recollect the patient.The needle may have gone all the way through the vein. Pulling the needle back slightly may cause blood to resume flowing.
The tube you are using may have insufficient vacuum. Try another tube. Never vigorously probe the patient’s arm with a needle. At the first sign of discomfort the needle should be withdrawn. The patient may then be redrawn be yourself or another phlebotomist.Relevant topics: Insufficient volume, Partial collection tubes, What if no blood flows | View Page |
| What could the phlebotomist do at this point to renew blood flow? | View Page |
| Butterfly needles with built-in safety features continued Two examples of butterfly needles with built-in safety devices are shown.The Punctur-Guard™ (Bioplexus), shown above, uses an internal blunt needle which is activated after blood is drawn. The activated device showing the blunt internal needle is shown in the inset on the upper right.
The Angel Wing ™ (Monoject), is activated by sliding a safety shield over the needle after venipuncture.
| View Page |
| Needle holders with built-in protection devices You will be required to use appropriate safety devices with your needle holder. Various options are available.
The Needle-Pro™ Needle protection device (Sims Portex) shown here is an example of a needle holder with a built-in safety device.
It is activated after venipuncture by pressing the orange protection device against any flat surface so as to engage the sheath firmly on the needle.
| View Page |
| Syringes Syringes consists of:A barrel, which holds the blood.
A plunger that allows suction to be appliedA tip to which the needle is connected.Syringes have ml (cc) markings to show how much blood has been collected.
| View Page |
| Multiple draw needles Multiple draw needles are used with vacuum collection tubes.They allow the collection of blood into multiple vacuum collection tubes during a single venipuncture.
They have a retractable sheath over the portion of the needle that penetrates the blood tube.
| View Page |
| Multiple draw needles with built-in safety features. You will be required to use multiple draw needles with built-in Safety features.
One example is the Puncture-Guard™ (BioPlexus) needle, which uses an internal blunt needle (detail above) that is activated with forward pressure on the final blood tube prior to withdrawal of the needle from the vein.
Refer to your institution’s and the manufacturer’s procedure manuals before using these devices.
| View Page |
| Needle holders, built-in protection devices contd When the orange safety sheath is engaged, as shown on the right, it protects the user from needlestick injury, until the device is properly disposed of in an approved sharps container.
Refer to the manufacturer’s instructions, and your procedure manual for detailed instructions prior to use. | View Page |
| Syringes with built-in safety devices contd. After use, a safety shield is slid over the needle, and locked into place.
The safety syringe with the shield locked in place is shown here. | View Page |
| Needles Needles come in many sizes.
The size of the needle is called the gauge.
The larger the needle, the smaller the gauge number.
For most routine venipunctures, a 21 or 22 gauge needle is used.
| View Page |
| Needle components The tip of the needle consists of a:
A very sharp tip for puncture.A bevel which allows for blood flow.
A barrel which allows for blood flow.
| View Page |
| Needles with built-in safety devices You will be using needles and/or needle holders with built-in safety devices.
Various such needles are on the market.
Remember that you must still activate the safety device to get the protection offered.
So careful attention to what you are doing is still one of the best ways to protect yourself against needlestick injury.
| View Page |
| Butterflies with built-in safety features You will be using butterfly needles with built in safety features.
Butterfly needles are the number-one cause of needlestick injuries, so proper use of their safety devices is critical.
Their use is described in greater detail in the section on butterfly needle blood collection.
| View Page |
| Plastic holders used with the evacuated tube system A plastic holder must be used with the evacuated tube system.
The needle screws into the holder to allow blood collection.
| View Page |
| Remove needle Removing the needle:Gently release the tourniquet before the last tube of blood is filled.Remove the last tube from the needle.Withdraw the needle in a single quick movement. | View Page |
| Routine Venipuncture equipment continued Basic equipment includes: Alcohol swab, Bandage, Tube(s), Needle, Needle holderDo not remove the needle cover until you are ready to perform the venipuncture. | View Page |
| Multiple tube collections If you are drawing more than one tube:Keep a firm grip in the needle holder while pressing down on the patients arm.Use your other arm to interchange tubes. | View Page |
| Needle disposal Remove the needle from the holder if appropriate, and properly discard it in an approved sharps disposal container.Discard all waste and gloves in a red biohazardous waste container.
Wash hands.
| View Page |
| Alternate Sites If no veins are accessible on the arm, you may try the veins on the back of the hand.Use a much smaller needle for these hand veins. | View Page |
| Attach needle to holder Attach the needle to the needle holder. | View Page |
| Place tube into holder Place the first tube into the needle holder. | View Page |
| Insert needle With the needle bevel up, insert the needle into the vein. | View Page |
| Push tube onto holder Gently push the tube onto the needle holder so that the catheter inside the needle holder penetrates the tube.Blood flow should be visible at this point. | View Page |
| Adjust needle Advance or withdraw the needle slightly, if necessary, to establish the flow of blood. | View Page |
| Butterfly needle - Butterfly needle collections Butterfly needles (also known as a winged infusion set), are available in smaller gauges, and are used to draw venous blood from children, and adults with difficult veins.
| View Page |
| Butterfly needle - Angel WingTM safety butterfly The Angel Wing™ (Monoject), is activated by sliding a stainless steel safety shield over the needle after withdrawal from the vein.The Angel Wing™ (Monoject), is activated by sliding a stainless steel safety shield over the needle after withdrawal from the vein. | View Page |
| Butterfly needle - Butterfly needles with built-in safety features You will be using butterfly needles with built-in safety device. The safety device must be activated upon completion of the blood collection.You will be using butterfly needles with built-in safety device. The safety device must be activated upon completion of the blood collection.The Angel Wing™ (Monoject) safety butterfly is shown here.
| View Page |
| Syringe - Transferring blood to collection tubes After collecting the blood specimen into a syringe, properly activate the appropriate safety device, and dispose of the needle in a sharps container.Attach the syringe to a blood transfer device by twisting the needle tip into the hub of the device.Push a vacuum blood collection tube into the holder of the transfer device, and let the tube fill to the appropriate level.
| View Page |
| Butterfly needle - Butterfly needle collections continued Butterfly needles come attached to a small tube which may be connected to:An evacuated tube holder, orA syringe. | View Page |
| Butterfly needle - Butterfly needles and needle-stick injuries Butterfly needles, because of their flexibility, are the number one cause of needle-stick injuries among phlebotomists.Use extra caution when using butterfly needles. | View Page |
| Butterfly needle - Punctur-GuardTM safety butterfly Another type of safety butterfly needle is shown to the right.The Punctur-Guard™ (Bioplexus) uses an internal blunt needle (arrow) that is activated by manually locking a small lever on the butterfly.
Please refer to your facility’s and the manufacturer’s procedure manuals for detailed instructions.
| View Page |
| Collection methods Blood for culture can be collected in several ways:Standard needle attached to a syringe.Butterfly needle attached to a syringe.Blood culture bottle attached directly to tube holder (not generally recommended).Follow you own facilities’ procedure for blood culture collection. | View Page |
| Activate needle safety device After collecting the blood, activate the needle safety device according to manufacturer’s instructions, and place it in a sharps disposal container.
If blood was collected into a syringe, insert the syringe tip into the hub of a blood transfer device, and rotate the syringe clockwise to secure it to the device.
Push the blood culture bottle into the holder of the transfer device, and draw the appropriate volume of blood into the blood culture bottles. | View Page |
| Hematosis A hematoma is a blood clot which forms within the body. It is caused by leakage of blood into the tissues from an injured vein . It will resolve spontaneously.Hematomas are caused by excessive needle trauma to a vein, for example, by a needle which passed entirely through a vein and came out the other side.Apply compression to help stabilize a hematoma.
| View Page |
| Fainting continued If a patient faints during venipuncture: Gently remove the tourniquet and needle from the patients arm, apply gauze and pressure to the skin puncture site.
Call for help. If the patient is seated, place his head between his knees. A cold compress on the back of the neck or ammonium salts may help to revive the patient more quickly. | View Page |
| What if no blood flows when the needle is in place? The needle may not be in a vein. Try slightly manipulating the needle. If no blood flows, withdraw the needle and repeat the venipuncture. Never probe the patient’s arm with the needle. The bevel of the needle may be compressed against the inside of the vein wall. Slightly manipulating the needle should result in blood flow.
The needle may have passed entirely through the vein. Pull it back slightly, and blood should flow. | View Page |
| Insufficient volume Insufficient blood volume (short draws) within a collection tube containing anticoagulant will result in an incorrect ratio of blood to anticoagulant, and yield incorrect test results.Short draws can be caused by: A vein collapsing during phlebotomy.The needle coming out of the vein before the collection tube is full.Loss of collection tube vacuum before the tube is full. (Always keep extra tubes on hand.) | View Page |
| Causes of hemolysis Hemolysis can be caused by: Shaking the tube too hard.Using a needle that is too small.Pulling back too hard on a syringe plunger.Pushing on a syringe plunger too hard when expelling blood into a collection device.
| View Page |
| What are bloodborne pathogens? Bloodborne pathogens are infectious micro-organisms which live in the bloodstream.You can be exposed to bloodborne pathogens if you are injured with a contaminated needle.You can also be exposed if your mucous membranes, including eyes, mouth, or the inside of your nose come into contact with contaminated body fluids.
| View Page |
| Needlestick safety and prevention act continued There are many different types of needle safety devices on the market.
As you go through this program, we will introduce you to some of them | View Page |