Needle Information and Courses from MediaLab, Inc.

The sites used to obtain bone marrow samples are:illiac crest (posterior, anterior)sternumspinal processestibia - (infants and newborns)The illiac crest is the most common site for bone marrow collection. Sternal aspiration can have serious or even fatal consequences if the needle penetrates the heart.

The virus is spread when body fluids from an individual with the Hepatitis B virus are introduced into the body of a susceptible person.This contact may occur during introduction of blood or potentially infectious body fluid: Through an opening or sore in the skin. Via a puncture with a contaminated sharp such as a needle. Through direct contact with mucous membranes that line the insides of the mouth, nose, eyes, and the genital organs. HBV is not spread through casual contact, such as handshake, or through sweat.

HIV is spread in the community just like HBV. Sexual contact Via a puncture with a contaminated sharp such as a needle. Through direct contact with mucous membranes that line the insides of the mouth, nose, eyes, and the genital organs. From a mother to her child

Most hospitals use some form of needle/holder combination that incorporates a needle safety device. This device has a mechanism that will cover the needle after use. It must be activated as soon as the task is completed. The device that is pictured here is just one of many options that are currently available. There are also needleless systems that use special adaptors which attach to some intravenous lines that will permit blood to be obtained without the use of needles.

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

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.

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

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.

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.

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.

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.

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.

A plastic holder must be used with the evacuated tube system. The needle screws into the holder to allow blood collection.

Basic equipment includes: Alcohol swab, Bandage, Tube(s), Needle, Needle holderDo not remove the needle cover until you are ready to perform the venipuncture.

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.

Attach the needle to the needle holder.

With the needle bevel up, insert the needle into the vein.

Advance or withdraw the needle slightly, if necessary, to establish the flow of blood.

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.

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.

Butterfly needles, because of their flexibility, are the number one cause of needle-stick injuries among phlebotomists.Use extra caution when using butterfly needles.

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.

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.

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.

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.

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

Fill blood collection tubes completely (until vacuum is exhausted) to ensure the correct blood to anticoagulant ratio necessary for accurate patient results. Specimens may be rejected by the laboratory if the tube is short-filled or over-filled. To avoid short-filling of tubes, the phlebotomist must ensure that the blood flow stops completely before removing the tube from the needle. When using a winged device (butterfly) to collect blood for coagulation studies (e.g., protime, aPTT), the phlebotomist must draw a light blue top "waste" tube before attaching another light blue top tube for testing. If the air in the tubing of the winged device is not displaced into a waste tube and is drawn into the tube used for testing, the tube used for testing will short-fill. The laboratory may reject the specimen because of invalid blood to anticoagulant ratio.

Needles that are used for venipuncture are available in a variety of lengths and diameters. The diameter of the needle is referred to as the needle gauge; the larger the diameter of the needle, the smaller the gauge number. The image on this page illustrates the relative gauges of needles that are available for venipuncture. Needles that are routinely used for venipuncture are available in 3/4 inch, 1 inch and 1 1/2 inch lengths. The phlebotomist determines the gauge and length of the needle to use for a venipuncture after assessing the vein.

The phlebotomist has a choice of several blood collection systems. Three that are commonly used are discussed on the following pages. Evacuated Tube SystemThe primary choice for a routine venipuncture that will be performed on an adult or an older child is a blood collection system that consists of a holder (or adapter), a needle that is pointed on both ends, and evacuated blood collection tubes. One end of the needle will pierce the vein and the other end will pierce the stopper of the evacuated tube so that blood will flow into the tube to fill the vacuum. A safety device is required on either the holder or the needle to comply with current standards for needle safety. Two examples of needle holders equipped with safety devices are shown on this page.

The winged device is another popular choice for the phlebotomist. This may be chosen for pediatric venipuncture, small delicate veins on adults (particularly geriatric patients), or hand veins. The device can be used with a needle holder and evacuated tube or a syringe. A needle safety device is incorporated into the design of the winged device to prevent needlestick injury.

A tourniquet is used by the phlebotomist to assess and determine the location of a suitable vein for venipuncture. Single-use, latex-free tourniquets are preferred but reusable tourniquets are acceptable. However, if the reusable tourniquet becomes contaminated with blood or body fluid, it must be discarded immediately to avoid the spread of harmful contaminants to other patients. Follow the guidelines established by your facility for cleaning reusable tourniquets.Proper application of a tourniquet will partially impede venous blood flow back toward the heart and cause the blood to temporarily pool in the vein so the vein is more prominent and the blood is more easily obtained. The tourniquet is applied three to four inches above the needle insertion point and should remain in place no longer than one minute to prevent hemoconcentration. If the tourniquet is used during preliminary vein selection, it is best to release the tourniquet after assessing the vein and while you are assembling your supplies. Reapply the tourniquet just before starting the venipuncture; it should then be released soon after the needle has been inserted into the vein and the blood flows into the first tube. If collecting multiple tubes, the tourniquet may remain in place until blood enters the last tube.

Equipment: To successfully enter a hand vein, the phlebotomist must choose equipment that will allow needle entry at a very small angle. A winged device with a small gauged needle of 3/4 inch length is most often used to obtain blood from a hand vein. A syringe is usually attached to the end of the tubing of this device. By using a syringe, the phlebotomist can control the amount of pressure on the vein and avoid vein collapse. Evacuated tubes may collapse a vein by exerting too much pressure on the delicate vein. If available, smaller tubes containing less vacuum may be used.Insertion angle: The angle at which the needle is inserted into a hand vein is smaller compared to the angle of needle insertion into veins of the antecubital area. When drawing from a hand, the needle should be inserted into the vein at approximately a 15 degree angle to allow easier access of the surface hand veins. By inserting the needle at this angle, the risk of the needle going "through" the vein and puncturing the bony structures underneath are reduced.

Required Step Description Step #1 Wash your hands. Clean your hands with soap and water or gel cleanser. Step #2 Positively identify patient using unique identifiers. Ask the patient to state his/her first and last name; if the patient is unable to give you this information, ask the patient's caregiver to confirm the patient's name. A second unique identifier must also be used. Step #3 Special test requirements Determine if the test to be obtained has any special requirements. For example, should the patient be fasting? Is this a timed test? If any requirements are not met, consult with the caregiver to determine a course of action. Step #4 Prepare the patient Explain the procedure to the patient and obtain cooperation. Usually the patient will extend an arm. (This is a form of implied consent.) Position the arm for venipuncture; support the arm on a firm surface; the arm should be in a downward position. Step #5 Site determination The patient can make a fist, but should not pump the hand open and closed. Apply tourniquet Palpate the vein. Release the tourniquet and assemble appropriate equipment. Step #6 Aseptic technique Wear gloves that have not been altered in any way. Cleanse site with approved disinfectant. Allow the disinfectant to air-dry to avoid hemolysis of the specimen and discomfort to the patient. Step #7 Specimen collection Re-apply tourniquet about 3-4 inches above puncture site, insert needle, bevel-side up, at about a 30° angle, and collect specimens. Remove needle and immediately activate the safety device. Mix specimens by gentle inversion 5-10 times. Step #8 Patient care Apply direct pressure to stop bleeding at puncture site; do not have patient bend arm as this may cause a hematoma to form. After about 2 minutes, check the puncture site to verify that bleeding has stopped. Apply bandage if appropriate. Thank the patient for his/her cooperation. Step #9 Specimen labeling Label specimen(s) in the presence of the patient including all the information that is required by your facility. Check the labeled tubes a second time against the patient's wristband to verify labeling accuracy. A professional phlebotomist follows the procedure in the same way for every venipuncture. This ensures that none of the vital steps are omitted. The phlebotomist who is consistent in performance and who concentrates fully to obtain a quality specimen is an indispensable part of the healthcare team.

0.1 ml of purified protein derivative (PPD) is injected intradermally on the left arm.The needle tip is inserted so that the needle is visible under the first layer of skin, bevel up.The PPD is injected slowly to produce a small wheal measuring 5-6 mm in diameter.