Potential problems associated with venipuncture

Issues associated with venipuncture include bruising, fainting, and potential tissue injury. Additionally, failure to obtain an adequate specimen can lead to the need to redraw a patient. Remaining calm helps you think clearly about the situation. Determining the cause of the problem will help you decide whether a second attempt is warranted. Knowing how and when to respond to adverse events during the venipuncture procedure is essential for patient safety and specimen integrity.

Hematoma

A hematoma is a large, painful, bruised area at the puncture site caused by blood leaking into the tissue, which causes the tissue around the puncture site to swell. The most common causes of hematoma formation during the draw are excessive probing with the needle to locate a vein, failure to insert the needle far enough into the vein, and passing the needle through the vein. A hematoma can also form after a draw if the tourniquet is not removed before removing the needle, if the vacuum tube is not removed from the hub of the needle before the needle is withdrawn, if adequate pressure is not applied at the puncture site, or if the elbow is bent while pressure is applied. If a hematoma forms, discontinue the procedure STAT, apply pressure to the area for a minimum of 3 minutes, and then apply an ice pack to the area. Notify the provider and observe the site to determine whether the bleeding has stopped. Depending on the facility’s policy, an incident report may have to be completed and documented in the patient’s record. A hematoma may also occur if the puncture reopens and bleeds into the tissue due to heavy lifting with the venipuncture arm. Instruct the patient to be careful with the arm for several hours after the procedure.

Nerve damage and other complications

Nerve damage can be a consequence of venipuncture, but the risk is very small. Preventive measures include the following:

• Avoiding the basilic vein for phlebotomy
• Refraining from blind probing (moving the needle in the arm with the hope of finding a vein) if the vein is missed with the initial draw

As a rule, it is wise to limit yourself to two venipuncture attempts for a patient. If a second attempt is unsuccessful, ask whether the patient would allow another phlebotomist to look at his or her arms. If another phlebotomist feels confident to attempt a venipuncture, that person will need to get permission from the patient first. If the patient does not give permission, it may be better to reschedule the venipuncture for another time. This strategy lets patients know that they have input into their care and some measure of control of the situation. At one time or another, everyone is unsuccessful in obtaining a blood sample, so do not have bad feelings about it. Make the best of the situation, learn from the experience, and treat the patient with kindness. We are all human, and our patients are usually quite understanding.

Managing possible blood complications

Complication	Management strategies
Burned area	Choose another site because these areas are prone to infection.
Convulsions	Stay calm. Remove the needle and quickly dispose of it in a sharps container. Then help guide the patient to the floor, protecting him or her from injury. Call for help.
Damaged or scarred veins or infected areas	Look for an alternative site; do not draw blood from scarred or infected areas.
Edema	Avoid the area; look for an alternative site.
Intravenous (IV) therapy or blood transfusion sites	Blood samples should not be drawn from an arm that is also the site for IV infusion or blood transfusion because of the dilution factor.
Mastectomy	Do not draw blood from the side of the mastectomy, because mastectomy surgery causes lymphostasis, which may produce false results.
Nausea	Place a cold cloth on the patient’s forehead, give the patient a basin in case of vomiting, and instruct him or her to take deep breaths. Alert the provider.
No blood	Manipulate the needle slightly or remove the vacuum tube, and perform the blood draw again using a syringe or butterfly setup.
Petechiae	Loosen the tourniquet because this complication usually results from the tourniquet being in place longer than 2 minutes.

Fainting

Fainting, or syncope, can have serious consequences, so the phlebotomist must always be prepared to act quickly. Positioning the patient in a blood collection chair (by turning the armrest pad in front of the patient) prevents bodily injury if the person faints. Making eye contact and observing the patient before phlebotomy can help you estimate his or her level of comfort with the procedure. Constant light conversation with the patient during the venipuncture can help identify if the patient is distressed or anxious. As you finish the venipuncture, observe the patient’s face, and assess the breathing rate if the patient seems anxious. Safety comes first. Make sure patients are not in a position in which they can be hurt.

According to CLSI, the procedure for a fainting patient or one who is nonresponsive is as follows:

• If the patient begins to faint, quickly remove the tourniquet and needle from the arm, immediately activate the needle safety device, apply pressure to the site, and dispose of the unit in a sharps container to prevent an accidental exposure.
• Notify staff members for assistance.
• Lay the patient flat or lower the head if the patient is sitting.
• Loosen tight clothing.
• Do not use ammonia inhalants/capsules because these are associated with adverse effects and are no longer recommended.
• Apply a cold compress or washcloth to the patient’s forehead and back of the neck.
• Monitor the patient’s pulse, blood pressure, and respiration rate.
• Stay with the patient until recovery is complete.
• Document the incident according to facility policies.
• When the patient regains consciousness, they must remain in the facility for at least 15 minutes and should not operate a vehicle for at least 30 minutes.

Some patients have a history of fainting with venipunctures. Fainting can be related to several conditions, including vasovagal syncope and postural orthostatic tachycardia syndrome (POTS). If a patient warns you that they might faint, anticipate that the patient will faint and take precautions before starting the procedure. Do not minimize what the patient states by telling the patient to “just relax.” Listen to your patient.

Specimen re-collection

Sometimes problems with a sample cannot be determined until the specimen is analyzed in the laboratory. Rejected specimens must be re-collected. The laboratory may reject a specimen for reasons that include the following:

• Unlabeled or mislabeled specimen
• Quantity not sufficient (QNS), which means there is an insufficient quantity of specimen for the test
• Defective tube
• Incorrect tube used for the test ordered (incorrect stopper color)
• Hemolysis (destruction of red blood cells)
• Clotted blood in an anticoagulated specimen
• Improper handling

Hemolysis is the major cause of specimen rejection. It cannot be detected until the blood cells are separated from the plasma or serum. It is crucial to take steps to prevent red blood cell damage during collection. Hemolyzed serum or plasma appears rosy to bright red because of the release of hemoglobin from the cells. Some routine tests adversely affected by hemolysis are chemistry tests for electrolytes (e.g., potassium, sodium), bilirubin, total protein, and liver enzymes.

Pediatric phlebotomy

Obtaining blood from children and infants may be difficult and potentially hazardous. The procedure should be performed by personnel trained in pediatric phlebotomy. Successfully obtaining blood from children requires skill and an understanding of children and their development. Good communication skills are essential when dealing with children. The phlebotomist must gain the child’s trust and often that of the parent or guardian. Parents frequently ask the phlebotomist to explain the tests being done and the reasons for testing. Be respectful when talking to parents. Defer to the provider if questions come up about specific information regarding possible diseases or conditions the child may have.

Role of the parent or guardian

A parent or guardian may be helpful during phlebotomy. Ask the parent or guardian about the child’s previous phlebotomy experiences and how cooperative the child has been in the past. Respectfully determine whether the parent or guardian seems comfortable assisting in restraining an uncooperative child. Parental behavior greatly influences the child’s behavior during the procedure. Children should never be restrained in a way that might cause physical injury or pain. If the parent or guardian is unable or unwilling to assist with the procedure, always refer to the office or laboratory policy on procedural holds for phlebotomy.

Pediatric concerns

Learning Objective: Describe the concerns for performing phlebotomy on a pediatric patient.

Removing large amounts of blood, especially from premature infants, may result in anemia. The amount of blood withdrawn must be recorded in the child’s chart. Puncturing deep veins in children may result in serious complications, such as cardiac arrest, hemorrhage, venous thrombosis, damage to surrounding tissues, and infection.

In addition, the child could be harmed during restraint. To prevent these problems, blood should be collected only by dermal puncture from children younger than age 2 unless the procedure warrants venous collection (lead levels or blood culture). Venipuncture on children younger than age 2 should be performed only on surface veins, including the dorsal hand vein, using a 23-gauge winged infusion set coupled to a syringe or a pediatric vacuum tube collection set.

General guidelines for pediatric venipuncture

Weight (LB)	Single Draw Limit
8–10	3.5mL
11–15	5mL
16–40	10mL
41–60	20mL
61–65	25mL
66–80	30mL

Tips for pediatric phlebotomy

When required to perform pediatric phlebotomy, the medical assistant should remember to do the following:

• Wear a colorful, fluid-impermeable jacket lab coat, if possible.
• Be truthful about the discomfort the child will feel.
• Provide tokens and praise for bravery.
• Try to lessen the child’s fears.

Topical anesthetics (e.g., ethyl chloride [EC] spray or EMLA cream) may be used to reduce pain at the puncture site. In most cases, a calm, professional phlebotomist who understands children and relates to them on their level can gain the trust needed. Work to perform a successful venipuncture or capillary puncture with minimal restraint and frustration.