VENIPUNCTURE MODULE 5: THE VENIPUNCTURE PROCEDURE

Transcription

1 VENIPUNCTURE MODULE 5: THE VENIPUNCTURE PROCEDURE Version date January 2008 AUTHOR: Judy C. Arbique BHSc, ART (CSMLS), MLT (CSMLS), CLS (NCA) Halifax, NS Arbique-Rendell Onsite Training & Consulting 23 Braeside Lane Halifax, NS B3M 3J6 Tel: Website: Page 1 of 29 Version: January 2008

2 5.0 Introduction 5 THE VENIPUNCTURE PROCEDURE Blood collection must be performed in a manner that will not result in harm to the patient or the phlebotomist. It should also not affect the integrity of the sample and subsequently the accuracy of test results. This module introduces participants to venipuncture using the evacuated tube system and the syringe system, using both conventional needles and winged infusion sets. Module 5 Objectives At the end of this module, the learner will be able to: 1. Explain the correct technique for hand washing. 2. Describe the appropriate steps involved in drawing blood from a vein using the evacuated system. 3. Describe the situations in which using a winged infusion device for venipuncture is appropriate. 4. Describe the appropriate steps involved in drawing blood from a vein using a winged infusion set with the evacuated system and with a syringe. Page 2 of 29 Version: January 2008

3 5.1 Confirm patient identification Ask the client to confirm his name and date of birth. Check verbal information against the information on the requisition and sample labels. In the case of inpatients, confirm verbal information with information on the patient s identification band. Figure 5-I: Client Identification 5.2 Wash hands and put on gloves Gloves must be changed and hands washed after patient contact. Gloves must be changed immediately if visibly contaminated with blood, or if torn or perforated. Gloves must not be washed or disinfected for reuse: detergents and disinfectants may cause deterioration and allow blood to penetrate through undetected holes. Wash hands thoroughly before beginning work, and each time gloves are removed between patients. Lather hands well with soap or detergent, rubbing thoroughly and rinsing well. The three-minute scrub should be used in special situations such as the nursery, burn unit, and reverse isolation. Page 3 of 29 Version: January 2008

4 Figure 5-II: Routine Hand washing Routine hand-washing: 1. Remove any jewellery, rings and watch. 2. Do not allow body or clothing to touch the sink. 3. Wet hands under warm, running water. 4. Apply soap and work up lather. Rub hands together to create friction, loosening dead skin, dirt, and debris. 5. Scrub the entire hand including between the fingers and around the knuckles and nails for at least 15 seconds. 6. Remove debris under fingernails with an orange stick or pick. 7. Rinse hands in a downward motion from wrists to fingertips. 8. Reapply soap and lather again. 9. Scrub hands thoroughly as described above. 10. Rinse hands in a downward motion from wrists to fingertips. 11. Dry hands with a clean paper towel. 12. Turn faucet off with another piece of clean paper towel. Page 4 of 29 Version: January 2008

5 Figure 5-III: Avoid Touching Faucet Controls Figure 2-IV: Put on gloves Page 5 of 29 Version: January 2008

6 5.3 Position client, select vein and apply tourniquet Refer to Venipuncture: Part 1 for techniques in positioning client, vein selection and tourniquet application. Figure 2-V: Palpate the Vein 5.4 Release the tourniquet Once a vein has been selected, release the tourniquet while cleansing the site and assembling equipment. Local stasis can occur resulting in haemoconcentration and possible haematoma formation, as blood moves into the surrounding tissue. Erroneous test results may occur for protein, packed cell volume, and other cellular elements. If the tourniquet is applied for vein selection, it should be released and reapplied after 2 minutes, just prior to actual penetration. Some phlebotomists choose not to glove until after a vein has been selected. The problem with this is that there are situations where you have no alternative but to glove prior to approaching the client (e.g. contact measures, protective isolation). Wearing gloves at all stages of phlebotomy is now accepted as standard practice. Page 6 of 29 Version: January 2008

7 Figure 5-VI: Release the Tourniquet 5.5 Cleanse the venipuncture site Cleanse the venipuncture site with alcohol prep pad or other appropriate antiseptic such as 70% isopropyl alcohol solution or 0.5% chlorhexidine-gluconate. Cleansing will not sterilize the site, but will reduce the risk of bacterial contamination of the specimen and introduction of infection to the patient via the venipuncture site. Cleanse with a circular motion, moving from the centre of the site, outward. Apply enough pressure to remove surface dirt and debris. Figure 5-VII: Cleanse the Venipuncture Site Courtesy and ARO Training & Consulting Allow site to dry: Penetration of the skin with a needle while alcohol is still wet may result in haemolysis of specimen and discomfort to patient. Allowing the site to air-dry also gives the antiseptic time to do its job killing bacteria on the skin surface. Do not wipe the site with gauze or cotton ball that is not sterile as bacteria may be reintroduced to the area and contaminate the area increasing the risk of infection. Page 7 of 29 Version: January 2008

8 5.6 Assemble equipment and supplies Some phlebotomists choose to perform this step prior to cleansing the site. If this is your practice, you must not then hurry through the cleansing procedure because you don t have time to allow the cleansed site to air-dry. Cleansing the site prior to assembling equipment and supplies makes better use of your time, and ensures that the cleansed site is given time to adequately dry before needle insertion. Check the needle to ensure that the closure seal has not been broken. If the seal is broken, discard the needle and get a new one that has an intact seal. Twist the outer cover of the needle to break the seal and pull the plastic cover from the end with the rubber sleeve. Attach this end to the small end of the needle holder and screw it securely in place. Do not use excessive force as the plastic threads that hold the needle to the holder may be damaged. Figure 5-VIII: Attach Needle to Holder Select the tubes required for testing based on the tests ordered on the test request form or requisition. Place tubes in the proper order of draw. Figure 5-IX: Blood Collection Cart Page 8 of 29 Version: January 2008

9 Place a cotton ball or gauze pad in easy reach so that you can place it on the venipuncture site when removing the needle from the vein. Place the sharps container within easy reach so that the needle assembly can be discarded immediately following removal from the vein. Follow regulations regarding the removal of the needle from the holder the Needle-stick Safety and Prevention Act of 2001 mandates that needles should not be removed from the holder prior to disposal. Canadian provinces have also begun to implement needle safety device regulations (September, 2007). Novice collectors may also choose to open a fresh alcohol pad in the event that they need to re-cleanse the gloved finger in order to re-palpate the site prior to needle insertion. 5.7 Check equipment and supplies Before beginning venipuncture, recheck tube selection and equipment to make sure that everything necessary is within easy reach, without having to cross-over the blood collection area. If you will be changing tubes with your left hand, ensure that tubes and gauze or cotton balls are on the left side of the client s arm, and that the sharps container is on the same side as the hand that you will be using to remove the needle following sample collection. Tap all tubes containing additives prior to use to ensure that the additive is not lodged against the stopper or tube wall. Check requisition for special handling instructions STAT, transport on ice, protect from light, keep warm, etc, and ensure that the necessary supplies are available prior to sample collection. 5.8 Reapply tourniquet The tourniquet should be reapplied when you are ready to perform the venipuncture. Figure 5-X: Reapply Tourniquet Page 9 of 29 Version: January 2008

10 If it is necessary to palpate again to relocate the vein, the site must be cleansed again. This is often a problem for novice collectors, and sometimes even for experienced collectors when the vein is not visible on the surface. A number of techniques can be used to mark your target. McCall and Tankersley in Phlebotomy Essentials suggest placing a freshly opened alcohol pad just below your target with the corner pointing in the direction of needle entry. Another technique is to memorize the location of the vein in relation to a hair, mole, pore or other landmark in the vicinity of the vein land marking should be performed when the vein is anchored, as this will be the location of the vein when you are ready to penetrate the vein. Alternatively, the gloved finger can be cleansed in the same manner as the venipuncture site and the vein re-palpated. This is only an option for any occasion that gloves are worn it is not an acceptable practice when gloves are not worn. 5.9 Venipuncture 1. Remove needle cap and examine the needle for defects. If the needle looks defective in any way (e.g. barb, hook, dirt, debris), discard it and replace with a new needle. Do not allow the needle to come into contact with anything prior to venipuncture. If the exposed needle touches anything, replace it with a new one before penetrating the patient s skin. Figure 5-XI: Inspect Needle for Defects 2. Hold tube/needle holder in the dominant hand; thumb on top, fingers underneath. The needle should be pointing in a direction parallel to the vein. Some phlebotomists prefer to have the first collection tube inserted in the holder during vein penetration if this is your practice, ensure that the tube is pushed onto the needle far enough to keep it from falling out of the holder: if the tube is pushed too far onto the needle, the vacuum will be released and the tube will not fill. Always have an extra tube close by, in case of faulty vacuum. Page 10 of 29 Version: January 2008

11 Figure 5-XII: Use Low Needle Angle 3. Anchor the vein during the venipuncture: place the thumb of the non-dominant hand 1 to 2 inches below the puncture site and press down on the skin, while stretching the skin of the arm toward the hand in the direction that the vein is running. Anchoring the vein will prevent it from rolling or moving to the side when the needle is inserted. The patient s elbow can also be supported with this hand to keep her from drawing her arm back as the needle is inserted. Figure 5-XIII: Anchor the Vein Some phlebotomists anchor the vein at the bottom with the thumb and at the top with the index finger (window anchor): this is not recommended as the chance of needle-stick injury is increased if the patient moves. Page 11 of 29 Version: January 2008

12 Figure 5-XIV: Two-finger or Window Anchor 4. Slide the needle under the skin, bevel up. The patient should be warned just prior to penetration so that they do not jerk from the shock of the needle entering the skin. Figure 5-XV: Insert Needle into the Vein 5. The needle should be inserted at an angle of approximately 15 degrees the needle angle is dependent on the depth of the vein; deeper veins may require a higher angle. Use the lowest needle angle possible to avoid puncturing the back wall of the vein and encouraging bleeding into underlying tissues. A needle angle of greater than 30 degrees can result in serious injury to the patient. You know you are in the vein when you feel a slight decrease in resistance. The needle should be inserted into the vein for about a centimetre to ensure that the entire bevel is in the vein to avoid bleeding into the surrounding area. 6. While holding the needle-holder steady against the client s arm using the fingers under the holder as support, push the first tube onto the needle. Tubes can be placed on the holder with the hand that was used to anchor the vein prior to puncture. Some phlebotomists change hands at this point to make use of greater flexibility of the dominant hand for changing and mixing tubes, and other tasks. Phlebotomists should choose the technique that feels most natural. If you don t have to switch hands, don t! Unnecessary additional steps introduce new opportunities for problems or errors. Do not push the needle holder forward when applying tubes as the needle could be forced Page 12 of 29 Version: January 2008

13 through the vein. When the needle is properly positioned in the vein, blood will flow into the tube when the stopper of the tube is pierced. Figure 5-XVI: Engage Tube on Back-end of Needle in Holder 7. When blood flow has been established, or within 1-minute of tourniquet application, release the tourniquet. The longer the tourniquet application, the greater chance of haemoconcentration and altered test results. Figure 5-XVII: Final Release of Tourniquet 8. Allow tubes to fill completely before removing from the holder: tubes have specific vacuum pressures to ensure a proper ratio of blood to additive. If the tube is removed before it is filled, the blood to additive ratio will not be correct and erroneous test results may occur. Do not allow tube contents to contact the stopper. Back-flow of blood from the tube into the vein may occur resulting in an adverse patient reaction. Ensuring that the client is positioned with the arm in a downward position will help ensure that the tube fills from the bottom to the top, reducing the risk of tube additives reaching the tube stopper and entering the client s vein. Page 13 of 29 Version: January 2008

14 Figure 5-XVIII: Allow Tube to Fill Completely 9. When changing tubes do not use jerky movements: gently ease tubes on and off the needle with a turning motion while bracing the thumb against the flange of the holder. Figure 2-XIX: Gently Ease Tube off the Needle 10. Gently mix tubes containing additives 8-10 times upon removal from the holder. Inadequate mixing will result in clot formation or partial clotting, which may affect test results. Do not shake tubes as this will result in haemolysis of the specimen. Page 14 of 29 Version: January 2008

15 Figure 5-XX: Invert the Tube 8-10 Times before Setting it Down Tubes should be collected in the proper order of draw for the evacuated tube method: 1. Blood culture bottles or yellow stopper SPS tube 2. Light blue stopper (sodium citrate) - coagulation studies (plasma) 3. Serum tubes - red stopper glass non-additive tube, red stopper plastic tube containing clot activator, red/grey stopper (clot activator and gel separator) 4. Green or green/grey (heparin) plasma 5. Lavender stopper (EDTA) - CBC, blood counts, differentials (whole blood) 6. Grey stopper (oxalate/fluoride) glucose (plasma) If you collect a tube out of order in error, collect a discard tube before continuing on with the next tube in the proper order of draw. 11. When the last tube has been removed from the holder and mixed, withdraw the needle and apply pressure to the site with gauze pad. If pressure is applied while removing the needle, the patient will feel some discomfort, and the needle may slit the vein or the skin upon withdrawal. Do not use alcohol prep to apply pressure this causes a stinging sensation to the patient. A cotton or rayon ball may be used to apply pressure, but the fibres tend to stick to the site, initiating bleeding when it is removed. Page 15 of 29 Version: January 2008

16 Figure 5-XXI: Remove Needle Slowly Failure to remove the tourniquet prior to removal of the needle may result in a haematoma. 12. If using a needle safety device, activate the device upon removal prior to disposal. Safety devices only work when used properly! Figure 5-XXII: Engage Safety Device Courtesy and Becton-Dickinson and Company 13. Apply pressure to the puncture site 3-5 minutes or until bleeding has totally stopped. If pressure is released too soon, bleeding may occur into the surrounding tissue resulting in a bruise or haematoma. If the patient is alert, she can apply pressure while tubes are labelled and equipment is discarded or put away. However, it is the phlebotomist s responsibility to ensure that the client is applying pressure appropriately. If the site continues to bleed following the 3-5 minutes pressure, elevate the arm and continue to hold pressure, and notify the client s direct care-giver before leaving. Page 16 of 29 Version: January 2008

17 Figure 5-XXIII: Apply Pressure until Bleeding has Stopped Do not leave needle caps and other material in patient s room discard properly. Do not bend the arm up to apply pressure: bleeding may occur into surrounding tissue. Keep the arm raised and straightened. 14. Check the patient s arm to ensure bleeding has stopped and apply bandage or tape over folded square of gauze. Some institutions prefer not to bandage, because of the tendency to irritate the skin and leave a sticky surface that may interfere with later venipunctures. However, covering the site keeps it clean and reduces the risk of infection as well as reducing the risk of blood stains on the client s clothing if the site begins to seep. Figure 5-XXIV: Bandage the Venipuncture Site The patient should be instructed not to carry a heavy purse or object on the collection side for approximately 1 hour the pressure on the vein may reinitiate bleeding. 15. After completion of venipuncture, dispose of needles in proper sharps container. Do not recap needles. If it is necessary at some time to recap the needle, a one-hand motion should be used, scooping the cap onto the needle. Page 17 of 29 Version: January 2008

18 Figure 5-XXV: Dispose of Needle (and holder) in Approved Sharps Container Courtesy and ARO Training & Consulting 16. Label tubes, and sign requisition with initials and time of collection, including necessary additional information (e.g. AC/PC). Ensure that label information is complete and matches the information on the requisition. If labels have not been provided containing patient information or if additional labels are required, prepare labels ensuring that patient s first and last names are printed legibly, as well as patient identification number and date of birth. Tubes should not be pre-labelled. They could be mistakenly used for the wrong patient. Figure 5-XXVI: Sign and Date Requisition 17. Recheck requisition for special handling instructions STAT, transport on ice, protect from light, keep warm, etc. 18. Remove and discard gloves, and wash hands. Gloves should be removed aseptically: grasp glove of one hand at the outside wrist and pull it off of the hand inside out into the gloved hand; slip non-gloved fingers into inside wrist of gloved hand and roll off without touching the outside of the gloved hand. Successful removal should result in the first glove contained inside the second glove. Dispose of gloves in biohazard waste container and wash hands before proceeding to the next patient. Page 18 of 29 Version: January 2008

19 Figure 5-XXVII: Dispose of Gloves in Appropriate Container 19. Thank clients for their co-operation. 20. Transport specimens to the laboratory or proceed to next patient, as appropriate Venipuncture by syringe Because of safety reasons the CLSI cautions against the use of needle and syringe. Use of needle and syringe has been associated with a greater incidence of needle-stick injuries. Because of the delay from collection into the syringe and transfer to appropriate tubes containing anticoagulants or other additives, the quality of the sample may be adversely affected. However, syringes are useful for clients whose veins are delicate or damaged when the force of the tube vacuum may cause vein collapse. The syringe consists of two parts: the barrel and the plunger. Syringes are sterile, individually wrapped, plastic and disposable. When the syringe plunger is drawn back it creates a vacuum that draws blood into the syringe barrel when the needle is inserted into a vein. Unlike the evacuated tube, the vacuum created by applying pressure to the plunger is gradual and can be controlled by the phlebotomist so that sufficient pressure can be applied to draw blood into the barrel without causing the vein to collapse. When the vein collapses, the vein wall is pulled against the bevel of the needle in the vein so that it obstructs blood flow. Syringes come in a variety of sizes for various uses (1-ml to 50-ml or more). For routine blood collection, 5-ml, 10-ml and 20-ml syringes are commonly used. Anything larger than a 20-ml syringe would require bracing your foot against the client s chest to apply sufficient pressure to draw back on the plunger! Reusable glass syringes are no longer routinely used, but if used, must be washed and sterilized before reuse. Page 19 of 29 Version: January 2008

20 Depending on the amount of blood required for testing, and the number of different blood collection tubes that the blood must be transferred to, more than one syringe may have to be filled. A buddy-system works well for syringe draws so that filled syringes can be handed to a helper to transfer to the appropriate tubes; thereby, reducing transfer times to additivecontaining tubes. In addition to the syringe barrel and plunger, a needle is required to access the vein and transport blood to the barrel. Syringe needles are available in a variety of sizes, depending on syringe usage injection or blood-draw. The most common used gauges are Needles are also available in a variety of lengths for blood-draw, a 1 to 1.5 inch length is commonly used. With the introduction of safer-needle assemblies, re-sheathing needles are recommended to reduce the risk of needle-stick injury. In addition to conventional needles, winged-infusion devices (e.g. Butterfly) may also be used with syringes, for small or difficult to access veins. Syringe transfer devices should be used when transferring blood from the syringe to appropriate blood collection tubes. Syringe transfer devices protect the phlebotomist from inadvertent needle-stick injury during blood transfer. Transfer devices look much like the holder used in the evacuated tube system, having an adapter on one end for the syringe, and a transfer needle sheathed in rubber on the inside of the holder like the tube end of needles used with the evacuated tube system. The transfer device attaches to the syringe barrel (after needle removal), and blood collection tubes are pierced with the sheathed needle on the inside of the transfer device as is shown below Syringe transfer device 1. Following vein selection, tourniquet removal and site preparation, select equipment, depending on the amount of blood to be drawn (syringe size and number of syringes), and the size and integrity of the vein (needle gauge and type). 2. While the site is drying, assemble the needle and syringe. Before opening the syringe assembly, exercise the plunger prior to use the plunger may not move smoothly through the syringe barrel. The syringe assembly is generally packaged with the plunger pulled back slightly from the end of the barrel gently push the plunger to the end of the barrel before opening the package. This will ensure that the plunger will move freely in the barrel during blood withdrawal, and won t result in contamination of the syringe assembly. Remove syringe from the paper packaging. Remove needle from packaging and attach to the luer end of the syringe barrel. Do not remove needle cap until ready to insert the needle into the vein. Use aseptic technique when removing the syringe components from their packaging and assembling you do have gloves on, right? Page 20 of 29 Version: January 2008

21 3. Reapply tourniquet, pick up the syringe/needle assembly and using the same technique as in the evacuated venipuncture procedure above, remove the cap, check for defects, orient the needle so that the bevel is up, anchor the vein, and insert the needle into the vein using the lowest possible needle angle to allow adequate penetration into the vein lumen. When the needle is properly inserted in the vein, blood will appear in the hub of the needle (flash) the needle hub is the plastic portion at the very end of the needle that attaches to the luer attachment of the syringe barrel. 4. Remove tourniquet once blood appears in the needle hub. 5. Holding the syringe assembly firmly in place, slowly pull back on the syringe plunger to draw blood into the syringe barrel. 6. Once the syringe is filled, and if only one syringe is required, place a gauze pad over the end of the needle do not press remove needle, apply pressure, and activate needle safety device. If working with a buddy, hand the syringe to your buddy for blood transfer to appropriate tubes. If not working with a buddy, continue to apply pressure or if the client is able, ask him/her to apply pressure while you attend to blood transfer. If the client applies pressure, it is your responsibility to ensure that they are applying adequate pressure until bleeding has stopped. 7. If more than one syringe volume is required, place a gauze pad under the needle hub to catch blood that drips when the syringe is removed from the needle. While holding the needle firmly in place in the client s vein, twist the syringe in a counter-clock-wise position to remove from the needle, and attach the second syringe. If working with a buddy, pass the first syringe to the buddy for blood transfer. If working alone, blood transfer will have to be delayed until subsequent syringes are filled. 8. Blood transfer using syringe transfer device. Transfer blood to appropriate blood collection tubes. To transfer blood from syringe to blood tubes, remove the activated safety needle and dispose immediately into sharps container. Attach the syringe to the transfer device by securing the luer end of the syringe to the luer attachment on the transfer device. Holding the syringe vertical with the transfer device at the lower end, place the transfer device over the first tube to which blood will be transferred and push the tube onto the sheathed needle to penetrate the tube stopper. Do not apply pressure to the plunger the tube vacuum will draw the required volume of blood into the tube. Applying pressure to the plunger may lead to sample haemolysis or cause the tube stopper to pop off. Page 21 of 29 Version: January 2008

22 Figure 5-XXVIII: Transfer Blood from Syringe to Tube(s) using Safety Transfer Device Safety Transfer (Courtesy and Becton, and Dickinson Company) When tube vacuum is expired, remove the tube from the needle and gently invert tube 8-10 times to mix blood with tube contents. Proceed to transfer blood to the next tube following the order of draw as described below under order of draw. Dispose of the entire syringe/transfer device into an approved sharps container. 9. Blood transfer without syringe transfer device. If a syringe transfer device is not available, place the appropriate blood collection tubes in a tube rack in the order of draw as described below. DO NOT HOLD THE TUBES IN YOUR HAND DURING BLOOD TRANSFER UNLESS A SYRINGE TRANSFER DEVICE IS USED. If transferring blood from a syringe without a needle i.e. the first syringe when multiple syringes have been collected attach an 18or 21 gauge needle to the syringe for blood transfer. With the tube secured in the tube rack, penetrate the stopper of the tube with the syringe needle. Penetrate the tube stopper at a slant so that the needle is directed against the side of the tube slanting the needle against the tube wall will reduce the risk of haemolysis as shear forces will be less when blood runs down the inner tube wall than when blood is pulled directly to the bottom of the tube. Allow the vacuum to draw the required volume of sample into the tube. As described under transfer device use, do not apply pressure to the plunger allow the tube vacuum to draw blood into the tube. Withdraw the needle from the tube when the vacuum is exhausted, mix the tube 8-10 times, and proceed to fill the second tube. Continue filling and mixing until all tubes have been filled. Discard the needle/syringe assembly without disassembling. If blood is to be transferred from a syringe with a needle already attached, transfer blood to tubes through this needle. Previous recommendations to remove the needle used to penetrate the vein and replace it with a larger diameter needle prior to transfer, pose an increased risk of needle-stick injury and are no longer recommended. Page 22 of 29 Version: January 2008

23 If the syringe and/or needle have a safety device, activate it prior to syringe disposal. Figure 5-XXIX: Engage Syringe Safety Device Courtesy and Kendall Healthcare Systems 10. Blood is transferred to blood collection tubes using the same order of draw as described for the evacuated tube system: Blood culture bottles or yellow stopper SPS tube Light blue stopper (sodium citrate) - coagulation studies (plasma) Serum tubes - red stopper glass non-additive tube, red stopper plastic tube containing clot activator, red/grey stopper (clot activator and gel separator) Green or green/grey (heparin) plasma Lavender stopper (EDTA) - CBC, blood counts, differentials (whole blood) Grey stopper (oxalate/fluoride) glucose (plasma) The only difference is that if working alone and more than one syringe volume is required, blood for coagulation studies should be transferred from the freshest syringe full of blood the last syringe collected, followed by anticoagulant samples. The first syringe should be maintained, if possible, for transfer to serum tubes. The clotting process begins as soon as blood is removed from the vein; therefore, sample quality and test results may be adversely affected by delays in transfer to anticoagulant containing tubes; whereas, serum tubes will result in sample clotting anyways and are not likely to be affected in the same way by transfer delay Venipuncture combination systems Combination blood collection systems (e.g. S-Monovette Starstedt allow for collection by either an evacuated tube or syringe technique. The systems consist of a tube with an internal plunger that is attached to a needle for venous access. Depending on vein fragility, the sample can be collected by activating the evacuated tube mechanism, or manually by applying pressure to the plunger. The system offers a choice in technique dependent on vein integrity, and the sample does not have to be transferred to tubes following collection into the syringe, because the barrel of the syringe doubles as a tube containing appropriate additives. The disadvantage is that tubes must be removed from the needle and a new one attached, if necessary, without dislodging the needle from the vein. Page 23 of 29 Version: January 2008

24 Figure 5-XXX: S-Monovette Combination System S-Monovette (Courtesy and Sarstedt Company) For more information on combination system use, visit the S-Monovette website: Venipuncture winged infusion device A winged infusion set allows more flexibility than the traditional needle and tube holder provides. Generally, winged infusion use is preserved for hand veins, paediatric patients, and other small or difficult to access veins. The cost of the winged infusion set precludes its use for routine blood collection, as does the greater incidence of needle-stick injuries associated with winged infusion use. The winged infusion set consists of a needle at one end that is inserted into the client s vein. The needle is attached to a length of tubing (tube lengths vary from 5 inches to 12 inches). The greater the length of tubing, the more air that will be introduced in the first blood collection tube and very short or very long tubing lengths can be awkward to deal with. Figure 5-XXXI: Winged Infusion use with Evacuated Tube System Vacuette (Greiner Bio-One Pre-analytical Systems) At the juncture of the needle and tubing is a set of plastic extensions that resemble wings (commonly referred to as butterfly wings) that serve as a holder for needle insertion when folded up, and as a stabilizer once the needle is inserted into the vein. Figure 5-XXXII: Winged Infusion Needle (Syringe) Vacuette (Greiner Bio-One Pre-analytical Systems) Generally, the phlebotomist does not have to hold the needle in place once it is inserted sufficiently into the vein lumen. Page 24 of 29 Version: January 2008

25 Figure 5- XXXIII: Flash in Needle Hub Push Button Blood Collection Set (Courtesy and Becton, Dickinson and Company) At the other end of the length of tubing is a luer attachment for a syringe, or a luer attachment connected to a multi-sample adapter that can be used with the evacuated tube system. Figure 5- XXXIV: Winged Infusion Needle (Evacuated Tube System) Luer attachment for syringe Multi-sample adapter The multi-sample adapter has the appearance of the back-end of a needle used with the evacuated tube system rubber sheathed needle with threads, which is screwed into the evacuated system tube holder. Winged infusion sets can be purchased with or without multi-sample adapters, and multisample adapters can be purchased separately. Winged infusion needles also come in a variety of sizes from 21-gauge to 27-gauge. For large healthy veins, which generally would preclude use of the winged infusion set, a 21- gauge needle can be used; whereas, for small fragile veins, 23-gauge needles are used. Needles with a smaller diameter than 23-gauge should not be used with adults, because of the greater chance of haemolysis that exists with smaller needle diameters. Cells are exposed to greater trauma as they pass through smaller diameter needles. 25-gauge needles are reserved for paediatric use with veins that are too small to accommodate a larger diameter needle. Page 25 of 29 Version: January 2008

26 Figure 5- XXXV: Winged Infusion Gauge Color Codes Push Button Blood Collection Sets (Courtesy and Becton, Dickinson and Company) Winged infusion sets are available with a variety of safety devices to reduce the risk of needle-stick injury, but these re-sheathing features apply to the vein access needle end many needle-stick injuries associated with winged infusion use occur from the rubbersheathed needle end, either because we forget there is a needle there out of sight, out of mind or, because the assembly is not completely deposited into the sharps container and one of the needle ends protrudes from the container. Figure 5-XXXVI: Activate Safety Device Activation of push button retracts needle before removal from vein. Push Button Blood Collection Sets (Courtesy and Becton, Dickinson and Company) Figure 5- XXXVII: Sheathing Winged Infusion Needles Safety shield is pushed forward over needle following removal from vein. Safety-Lok Blood Collection Sets (Courtesy and Becton, Dickinson and Company) Collection procedure using winged-infusion blood collection set 1. Following vein selection, tourniquet removal and site preparation, select equipment, depending on the testing required, and the size and integrity of the vein (needle gauge and tubing length). 2. While the site is drying, assemble equipment. Using aseptic technique, remove winged infusion set from packaging keep the package to place under needle if collecting by syringe and more than one syringe volume is required. The infusion set tubing will be coiled upon removal from the package to prevent one end Page 26 of 29 Version: January 2008

27 from coming back and biting you (needle-stick), hold the infusion set firmly at the wings and stretch the tubing straight with the other hand to prevent it from recoiling during use. Take care not to engage the re-sheathing device. Attach the infusion set to the evacuated tube holder or syringe, as appropriate. Do not remove the needle protective cap. 3. Re-apply the tourniquet, pick up the needle end of the winged infusion assembly the tube holder (or syringe) can be placed close to the client s arm remove the needle cover, check for defects and orient the needle so that the bevel is up. Pinch the plastic wings together on top of the needle between your thumb and forefinger, anchor the vein, and insert the needle into the vein using the lowest possible needle angle to allow adequate penetration into the vein lumen. When the needle is properly inserted in the vein, blood will appear in the tubing (flash). Seat the needle by threading it further slightly into the lumen of the vein so that it does not pop or twist out of the vein when you release the needle. In some cases, you may have to continue to hold the needle in place. 4. If collecting by syringe, follow the procedure described above for syringe collection, using the plastic package to catch drips of blood when changing syringes. 5. If collecting by evacuated tube system, hold the tube holder in a downward position and place tubes on the holder following the order of draw as described for the evacuated tube system. The tube holder is maintained in a downward position to ensure that tube contents do not inadvertently reach the tube stopper and enter the needle, tubing and client s vein. Always fill tubes from the bottom up! COLLECT DISCARD TUBE IF COAGULATION STUDIES ARE REQUIRED. A draw loss of approximately 0.5-mL will occur due to air displacement resulting from air in the length of tubing in the winged infusion set. If blood for coagulation studies are required PTT, INR, etc., a discard tube should be collected before the light blue tube containing sodium citrate. Air displacement will result in an incomplete fill of the first tube in the order of draw the first tube in the order of draw is the light blue sodium citrate tube used for coagulation studies. This tube must be completely filled in order to ensure a 9:1 ratio of blood to anticoagulant. Incomplete filling of tubes for coagulation studies may result in inaccurate test results. Collect a small amount of blood into a discard tube (tube without an additive or a tube containing the same contents as the one used for coagulation studies) to displace the air in the tubing, remove the tube, discard and proceed to collect tube for coagulation studies followed by other tubes required for testing, following the order of draw described for the evacuated system: Blood culture bottles or yellow stopper SPS tube Light blue stopper (sodium citrate) - coagulation studies (plasma) Serum tubes - red stopper glass non-additive tube, red stopper plastic tube containing clot activator, red/grey stopper (clot activator and gel separator) Page 27 of 29 Version: January 2008

28 Green or green/grey (heparin) plasma Lavender stopper (EDTA) - CBC, blood counts, differentials (whole blood) Grey stopper (oxalate/fluoride) glucose (plasma) 6. Remove tourniquet once blood flow is ensured. In some cases, the tourniquet may have to be left in place during blood draw to maintain blood flow from difficult veins if this is the case, the tourniquet should be removed within one minute of application to reduce the risk of haemoconcentration. 7. Mix tubes 8-10 times as they are removed from the tube holder. 8. Following filling of the last tube, remove it from the holder, mix 8-10 times, place gauze over the needle, and remove the needle do not apply pressure to the gauze until the needle has been removed. Upon removal of the needle, activate the safety device and dispose of the entire unit it the sharps container. Page 28 of 29 Version: January 2008

29 REFERENCES 1. Clinical Laboratory and Standards Institute. Procedure for the Collection of Diagnostic Blood Specimens by Venipuncture; Approved Standard - Fifth Edition. CLSI; H3-A5; 23(32); McCall RE, Tankersley CM. Phlebotomy Essentials Third Edition. Lippincott Williams & Wilkins. Philadelphia Page 29 of 29 Version: January 2008