Sr. Lab Guy
20 Years Experience
San Bernardino, CA
Male, 52
For 6 years I was a Laboratory Technician in the Air Force Reserves, working all aspects of the laboratory as well as accomplishing "blood draws" (phlebotomy) in every imaginable setting (inpatient and outpatient). I have also worked in the private sector for hospitals, doctor offices, and clinical lab sites. This was my primary field for 20 total years (which began with the Air Force training). I've been in a new career for ten years, though I recall virtually all of my lab science.
4. My answer for this question is contained in my answer to your first question.
5. You've likely hit a nerve such as the medial antebrachial cutaneous nerve. End the blood draw and try for the cephalic vein at the antecubital site.
6. Generally you should not wipe the site after using alcohol, you should let it air dry to avoid contaminating the site and potentially causing, though rare, phlebitis.
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Hi Juli, Most places have exact protocols in place based on their own laboratory's procedures, and those in turn would likely follow their region's or national guidelines. In general, though, a PICC Line (peripherally inserted central catheter or somtimes called a percutaneous indwelling central catheter) is virtually always in the realm of the nursing department, due to the sensitive nature of this line. As I recall, central lines, PICC Lines, and even blood drawn from I.V. sites (often as a last resort for extremely difficult draws) are all required to be flushed with saline and/or heparin (again, exact protocols are ususlly a function of the particular institution) prior to withdrawal of blood for analysis. That's something most phlebotomists are not allowed to do, only nursing personnel. Also, again, depending on the institution, there may be a waiting period. If the line has an active I.V., I've seen wait times as high as one hour and as low as fifteen minutes. And the wait time can apply to both the cessation (temporarily) of the I.V. AND the flushing with saline and/or heparin, so those wait times can double overall. After the wait period, the nurse usually swabs the port with iodine (and in some places with alcohol first) waits for it to dry, then withdraws the amount of blood required. He or she would then inject the sample into the blood culture bottle (after first having swabbed it with iodine {and in some places, alcohol first}) and invert the bottle a few times to mix well. Doctors most often order blood cultures as a series. For example, "Blood Cultures x3", and the time between each blood culture draw would depend on the institution as well, and even the doctor's preference (I've seen 20 minutes apart, 30 minutes apart, 1 hour apart, etc.) If you're looking for an exact protocol in preparation for an exam, I would respectfully suggest checking with your resources for a clear answer as an exact protocol may depend on that as well. Sorry I couldn't be more precise.
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This one had me wondering. Normally, if you've redirected "multiple times" and then blood begins flowing into the tube, it's a good thing (in general, but that presumes you've redirected only a few times and without significant trauma). If the "multiple" redirects were in fact quite numerous and/or traumatic, you'll likely risk having hemolysis in the tube (hemolysis is a central theme in most blood draws) and of course redirecting, if done wrong, can be very painful for the patient and can leave horrible scarring and even an extremely painful hematoma. Also, I'm taking an educated guess here, the reference in your question to "blood spurts" COULD mean that a phlebotomist redirected too deeply and has compromised an artery. Arterial blood in vitro is cherry red and very different from blood from a vein in appearance. Again, trying to cover all bases. And the risk for an arterial draw by a phlebotomist who is not certified for that procedure is a very nasty hematoma for your patient, or worse, depending on the patient's condition.
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Hi Alicia,
Your question is a perennial scenario for phlebotomists. Over the years, I finally realized that the secret to "redirecting" the needle during venipuncture in an especially well-endowed arm is to be proactive BEFORE that needle even touches the skin. By this I mean, have the patient make a fist around a large object, one that fits the relative size of their hand. In the past, I've had patients use everything from a few hand towels to a few large (unused, needle-less) syringes. This creates, in effect, a larger fist, one that can exert more pressure per square inch than just a hand without this assist. Then, and this next part you need to be careful about (I'll explain that in a moment), you tell the patient that the tourniquet is going to be "really tight" so that you can "see" the vein better. Now tie that tourniquet tight, tighter than usual. But not so tight as to cut off arterial circulation (which by the way is actually fairly hard to do at the antecubital site - but not impossible). Have them open their hand momentarily to check for circulation. You should be able to see blood flow returning to the palm of the hand (turns white to red). You can also feel for a radial pulse if necessary. Finally, have them make a tight fist again around the aforementioned object, and then have them make their arm as straight as possible. You should easily be able to feel a vein. Note: I realize your question asks what to do DURING a difficult draw. My answer would be to ask a fellow phlebotomist or a nurse to re-tie the tourniquet tighter, feel for the vein above the entry site, and carefully redirect. If that's not possible, you'll need to withdraw the needle and try again, preferably at a different vein. Some text books will tell you that tourniquets that are too tight can cause hemolysis in the tubes, and also cause invalid electrolyte levels. I have to say, for the short period the tourniquet is in place, not once did I find this to be true. A tourniquet, tight or otherwise, left in place TOO LONG, will cause the above. I have seen that. But not for short periods. Hope this helps. Best of luck to you.
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Blood draws from babies are usually in very small amounts. As as a phlebotomist you know qualitatively that you shouldn't draw large amounts of blood from infants. Most institutes have their own guidelines. One protocol I've seen is (from drgreene.com):
"GUIDELINES FOR PEDIATRIC BLOOD DRAWS"
"...general rule of thumb I use as an outside limit for blood draws, because at these levels of blood loss there can be measurable health consequences. Blood draws in infants and children should not exceed 5% of their total blood volume in any 24 hour period, unless medically necessary. This is a generous upper limit. Ideally it should be less than 3% of the total blood volume, and where possible, micro-sampling techniques to reduce the amount further are preferred. Blood draws in infants and children should not exceed 10% of the total blood volume in any one-month period, unless medically necessary."
* * * * * * * * * * * * * * * * * *
Samir, most of the time I used microtainers for blood draws on infants, whether capillary or venipuncture. These are very small plastic tubes that are, I believe, 0.5 ml when full. Half of a milliliter or even a full milliliter is not much blood for an infant. And I seem to recall that the average total blood volume (TBV) for babies is around 350 ml.
So, in your question, (3) 5 ml tubes is 15 ml total. From my experience that's way more than you'd ever need from an infant, and about 4% of the average TBV. It's probably not approaching hypovolemic trouble, but still an unnecessary amount of blood for the usual testing requirements.
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Hi Samir, I'm going to base my answers to your various questions according to real-life experience and also to questions I may recall on any state, military, or local school exams that come to mind. Please note that, if these are questions you have in preparation for any exams or quizzes, you should check for answers in your resources as well, be they hardcover or online. But I don't mind sharing what I know, so...on to your first question.
You asked: "A patient is a difficult draw, so the phlebotomist uses the exact same site each time."
Ok, this is more complicated than it seems. Usually, this refers to an inpatient who may have I.V.'s or a shunt on one arm, leaving only one "good" arm to draw from. It CAN refer to an outpatient also though (less often in my experience) who is a dialysis patient, heroin user, or otherwise has only one arm that is useable for venipuncture. You write "Exact same site". If by that you mean the exact same tiny hole you had just tried but failed to withdraw from, that is not advisable. In addition to the pain this could cause the patient, you are risking hemolysis of the blood sample in the tube, which will likely invalidate glucose and electrolyte readings, just to name a few. You could also cause unnecessary scarring and while rare even local phlebitis. If absolutely necessary (i.e. no veins on the hand, or areas of the arm above or below the antecubital are available), you can use the same vein, but above or below the "exact same site". You will need to hold the previous draw first to make sure it has clotted enough to begin the second draw (3 to 5 full minutes). If that is not possible, I would check with the tech-in-charge about asking a respiratory tech for an arterial draw or a line-draw by a nurse (both methods, I emphasize, would require permission).
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As a lab technician and phlebotomist, I was never involved with drug testing of hair samples. I recommend you call a local hospital lab and ask for the phone number of a reference lab that handles this type of testing and give them a call. Sorry I couldn't be more helpful.
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