1. Venipuncture Complications
Chapter 11
Venipuncture Complications

2. Learning Objectives
Explain the procedure to be followed in these situations:
a. The patient is not in his or her room.
b. The patient has no identification band.
c. The patient is sleeping, unconscious, or apprehensive.
d. Clergy or a physician is with the patient.
e. Visitors are present.
f. The patient cannot understand you.
g. The patient refuses to have blood drawn.

3. Learning Objectives
List at least four sites that must be avoided when collecting blood, and explain why.
Describe techniques that can be used to help locate a vein.
Discuss limitations and precautions to be followed if a leg or hand vein is considered for venipuncture.

4. Learning Objectives
List at least two situations in which alcohol should not be used to clean the venipuncture site, and state at least one alternative.
Describe four potential problems associated with tourniquet application.
Define syncope, and explain what to do when a patient experiences this condition during the collection of blood.

5. Learning Objectives
Describe the actions to be taken if a patient has a seizure, complains of nausea or vomits.
List three reasons why blood may not flow into a tube, and explain how to prevent or correct the problem.

6. Learning Objectives
Explain what should be done in the following situations:
a. An artery is inadvertently punctured.
b. No blood is collected on the first try.
c. The patient requests something.
d. There is prolonged bleeding from the
puncture site.

7. Learning Objectives
List the causes of a hemolyzed sample and name the test results that may be affected.
List tests that may be affected by a patient’s position.
Describe five long-term complications associated with venipuncture, and explain how they can be avoided.
State reasons why a sample may be rejected by the laboratory.

8. Venipuncture Complications
Many factors can interfere with blood collection, but by knowing what to expect and planning ahead, you will be able to deal with most complications and you will be better prepared in your work as a phlebotomist.

9. Factors That Prevent Access to the Patient
Locating the Patient.
- If the patient is not in his room, check at the nursing station.
- If the patient is in another area and the test is stat or timed, go to that area and draw the patient.
Make every effort to locate the patient. If you cannot find the patient, make sure that you have reported to the nurse and then to your supervisor and then document on the requisition.

10. Factors That Prevent Access to the Patient
Identifying the Patient.
- The information on the requisition must match the information on the armband exactly before drawing blood.
- Resolve any discrepancy before collecting the specimen.
- Do not draw a patient without an armband.
- Some facilities may also require a special armband for Blood Bank specimens.
Situations that can make identification difficult include: ER requisitions, ER collections, telephone orders. And requisitions given to you on site.

11. Barriers to Communicating With the Patient
Sleeping or Unconscious Patient.
- Never draw blood from a sleeping patient.
Gently wake patient before proceeding.
- Follow the procedure and talk to an unconscious patient. They may still be able to hear you even if they cannot respond.
Have the nurse or family member ID the unconscious patient for you even if the information on the armband matches. Always document the name of the person that provided the information on the requisition.

12. Barriers to Communicating With the Patient
Presence of a physician or clergy.
- Unless it is a stat or timed test, return at another time and document.
- If the test is stat or timed, announce yourself and wait for permission to enter.
Physician and clergy time is private time for the patient.

13. Barriers to Communicating With the Patient
Presence of Visitors.
- Greet visitors as you would the patient.
- You may ask them to step out while you collect your specimen.
- Sometimes family may be helpful if the patient is a child.
If you encounter any difficulty with a visitor or family member who will not leave, go to the nurses’ station and get assistance.

14. Barriers to Communicating With the Patient
Apprehensive Patients.
- Good communication skills can help to put a nervous patient at ease.
- If you suspect that you may still have difficulty, ask for assistance from a family member or nursing staff.
You may need assistance with children and elderly patients that may be a little disoriented. Do not draw the blood unless you are sure that you can do so safely for both you and the patient.

15. Barriers to Communicating With the Patient
Language Problems.
- For non-English speaking patients, you may need a translator.
- You may also demonstrate to the patient what you are going to do.
- If the patient extends his arm, you will know that he understands what you need to do.
Never stick a patient unless you are sure they understand what you are going to do.

16. Barriers to Communicating With the Patient
Patient Refusal.
- According to the Patient Bill of Rights, the patient does have the right to refuse.
- Try to find out the reason for the refusal.
- Tell the patient the tests are needed for treatment.
- If the patient still refuses, report to the nurse and your supervisor, and document.
Forcing a patient of sound mind and legal age to have his blood drawn, can result in a charge of assault and battery.

17. Problems in Site Selection
Occluded (Blocked) or Sclerosed Veins.
- Veins will feel hard and have no bounce.
- These veins may be susceptible to infection or produce erroneous test results because of impaired blood flow.
Inflammation, chemotherapy, arteriosclerotic disease and repeated punctures can damage the veins.

18. Problems in Site Selection
Hematomas.
- Can be caused by going through the vein, having the bevel only partially in the vein, or by failure to apply enough pressure post puncture.
- Hematomas can obstruct blood flow and thereby alter test result if the specimen is collected from that area.
Hematomas can also result from using too large of a needle on a small vein.

19. Problems in Site Selection
Edematous Tissue.
- The arm may be swollen due to the accumulation of tissue fluid or from an IV that has infiltrated into the tissues.
- Collection here can alter test result due to contamination with tissue fluid.
Burns and Scars.
- These sites are susceptible to infection and may be painful to the patient and difficult to penetrate.
If all else fails, draw from the back of the patient’s hand where you can gently massage the fluid away from the vein before sticking.

20. Problems in Site Selection
Mastectomies.
- Collection on the side of the mastectomy can cause lymphostasis or an accumulation of lymph fluid if a tourniquet is used on that arm.
- The patient has increased risk of an infection.
Make sure that you know your facilities policy on collecting specimens from a mastectomy patient. In the case of a double mastectomy, draw the patient from the hand and without using a tourniquet.

21. Problems in Site Selection
Avoid any areas of disruption in the skin such as open lesions, rashes, recent tattoos, or incompletely healed stitches.
These sites should be avoided because the patient is at increased risk of infection.
Always document any problems encountered when collecting a specimen.

22. Difficulty in Finding a Vein
Always check both arms.
Massage the arm from the wrist to the elbow.
Dangle the arm in a downward position.
Apply heat – use an infant heel warmer.
Rotate the wrist to check the cephalic vein.
Use a blood pressure cuff.
Use an alternate site such as the hand, foot or leg with butterfly or winged infusion set (WIS).
Always ask the patient where the best place to collect blood is located. If using a BP cuff, do not inflate to more than about 80 mm Hg. Do not do foot or leg veins if the patient is a diabetic or prone to developing blood clots and is receiving anticoagulation therapy. Physician permission may be required for foot or leg punctures.

23. Hand Collection Using a WIS
Make sure to follow standard precautions – washing hands at the beginning and end of the procedure and wearing gloves. (1) Straighten out tubing and attach tube holder or syringe. Insert the first tube without puncturing tube stopper. Demonstrate to students.
WIS uses a smaller gauge needle which is more suitable for hand veins or fragile veins.
Courtesy of Zack Bent.  From Garrels M, Oatis CS: Laboratory Testing for Ambulatory Settings: A Guide for Health Care Professionals.  Philadelphia, Saunders, 2006.

24. Hand Collection Using a WIS
Position the patient’s hand and apply the tourniquet.
Have patient make a fist and support wrist with a towel to keep the knuckles down and out of the way. Tourniquet should be 2 to 4 inches above the puncture site.
From Bonewit-West K: Clinical Procedures for Medical Assistants, 6th ed. Philadelphia, Saunders, 2004.

25. Hand Collection Using a WIS
Insert the needle.
- Choose the largest and straightest vein.
- Anchor the vein with your nondominant hand.
- Insert the needle into the vein using the wings in an “up” position, bevel up with a 10 to 15 degree angle.
Fold the wings up and grasp high enough up so that the tubing is visible when inserting the needle.

26. Hand Collection Using a WIS
A flash of blood will appear in the tubing when the vein is entered.
Gently thread the needle into the lumen of the vein to stabilize.
Hold the needle in place with one hand while using the other to handle the tubes.
If the WIS is properly seated in the vein, you should be able to release the wings and still maintain the vein.

27. Hand Collection Using a WIS
Point out the position of the WIS in the hand and the holding technique.

28. Hand Collection Using a WIS
Collect the sample.
Use the nondominant hand to switch tubes or to gently pull back on the syringe plunger. Make sure to invert tubes with additives immediately.
Courtesy of Zack Bent.  From Garrels M, Oatis CS: Laboratory Testing for Ambulatory Settings: A Guide for Health Care Professionals.  Philadelphia, Saunders, 2006.

29. Hand Collection Using a WIS
Finish the collection.
- Release the tourniquet when the first tube is filled.
- Remove the needle and activate the safety device.
Attend to the patient.
- Apply direct pressure to the puncture site.
You may have to hold pressure longer to prevent bruising or a hematoma because the vein is closer to the surface.

30. Hand Collection Using a WIS

31. Hand Collection Using a WIS
Dispose of the WIS into a sharps container.
- If using the ETS, dispose of the assembly intact.
- If using a syringe, use a needleless transfer device to transfer the sample and then dispose of the assembly intact.
If using a WIS to draw a PT or APTT, use a “clear” tube with no additive to fill the tubing with blood so as not to displace some of vacuum in the lt. Blue tube which would change the 9:1 ration and give inaccurate test result. If no clear tubes are available, use another lt. Blue tube first.

32. Problems Associated With Cleaning the Site
Patients allergic to alcohol may require the use of povidone iodine (water based) or chlohexidine gluconate.
Alcohol cannot be used to clean the skin for a blood alcohol test.
Do not use povidone iodine for dermal punctures because it may elevate test results.
If the patient is allergic to alcohol and iodine and you have no other antiseptic available, use soap and water. Make sure to document.

33. Problems Associated With Tourniquet Application
Hemoconcentration – alteration in the ratio of cellular elements in the blood.
- Plasma and smaller elements filter into the tissues when the tourniquet is on longer than one minute which leaves a concentration of larger elements in the blood.
- Increased values are seen in proteins, RBCs, enzymes, iron, calcium, potassium, and lactic acid.
- Can also be caused by fist pumping, occluded veins, or dehydration.
Hemoconcentration can be avoided by releasing the tourniquet as soon as blood flows into the first tube.

34. Problems Associated With Tourniquet Application
Petechiae – small, non-raised red spots on the skin of a patient with a capillary wall or platelet disorder.
- Make to apply extra pressure post draw.
Tourniquet Too Tight – patient will complain of numbness or tingling in arm.
- Loosen tourniquet and begin again.
Sometimes certain medications that affect platelet function can cause petechiae.

35. Problems Associated With Tourniquet Application
Latex Allergy
- All patients must be asked whether they have a latex allergy.
- Use nonlatex gloves and tourniquets.
- Use nonlatex bandages.
Your lab should have a policy in place in case a patient has an anaphylactic reaction.

36. Complications During Collection
Syncope (fainting)
- Remove tourniquet and needle immediately, apply pressure and document.
- Do not leave the patient; call for help.
Seizures
- Do not leave the patient; call for help.
- Do not put anything in the patient’s mouth so as to cause an injury.
Always ask the patient if he has any history of fainting during a venipuncture so that you can lie him down ahead of time to prevent the incident. Patients should sit for 30 mins. post fainting before leaving and driving. Some facilities have orange juice available for patient to drink.

37. Complications During Collection
Pain
- Warn the patient prior to stick.
Nausea and Vomiting (Emesis)
- Provide a wet washcloth and emesis basin.
Hematoma – swelling of tissue around site as it fills with blood.
- Remove tourniquet and needle immediately, apply pressure and a cool compress.
Pain will be lessened if the skin is anchored tightly. If the patient vomits, keep the head down so that the emesis is not aspirated.

38. Complications During Collection
Lack of Blood Flow
- Can be caused by a defective tube, missing the vein, or improperly positioned needle.
- Intermittent flow indicates improperly positioned needle or a collapsed vein.
- Always try to reposition or try a new tube before aborting the draw.
Improper needle position can be avoided by using the correct entry angle. Always have spare tubes close at hand so that in the event of a bad tube you do not have to restick the patient.

39. Complications During Collection
Defective Evacuated Tubes
- Always examine tubes for cracks and have spares easily accessible.
Improperly Positioned Needle
- Corrective action must be taken to reposition the needle so that the patient does not need to be stuck again.
OSHA has recommended the switch to plastic tubes wherever possible because of safety issues.

40. Improperly Positioned Needle
The bevel is stuck to the vein wall. Slightly rotate the needle.
Always check needle position before aborting a draw.

41. Improperly Positioned Needle
The needle has passed through both sides of the vein. Slowly pull back on the needle and watch for the blood to come into the tube.
Have spare tubes ready in case you may have lost some the vacuum in the tube and the blood flow is intermittent.

42. Improperly Positioned Needle
The needle is not advance far enough into the vein. Slowly advance the needle and feel for the give of the vein and watch for blood to appear into the tube.
Have a spare tube handy in case you have lost some of the vacuum in your tube.

43. Improperly Positioned Needle
The vein was missed completely. Remove the tourniquet, pull the needle out slightly, palpate to relocate the vein, and redirect the needle.
Pull the needle out only until you see the back of the bevel. Pull the skin tight below the site and advance the needle. Never redirect horizontally because a laceration of the vein could result.

44. Complications During Collection
Collapsed Vein – too much vacuum on a small vein.
- Use smaller tubes or try with a syringe.
Inadvertent Arterial Puncture
- Noted because of pulsating, bright red blood.
- Apply pressure for at least 5 min. or until bleeding has stopped.
- Log the specimen in as “arterial” because some test values will be altered.
The brachial artery has the potential for being punctured when the basilic vein is used. Always check both arms before using the basilic vein.

45. Complications During Collection
Failure to Collect on the First Try
- The guidelines allow for a 2nd attempt.
- Use a clean needle and tube.
- Try the other arm or go below 1st attempt.
- If you have tried twice, call for another phlebotomist to help.
Always observe the person who comes to draw next so that you will have a better idea of what to do so you can be successful.

46. Problems in Completing the Procedure
Patient Requests
- Refer any patient requests to the nurse.
Prolonged Bleeding
- Bleeding should stop within 5 min.
- Patients on anticoagulants may bleed longer and require more pressure.
You are responsible to make sure the patient has stopped bleeding before leaving the bedside or allowing him to leave. Report any prolonged bleeding to the nurse or doctor.

47. Factors That Affect Sample Integrity
Hemolysis – the destruction of RBCs, resulting in release of hemoglobin and cellular contents into the plasma.
- The serum or plasma will appear red.
- Many test values will be altered.
- The lab will have to ask for a redraw.
Refer to Box 11-1 for the causes of hemolysis and Box 11-2 for the tests that are affected by hemolysis.

48. Causes of Hemolysis
Follow procedures and make good decisions with regard to choice of vein and equipment used can prevent hemolysis.

49. Tests Affected by Hemolysis
Potassium is the most critical test affected by hemolysis. The level must be monitored especially in cardiac patients.

50. Factors That Affect Sample Integrity
Patient Position
- The physician may request that a patient lie down for specimen collection.
Reflux of Anticoagulant
- backflow of blood from the tube out the needle if the last tube is not released before withdrawing needle.
Refer to Box 11-3 for tests affected by patient position.
In reflux the patient may have a reaction to the additive in the blood that has dripped back into the venipuncture site. Also the tube may now be contaminated. Keep the patient’s arm angled downward.

51. Tests Affected by Patient Position
Some labs that do only outpatient testing have their own reference (normal) values based on ambulatory patients versus bedridden patients.

52. Long Term Complications Associated With Venipuncture
Anemia
- Follow your facility’s policy on frequency and amount of blood that can be drawn.
Nerve Damage
- Remove the needle immediately if the patient has any numbness or tingling.
- Use the basilic vein as last resort.
Infection
- Follow aseptic procedures.
- Patients should leave bandage on for at least 15 min. post puncture.
Make sure to take minimal amounts of blood on infants, children and geriatric patients.
Using the basilic vein can result in inadvertent puncture of the brachial artery.

53. Causes of Hematomas Excessive probing to obtain blood.
Failure to insert needle into vein.
Inserting needle through the vein.
Failure to remove tourniquet before withdrawing needle.
Inadequate pressure after needle removal.
Bending the elbow while applying pressure.
It is important to hold adequate pressure on hematoma sites so as to force the surrounding tissues to absorb the blood and not cause compartment syndrome.

54. Compartment Syndrome
A condition in which pressure within the tissue prevents blood from flowing freely.
Causes swelling, pain and may result in permanent nerve damage.
Pain, burning, and numbness may be followed by paralysis distal to the puncture site.
The patient should be instructed to see medical attention immediately.

55. Specimen Rejection
Labs must keep track of the number of specimens rejected and who collected them for quality control procedures required by inspection agencies.

56. Specimen Recollection
Documentation of this also required by inspection agencies.