What Is an Advantage From Drawing Blood From Veins

Venipuncture

Kenneth R. Harbert , in Essential Clinical Procedures (Second Edition), 2007

BACKGROUND AND HISTORY

Venipuncture evolved from the practice of phlebotomy. The word phlebotomy is derived from two Greek words referring to "veins" and "cutting"; thus, phlebotomy can be defined as the incision of a vein for bloodletting or collection. Since early times, humans have appreciated the association between blood and life itself. Many medical principles and procedures have evolved from this belief. Hippocrates (460-377 bc) stated that disease was the result of excess substances such as blood, phlegm, black bile, and yellow bile within the body. It was believed that removal of the excess of these substances would restore balance (McCall, 1998). From this belief arose the practice of bloodletting—the first form of phlebotomy. By the 17th and 18th centuries, phlebotomy was a major therapy for those practicing the healing arts. Lancets were among the primary instruments used by clinicians in the 18th century.

Methods and procedures associated with phlebotomy today are dramatically improved. Only rarely today is phlebotomy used as a therapeutic modality (e.g., for patients with polycythemia). Instead, the primary purpose of phlebotomy is to obtain a sample of blood for diagnostic testing. The development of sophisticated laboratory equipment has reduced the need for venipuncture by requiring smaller quantities of blood for diagnostic assessments, amounts that often can be obtained by simply puncturing the skin without directly accessing the veins. There are many ways to obtain a blood sample using the venipuncture method. The procedures in this chapter describe techniques using Vacutainers, syringes, and infusion sets.

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Extraction Techniques and Applications: Biological/Medical and Environmental/Forensics

K. Lew , in Comprehensive Sampling and Sample Preparation, 2012

3.05.4.1 Venipuncture

Venipuncture is when a vein is pierced by a needle for either intravenous injection or the removal of blood. Veins are favored over arteries because they have thinner walls, and thus they are easier to pierce. There is also lower blood pressure in veins so that bleeding can be stopped more quickly and easily than with arterial puncture. The most site for venipuncture is the antecubital fossa located in the anterior elbow at the fold. This area houses three veins: the cephalic, median cubital, and basilic veins (Figure 1). The veins may be visible in some individuals but not others, or more easily felt in some, depending on the amount of muscle and fat tissue they have. Vein patterns may also run differently between individuals. Generally, the cephalic vein runs along almost the entire length of the arm and the median cubital vein connects the cephalic vein with the basilic vein. Of these three veins, the preferred one for venipuncture is the median cubital vein because it is larger and has a lower tendency to move or roll when the needle is inserted. There are also fewer nerve endings surrounding this vein making venipuncture less painful at this site. In some people the cephalic and/or basilic veins may be more easily located than the median cubital vein and may be a more appropriate vein to draw blood from. The phlebotomist must take care in anchoring those veins well to prevent rolling.

Figure 1. Major arm veins used for phlebotomy. The median cubital vein is the larger and more stable vein and is preferred for venipuncture. The cephalic and basilic veins have a greater tendency to roll and veinpuncture may be more painful from these sites.

Sometimes venipuncture is performed on hand veins when the veins in the antecubital fossa are not appropriate. Blood is collected from the dorsal or back side of the hand (Figure 2). Similar to veins in the antecubital fossa, they are prominent in different positions on different individuals. Veins in the hand have a tendency to move or roll; thus, the phlebotomist should ensure that the skin is pulled taut and the vein is well anchored down prior to needle insertion.

Figure 2. Distended veins on the dorsal side of the hand. Phlebotomy is done on the hand when veins from the antecubital fossa are not available nor suitable.

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The Laboratory Woodchuck (Marmota monax)

Christine A. Bellezza DVM , ... Bud C. Tennant DVM, DACVIM , in Laboratory Animal Medicine (Third Edition), 2015

a Venipuncture

Venipuncture in woodchucks can be challenging because they lack readily accessible peripheral veins and general anesthesia is usually required. Woodchcucks can be routinely bled from the femoral vein or artery (Fig. 8.5). Following anesthesia, the venipuncture site is clipped and scrubbed with alcohol and an antiseptic. The femoral pulse is palpated in the inguinal region and is used as a reference point since the vessels are not visible. A vacutainer tube and a 22-gauge, 1" needle may be used. Direct pressure is applied following venipuncture to minimize hematoma formation.

Figure 8.5. Bleeding the anesthetized woodchuck from the femoral canal.

Samples can also be obtained from the maxillary or linguifacial veins (Fig. 8.6) which run in close proximity to the clavicle. Here, the woodchuck is placed on its back, head toward the phlebotomist, and a 22-gauge, 1" needle is directed straight into the notch formed where the clavicle meets the sternum. Care must be taken to avoid entering the thorax. Cardiac puncture has been used and is the easiest and quickest method to obtain large amounts of blood, but complications such as cardiac tamponade and death may occur. Small amounts of blood can be obtained from the cephalic veins (on the medial aspect of the front legs) or tarsal veins (on the dorsal aspect of the rear feet).

Figure 8.6. Bleeding from the anesthetized woodchuck from the linguofacial vein.

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Intravenous Moderate Sedation

In Sedation (Sixth Edition), 2018

Disadvantages

1.

Venipuncture is necessary. Although most adult patients tolerate venipuncture with little or no difficulty, some patients are psychologically unable to "handle" needles anywhere in their body. Children may be particularly difficult to manage via this route because veins are proportionally smaller in smaller patients, making venipuncture itself more difficult. Younger children requiring IV moderate sedation will usually pose severe management problems (the "precooperative" patient) or be physically unable to control themselves. Not all patients, even adults, have veins that are easy to visualize and gain access to with a needle. Probably the most significant challenge facing the dentist learning IV moderate sedation is to develop a degree of proficiency at venipuncture. Venipuncture is a learned skill, one that becomes easier to perform as experience is gained.

2.

Complications may arise at the venipuncture site. As discussed in Chapter 27, a variety of minor and some major complications can develop at the venipuncture site. These include hematoma, phlebitis, and intraarterial injection of a drug.

3.

Monitoring of the patient receiving IV moderate sedation must be more intensive than that required in most other moderate sedation techniques. Because intravenously administered drugs act rapidly, the entire dental team must be trained to assess the physical and mental status of the patient throughout the procedure. The greater the depth of sedation (deep > moderate > minimal), the greater is the need for increased patient monitoring.

4.

Recovery from intravenously administered drugs is not complete at the end of the dental treatment. All patients receiving any intravenously administered CNS depressant must be escorted from the dental office by a responsible adult companion.

5.

Although the depth of sedation provided by intravenously administered drugs can be increased rapidly (by administration of additional drug), the converse is not true. Many intravenously administered drugs cannot be reversed by specific drug antagonists. Although antagonists do exist for several drug groups, specifically opioids, benzodiazepines, and anticholinergics, they are not recommended for routine administration. ^3–5 Should a patient become overly sedated (deep instead of moderate; moderate instead of minimal), the initial, and most effective, management in all situations is the maintenance of basic life support: assess the patient's airway, assist or support ventilation, and provide for the effective circulation of oxygenated blood. Following these steps (P-C-A-B [basic life support]), consideration may be given to antidotal drug therapy.

Box 21.1 summarizes the advantages and disadvantages of the IV route of drug administration.

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Left-Atrial Appendage Occluders

Arwa Younis , ... Michael Glikson , in Cardiovascular Thrombus, 2018

Anticoagulation During Device Implantation

Femoral venous puncture does not necessitate withdrawal of anticoagulant therapy. Nevertheless, most operators aim to perform the procedure with normal-level INR at baseline and then use intravenous antithrombotic agents (mostly unfractionated heparin) during the procedure (Table 36.4). The antithrombotic protocol of the PROTECT AF study [43] mandated an INR   <   2.0 at the onset of the procedures. ASA 81–325   mg was initiated at least 1   day before the procedure (we recommend a loading dose if the patient is not on chronic aspirin therapy). In patients who are candidates for postprocedure therapy with DAPT, a loading dose of aspirin and clopidogrel is indicated unless they are already receiving this treatment. Weight-adjusted heparin (70–100   IU/kg) is administered after transseptal puncture to maintain an activated clotting time (ACT)   >   200   s for the procedure duration [60]. However, some operators perform the procedure while the patient receives OAC with a therapeutic level of the INR, a practice analogous to the widespread use of warfarin during AF ablation. Several small studies showed that the combined procedures of catheter ablation for AF and Watchman LAA implant—while warfarin or NOACs are onboard—appear to be feasible and safe, with excellent rates of LAAO and an observed stroke rate of 0.5% per year during midterm follow-up; this without a significant increase in bleeding risk [89,90]. Intravenous administration of antithrombotic agents is generally provided (at the latest) immediately after traversing the interatrial septum. A weight-adjusted bolus of unfractionated heparin (70–100   IU/kg) is most commonly used, thus maintaining an ACT   ≥   250   s. LAAO may be performed as part of a combined procedure while a different type of antithrombotic medication is used, e.g., the direct thrombin inhibitor bivalirudin. This approach requires no further anticoagulation. Upon completion of the procedure the heparin is not reversed and various hemostatic techniques are used for safe sheath removal.

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Alcohol: Blood and Body Fluid Analysis

J.C. Hunsaker , ... G.D. Dukes , in Encyclopedia of Forensic and Legal Medicine (Second Edition), 2016

Specimen Selection and Collection – Living Subjects

Currently accepted venipuncture (World Health Organization, 2010) consists of cutaneous application of a nonalcoholic antiseptic (e.g., povidone iodine) and withdrawal of a sufficient aliquot of cubital venous or finger tip capillary whole blood by sterile needle to a sealed sterile vile (Table 6). Anticoagulants and microorganism-inhibiting chemicals are typically added. Importantly, venous blood does not precisely reflect the cerebral BAC, which ultimately defines the biochemical effects of EA, unless absorption and distribution of EA is complete at collection (Williams and Leikin, 1999a,b; World Health Organization, 2010).

Table 6. Accepted collection, transport, and storage of blood from living persons

•

Cutaneous application of nonvolatile antiseptic

•

Percutaneous venipuncture of cubital vein or finger tip capillary

•

Withdrawal of sample by sterile needle to sterile container

•

Vacuum glass collection tubes are acceptable legally

•

Filling container sufficiently to avoid evaporation

○

Use of clean container without anticoagulant allowing blood to clot (for serum)

○

1–2% NaF

•

EDTA or potassium oxalate

•

Proper labeling, laboratory request form, and chain of custody on or with container

•

Refrigeration (4   °C) or prompt delivery to analytical laboratory

•

Recording of receipt and disposition of specimen by receiving analyst

•

Analysis or storage (refrigeration or frozen (−20   °C)) of specimen

Abbreviations: C, centigrade; EDTA, ethylenediaminetetraacetic acid; NaF, sodium fluoride.

Randomly collected, first-voided urine is generally valuable only in confirming the presence of EA because the concentration (UAC) is subject to multiple uncontrolled variables (Jones, 2006; Payne et al., 1967). Over the last decade saliva, or oral fluid (Choo and Huestis, 2004), has gained acceptance as a satisfactory matrix for on-the-spot testing for EA, both qualitative and semiquantitative, applicable to workplace or clinical settings such as emergency departments.

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Venous access systems, port catheters, and central lines

Hans-Heinrich Wolf , ... Christof Kramm , in Supportive Oncology, 2011

Mechanical complications

Individuals performing venous and arterial puncture routinely use assisted sonography for catheter placement to avoid bleeding complications, especially in thrombocytopenic patients. ² In some pediatric hospitals, patients are examined even more carefully to avoid incorrect or arterial CVC placement with radiographic, echocardiographic, and blood oxygenation assessments. Before a CVL is used for chemotherapy, a blood sample should be aspirated; this should be followed by injection of saline, then drug infusion should be started. ³ Local discomfort or swelling should be assessed. After chemotherapy administration, the device should be flushed with at least 25   ml saline. Compatibility of cytotoxic drugs and central venous devices needs to be considered to avoid chemical interactions.

This chapter does not focus on surgical problems following the implantation of catheters and ports; however, complication rates depend on perioperative conditions, surgical experience, technique of catheter placement used, the product that is being administered, and postoperative care. They are also influenced by the patient's condition, age, and performance status. The port should be sutured in the fascia, preferably with nonabsorbable sutures to prevent distortion and possible catheter retraction. Port catheter retraction is a rare complication. A safe connection between catheter and port chamber should be assured by the surgeon. Any use of clamps has to be avoided. Radiographs are performed postoperatively and after extraction to ensure placement.

Implantation of port catheters is intended to provide safe venous access. However, extravasation injuries can still range up to 6%. Irritant drugs cause inflammation and pain at the site of an extravasation; vesicant drugs may induce severe soft tissue necrosis or persistent ulceration, which will require surgical treatment. Extravasation may occur as the result of leakage or needle dislocation during infusion: The puncture may have been made outside the reservoir, or the needle may have become dislodged from the port membrane. Correct placement and proper infusion rate control are important to avoid needle dislocation. Correct placement requires the catheter tip to be in the distal superior caval vein; this should be documented by radiography. Radiography should also be performed if malfunction of the port system, port occlusion, or venous thrombosis is suspected. Spontaneous migration of the catheter tip can cause pain in the neck and shoulder, phlebitis, or ascending thrombosis of cervical and cerebral veins, with an incidence of 0.9% to 1.8%. Catheters should be replaced interventionally by experienced radiologists.

Catheter disconnection is a rare complication (incidence, 0.1%–2 %). Several patient-related reasons for catheter disconnection are known, such as extensive arm movements during sports and the use of backpacking equipment. Increased intraluminal pressure, especially with catheter flushing, increases the risk of disconnection or will cause damage to the port reservoirs. To avoid excessive intraluminal peak pressures, the syringe used for injections should hold at least 10 ml; in very small children (body weight less than 10 kg), even less volume (5-ml syringes) and reduced injection time (at least 1 minute) should be provided for flushing. Port chamber defects are related to flaws in the port material or construction port defects; the device should be disposed of immediately.

Other mechanical complications include the pinch-off syndrome (Fig. 34-1), ⁴ catheter fragmentation, rupture or embolization, catheter disconnection, port chamber defects (Fig. 34-2), ⁴ and port catheter retraction, respectively. Mechanical compression of the CVL between the clavicle and the upper rib is referred to as the pinch-off syndrome and is observed in up to 5% of ports. Compression causes transient obstruction of the catheter and possibly catheter fragmentation. Impaired reflux and reduced flow may be warning signs.

The incidence of pinch-off syndrome rises with medial and infraclavicular catheter insertions. The syndrome is prevented by introducing the catheter into the internal jugular vein or by inserting it into the subclavian vein at a more lateral position between clavicle and rib. If chest radiography reveals the pinch-off syndrome, the catheter should be replaced. Catheter embolization can induce ventricular tachycardia, mechanical irritation of the myocardium, thrombosis, and endocarditis. Embolized catheters should be removed transvenously by an interventional radiologist.

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Challenges in Clinical Microbiology Testing

Laura Chandler , in Accurate Results in the Clinical Laboratory, 2013

Inadequate Preparation of the Draw Site

Preparation of the venipuncture site to inactivate skin organisms is necessary to prevent growth of contaminants. The isolation and identification of blood culture contaminants is a significant problem for clinical microbiology laboratories and for patient care providers. Workup of contaminating organisms adds extra, unnecessary work for the laboratory and, importantly, may provide misleading results to clinicians, resulting in unnecessary antimicrobial therapy for patients. Careful adherence to the laboratory's procedure for preparation of the draw site for blood cultures can reduce the growth of microbial contaminants [9,10]. A policy for workup of positive blood cultures based on the organism identification and number of bottles may help prevent excess work and misleading reports from the laboratory.

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Venipuncture Technique

In Sedation (Sixth Edition), 2018

Hollow Metal Needle

Although not recommended for use in routine IV drug administration, the hollow metal needle may be used for venipuncture in emergency situations or in procedures, such as the drawing of blood samples for laboratory analysis, when only short-term cannulation is required. The hollow metal needle will almost always be attached to a syringe, which contains a drug to be injected or into which blood is to be drawn.

Basic Technique—Hollow Metal Needle

The basic technique of venipuncture is the same as that described earlier for the winged infusion set. However, once the metal needle enters the vein, great care must be taken as the needle is advanced, because it is often difficult to obtain the correct needle angulation within the vein with a syringe attached (syringes are available that have an eccentrically placed needle, making venipuncture somewhat easier). The tourniquet is removed and the syringe held securely in place.

Before the administration of the drug, an aspiration test must be performed to confirm that the needle tip remains within the vessel's lumen. With one hand holding the syringe in position, the other hand gently pulls the plunger of the syringe until a backflow of blood is observed. This technique (drawing of blood into the syringe) is called barbotage (Fig. 24.13). The drug is then administered.

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Venipuncture Technique

Stanley F. Malamed DDS , in Sedation (Fifth Edition), 2010

Basic Technique—Hollow Metal Needle

The basic technique of venipuncture is the same as that described earlier for the winged infusion set. However, once the metal needle enters the vein, great care must be taken as the needle is advanced because it is often difficult to obtain the correct needle angulation within the vein with a syringe attached (syringes are available that have an eccentrically placed needle, making venipuncture somewhat easier). The tourniquet is removed and the syringe held securely in place.

Before the administration of the drug, an aspiration test must be performed to confirm that the needle tip remains within the vessel's lumen. With one hand holding the syringe in position, the other hand gently pulls the plunger of the syringe until a backflow of blood is observed. This technique (drawing of blood into the syringe) is called barbotage (Figure 24-21). The drug is then administered.

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What Is an Advantage From Drawing Blood From Veins

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