Remember that veins should ideally feel bouncy. Hard and dense structures may be nerves or tendons. Subcutaneous tissue feels squishy and muscle feels hard. If a vein feels hard, it may be scarred or sclerosed. Warning: Make sure you are confident that the structure you’re palpitating is indeed a vein. Inadvertently nicking a nerve causes intense pain. Additionally, a hematoma may compress the nerve and lead to long-term damage.
Warning: Do not make lateral (side-to-side) movements with the needle. This is very painful, risks damage to underlying structures, and widens the needle hole to prolong bleeding time.
Elderly patients often have fragile skin and veins that roll quite easily, When a vein rolls, the needle tends to push the vein aside rather than penetrating through. Therefore, your anchor should be gentle but firm to prevent the vein from moving away from you. Warning: Some phlebotomists use a method of anchoring called the “C-hold”, in which the index finger pulls upwards superiorly while the thumb pulls downwards inferiorly. While this may be effective in some difficult draws, the risk of a needlestick injury is higher if the patient has a withdrawal reflex and the needle recoils back into your finger.
Needle not inserted far enough: the bevel is in the skin or subcutaneous tissue and has not penetrated the vein. This is a common occurrence when drawing from obese patients. To correct this issue, slowly advance the needle forward. Needle is partially or completely through the vein: the bevel penetrates the posterior wall of the vein. A small spurt of blood may appear in the hub as the bevel travels through the vein, but no blood flow is established. This happens when the needle is advanced too far, too quickly, or at too steep of an angle. A bevel that is partially or completely through the vein has the potential to cause a hematoma when blood leaks out of the vessel into the surrounding tissues. To correct this issue, anchor the vein and withdraw the needle slightly until blood flows. . Needle is only partially in the vein: the bevel is beneath the skin and has begun to penetrate the vein, but not completely. Blood flow may be very slow. To correct this issue, anchor the vein and slightly advance the needle. Needle is against the vein wall: the bevel is pressed against the wall of the vessel, impairing blood flow. This may happen if there is a bend or fork within the vasculature. To correct this issue, either withdraw the needle slightly or rotate the assembly a quarter-turn. Needle is in contact with a valve: the bevel is stuck in a venous valve, impairing blood flow. A subtle vibration or buzzing sensation may be felt as the valve attempts to open and close. This may happen if there is a bend or fork within the vasculature. To correct this issue, withdraw the needle slightly. Needle is beside the vein: the bevel pushed and slipped past the vein rather than penetrating the wall, a phenomenon known as “rolling”. This most often occurs when the vein isn’t securely anchored and taut. To correct this issue, hold a firm anchor and attempt a redirect.
If you are using a butterfly, try to retie the tourniquet around the patient’s arm to increase pressure and re-establish blood flow. You may also remove the tube, wait a few seconds for blood flow to resume, and then engage a short drawtube.
Use pillows or foam wedges to elevate the arm and help with extension. If the patient is sitting in a phlebotomy chair, make sure they are sitting upright with their back against the chair. Adjust the height and swivel the chair to ensure your body is in line with the vein. Try rotating the arm to better expose the cephalic or basilic vein.
Keep in mind that elderly patients often have fragile veins. Too tight of a tourniquet may cause the vein to collapse upon needle insertion.
Each time a vein is accessed with a needle, scar tissue forms as part of the body’s healing process. Over time and with several repeated punctures, significant amounts of scar tissue builds up. This makes every subsequent poke harder and harder because scar tissue is more fibrous and tougher to puncture. Look for visual clues which may help assess the patient’s condition. Patches of purple or yellow may suggest bruising after a recent venipuncture. Scan the skin for lines of blue indicating a prominently visible vein. Track marks are not only found on IV drug users, but also on chronically ill patients requiring repeated vascular access and blood draws and may be a sign of an anticipated difficult draw. Be methodical in your search for a vein. Start with the arm closest to you and palpate the antecubital fossa. Feel for the median cubital first, the cephalic vein second, and the basilic vein third. Switch to the other arm if you can’t find anything. Look at the dorsum of the hand as a last resort.
A 21-gauge needle (e. g. BD Eclipse green-capped) is used for most routine and uncomplicated venipunctures. 23-gauge needles (e. g. BD Eclipse black-capped) have a smaller diameter and may be more suitable for smaller veins. Butterflies are incredibly valuable tools for tackling difficult draws, owing to their precision, shorter shaft length, and maneuverability. By holding the needle either by the plastic wings or the hub, phlebotomists can achieve a shallower angle, typically 10-15 degrees.
