Course of action after failed venipuncture

[Castro Viejo]

POLL: SEE ABOVE

For those of you who have become quite adept at the art of phlebotomy, what has become your second option after numerous, failed attempts at drawing blood through the antecubital vein, veins of the hand or forearm? Just curious. There's no wrong answer in the poll above.

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[Diogenes]

dude, if you post this question on the "yes... I found my broken antenna" thread in the lounge I bet oldman will answer it for you. He's a phlebotomist.

 

[Nanon]

You optimally should quit after 3 failed sticks, and get in someone better. A and Fem-sticks are really, really painful and require a lot of finesse... if you aren't getting a vein, you probably won't be getting an artery. And unless you've been doing venipuncture on junkies, it's hard to get a foot stick on a concious (ticklish) patient. At least, that's been my experience.

Nanon

 

[mile_26]

I will "hot-pack" the area (arm & foot veins) for 20 mins and try again. But, after 3 sticks, I will have someone else give it a try. I have called Anesthesia to get it...and they have used the neck veins--in an emergency. I do not like arterial sticks.

 

[tussy]

At my institution the junior resident is that last person called for IVs (ie called after nobody else can get it) that means i have to get it cause there is nobody else to call in which means many many pokes in a tough patient. If it's absolutely impossible and the patients needs an IV, then i'd have to put in a central line. Therefore I've gotten pretty good over the last year.

Here are my tricks:

Use a BP cuff rather than a rubber tourneque - pump it up somewhere between the patients systolic and diastolic pressures - it'll hurt the patient, so don't leave it up too long.

Wrap the patients arm in hot, wet towels. Wrap it really well, then come back in 10 minutes so the veins are nicely dilated.

Use local anesthetic if you're in a sensitive area or are trying many many times, or you have a nervous patient

For venepucture - use a butterfly connected to a syringe or vacutainer. You can get into smaller veins that way.

Take your time - don't just stab randomly.

For IVs - the external jug always works when there is nothing else left - use a large bore IV (i like a 16 or 14 gauge). If the patient is aggitated, then suture your IV in place and then tape it down well with lots of tegaderms/opsites. It'll be next to impossible for the patient (or nurse) to accidently yank it out.

 

[Darth Vader]

I hate hate hate having to try again after missing the first time. Especially when they are so nervous and cringe the first time. I know that it doesn't actually hurt that much to have your blood drawn, but some people get soo emotional about it that it really helps if you can get it the first time. I always try to get a nurse to do it if I missed the first time.

 

[Castro Viejo]

Originally posted by Darth Vader
I hate hate hate having to try again after missing the first time. Especially when they are so nervous and cringe the first time. I know that it doesn't actually hurt that much to have your blood drawn, but some people get soo emotional about it that it really helps if you can get it the first time. I always try to get a nurse to do it if I missed the first time.

Try to get a nurse to do it at a municipal hospital. Boy, you must go to one of them fancy private schools.

 

[tussy]

Originally posted by Darth Vader
[B I always try to get a nurse to do it if I missed the first time. [/B]

I only get called to do IVs and venipucture after all the nurses and the IV team have failed.

 

[Castro Viejo]

Originally posted by Nanon
You optimally should quit after 3 failed sticks, and get in someone better. A and Fem-sticks are really, really painful and require a lot of finesse... if you aren't getting a vein, you probably won't be getting an artery. And unless you've been doing venipuncture on junkies, it's hard to get a foot stick on a concious (ticklish) patient. At least, that's been my experience.

It's been my experience that in an obese patient the best thing to do, after you've gone through the ritual of putting the tourniquet on, feeling for a vein, and then taking it off in frustration, is to just do an a-stick. They're painful, I'm sure, but if you gotta get the blood you gotta get the blood, and they're somewhat easy if the patient has a nice, hefty pulse. If it's something that can wait until the morning and God smiles on you, hopefully phlebotomy will come and do it -- but they've been known to go for an artery as well.

I'll have to ask Old Man.

 

[12R34Y]

I agree with all of your methods except one.......the use of a local anesthetic prior to venipuncture.

If you are referring to using intradermal lidocaine to numb the area first then I disagree. I think if you have a nervous patient then one stick is better than 2. Secondly, the lidocaine burns like a son-of-a-gun. Thirdly, the bleb you created around the vein causes the vein to actually disappear more.

If you were referring to a topical numbing agent like creams than I agree with you.

and most definately.....the EJ is a very great way to gain access.

later

 

[vixen]

hey i had an arterial line done last night....the doc had to put lidocaine 3x and still couldn't find my artery...she said it was so tiny, she used a guidewire and stillcouldn't find it....they called they anesthesiologist on call, and while he was making it there, she tried again, and didn't really get it and blood was pouring into my hand...when the anesthesiologist got there, he also had to use a guidewire, but eventually got it.....now my wrist hurts like a b!tch....do think thats why it took so long to get it, cause my wrist is so small and my artery was hard to find?

 

[Castro Viejo]

I think an arterial line ordinarily requires a guide wire -- those things are a bit floppy to be used to fish for an artery. Anyway if it was difficult to get then it's conceivable they kept missing it and that means that it's entirely possible that it's small. But of course it could just be that their skill in placing a-lines wasn't up to snuff. Oooh... Fightin' words.

 

[StellaBlue]

Hot pack...dangle the limb. Never a local because the initial stick could cause vasoconstriction...fight or flight...a couple of light slaps on the vein...use the smallest gauge indicated if only for a draw or first IV acsess in a stable patient. Patience is a key....being to eager to fill the 10cc or 20cc syringe can loss the site. I always make certain that I have the pt's skin taut...easier to puncture, prevents rolling...if they do roll I find a nice biforcation to start from....even when, in an obese pt, you have no visual...know your anatomy...or a vein may not be clear but a slight discoloration indicating one is. After the 2nd try pass it to someone else...being frustrated is not condusive to a stick. Just some thoughts...

 

[CANES2006]

Please don't try for the foot. It is super painful to get sticked with a needle there. Spare the poor patient some pain.

 

[surg]

Since I only get called after phlebotomy has tried and given up and nursing isn't taught phlebotomy any more where I am (so the more experienced nurses can be helpful, but the junior ones in general have done less than a medical student) I am in the uneviable position of having to get blood or else!
Practice, practice, practice. It will save you hours of sleep as an intern to be able to put in an IV or draw blood quickly, especially if you have a VA in your residency.

My mental algorithm for phlebotomy looks like this (IVs are a whole different story):
1) Ask pt where they have tried already and how many times they tried (you would be surprised how few times people try before they give up)

2) If pt reports multiple sticks in forearm and hand, I take a quick look at them with a tourniquet on. If it is because their hands are swollen with edema I have them put their hand on their bedside table and lean on it with my hands for a while to squeeze out the edema and then go for it. Otherwise, I skip straight to #4

3) tourniquet above the elbow and look for a visible vein anywhere that looks reasonable and try with a 20g butterfly

4) if no vein: do an anatomic stick of each antecub, based on my knowledge of anatomy, I usually try both the antecubital and the basilic veins, and sometimes the cephalic just to be complete.

5) If that fails (not to often) I got to the foot and take a look, usually there is a visible vessel and I slap some lidocaine jelly on it and come back in about 10 minutes and come back (no study shows this works, but it makes it feel cool and patients convince themselves it doesn't hurt as much, the wonders of the placebo effect). If there is no vessel, I access the vessel in the crook of the ankle (if you dorsiflex the ankle you will feel a little fossa right smack in the middle of the anterior part of the ankle where a branch of the saphenous is). If there isn't a good flow there, I see if I can draw the saph. vein on the leg.

6) If I'm really striking out: radial art stick, if having trouble consider marking the artery using a doppler

7) finallly when all else fails femoral stick (I really don't care if it is the artery or vein to be honest). This is something you can numb them up for since you know it's going to be there.

I'd say 95% of the time I can stop at #4, 4.9% of the time I can stop by #6, and I can count the number of fem sticks I've done purely for venipuncture on one hand probably. I've done the dangle thing (not unusual for me to kneel on the floor with the hand hanging off the bed to draw a smaller hand vein), but not a hot pack, I'll have to try that. Makes sense to me.

 

[The kitchen sink]

For blood draws, I look for visible veins (as above posters have mentioned), you'd be surprised what people can miss. Otherwise, I a-stick and move on with my life (I work in a large, busy city hospital).

 

[realfakedoctor_md]

Though not a doc, I work as a Tech in a busy urban ED that has been gracious enough to teach us ultrasound guided IV placement. My go to after 2 misses peripherally is to break out the US machine. Usually the basilic vein works best, though sometimes you can spot median cubital vein really clearly. Both usually allow for the placement of a 16g, 18g, or 20g. With more practice, starting US guided lines becomes relatively quick (nearly as quick as peripheral for some of the more experienced Techs). If it's an emergency and a US IV doesn't work, docs will place an EJ or an IO while I work on getting a large bore IV.