Question about blood draws with butterfly needle

[Lippincott]

I've been having some issues stabilizing the needle once I get the flash. As a result, the flow of blood can be slow into the vacutainer, because the needle is hitting the walls of the vein, or it'll slip out completely.

What are some tips about stabilzing? What I am doing currently is inserting the needle at about a 15 degree angle and STOPPING as soon as I see a flash (because I am afraid to puncture the posterior wall of the vein). Often times, this means only a quarter of the needle is under the skin.

Should I try inserting BELOW the vein instead of on top of it, and pushing the needle all the way in until it is completely under the skin and the hub can rest on the skin? Should I not worry about puncturing the posterior wall of the vein, and pull the needle back until blood returns?

Any tips would be appreciated. Thanks,.

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[Blade28]

Sometimes once you see a flash the tip of the needle is actually at the back wall of the vein. Try pulling back a millimeter or so and see if the blood flows easily.

 

[SeventhSon]

The key is to have an angle of insertion that is very low so that this isn't an issue. If you really are putting in the needle at 15 degrees, it is very rare that you will go through the deep wall of the vein. TIn terms of knowing where you are based on the flash, this is something that you can't really explain, you have to just keep doing it and then you know. I trust my pre-stick palpation of the vein to a large extent

I've been having some issues stabilizing the needle once I get the flash. As a result, the flow of blood can be slow into the vacutainer, because the needle is hitting the walls of the vein, or it'll slip out completely.

What are some tips about stabilzing? What I am doing currently is inserting the needle at about a 15 degree angle and STOPPING as soon as I see a flash (because I am afraid to puncture the posterior wall of the vein). Often times, this means only a quarter of the needle is under the skin.

Should I try inserting BELOW the vein instead of on top of it, and pushing the needle all the way in until it is completely under the skin and the hub can rest on the skin? Should I not worry about puncturing the posterior wall of the vein, and pull the needle back until blood returns?

Any tips would be appreciated. Thanks,.

 

[msurodeo]

Try increasing your angle. For many students, the depth is not the problem. They concentrate so much on keeping a low angle that their sticks are unsuccessful. If a slight adjustment backwards doesn't fix it (because the natural inclination of beginners is to inadvertently continue to advance the needle because they're concentrating so hard) a slight increase in your angle usually will. And, don't overanalyze too much. Just keep plugging away at it. (No pun intended) It's only blood draws...after you have a few hundred under your belt you'll be able to stick a baby in a dark room.

 

[lord_jeebus]

The key is to have an angle of insertion that is very low so that this isn't an issue. If you really are putting in the needle at 15 degrees, it is very rare that you will go through the deep wall of the vein. TIn terms of knowing where you are based on the flash, this is something that you can't really explain, you have to just keep doing it and then you know. I trust my pre-stick palpation of the vein to a large extent

Venous access master and physiology master (on the Step I forum)!?

Please tell me you're thinking anesthesiology

 

[DrBubbles]

The other trick I learned is not to visualize the entry point of the needle into the vein, but to visualize the pathway of the needle into the vein. So, instead of keeping your eyes vocused on what's happening at the sight of insertion, try and 'watch' the tip of the needle as it travels through the vein--this may help get the right angle and the right depth.

 

[Ashers]

The needle might also not be in the vein as far as you think, especially if it's falling out. The flash just means the bevel's in, some adjustment of the position, as others have described, will most likely increase the flow, unless the vein in blown.

 

[SeventhSon]

i'm DT free clinic Lab Manager (i do all the blood draws)

And yeah actually I should correct myself... a large angle of insertion isn't necessarily a bad thing... it's actually your best bet when you can only palpate your best vein for super-short distance, but it definitely increases the chance you will pierce the deep wall

 

[howelljolly]

Something else you might try, if you know how to start an IV...

Its all a matter of Feeling. Start a medium bore IV (~20g) on a really prominent distended (easy) vein. Pay attention to feeling the resistance of the vein, and the "pop" when you get thru. Pay attention to the lack of resistance while you thread the catheter. Note any increased resistance when the catheter touches the vessel.

A butterfly is much the same feelings on a finer scale (same entry angle smaller pop, less resistance changes). Feel where you are and where you are going. (just dont get carried away and go too far)

Once the butterfly is in, and flowing, stabilize ONE of the butterfly wings with one finger on your hand which is stabilizing the patients arm. The patents arm and the butterfly, which is threaded inside the lumen of the vein will move as one unit.

Hope that helps

 

[patzan]

call a nurse or phlebotomist - not a 1st year med student.

 

[howelljolly]

call a nurse or phlebotomist - not a 1st year med student.

Oh, right! I forgot what I actually had done when I couldnt get the blood.

 

[LJDHC05]

Sometimes if you straighten out the tubing a bit, or apply a little bit of backwards pressure on the tubing while stabilizing the needle with your other hand it helps with the flow rate.

Failing that, you're either in too far or not far enough, and you'll learn how both of them feel eventually. I usually continue to advance slightly after I see the flash. You're almost never against the deep wall unless you're at a really steep angle of insertion. If you pull out too early, you'll blow the vein and the patient will give you all sorts of angry looks while you search for another (especially when they're deathly afraid of needles).

 

[Cranial Gavage]

I used to have the same problem early on as a phlebotomist. For me, the most common reason for a butterfly to stop after a flash is illustrated below:

Simply increasing the angle (without even changing the level of penetration) can restart the flow.

 

[Cranial Gavage]

By the way, I avoid the butterfly in favor of the vacutainer + needle whenever possible. It takes a bit more practice to use, but you may like it better once you're comfortable with it (faster tube filling, fewer flow problems.)

 

[geogil]

If you can't get the butterfly to work, use a syringe. Sometimes the blood stops flowing with a butterfly/vacutainer combo because the vein walls are being sucked together by the vacuum from the tube. When this happens, you usually get a small splatter of blood in the tube and then nothing flows despite any readjustments. I prefer syringes to butterflies because they're safer and you have just as much control over depth and angle. Good luck, and really, the key is practice practice practice.

 

[howelljolly]

If you can't get the butterfly to work, use a syringe. Sometimes the blood stops flowing with a butterfly/vacutainer combo because the vein walls are being sucked together by the vacuum from the tube. When this happens, you usually get a small splatter of blood in the tube and then nothing flows despite any readjustments. I prefer syringes to butterflies because they're safer and you have just as much control over depth and angle. Good luck, and really, the key is practice practice practice.

Correction, if I may.

You really shouldnt use a just a needle and syringe to draw routine peripheral venous blood and especially not to give IV meds. Especially not with a 21 - 21 gauge needle like the one on a butterfly. For an arterial or femoral venous sample, its fine.

For the routine draws, Im not sure why its not used. It might have to do with hemolysis of the blood in the syringe. However, if it has to do with the needle, angle of insertion, or technique, but not the syringe itself, you might try this method which still allows you to control th vaccuum with a syringe:

Carefully twist off the grey latex covered spike from the back of the butterfly tubing, and attach the syringe without the needle to the leuer (sp?) lock connection remaining on the tail end of the butterfly tubing. (So you have butterfly>tubing.syringe)
Use the butterfly needle as usual, and control the amount of vaccuum by pulling back on the plunger.
Then you can fill the test tubes by poking the rubber stopper with the blood filled syringe.

 

[ecca58]

This is what helps me whenever I have to butterfly someone.

(1) Insert butterfly needle with a larger-than-expected insertion angle (for me, I stick people around 20~30 degree angle).

(2) Stop advancing when flash is noted to prevent complete piercing of the vein.

(3) Decrease the insertion angle (for me, it's probably 15 degrees)

(4) Advance the needle a little bit more for stabilization.

This is what I was taught by my orientor in the ED. It also helped me alot on my IVs, too. I hope it helps!!!

 

[Flopotomist]

Correction, if I may.

You really shouldnt use a just a needle and syringe to draw routine peripheral venous blood Especially not with a 21 - 21 gauge needle like the one on a butterfly. .

For the routine draws, Im not sure why its not used. It might have to do with hemolysis of the blood in the syringe.

Is there any evidence to support this? I often use the butterfly attached to a syringe as a rescue draw in the hand if I can't manage to just use a regular needle/vacutainer somewhere else. I find that if I hook a vacutainer directly to the butterfly in a really small vein, the walls collapse on each other from the powerful vacuum, and I can control this better with a syringe.

Seems like there would be LESS hemolysis from a SLOWLY filled syringe than from a rapidly filled vacutainer.

 

[howelljolly]

Im not sure. but, some things that might make a difference...

the surface of the inside of the syringe making contact with the blood (its plastic, not glass)

transfering the blood from the syringe to the tube may hemolyze it (it fills VERY rapidly)

But, besides that, its pretty well accepted these days that a syringe and regular needle into a vein is a bad idea.

 

[Flopotomist]

But, besides that, its pretty well accepted these days that a syringe and regular needle into a vein is a bad idea.

pretty well accepted by whom? Is there evidence to support this somewhere because a quick pubmed search reveals that the vactuainer (in at least one study) had HIGHER rates of hemolysis contrasted with a needle and syringe.

http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

 

[howelljolly]

I dont know. There are tons of dogmatic statements that medical types repeat because they hear them, and take them on faith rather than evidence.... maybe because they arent worth testing. For example, you cant draw blood from the arm that is ipsilateral to a mastectomy; or administering supplimental oxygen to a COPD patient will terminate their hypoxic drive to breath.

I learned that IM, SubQ, and intradermal injections are done with a syringe and needle; IV medications are administered by angiocath, butterfly, PICC, or central line; Blood is drawn with a butterfly, vaccutainer, or a fresh med lock.

Intuitively I'd say that these techniqes are designed to minimize vein rupture with a needle and syringe.

IV access with a syringe and needle is called a "hotshot" and is against the "rules" where I used to work.

And this is what I taught my students about phlebotomy and IV access.

Ive been trying to avoid using that term for fear that you'll now go and use that technique every time.

Do what you want. I plan on never drawing blood from a peripheral vein again.

 

[geogil]

I am not talking about pushing IV meds. You don't do that with a phlebotomy needle anyway. There is absolutely nothing wrong with a 21 gauge needle. Using a syringe with a needle is just fine for drawing blood. Why wouldn't it be? It gives you far more control over the rate of flow into the syringe and there is less hemolysis. I worked as a phleb for several years and never had any problems using syringes.
-I agree that using a needle in a IV is a dumb idea
-If you're using a 23 G butterfly, or a 23 G needle, the vein doesn't know the difference. Really, the size difference between a 23, 21 and 20 G aren't huge. I don't see why using a syringe is a bad idea. At the lab I worked for as an undergrad something like 90% of the dirty needle sticks came from butterflies, which was way disproportionate to the amount they were used. For that reason, I say that butterflies are less safe than syringes.

 

[howelljolly]

I'd find it difficult to hold the business end of a syringe perfectly still while pulling back on the plunger... especially if the patient can't hold their own arm still. So, Id be worried about rupturing a vein. I guess thats just me.

As far as pushing meds thru a butterfly, theres actually nothing wrong with that. It even says so on some of the packages for butterflies, and at least one brand doesn't even include a spike (you have to attach a spike thats used for saline locks. An ER that I worked at did it often. (For someone who needs just one IV medication, and is being discharged)

 

[geogil]

Im not sure. but, some things that might make a difference...

the surface of the inside of the syringe making contact with the blood (its plastic, not glass)

What do you think SST and PST tubes are made of? All the tubes I've ever used were plastic, excepting citrate coag tubes. The only problems plastic causes are platelet aggregation, which is why glass is used in coag.

transfering the blood from the syringe to the tube may hemolyze it (it fills VERY rapidly),

Yes, but the tube pulls blood out of the vein at exacly the same rate! the vacuum in the tube is the same regardless, ergo the rate of filling is the same.

But, besides that, its pretty well accepted these days that a syringe and regular needle into a vein is a bad idea.

NO. I don't know where you heard this, but it's not true. Do you have any evidence to show that it's "pretty well accepted"?

 

[geogil]

I'd find it difficult to hold the business end of a syringe perfectly still while pulling back on the plunger... especially if the patient can't hold their own arm still. So, Id be worried about rupturing a vein. I guess thats just me.

Yeah, it just takes practice. I would do this on hands sometimes, just to make sure that I could use a syringe anwhere anytime. There were times when I didn't have a butterfly and only had a syringe, so being able to do anything with a syringe is a useful skill (we're talking blood draws, not meds). You're right though, the danger of blowing a vein goes up. You just need steady hands and good judgement. Obviously, this is not a technique to use on a combatitive or shaking patient.