To sum up, manycomplications and subsequently, injuries, can arise from a venipunctureprocedure. In order to minimize the risk of complications or injuries, extraattention and precaution should be given by the phlebotomist during theprocedure.
Phlebotomists should bear in mind to never be over complacent andtake things for granted during the procedure which can resultin complications or injuries of varying severity. Causing a patient permanentinjury for life or causing a needle stick injury to the phlebotomist themselvesis irreversible and apologizing or being filled with regret then will be toolate. Additionally, the safety of both the patientsand phlebotomists is of utmost importance and should never be compromised atany point of time. Not only should phlebotomists be vigilant, but also be aware of the complications that may arise fromor during the procedure, make informed decisions, and to think on their feetand react promptly to different situations. Phlebotomists plays acrucial role in medical diagnosis, preventive healthcare and treatment ofdiseases.
It is of great importance to keep in mind these points to ensure thatthe entire procedure is performed successfully and the risk of complications orinjuries are minimized.The Centers for DiseaseControl and Prevention (CDC) estimates that about 385,000 sharps-related andneedle-stick injuries have occurred to hospital-based healthcare personnel (Cdc.gov,2015).
These injuries are primarily associated with the transmission ofinfectious diseases such as, hepatitis B virus (HBV), hepatitis C virus (HCV),and human immunodeficiency virus (HIV), as well as other pathogens (Cdc.gov,2015). In 2011, 52% of percutaneous injuries happened during the usage ofhollow-bore needles and 41% occurred after usage and the disposal of needles (Cdc.gov,2011). 30% of the percutaneous injuries using hollow-bore needles happened dueto percutaneous blood sampling and 27% of that was during venipuncture (Cdc.gov,2011). It has been estimated that 56% of the injuries that occurred could beprevented by using safer devices that are available, using needles only whennecessary, ensuring proper disposal of sharps, activating the safety deviceafter usage and having safer work practices (Cdc.
gov, 2011).Apart from thecomplications that may arise, the nature of the job places phlebotomistscontinuously in potential needle-stick situations, and they may experience ahigh absolute number of injuries.Consequently,partially filled tubes will result from these instances. The amount ofanticoagulant manufacturers place in their tubes is calculated to provide theproper blood-to-anticoagulant ratio when completely filled.
Therefore, all tubes should be filled totheir stated volume. Short draws disrupt the physiology of the specimen andalter the anticoagulant-to-blood ratio, resulting in hemolysis and producingspurious results. Phlebotomists who submit a tube that does not reach thestated volume put the patient at risk of being diagnosed, medicated and/ortreated according to erroneous results especially in the case of coagulation tests.The tube most sensitive to underfilling is the sodium citrate tube used forcoagulation studies.
Any citrate tube filled less than 90 percent of its statedvolume will yield falsely lengthened activatedpartial thromboplastin time test results and can result in the physicianadjusting anticoagulant dosage to a degree that risks serious complications.Additionally, underfilling a EDTA tube leads to erroneous results due toexcessive anticoagulation. When the ratio of EDTA to blood is too high, the redcells tend to shrink. As a result, hematocrit, mean cell volume (MCV), and themean corpuscular hemoglobin concentration (MCHC) will be affected.Failureto draw blood or a short draw, where insufficient blood is collected, may bedue to several factors such as improper insertion of needle, loss of vacuum intube and vein collapse. Not inserting the needle deepenough, inserting the needle through the vein or movement of the needleout of the vein while the tube is filling will resultin no blood flow, while holding the needle bevel against the vein wall willresult in reduced blood flow.
Occasionally, tubes may have no vacuum because ofmanufacturer’s error or a defect in the tube. Loss of tube vacuum canresult from exposing the bevel of the needle to the air when collecting fromvery superficial veins. Small or fragile veins, such as those seen in elderlypatients, may collapse in response to the suction of the tube vacuum orexcessive force in drawing back on the syringe plunger. If this occurs, veins will seem todisappear. It is best to carefullyevaluate the patient’s veins before venipuncture and select the appropriateequipment for the vein selected.
Amongcomplications associated with phlebotomy, nerve damage can occur which ispotentially serious and often results in lawsuits. Occasionally, even whenproper technique and equipment are used, a patient may sustain nerve damage.Damage to nerves can be permanent. Nerve damage can occur when the needle hitsa nerve that runs close to the vein identified, causing a sharp, pain electrictingling sensation. This is caused by excessive probing, selection ofinappropriate insertion sites or convulsions by the patient during phlebotomy.Additionally, if the side or backwall of the vein is ruptured, blood may flowout and press on the nerve(s) resulting in a compression nerve injury.
Compression nerve injuries can be very subtle compared to direct punctures andmay take days before signs of damage are recognized.TheU.S. National Library of Medicine explains that a risk of infection is presentwhenever the skin is broken (Boyd, 2017). Inadequate cleaning of the insertionsite, poor aseptic techniques or using contaminated equipment can lead toinfections which may be localized or systemic. Cellulitis is an inflammation orinfection in the tissue below the skin surface.
It is a rare complication ofvenipuncture. Cellulitis is more likely to occur when fluids are given thanduring a blood draw. Phlebitis is an inflammation of a vein, which is anothercomplication of the venipuncture procedure. Sepsis–a serious bloodinfection–is also possible following venipuncture.
Sepsis is more likely tooccur in patients who have a compromised immune system. This includes theelderly, patients with immune system disorders and those taking drugs tosuppress the immune system. Burned areas on the arm should be avoided as it isvery sensitive and susceptible to infection. Properly cleaning the site priorto venipuncture, good aseptic techniques and keeping any dressing over thevenipuncture site clean greatly reduces the risk of infection-relatedcomplications.Hemolysisresults from the breakdown of red blood cells and the release of hemoglobininto the plasma/serum portion of the specimen. Severe hemolysis may affect test results and is often due to impropertechnique. Several factors may contribute to hemolysis such as drawing bloodfrom a hematoma, not allowing alcohol to dry before beginning venipuncture, notwiping away the first drop of blood from skin puncture, using small gaugeneedles, excessive force on syringe plunger, excessive probing, forcing bloodfrom a syringe into vacuum tubes, inappropriate blood-to-anticoagulant ratiodue to underfilling, vigorous mixing of tubes and rough handling duringtransport. Hemolysis may also result in falsely elevatedpotassium, magnesium, lactate dehydrogenase, iron, phosphorous, ammonia andtotal protein levels.
Hemolyzed samples may show decreased red cell count andhematocrit. Asmentioned previously, hemoconcentration is another complication that can arise.Prolonged application of the tourniquet can result instagnation of the normal blood flow: this is known as venous stasis. Whenvenous stasis occurs, the plasma portion of the blood filters into thesurrounding tissues leaving behind larger molecules such as red blood cells,enzymes, iron, and calcium. This change in balance is known ashemoconcentration. Hemoconcentration can also be caused by other situationswhere extensive blood pooling occurs, such as vigorous clenching of the fist,long-term IV therapy, probing, sclerosed or occluded veins, edematous areas andhematomas.
Hemoconcentration may result in falsely elevated potassium,magnesium, lactate dehydrogenase, phosphorus, ammonia and total protein levels.Hematomaformation is the most common complication of venipuncture. This occurs when theneedle is improperly inserted or partially inserted into the vein, allowing theleakage of blood from the vein into the surrounding tissues and accumulationunder the skin during or following venipuncture. A primary indication isswelling around the venipuncture site while the needle is being inserted whichwill result in a bruise. Blood collection from these areas is not painful tothe patient but may result in the collection of old hemolyzed blood rather thancirculating venous blood, due to a slowdown of blood flow to the area. Additionally, pressure from the bloodcollected in the tissues may apply pressure to the blood vessels in this area,interfering with blood flow and resulting in hemoconcentration in samplescollected from this area. Hematoma can be caused by excessive probing, largegauge needles, small fragile veins, partial insertion of needle into the veinallowing leakage, penetration of needle through the vein, removal of needleprior to releasing the tourniquet, insufficient pressure not applied followingvenipuncture and bending the arm up at the elbow while applying pressure.
Theelasticity of vein walls is usually sufficient to prevent blood leakage duringvenipuncture; however, older patients and patients with small or difficultveins may be more susceptible to the formation of a hematoma. Additionally, theUniversity of Maryland Medical Center reports that, occasionally, a patientwill bleed longer than normal after a venipuncture (Boyd, 2017). Thisis more common in patients with certain bleeding conditions such as hemophilia.Patients on anticoagulant therapy, blood thinners, certain drugs (eg. aspirin) or with low platelet count are also at increasedrisk of this complication.Venipunctureis the act of puncturing the vein as part of a medical procedure, typically towithdraw a blood sample or for an intravenous injection. Venipuncture has beenpracticed for centuries and is the most common invasive medical procedureperformed by trained medical professionals known as phlebotomists.
Thisprocedure requires skills in identifying a vein, inserting a needle into thatvein and then extracting blood without any complications. Despite the caretaken and prior training, a variety of adverse complications may arise fromvenipuncture collection. There are many complications that can surface, however,more common complications in venipuncture include hematoma formation,hemoconcentration, hemolysis, infection, nerve damage and failure to draw bloodor short draw. Additionally, not only can patients sustain injuries through theprocedure but phlebotomists are at high risk of sustaining injuries too, due tothe nature of their job.