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Discernment and the Difficult Draw

Overcoming challenging venipunctures takes skill and experience

by Dennis Ernst • June 09, 2020


doctor giving thumbs up

If 6.4 percent of all venipuncture attempts require more than one stick, that’s a lot of frustration on both ends of the needle.(1) What can make the difference between a failed attempt and a successful collection? Discernment. Discernment is the quality of being able to grasp and comprehend what is obscure; a power to see what is not obvious. For those who draw blood samples, discernment allows the well-trained and experienced phlebotomist to rely upon more than just what meets the eye during site selection.

More than meets the eye

A physical limitation phlebotomists routinely see in their patients is veins that are not visible or easily palpated. This is common with obese patients where adipose tissue can be mistaken for a vein in the antecubital area. As with any difficult draw, discerning collectors should take their time in locating a vein, relying on their tactile survey of the area—specifically, the spongy, resilient nature of veins when palpated—to successfully discriminate between structures below the skin’s surface. To increase filling and palpability of difficult-to-find veins, lower the patient’s arm below the plane of the heart. Just be sure to avoid such techniques as slapping the patient’s skin, since this is considered overly aggressive and unprofessional. Another way to increase blood flow and aid vein location is by applying a warm compress for several minutes to the area being surveyed. Once identified, creases, freckles or contours in the skin can serve as visible guideposts to the vein’s location, helping collectors resist the temptation to repalpate the cleansed site.

Rolling, rolling, rolling

Just because a vein is visible doesn’t mean you’re home free. Veins that are not properly anchored during the draw, referred to as “rolling veins,” are a frequent cause for failed venipunctures. Insightful phlebotomists can compensate for veins that are not naturally stationary by stabilizing every vein selected prior to the puncture. This is accomplished by pulling the skin taut with the thumb of the free hand from below the intended puncture site. Techniques that anchor the vein from above and below the puncture site should never be used, as these methods place the collector’s index finger at greater risk for an accidental needlestick. If the vein is missed, a calculated relocation of the needle can be attempted by pulling back slightly or advancing the needle farther into the vein.(2) However, lateral (side-to-side) relocation of the needle is considered probing and is not recommended. Because of the close proximity of nerves and the brachial artery, needle relocation should not be attempted in the area of the basilic vein.

Delicate balance

When presented with small or fragile veins, as is often the case in pediatric and geriatric patients, a successful venipuncture requires a delicate balance between technique and the correct equipment. Selecting a smaller bore needle, such as a 23-gauge needle and applying less vacuum are two ways to reduce the stress to fragile veins. If the vein is suspected to have collapsed while using a tube holder method, trying a pediatric tube may salvage the draw. When assessing the difficulty of a draw, a syringe offers the most control over the negative pressure asserted within the vein. Should a vein collapse while using a syringe, momentarily release the pressure on the plunger, then gently pull back again. If this does not restore blood flow, terminate the venipuncture and select another site. In the event of hematoma formation, terminate the draw immediately and apply firm pressure to the puncture site until bleeding has ceased. Provide proper post-venipuncture care, according to your facility’s protocol.

Outside your element

girl having her blood drawn on exam table

Collections in unconventional settings come with their own set of unique challenges. Failure to properly position a patient can complicate the procedure, given that most draws of this nature are performed without benefit of a phlebotomy chair or other personnel. Should the patient experience an adverse reaction, the risk of injury can be significant in such uncontrolled environments. Perceptive phlebotomists know to always position the patient for safety’s sake by either seating patients in a chair with two arms or reclining them on a sofa or bed. But proper placement doesn’t just refer to the patient. Also crucial to the success of the draw is the accessibility of supplies, which should be within easy reach. This prevents the collector from having to stretch or reach across the patient in the event another tube is needed or supplies are dropped or forgotten. Discerning phlebotomists anticipate the difficulties that improper positioning can create in such situations, and make it their motto to never draw blood from a patient who is standing or seated on an armless chair, exam table, or stool.

Fear and loathing

A patient’s level of apprehension can take a what should be a routine draw and escalate the difficulty exponentially. It has been estimated that up to 20% of the population is predisposed to needle phobia.(3) Given that knowledge, perceptive phlebotomists remain on the lookout for the tell-tale signs of shock reflex in their patients, such as fainting, dizziness, pallor, perspiration, and nausea while the patient is in their care. Although there are various alternatives available to minimize a patient’s physical discomfort and anxiety, one of the simplest methods to manage needle phobia patients is to lay them flat with the legs raised and apply an ice pack to the intended puncture site for 10 to 15 minutes prior to the venipuncture.(4) Regardless of the age or level of emotion demonstrated by the patient, collectors should respond with compassion and patience rather than scolding or ridicule. Employing age-appropriate strategies to calm fears can further prevent a patient’s encounter with a needle from becoming a life-altering traumatic event. However, there are times when no amount of coaxing or cajoling can secure cooperation. Always seek assistance when drawing from combative patients, cognitively impaired patients, or those under the influence of mind altering substances using appropriate restraint as necessary.

Lost in translation

Astute phlebotomists who always use an active method of patient identification—where the patient is asked to state his/her name and other unique patient identifiers rather than merely affirm what the collector states—will quickly detect if a patient is hard of hearing or does not speak the language. Every patient deserves the right to hear and be heard. For patients who do not speak the language of the collector, interpreter services should be available to ensure proper identification, answer any questions, and provide post-venipuncture care instructions to the patient.

1) Howanitz PJ, Schifman RB. Inpatient phlebotomy practices. A College of American Pathologists Q-Probes quality improvement study of 2,351,643 phlebotomy requests. Arch Pathol Lab Med. 1994;118(6):601-5.
2) CLSI. Collection of Diagnostic Venous Blood Specimens; Approved Standard—Seventh Edition. CLSI document GP41-A7. Wayne, PA: Clinical and Laboratory Standards Institute; 2017.
3) What patients must know about needle phobia. Phlebotomy Today. 2003;4(8).
4) Ernst D. Applied Phlebotomy. Lippincott, Williams & Wilkins. Philadelphia, PA. 2005.

[Editor's Note: The Center for Phlebotomy Education has produced a video titled Successful Strategies for Difficult Draws, available in DVD and streaming versions, both available on the Center's web site. More information.]

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