Question:

We have an inpatient phlebotomist who routinely uses 20 mL syringes when she needs a lot of blood for the tests ordered. I would never teach someone to draw blood with a 20 mL syringe since we all have access to tube holders and butterfly devices. When I teach phlebotomists, I tell them to choose the appropriate venipuncture device based on the patients' vein status, age, depth, and so on. I want to wean her off such large syringes. There's a lot of disagreement among other managers on what the standards say. What should we be doing?

Our response: 

First off, you should be getting a copy of the standard. That would end your arguments faster and with more acceptance by all involved. Every lab should have a copy of CLSI's GP41 in their library. Every passage needs to be reflected in your standards and policies if you are to be operating within the standard of care. If a patient ever seeks legal representation for an injury or complications he/she thinks was the result of a blood draw, you can bet his/her attorney will get a copy and compare it with your written procedure. [Editor's note: we anticipate CLSI to release its long-awaited revision of GP41 in May or June.]

The current standard does not restrict the size of a syringe. It merely reminds users that syringes are not the safest way to draw blood, and should be avoided. That's because it is the one device that's in use when most accidental needlesticks are sustained. Sometimes the patient's vein requires a syringe if the veins are small and/or fragile, and it is anticipated they will collapse when using the evacuated tube method (needle/ or butterfly/tube holder combination). A syringe allows the user to control the negative pressure applied to the inside of the vein whereas when a tube holder assembly is in use, all the vacuum in the tube gets transferred to the interior of the vein, causing collapse in some cases. 

When the physician orders blood cultures on patients with small or fragile veins, attaching a needle or winged collection set to a syringe and applying gentle pulling pressure to the plunger may be the only way the sample can be obtained. We recommend allowing your phlebotomists to use syringes when, in their professional judgment, it would be the most successful choice of equipment.