Dear Center for Phlebotomy Education:

Our Cancer Center is requesting we draw only from hand veins on patients who will have chemo that day and when their other arm is unavailable because of mastectomy, lumpectomy, or other reasons. This is the first time anyone has ask us to completely avoid all draws in the median area of the antecubital. My concern is that if we draw the hand and have an issue, are we 
violating the standards in regards to vein selection? What should we do?

Our response:  First, physicians can't order you to deviate from the standards without putting you at risk of operating beneath the standard of care. Your lab assumes the responsibility and owns the outcome. That said, there's nothing against the standard to draw from a hand vein when an antecubital is available. It's a low-risk draw. We've never seen a legal case involving a hand vein. However, hand veins have been found to be 2.6% less successful, and more likely to be hemolyzed by the same percentage.

The reason for this request by the Cancer Center is that many chemotherapy drugs can cause “extravasation” of the drug into the tissues surrounding a prior venipuncture should the puncture not seal completely. This can cause extreme and debilitating damage to those tissues, which, in severe cases, has caused the need for amputation of the limb. Work with the Cancer Center to the best of your ability, and notify them if you are unable to comply with their request for a hand draw. That way, they will be forewarned about the potential for extravasation in a particular area. It’s all about communication to keep our patients safe.

If you have to go this route, make sure your staff doubles their diligence in applying pressure and observing for hematoma. Keep in mind, the order will result in more syringe and butterfly draws, both of which will increase the risk of needlesticks. 

Got a challenging phlebotomy situation or work-related question? Email us your submission at [email protected] and you just might see it as a future case study. (Names and identifiers will be removed to assure anonymity.)