Phlebotomy/IV catheters

What are the indications for venipuncture?

- any time a sample of venous blood is necessary in quantities larger than those readily available by finger stick methods

- can be diagnostic or therapeutic

Caution needs to be taken when considering venipuncture for patients with what conditions?

- Anticoagulant or antiplatelet therapy

- DIC

- Hyperfibrinolysis

- Thrombocytopenia

- Hemophilia

- Other bleeding disorders

What are the characteristics of good veins?

- larger the better

- bouncy and resilient

- well anchored (don't want it to "roll")

Which vein is best for venipuncture because of prominence and accessibility?

median cubital

What else can be done upon initial insertion with an IV?

draw blood from IV catheter site prior to fluid administration

What does the C/I for venipuncture have to do with in general, instead of listing it all out?

site selection

Do not perform venipuncture if the area or extremity is affected by:

- lymphedema or s/p lymph node dissection

- Ipsilateral mastectomy

- A limb with a vascular anomaly such as an AV fistula/ shunt (for dialysis)

- An arm with a cannula in place

- An IV infusion catheter distal to the proposed site of venipuncture

- Skin infection, rash, newly tattooed area, or with extensive scarring

- Hematoma

- Preexisting phlebitis or sclerosed veins

- Severe vascular disease or venous obstruction (DVT)

What are the components of whole blood?

- RBCs

- WBCs

- Platelets

- Plasma

What is plasma?

- fluid in which cells are suspended in the circulation/vasculature

- contains proteins, clotting factors, and fibrinogen

What is serum?

its what is left over when fibrinogen is removed from the plasma (without clotting factors or proteins)

What dictates what type of specimen is required?

type of test

STAT labs are often performed on what type of specimens?

plasma

What is a light blue top used for, what is the additive, and what does it collect?

- whole blood

- sodium citrate additive

- coagulation studies

What is a red top used for, what is the additive, and what does it collect?

- serum

- no additive

- blood banking, serum chemistries, and immunology/serology

What is a green top used for, what is the additive, and what does it collect?

- plasma

- heparin salt additive

- plasma chemistries

What is a lavender top used for, what is the additive, and what does it collect?

- whole

- EDTA additive

- CBC/A1C

What is similar to the lavender top, but is used in blood banking, type and cross, and type and stain?

pink top

What is a brown top used for, and what does it collect?

- plasma

- venous lead levels

What is a yellow top used for, and what is the additive?

- Acid-citrate-dextrose (ACD) solution additive

- HLA phenotyping and DNA, paternity testing

What is typically drawn last?

gray top

What is added to the gray top and what is it used for?

- Glycolytic inhibitor

- Glucose determinations

What is a royal blue top used for, what is the additive, and what does it collect?

- plasma or serum

- toxicology, trace element, or nutrient studies

What is the green-gray top (CAMO) and what is it used for?

- plasma separator tube

- chemistries

What is the red-grey top (TIGER TOP) and what is it used for?

- seru separator tube

- cheistries, lipids, etc

What is the black top used for?

ESR

What is the order of draw?

1. Yellow (culture tubes)

2. Light blue

3. Red THEN Tiger top

4. Camo THEN green

5. Lavender, pink, or pearl/white

6. Gray

What are the potential complications of venipuncture?

- Pain/discomfort

- Missed vein

- Puncturing through the vein

- Collapsed vein

- Bleeding, hematoma, or ecchymosis

- Thrombosis

- Infection/ inflammation (cellulitis/phlebitis)

- Vasovagal syncope/dizziness

What do you do if you miss the vein?

gently redirect needle, avoid snaking around

What do you do if you puncture through the vein?

withdraw the needle slightly

What should you try if the vein collapses?

try a smaller vacuum tube

What can help with vasovagal syncope/dizziness during venipuncture

supine positioning helps

What are the indications for IV catheterization?

- administer fluids, blood/blood products, and medications

- administration of diagnostic substances (dyes or contrast) or some nutritional components

What are the C/I to IV catheterization?

- sites of cellulitis, thrombophlebitis, significant burns, or lymphedema in any extremity.

- lower extremities of patients with peripheral vascular disease/venous insufficiency

- mastectomy, axillary lymph node dissection, indwelling fistula on ipsilateral side

What are the three areas that are most suitable for IV selection?

- Dorsum of hand

- Volar aspect of forearm

- Greater or lesser saphenous in foot

What types of veins/sites should be used first for IV catheterization?

most distal site & straightest vein

What are the sites to avoid for IV catheterization?

- dominant arm or hand

- Veins at areas of flexion

- Veins that are curved, roll, or bifurcate

Smaller numbered gauges have larger or smaller diameters compared to larger gauges?

larger

Catheters with larger gauges and shorter lengths allow for:

faster infusion of fluids

What are the considerations for IVs in geriatric/pediatric?

- more likely to have smaller, more fragile veins

- fewer options, thus careful initial IV placement

- use a small catheter (24 gauge)

- secure the line

What are the potential complications of IV catheterization?

- Hematoma

- Extravasation/Infiltration

- Thrombosis/thrombophlebitis

- Cellulitis/Bacteremia/Sepsis

- Embolization: Venous PE, Catheter sheering, or Air

IV sites should be changed how often?

every 96 hours

What is a patient education point for IV catheterization?

instruct on signs of infection

A 95 year old female presents to the ED with what appears to be mild dehydration. Her skin is tenting, her mouth is dry, she is alert and oriented x 3, and her BP is 105/75mmHg while lying flat. Which catheter size is your best option for inserting an IV line in this patient?

24 gauge

3 multiple choice options

A 65 year old male presents for an elective hernia repair. He has a history of amputation of the right upper extremity following a mining accident over 20 years ago and lymphedema in the left upper extremity. based on this information, which of the following is the best site for peripheral IV catheter insertion in this patient?

Right greater saphenous vein

3 multiple choice options

Which of the following is considered a contraindication to IV catheter insertion?

insertion in an area of cellulitis

3 multiple choice options

A 47-year old female with a history of invasive carcinoma of the left breast s/p radical mastectomy with axillary dissection presents for routine assessment of her lipids due to a family history of hyperlipidemia and early coronary artery disease. She is currently being treated for a cellulitis of her right hand, which developed after being bitten by a stray kitten. Considering the patient's history (acute & chronic), what are some considerations/precautions you must take when performing a venipuncture on this patient?

Don't draw blood from the left arm due to her history of left sided mastectomy & axillary dissection. Want to avoid the area of cellulitis on the right hand when drawing blood, but since the median cubital vein in the antecubital fossa is preferred anyway, this is not as big of an issue unless there are other problems with that site.

When selecting a site for IV catheterization, which of the following statements reflects the most appropriate standard to utilize?

Use the most distal veins first

3 multiple choice options

Choosing an IV catheter for a patient who presents with multiple traumas in need of significant fluid resuscitation and emergent transfer to the operating room (OR) would initially best be managed with intravenous (IV) catheter insertion of which size/gauge?

18 gauge

3 multiple choice options

What color tube is used for a fasting lipid panel?

tiger top

What color tube is used for a CBC w/ differential?

lavender

What color tube is used for an A1C?

lavender

what color tube should be used for a PT/INR?

light blue

What color tube should be used for a stand alone glucose (not part of a metabolic panel)?

gray

A 12 month old presents for a WCC, during which a heel stick is performed for lead screening. The level comes back elevated, so you follow-up with a venous lead sample for further evaluation & confirmation. This laboratory test should be collected in which of the following tubes?

Tan top

3 multiple choice options

Which gauge of needle is is typically utilized for venipuncture?

21-25G

When preparing the patient for phlebotomy or insertion of an IV, it is important to:

Identify a patient's allergies

3 multiple choice options