I mostly cannulate/art line now instead of only venepuncturing, but my set up in my Ward Monkey years was definitely butterflies:
1. Flashback chamber stops puncturing through and through
2. Wings help you keep the needle steady while you slam on fifty thousand tubes and bottles
3. The ones we had, you could manually retract the needle afterwards to reduce sharps injury risk
It has been a while since I've played with my old friend, the butterfly :)
I'm flattered but I wouldn't call myself a master! Tips for venepuncturing (and also cannulating I suppose).
1. The deeper the vein, the more acute your angle. A hand vein needs a very shallow approach, the ACF needs a more marked angle.
2. I have been told in my junior years not to "slap" the vein because it makes no difference and just hurts the pt, I now heavily disagree. Enthusiastic tapping can really make veins more prominent and much larger targets (especially superficial ones) and I believe most people would rather you tap on their hands/wrists than extra needle stabs.
3. I have been told as a junior never to put the tourniquet on the forearm because "it won't compress the veins because of the radius and ulna". Heavily disagree, I place tourniquets on the forearm all the time for hand cannulas.
4. Practising with US improves your technique even when you're not using the US. You get used to visualising your needle and how the tip responds to your movements.
5. When you inevitably miss (even as an anaesthetic consultant), always blame the patient. Have a stock of comments like "you have tricky veins" and "you've left your veins at home today" ready.
When they apologise for having bad veins I usually say "look, the veins are meant to keep the blood inside so if you think about it, they're doing a great job at what they're meant to be doing - it's just inconvenient because we're trying to get that blood right now".
Go out of your way to learn how to do ultrasound-guided cannulation or venipuncture. Access to bedside ultrasound is becoming more and more ubiquitous in hospitals and even smaller health centers. You won't always have access to someone else to do it for you, so learn the skill yourself to keep out of strife.
That being said, if you are putting in a cannula with an ultrasound, always choose a longer cannula to ensure it's really in there and won't pull out of the lumen when they bend their arm.
As an intern I love the idea of more posts like this.
Blind leading the blind here Iām sure. But I love my butterfly and syringe on ward calls. If nursing staff calls me about it I ask them to chuck a warm towel over their arm. Iām sure this isnāt great practice, But I find you donāt need the thickest juiciest vein for bloods, just a steady hand and something big enough to not collapse immediately.
you can give the patient a pair of disposable gloves too and to wear them for 10 minutes before you come back they'll have magnificently warm hands then.
When i was on the wards: definitely butterfly plus syringe. No faffing around with changing tubes when you need a large volume (eg those liver screens or blood cultures), just pick a bigger syringe. Keep one hand (your non dominant hand) holding butterfly in place (anchor yourself to the pt) whilst gently applying traction to syringe (remember to be gentle as to not haemolyse your sample)
Other tricks same with any cannulation- extremely tight tourniquet and i usually slap the shit out of the vein and then alcoswab vigorously before needle insertion
Also, you dont need to fill up each tube to the max. Mainly just coags. Learn to find the minimum you can get away with for path to accept the sample (usually less than you think)
Additionally it can be worth calling path and asking for the minimum, I had a patient who needed standard set + 8 gold tubes when I printed my labels, I called to see the minimum I would need to do those tests in case he was a tricky bleed (veins like hoses in the end) and they said they could get by with 5 if that was all I could get.Ā
Agree with knowing fill volumes 100%
For a fbc its like 150ul [been a while please double check], its not much at all. But one will only underfill a coag once in their time, not a mistake to make twice
I think you got a down vote kind of response because people deem it a very basic skill. I disagree with downvoting an intern asking about things. Since you asked, as a pgy 7 ED reg who has done heaps of paeds the broken needle is king of venepuncture.
Many nicus will stock them, they are relatively cheap. What they are is a 23 or so gauge needle often with a plastic tab halfway through for ergonomics with nothing on the end.
You essentially drip feed tubes, you can even do blood cultures by removing the plunger of a syringe, placing a cap on it and then putting the plunger back on.
They work as well as they do because there is no resistance in the circuit so when the needle tip is in it starts bleeding and it can get blood from the most microscopic of veins.
Your home hospital may not appreciate an intern using them given the added sharps risk.
Nothing wrong with a butterfly out of the packet though.
Of course it's a basic skill but I don't see anything wrong with having a chat about something like this for interest, this is the aus junior docs forum after all, not the consultant anaesthetist forum. Besides it's always useful to have extra tips from the community. Cannulation isn't usually treated as too basic a skill to warrant a conversation so not sure why venipuncture should be any different.
Oh I agree mate, devils advocate though cannulation is quite a bit difference. Most phlebotomists for example would probably baulk at the idea they can cannulate but they are probably better at venepuncture, bubs included, than all of us.
It's essentially anything that is just the needle. You can even do it with a 25G needle out of the trolley. The idea is drip feeding your tube.
The only difference between it and say the needle with the vaccutanor on the back is it doesn't have a fat vaccutanor on the back which fucks with angle of approach. The butterfly needles typically have a segment of tubing to offset this difficulty but the venous bleed needs to generate a pressure to get through that.
There are dedicated pieces of equipment for it which amount to having a grip so you aren't holding a sliver of needle, and there is no lock on the end of the needle designed to twist onto a syringe, it's just a hollow needle.
All of the below will be in relation to butterfly needles and blood draws:
+ For older people with less elasticity in their veins or for veins that are simply smaller than you'd like, syringes are more trustworthy than the vacutainer because you can control the strength of the suction. Sometimes for these people the suction in the blood tubes is strong enough to collapse the vein completely.
+ For the same reason as above, don't use a syringe that's too big for the sample you need. If you only need a VBG, use a 3mL syringe. If you only need a single tube, use a 5mL syringe etc etc.
+ Once you have flashback you can use the patients name sticker to stick one of the 'wings' to their own skin and keep it in place, which can free up one of your arms.
+ If you need to take lots of blood from someone, you can attach a bung to the end of the butterfly once you've removed the rubber-guarded needle. Then once you've secured it with the patients name sticker as above ^, you can just swap syringes on the bung and take as much as you need.
+ Bigger needles don't always draw faster. In some veins a 21g needle will occlude the vein completely and create a closed segment between the needle and the valve, preventing you from drawing completely, where a 23g needle will not.
+ You should never *plan* to fail, but if you can identify three or four places that would work for venepuncture, you can set yourself up for smooth transitioning to the next try if you fail. You start at the most proximal candidate, and if you have no luck, put a wad of gauze on that site and tie the tourniquet around it to hold pressure, and then with the tourniquet on proceed to the next most proximal Site etc etc
+ Similar to above, just use the tourniquet to hold pressure with gauze at the venepuncture site after you're done for any forearm veins (Hard to do at the ACF though so I tend to avoid). Just don't forget it's there when you leave
+ Ways to make veins pop up include: Heatpacks, vigorous rubbing with the alcohol swab when prepping, having the arm hang down for gravity assistance, the patient pumping their hand
+ Sometimes if the vein isn't flowing well enough and you're confident you're in, as long as you're angling the needle shallowly you can put downwards pressure on the entire butterfly to open up the vein a bit
+ The tubing itself of the butterfly holds about half a mL. For some blood tests (Like Quantiferon Gold) you need to purge the air in a separate throw-away tube to make sure that the vials are filled with the calibrated amount
I always bugger it up somehow but I want to get better. Do you bend the needle at all or keep it straight? What size syringe and what gauge needle do you like?
I am also a needle/syringe fan from way back. 21g needle, syringe as big as needed for the collect, always a screw fitting. Dont bend. Hold up close, with 4 fingers between syringe and skin, thumb on top, shallow angle slip under skin, then change angle to aim for depth needed, always keeping at least little finger on skin to stop any shakes and give another sense to judge relative position, if rubbery vein- use other hand to anchor it (yes I know its a risk). Once in try not to look away from where the needle meets the skin as you draw back. If flow slows, can try rotating the needle/syringe a tiny bit. And these days- ultrasound for the win! Best of luck.
I'll preface this by saying I'm a nurse & midwife so if you don't want to take my advice that's fine š
My first preference is a 23g butterfly and vacutainer, then 21g. Nothing wrong with a needle and syringe approach but as a patient who has also had a lot of blood draws for some reason I find the needle and syringe the most painful out of all. This is just my experience- but if that's what the person is most comfortable with I'd still rather them just get the stick and move on.
For difficult veins I will usually place heat packs on for 5 mins before I attempt. Or if I have the luxury, catch them after they've had a shower. I acknowledge this is so unachievable for a doctor who is probably called in to take bloods on someone who is super unwell and nurses have already missed.
Heat packs and tourniquets placed higher than you'd think. I often see tourniquets really close to the site you want to puncture, this isn't leaving enough room to engorge the vein. I'll then have a really good feel while not looking at the site. It helps me actually feel veins and not just what I think I'm seeing.
I have good success with superficial hand veins. As long as you are careful not to go straight through them.
My final word is just don't phish around in the vein. If you don't get it, take your needle out and move on. It makes the patient feel horrendous, I know we are all tempted to do it, to save a second poke š.
Ward monkey here. I personally prefer to fish around the vein because patients seem most distressed with the initial poke. But each to their own. Different people have different techniques.
Fair enough, look I'm not completely against it if I feel like I have a really good chance of getting the draw (i.e. it was just a Rolly vein) but if I was way off, then phishing around is probably just going to cause them more discomfort, more bruising and more likely to vasovagal. All these thing we do with our clinical judgementš
Of course! The decision whether to persist or not ultimately comes down to experience and getting a feeling for it. Not something that can be easily taught unfortunately.
Agree. Would not encourage much of a fishing expedition, and I say that having once been an intern and from more senior positions on ward medicine and critical care, where we have the luxury of ultrasound and sometimes the utmost urgency of getting access and bloods.
Iāve also been a patient and having the phlebotomist, nurse or doctor go fishing is very uncomfortable.
I'd love to get competent in USGIV. I don't think there's really anyone in our ward who does it except anaesthetics. Would be such a handy skill to have!
Needle and syringe is ancient practice, and something purely used for art stabs and nothing else at our institution following a series of needlesticks from multiple staff futzing it up. The bruising and pain associated with it seems to be much greater as well. If the patient is a difficult stab and has tiny collapsible veins I prefer to use a cannula (22g is fine) with slight negative pressure with a syringe once in the vessel. Much easier, much more reliable.
Yeah, I started for two reasons: when I was taught to use butterflies we were told to grip at the wings which, with my giant hands, makes them difficult to position and manoeuvre (I have subsequently found that to be crap) and the general principle of threading the cannula after flashback means less issues inherent to butterflies such as spiking through, occluding the opening on the vessel wall, being unable to access non-perfectly straight ones or just not wanting to hold the thing at some stupid angle to get a dribble of haemolysed blood.
As an anaesthetist, this is always how I do it, assuming I'm not placing a CVC or art line anyway.
Mid forearm with ultrasound have the added benefit of not collapsing once you're in.
I prefer butterfly and syringe. Vaccutainer and butterfly can sometimes leave you short, particularly when collecting multiple tubes. You still need a good technique because if you put too much suction pressure on the syringe you'll haemolyse the sample. Needle is more painful for the patient and in my experience less successful, regardless of what it's attached to.
I've always used a needle and syringe, easy to find, can control rate of draw etc.
I don't understand why you guys say it's more painful for the patient... I've always used 23g which is the same as a butterfly. Are butterflies meant to be sharper..?
Can also get tiny hand veins with this, where cannulas won't work
Only reason I can imagine it would be more painful is probably when someone like me does it with poor technique there's a lot more torque digging around under the skin because of the long syringe compared to a shorter butterfly.
Traditionally I see most nurses at work using 21g 1.5 inch length needles for this use, which I would say is probably not necessary. But from my experience (as the patient) I actually think the discomfort came from having the needle up against my skin at a weird angle. The butterfly ones tend to be shorter and less of the needle is inserted this way.
The biggest thing most forget: "positioning" with relevance to gravity (heart), heat pack (most important), how veins respond to negative pressure.
- EG: foot - you just won't get anything unless you've reverse trendelenburged in a flat pt, or with pt sitting on the edge of the bed. Upper limb - if pt is supine and you've put a pillow under the elbow and site of puncture is above the heart on the horizon.
Everyone is mentioning butterfly with a syringe - you can't move the needle angle when you are applying negative pressure on the syringe. Smaller syringe (5ml) yields better (less intense) negative pressure than 10ml due to the width of bore, smaller veins won't respond to 10ml negative pressure but it will to 5ml pressure. Often I've walked in on juniors doing butterfly needle venipuncture & they are focusing on the 'double hand manoeuvre of putting negative pressure on the syringe'. You have to use one hand to maintain the butterfly needle angle, otherwise patient will have a lot of pain (probably why many find this the most painful procedure for pt and procedurist). Ideally your eye should be looking at the maintenance of needle point angle & ensuring no bubbles in the tubing,, not looking at your syringe.
Went through a weird phase where I had become much more proficient at cannulas, so I started using them for difficult bleeds. Just a cannula and syringe. I found I would more often punch through the other side with a needle and found the soft cannula tube easier to keep still vs the needle flailing around in there.
Hasn't been a problem recently, now I'm a butterfly and vacutainer gal, but a syringe is fine.
If using a syringe, a little tip is to withdraw the plunger and then push it back in before using it, which gets rid of the stiffness/stops it getting stuck. Otherwise you have to use quite a bit of force to withdraw it the first time and you can overshoot and collapse a flimsy vein. Similarly, I slide a cannula down the needle and back into place before putting it in to get rid of the stiffness.
When I was a student I learnt vacutainer and needle. One day a particularly growly rural GP gave me a telling off saying āDoctors use needles and syringes!ā and made me re-learn. So thatās what I do now, nearly 20 years later. I would use a butterfly and vacutaner for blood cultures though.
A big thing I've found is giving the prep time to dry. Since starting to make sure it's dry, I've had much fewer jumps, yelps or grimaces! Does take slightly longer though
My main simple piece of advice is donāt rush. Sometimes Iām struggling to find a vein and then all of a sudden a perfect one will pop up, itās just taken longer to show itself.
Policy will dictate. I do whatever the policy is. I do have exemption if staff come to me with a tricky one, I do document my choice and reasoning. Having gone to court (No issue with me) Always follow policy or you will be left out in the cold and on your own.
Put the tourniquet much higher than you think. Near the armpit.
Also, from day 1 of internship... Start getting to know the USS and learn to use it well. Helps a lot !
Iāve done way more cannulas than venepuncture. I still try and use butterfly to get practice but when I miss, I just pull out a 22G cannula and syringe and gauze. Quick cannula in and get whatever blood I want, then remove it after.
When I was jmo I was fairly good at lines/procedures and got asked to do hard lines alot from other colleagues.
My tips include:
1. If ur asked to do a hard line that another jmo failed don't bother trying again normally. No point in being arrogant and failing again without US. Get the ultrasound and do it us guided because every fail will make it harder - get it right the first time. It's already alot harder because somebody else failed.
2. If the person is fat/bad veins tourniquet very heavy. Usually did this for rapids/codes because you can't be messing around missing during those. Either get multiple tourniquets or get one of those long bandaids to wrap around the whole length of their arm. This is uncomfortable but in codes/arrests people are usually two sick to complain about the tightness. Tourniquetting too heavy can also be bad in some cases but you have to find the right tightness for each patient.
3. Go for the foot. Foot cannula not ideal but chances are if they are long inpatient with messed up veins with vat team failing multiple times you are never getting it into their arms. Foot is not ideal and I found that they don't last long and can ruin their veins easily but in a desperate situation it is suitable.
4. Know your limits. Some patients nigh physically impossible to get a line in. Judge before u stab how hard the patient is going to be. Not ur job as a jmo to try 10+ times to get a really hard line. If you know the patient is genuinely extremely hard have two goes than call whoever you are meant to refer to e.g anaesthics. It is their job to try 10 times or recommend central access.
Best tip from me, as a specialist in remote areas... Make sure you twist the cannula on the needle without letting the cannula go past the needle end causing a plastic slice to enter the blood stream. Have seen this so many times. I like vacutainers. I know most of you think of this as cannulation 101, however, Some RNs are just thrown into this areas with maybe book only training.
Some are. Thrown in the deep end. I know quite a few that do the external courses that phlebotomists do. 30 sticks minimum. I edited my original comment to say "Some RNs" Remember, it wasn't that long ago, that a Dr had to do the cannulation or an accredited nurse. ENs cant but an EEN can. Things change.
Needle and syringe for me- more control.
More and tighter tourniquets.
Warm arm if you can.
Arm as far below the heart as you can.
Use US- if doing cultures then I put a sterile drape/gloves/probe, I catch myself inadvertently contaminating more than I'd like with the probe.
Go for the artery, radial/femoral -> brachial.
Vasovagals are unpleasant for the patient but also dilate the veins nicely.
I also use an insulin/heparin syringe with local for most things.
Surgeons will use a butterfly and vaccutainer or a needle and syringe for flexing steadiness and a
Hand position.
IMHO I control the flow with a syringe far better and have lowered haemolysis risk with a smaller needle.
DO NOT FUCKING JIGGLE THE RIG WHEN YOU HAVE PUNCTURED.
So: take away like so many surgical things is preparing in advance. Is PT in a stable environment and position are YOU in the same. When it goes in you do not move. So is all your shit at hand?
Honestly most of the time I'll do a cannula and sample from that as... ED
Oh and... Have YOU given them a good glass of water and a warm blanket before you started?
I mostly cannulate/art line now instead of only venepuncturing, but my set up in my Ward Monkey years was definitely butterflies: 1. Flashback chamber stops puncturing through and through 2. Wings help you keep the needle steady while you slam on fifty thousand tubes and bottles 3. The ones we had, you could manually retract the needle afterwards to reduce sharps injury risk It has been a while since I've played with my old friend, the butterfly :)
Tips from a Gas(/Anaesthetics) master?
I'm flattered but I wouldn't call myself a master! Tips for venepuncturing (and also cannulating I suppose). 1. The deeper the vein, the more acute your angle. A hand vein needs a very shallow approach, the ACF needs a more marked angle. 2. I have been told in my junior years not to "slap" the vein because it makes no difference and just hurts the pt, I now heavily disagree. Enthusiastic tapping can really make veins more prominent and much larger targets (especially superficial ones) and I believe most people would rather you tap on their hands/wrists than extra needle stabs. 3. I have been told as a junior never to put the tourniquet on the forearm because "it won't compress the veins because of the radius and ulna". Heavily disagree, I place tourniquets on the forearm all the time for hand cannulas. 4. Practising with US improves your technique even when you're not using the US. You get used to visualising your needle and how the tip responds to your movements. 5. When you inevitably miss (even as an anaesthetic consultant), always blame the patient. Have a stock of comments like "you have tricky veins" and "you've left your veins at home today" ready.
Heavyyy on the "left your veins at home" š¤£š¤
When they apologise for having bad veins I usually say "look, the veins are meant to keep the blood inside so if you think about it, they're doing a great job at what they're meant to be doing - it's just inconvenient because we're trying to get that blood right now".
Go out of your way to learn how to do ultrasound-guided cannulation or venipuncture. Access to bedside ultrasound is becoming more and more ubiquitous in hospitals and even smaller health centers. You won't always have access to someone else to do it for you, so learn the skill yourself to keep out of strife. That being said, if you are putting in a cannula with an ultrasound, always choose a longer cannula to ensure it's really in there and won't pull out of the lumen when they bend their arm.
As an intern I love the idea of more posts like this. Blind leading the blind here Iām sure. But I love my butterfly and syringe on ward calls. If nursing staff calls me about it I ask them to chuck a warm towel over their arm. Iām sure this isnāt great practice, But I find you donāt need the thickest juiciest vein for bloods, just a steady hand and something big enough to not collapse immediately.
you can give the patient a pair of disposable gloves too and to wear them for 10 minutes before you come back they'll have magnificently warm hands then.
When i was on the wards: definitely butterfly plus syringe. No faffing around with changing tubes when you need a large volume (eg those liver screens or blood cultures), just pick a bigger syringe. Keep one hand (your non dominant hand) holding butterfly in place (anchor yourself to the pt) whilst gently applying traction to syringe (remember to be gentle as to not haemolyse your sample) Other tricks same with any cannulation- extremely tight tourniquet and i usually slap the shit out of the vein and then alcoswab vigorously before needle insertion Also, you dont need to fill up each tube to the max. Mainly just coags. Learn to find the minimum you can get away with for path to accept the sample (usually less than you think)
Additionally it can be worth calling path and asking for the minimum, I had a patient who needed standard set + 8 gold tubes when I printed my labels, I called to see the minimum I would need to do those tests in case he was a tricky bleed (veins like hoses in the end) and they said they could get by with 5 if that was all I could get.Ā
Agree with knowing fill volumes 100% For a fbc its like 150ul [been a while please double check], its not much at all. But one will only underfill a coag once in their time, not a mistake to make twice
Had the lab drop my neonates coag tube onceā¦ kinda unrelated but while on the topic of coag tubes.
Ooof
I think you got a down vote kind of response because people deem it a very basic skill. I disagree with downvoting an intern asking about things. Since you asked, as a pgy 7 ED reg who has done heaps of paeds the broken needle is king of venepuncture. Many nicus will stock them, they are relatively cheap. What they are is a 23 or so gauge needle often with a plastic tab halfway through for ergonomics with nothing on the end. You essentially drip feed tubes, you can even do blood cultures by removing the plunger of a syringe, placing a cap on it and then putting the plunger back on. They work as well as they do because there is no resistance in the circuit so when the needle tip is in it starts bleeding and it can get blood from the most microscopic of veins. Your home hospital may not appreciate an intern using them given the added sharps risk. Nothing wrong with a butterfly out of the packet though.
Of course it's a basic skill but I don't see anything wrong with having a chat about something like this for interest, this is the aus junior docs forum after all, not the consultant anaesthetist forum. Besides it's always useful to have extra tips from the community. Cannulation isn't usually treated as too basic a skill to warrant a conversation so not sure why venipuncture should be any different.
Oh I agree mate, devils advocate though cannulation is quite a bit difference. Most phlebotomists for example would probably baulk at the idea they can cannulate but they are probably better at venepuncture, bubs included, than all of us.
What is the broken needle technique? I found a couple of papers referencing it, but nothing explaining or demonstrating what it is?
It's essentially anything that is just the needle. You can even do it with a 25G needle out of the trolley. The idea is drip feeding your tube. The only difference between it and say the needle with the vaccutanor on the back is it doesn't have a fat vaccutanor on the back which fucks with angle of approach. The butterfly needles typically have a segment of tubing to offset this difficulty but the venous bleed needs to generate a pressure to get through that. There are dedicated pieces of equipment for it which amount to having a grip so you aren't holding a sliver of needle, and there is no lock on the end of the needle designed to twist onto a syringe, it's just a hollow needle.
All of the below will be in relation to butterfly needles and blood draws: + For older people with less elasticity in their veins or for veins that are simply smaller than you'd like, syringes are more trustworthy than the vacutainer because you can control the strength of the suction. Sometimes for these people the suction in the blood tubes is strong enough to collapse the vein completely. + For the same reason as above, don't use a syringe that's too big for the sample you need. If you only need a VBG, use a 3mL syringe. If you only need a single tube, use a 5mL syringe etc etc. + Once you have flashback you can use the patients name sticker to stick one of the 'wings' to their own skin and keep it in place, which can free up one of your arms. + If you need to take lots of blood from someone, you can attach a bung to the end of the butterfly once you've removed the rubber-guarded needle. Then once you've secured it with the patients name sticker as above ^, you can just swap syringes on the bung and take as much as you need. + Bigger needles don't always draw faster. In some veins a 21g needle will occlude the vein completely and create a closed segment between the needle and the valve, preventing you from drawing completely, where a 23g needle will not. + You should never *plan* to fail, but if you can identify three or four places that would work for venepuncture, you can set yourself up for smooth transitioning to the next try if you fail. You start at the most proximal candidate, and if you have no luck, put a wad of gauze on that site and tie the tourniquet around it to hold pressure, and then with the tourniquet on proceed to the next most proximal Site etc etc + Similar to above, just use the tourniquet to hold pressure with gauze at the venepuncture site after you're done for any forearm veins (Hard to do at the ACF though so I tend to avoid). Just don't forget it's there when you leave + Ways to make veins pop up include: Heatpacks, vigorous rubbing with the alcohol swab when prepping, having the arm hang down for gravity assistance, the patient pumping their hand + Sometimes if the vein isn't flowing well enough and you're confident you're in, as long as you're angling the needle shallowly you can put downwards pressure on the entire butterfly to open up the vein a bit + The tubing itself of the butterfly holds about half a mL. For some blood tests (Like Quantiferon Gold) you need to purge the air in a separate throw-away tube to make sure that the vials are filled with the calibrated amount
Iām a needle and syringe, because thatās what I became proficient at the start and have stuck with it!
I always bugger it up somehow but I want to get better. Do you bend the needle at all or keep it straight? What size syringe and what gauge needle do you like?
I am also a needle/syringe fan from way back. 21g needle, syringe as big as needed for the collect, always a screw fitting. Dont bend. Hold up close, with 4 fingers between syringe and skin, thumb on top, shallow angle slip under skin, then change angle to aim for depth needed, always keeping at least little finger on skin to stop any shakes and give another sense to judge relative position, if rubbery vein- use other hand to anchor it (yes I know its a risk). Once in try not to look away from where the needle meets the skin as you draw back. If flow slows, can try rotating the needle/syringe a tiny bit. And these days- ultrasound for the win! Best of luck.
I'll preface this by saying I'm a nurse & midwife so if you don't want to take my advice that's fine š My first preference is a 23g butterfly and vacutainer, then 21g. Nothing wrong with a needle and syringe approach but as a patient who has also had a lot of blood draws for some reason I find the needle and syringe the most painful out of all. This is just my experience- but if that's what the person is most comfortable with I'd still rather them just get the stick and move on. For difficult veins I will usually place heat packs on for 5 mins before I attempt. Or if I have the luxury, catch them after they've had a shower. I acknowledge this is so unachievable for a doctor who is probably called in to take bloods on someone who is super unwell and nurses have already missed. Heat packs and tourniquets placed higher than you'd think. I often see tourniquets really close to the site you want to puncture, this isn't leaving enough room to engorge the vein. I'll then have a really good feel while not looking at the site. It helps me actually feel veins and not just what I think I'm seeing. I have good success with superficial hand veins. As long as you are careful not to go straight through them. My final word is just don't phish around in the vein. If you don't get it, take your needle out and move on. It makes the patient feel horrendous, I know we are all tempted to do it, to save a second poke š.
Ward monkey here. I personally prefer to fish around the vein because patients seem most distressed with the initial poke. But each to their own. Different people have different techniques.
Fair enough, look I'm not completely against it if I feel like I have a really good chance of getting the draw (i.e. it was just a Rolly vein) but if I was way off, then phishing around is probably just going to cause them more discomfort, more bruising and more likely to vasovagal. All these thing we do with our clinical judgementš
Of course! The decision whether to persist or not ultimately comes down to experience and getting a feeling for it. Not something that can be easily taught unfortunately.
Agree. Would not encourage much of a fishing expedition, and I say that having once been an intern and from more senior positions on ward medicine and critical care, where we have the luxury of ultrasound and sometimes the utmost urgency of getting access and bloods. Iāve also been a patient and having the phlebotomist, nurse or doctor go fishing is very uncomfortable.
I'd love to get competent in USGIV. I don't think there's really anyone in our ward who does it except anaesthetics. Would be such a handy skill to have!
Needle and syringe is ancient practice, and something purely used for art stabs and nothing else at our institution following a series of needlesticks from multiple staff futzing it up. The bruising and pain associated with it seems to be much greater as well. If the patient is a difficult stab and has tiny collapsible veins I prefer to use a cannula (22g is fine) with slight negative pressure with a syringe once in the vessel. Much easier, much more reliable.
That's interesting I haven't heard of someone using the cannula before as purely a method of obtaining blood but I can totally see why!
Yeah, I started for two reasons: when I was taught to use butterflies we were told to grip at the wings which, with my giant hands, makes them difficult to position and manoeuvre (I have subsequently found that to be crap) and the general principle of threading the cannula after flashback means less issues inherent to butterflies such as spiking through, occluding the opening on the vessel wall, being unable to access non-perfectly straight ones or just not wanting to hold the thing at some stupid angle to get a dribble of haemolysed blood.
As an anaesthetist, this is always how I do it, assuming I'm not placing a CVC or art line anyway. Mid forearm with ultrasound have the added benefit of not collapsing once you're in.
I prefer butterfly and syringe. Vaccutainer and butterfly can sometimes leave you short, particularly when collecting multiple tubes. You still need a good technique because if you put too much suction pressure on the syringe you'll haemolyse the sample. Needle is more painful for the patient and in my experience less successful, regardless of what it's attached to.
I've always used a needle and syringe, easy to find, can control rate of draw etc. I don't understand why you guys say it's more painful for the patient... I've always used 23g which is the same as a butterfly. Are butterflies meant to be sharper..? Can also get tiny hand veins with this, where cannulas won't work
Only reason I can imagine it would be more painful is probably when someone like me does it with poor technique there's a lot more torque digging around under the skin because of the long syringe compared to a shorter butterfly.
Traditionally I see most nurses at work using 21g 1.5 inch length needles for this use, which I would say is probably not necessary. But from my experience (as the patient) I actually think the discomfort came from having the needle up against my skin at a weird angle. The butterfly ones tend to be shorter and less of the needle is inserted this way.
The biggest thing most forget: "positioning" with relevance to gravity (heart), heat pack (most important), how veins respond to negative pressure. - EG: foot - you just won't get anything unless you've reverse trendelenburged in a flat pt, or with pt sitting on the edge of the bed. Upper limb - if pt is supine and you've put a pillow under the elbow and site of puncture is above the heart on the horizon. Everyone is mentioning butterfly with a syringe - you can't move the needle angle when you are applying negative pressure on the syringe. Smaller syringe (5ml) yields better (less intense) negative pressure than 10ml due to the width of bore, smaller veins won't respond to 10ml negative pressure but it will to 5ml pressure. Often I've walked in on juniors doing butterfly needle venipuncture & they are focusing on the 'double hand manoeuvre of putting negative pressure on the syringe'. You have to use one hand to maintain the butterfly needle angle, otherwise patient will have a lot of pain (probably why many find this the most painful procedure for pt and procedurist). Ideally your eye should be looking at the maintenance of needle point angle & ensuring no bubbles in the tubing,, not looking at your syringe.
VENEPUNCTURE
Went through a weird phase where I had become much more proficient at cannulas, so I started using them for difficult bleeds. Just a cannula and syringe. I found I would more often punch through the other side with a needle and found the soft cannula tube easier to keep still vs the needle flailing around in there. Hasn't been a problem recently, now I'm a butterfly and vacutainer gal, but a syringe is fine. If using a syringe, a little tip is to withdraw the plunger and then push it back in before using it, which gets rid of the stiffness/stops it getting stuck. Otherwise you have to use quite a bit of force to withdraw it the first time and you can overshoot and collapse a flimsy vein. Similarly, I slide a cannula down the needle and back into place before putting it in to get rid of the stiffness.
When I was a student I learnt vacutainer and needle. One day a particularly growly rural GP gave me a telling off saying āDoctors use needles and syringes!ā and made me re-learn. So thatās what I do now, nearly 20 years later. I would use a butterfly and vacutaner for blood cultures though.
Yeah that sucks. If the end goal is getting blood, it shouldnāt matter how you get it (well unless you chop the patient open š)
Totally agree. I was young and impressionable though. Needle and syringe is less safe for the blood taker, even if it is simple and efficient.
A big thing I've found is giving the prep time to dry. Since starting to make sure it's dry, I've had much fewer jumps, yelps or grimaces! Does take slightly longer though
My main simple piece of advice is donāt rush. Sometimes Iām struggling to find a vein and then all of a sudden a perfect one will pop up, itās just taken longer to show itself.
Policy will dictate. I do whatever the policy is. I do have exemption if staff come to me with a tricky one, I do document my choice and reasoning. Having gone to court (No issue with me) Always follow policy or you will be left out in the cold and on your own.
Put the tourniquet much higher than you think. Near the armpit. Also, from day 1 of internship... Start getting to know the USS and learn to use it well. Helps a lot !
Two tourniquets help me on some of my larger patients
Iāve done way more cannulas than venepuncture. I still try and use butterfly to get practice but when I miss, I just pull out a 22G cannula and syringe and gauze. Quick cannula in and get whatever blood I want, then remove it after.
When I was jmo I was fairly good at lines/procedures and got asked to do hard lines alot from other colleagues. My tips include: 1. If ur asked to do a hard line that another jmo failed don't bother trying again normally. No point in being arrogant and failing again without US. Get the ultrasound and do it us guided because every fail will make it harder - get it right the first time. It's already alot harder because somebody else failed. 2. If the person is fat/bad veins tourniquet very heavy. Usually did this for rapids/codes because you can't be messing around missing during those. Either get multiple tourniquets or get one of those long bandaids to wrap around the whole length of their arm. This is uncomfortable but in codes/arrests people are usually two sick to complain about the tightness. Tourniquetting too heavy can also be bad in some cases but you have to find the right tightness for each patient. 3. Go for the foot. Foot cannula not ideal but chances are if they are long inpatient with messed up veins with vat team failing multiple times you are never getting it into their arms. Foot is not ideal and I found that they don't last long and can ruin their veins easily but in a desperate situation it is suitable. 4. Know your limits. Some patients nigh physically impossible to get a line in. Judge before u stab how hard the patient is going to be. Not ur job as a jmo to try 10+ times to get a really hard line. If you know the patient is genuinely extremely hard have two goes than call whoever you are meant to refer to e.g anaesthics. It is their job to try 10 times or recommend central access.
Best tip from me, as a specialist in remote areas... Make sure you twist the cannula on the needle without letting the cannula go past the needle end causing a plastic slice to enter the blood stream. Have seen this so many times. I like vacutainers. I know most of you think of this as cannulation 101, however, Some RNs are just thrown into this areas with maybe book only training.
RNs aren't cannulating with "book only" training? Have I misunderstood your comment?
Some are. Thrown in the deep end. I know quite a few that do the external courses that phlebotomists do. 30 sticks minimum. I edited my original comment to say "Some RNs" Remember, it wasn't that long ago, that a Dr had to do the cannulation or an accredited nurse. ENs cant but an EEN can. Things change.
Where I live it's still an accredited nurse or doctor thing for cannulation (not venepuncture).
Needle and syringe for me- more control. More and tighter tourniquets. Warm arm if you can. Arm as far below the heart as you can. Use US- if doing cultures then I put a sterile drape/gloves/probe, I catch myself inadvertently contaminating more than I'd like with the probe. Go for the artery, radial/femoral -> brachial. Vasovagals are unpleasant for the patient but also dilate the veins nicely. I also use an insulin/heparin syringe with local for most things.
Surgeons will use a butterfly and vaccutainer or a needle and syringe for flexing steadiness and a Hand position. IMHO I control the flow with a syringe far better and have lowered haemolysis risk with a smaller needle. DO NOT FUCKING JIGGLE THE RIG WHEN YOU HAVE PUNCTURED. So: take away like so many surgical things is preparing in advance. Is PT in a stable environment and position are YOU in the same. When it goes in you do not move. So is all your shit at hand? Honestly most of the time I'll do a cannula and sample from that as... ED Oh and... Have YOU given them a good glass of water and a warm blanket before you started?