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Practical Procedures
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Difficult venipuncture
Special groups


  • Tourniquet
  • Gloves
  • Hazardous material container
  • Alcohol swab
  • Gauze or cotton
  • Sticking plaster
  • Needle and syringe or vacutainer
  • Blood bottles

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  • Tell the patient what you are about to do.
  • Place the patient's arm on a pillow and make sure it is comfortable.
  • Attach the tourniquet to the upper arm.
  • Put on your gloves.
  • Examine and palpate for a vein in the antecubital fossa.
  • Swab the skin with an alcohol swab and allow to dry.
  • Insert the needle at a 30° angle and advance until you feel the vein wall "give" (Fig. 1).
  • Attach the vacutainer tube, or gently pull back if using a syringe. (Note: For some samples, e.g., calcium, you need to take an uncuffed sample. Release the tourniquet when you have entered the vein).
  • Remove the tourniquet if still attached.
  • Withdraw the needle and syringe, simultaneously pressing down on the puncture site with the gauze.

Fig. 1 Venipuncture.

  • Dispose of the needle immediately in a hazardous material container.
  • Transfer blood to bottles if not using a vacutainer.
  • Apply a Band-Aid™, or a gauze pad with adhesive tape.

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Don't ask the patient to bend the arm up; this does not apply pressure to the puncture and will result in a bigger bruise.

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  Difficult venipuncture

If you are having difficulty drawing blood, abandon the vacutainer. The lack of a "flashback" makes it difficult to find deep-seated veins and the vacuum can collapse small veins, especially in older people.

If neither antecubital fossa yields a vein, try the forearm, the radial aspect of the wrists, the back of the hand, or even the base of the thumb. For these small veins, try a smaller needle (23-gauge, blue – but no smaller than this) or a butterfly system.

If you still have trouble, consider using the feet – this is more painful.

As a last resort, or in an emergency when the peripheral circulation is shut down, consider a femoral stab.

  • Locate the femoral pulse.
  • Swab the groin.
  • Aim 1 cm medial to the femoral pulse, with the needle at right angles to the skin.

Use of the femoral stab is a last resort – don't make it part of your phlebotomy routine!

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  Special groups
  • Intravenous (IV) drug users: if you can't get blood from an IV drug user, ask where the veins are (some will actually take the blood for you!).
  • Patients with renal disease: any patient who is on dialysis or approaching the need for dialysis requires care in taking blood.
  • Never perform venipuncture on a limb with an arteriovenous (AV) fistula (unless the renal team tell you that it's OK). Do not use veins at the wrist or forearm in either limb; these are vital for future fistula creation. Use the antecubital veins or veins on the back of the hand.

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