Blood Collection

Techniques

Mar ti n D i t t mann
An Informative guide
to venous blood
collection
Contents and copyright: Dr. Martin Dittmann
Translation: Fiona Colson
1 st printing 2001
Blood Collection Techniques

P re f a c e
>> Correct blood collection technique was, until today not a
theoretically taught subject, it was experienced by performing
techniques on patients, and was critically observed in this set-
ting. The aim of this booklet is to provide further understanding
of good and stable techniques for blood collection in every
situation, thus avoiding unnecessary mistakes that often impe-
de collection. However, achievement of this level of confiden-
ce and skill will only be reached with adequate and consistent
training.

>> Before attempting blood collection on a patient, it is extre-

mely important to be familiar and respectively confident with
the collection system to be implemented. It not only makes an
amateur impression, when one "fumbles", but it increases
anxiety levels of the patient, thus having a negative influence
on the vein condition.

>> To improve understanding, it is recommended to draw

blood from oneself, therefore obtaining the actual feel for the
procedure early in ones career; and thus, the exclamation "it
won’t hurt" will not indicate ignorance or the lack of practice
and skill as it so often suggests.

E q u i p m e n t f o r Ve n i p u n c t u re
>> Blood collection system: VACUETTE ®

>> Tourniquet

>> Disposable gloves

>> Sterile swab

>> Disinfectant or alcohol solution

>> Adhesive bandages

2
Ve i n S e l e c t i o n : P r i o r i t y L i s t
>> 1. Dorsal side
of the hand
(Dorsal veins)

>> 2. Antecubital
area of the arm
(Median, Basilic or
Cephalic veins)

>> 3. Dorsal side

of the foot
(Venous arch)

3
Blood Collection Techniques

>> 4. Subclavian
vein

Puncture
direction

>> 5. Femoral vein

or artery

Inspection
>> Prior to making the final selection of a site for venipuncture,
an inspection of the proposed area is necessary. The selection
sequence should correspond to the priority list; whereby 1 and
2 are good in 95% of cases and provide a satisfactory out-
come. The dorsal region of the foot is often underestimated (by
doctors and nurses) as to the pain inflicted upon the patient.
The subclavian vein as well as the femoral vein and artery are
only considered in special cases and used as a last alternative
for blood collection, and when so, should only be performed by
experienced personnel.

4
M e a s u re s t o i m p ro v e p ro m i n e n c e
of the vein
>> 1. Incline the
arm in a down-
ward position

>> 2. Stroke the

vein in a distal
direction

>> 3. Clench and

unclench the hand

5
Blood Collection Techniques

>> 4. Lightly tap

the vein

>> 5. Warm the

vein area (warm
towel, electric
blanket)

>> 6. Skin patch

with local
anaesthetising
substances

6
To u r n i q u e t A p p l i c a t i o n
>> Place the tourniquet
or blood pressure cuff
approximately a hands
width (7.5 cm) above the
anticipated puncture
site.

>> The tourniquet

should not cause the
patient any pain. It
should be tight enough
to restrict venous blood
flow, but not impede
arterial blood flow.
20 – 30 mmHg under the
systolic blood pressure
is recommended. i.e. in
healthy patients with a
systolic blood pressure
of 120 – 130 mmHg, the
pressure should be
under 100 mmHg.

The duration that the tourniquet is in place should not exceed

1 minute (risks falsifying results due to haemoconcentration).
When more time is required, the tourniquet must be released so
that blood flow can resume and normal skin colour returns to
the extremities.

>> When skin colour visibly changes to a bluish colour, relea-

se the tourniquet immediately and do not reapply until normal
colour has returned. Under no circumstance should the tourni-
quet be left in place for more than one minute. In cases where
blood flow is inadequate for collection, lightly reapply the tour-
niquet whilst performing blood collection.

7
Blood Collection Techniques

D i s i n f e c t i n g t h e p u n c t u re s i t e
>> Disinfect the puncture
site carefully and thorough-
ly. To singly wipe the site
with a disinfectant solu-
tion and immediately
puncture is unsatisfac-
tory and can result in
contamination of patient
and sample as well as
unnecessary pain.
To adequately disinfect
the area, wipe the skin
with a swab containing an alcohol solution. Wipe in an outward
moving circular motion.
The bacterial reduction of skin flora takes 3 minutes with an
alcohol solution, and 5 minutes with an iodine solution.
When the puncture is also in conjunction with the insertion of
an intravenous catheter, then a sterile swab must be used to
cover the puncture site, and the use of a mask, cap and lab
coat are imperative.
The use of sterile (disposable) gloves is essential for every
puncture, to avoid the risk of infection. e.g. Hepatitis, HIV etc.

R o u t i n e p u n c t u re p ro c e d u re
Puncture: Dorsal side of the hand
>> Even though the antecubital area of the arm (elbow region)
is more popular, one should always consider performing veni-
puncture on the dorsal surface of the hand. Every puncture
holds the possibility of failure, therefore this procedure allows
for movement from
distal to proximal thus
presenting a number of
puncture opportunities
when inserting an infusi-
on line.

>> For right handed per-

sonnel, the patient’s
puncture hand should

8
be held with the left
hand, holding the pati-
ent’s fingers and thumb
down so that the skin is
taut.

>> Insert the needle at an

angle of 10 – 20 degrees
to the skin, and in-line
with the middle of the
anticipated vein. As soon
as blood flow begins,
release the tourniquet.

Puncture: Antecubital area of the arm (elbow region)

>> This site is by far the most popular puncture site! It is
always rewarding to examine both arms and to select the pre-
ferred arm where the veins are most prominent. However, it is
also important to fulfil the patient’s wishes as to favoured arm,
etc, and it is your responsibility to support this where possible.
Most important is that the patient is relaxed and comfortable,
and in cases of being unsure, the patient can be requested to
lie down. The elbow should be extended and supported on a
specially positioned cus-
hion.
>> The vein calibre
amongst healthy and
relaxed adult patients
varies between 5 and
10 mm. Light squeezing
of the upper arm with the
hand improves vein visi-
bility by causing the
veins to slightly dilate.
Palpation of the vein
area can be done at this point without the use of sterile gloves.

9
Blood Collection Techniques

>> Ideally, when imple-

menting a blood pressu-
re cuff, the systolic
blood pressure should
be reduced by around
30 mmHg. Use your poin-
ter finger to determine
the prominence of the
targeted vein and to
check that there is no
pulsation (avoid artery
puncture). Perform a
professional disinfection
wearing new sterile
gloves.

>> Using the left hand,

pull the skin below the
tourniquet taut over the
arm and the vein, there-

fore reducing the effects

10 – 20°
of "rolling". Perform the
puncture with the needle
at a 10 – 20 degree
angle to the skin using
the right hand.

10 – 15 mm
>> Insert the needle
10 –15 mm until it reaches
the lumen of the vein.

10
>> Further penetration
nearly always indicates
that the destination point
has been missed. The
puncture hand should
continue to hold the pun-
cture device. After some
practice, a distinct "pop"
will be evident when enter-
ing the lumen of the vein.

>> Each unnecessary hand swap is to be avoided. Any jerking

movement with the needle in the vein results in unnecessary
pain for the patient. Use the left hand to insert a vacuum tube
into the holder.
>> As soon as blood
begins to flow into the
VACUETTE ® tube, relea-
se the pressure cuff.
Should the blood flow
lighten substantially,
tighten the tourniquet on
the arm again for a short
period of time.

A l t e r n a t i v e P u n c t u re S i t e s
Puncture: Dorsal side of the foot
>> Place the tourniquet approximately a hands width above the
venipuncture site. After tightening the skin over the vein, insert the
blood collection set needle into the vein at a 10 – 20 degree angle
to the skin. The flow of blood into the thin plastic tubing on the end
of the blood collection set confirms correct needle positioning.

Puncture: Subclavian vein

>> The puncture of the subclavian vein is practically always in
unison with insertion of a central catheter. To puncture the
subclavian vein exclusively for blood collection is uncommon
and only done when absolutely necessary.

11
Blood Collection Techniques

>> Divide from medial to lateral the area between the sterno-
clavicular and acromioclavicular articulations into 3 parts.
Encourage the patient to relax. The patient’s head should be
contra-lateral and slightly tilted to the side – never over
stretch.
An assistant should draw the puncture side arm towards the
caudal and hold it there so the patient is not cramped.
After providing the patient with a subcutaneous local ana-
esthetic to the region, insert the needle in the transition area
between the first and the second third. The needle should
always be in contact with the clavicle. The direction of the
needle should point towards the jugular region. Insert the
needle 2 to max 3.5 cm until the subclavian vein is penetrated
(standard patient 70 kg bodyweight). If penetration does not
occur, then the needle was not in direct contact with the cla-
vicle during insertion.
>> The subclavian vein is always open, even in patients suffe-
ring from shock.
In punctures involving the superior vena cava, the risk of pneu-
mothorax is present. In such cases success is dependent upon
skill and chance and should only be performed by experienced
personnel who can deal with such complications, e.g. pleura
drainage.

Puncture: Femoral artery or vein

>> Performance of a femoral artery puncture is a good source
for ABG’s (Arterial Blood Gases). The artery can be located
under the inguinal ligament and is palpable. Hold the artery
firmly in the left hand between the pointer and middle fingers.
After providing a local anaesthetic to the region, hold the blood
collection needle perpendicular to the vessel. "Dance" the
needle until the centre of the artery is determined and the
needle sits atop the vessel wall. Lightly tipping the needle
point towards the cranium (75 degrees), pierce the vessel wall.
Bright red arterial blood should then begin to flow.
>> The procedure involved in puncturing the femoral vein is
practically identical. The femoral vein lies lateral to the femoral
artery, however, in the case of the femoral vein, the blood will
not be so red and will not have the typical pulsating effect.

12
F a c t o r s l e a d i n g t o d i ff i c u l t v e i n
conditions

>> Anxiety and fear

>> Cold
>> Vasoconstriction of veins
>> Weak / Thin veins
>> Repeatedly punctured veins
>> Sclerosed or hardened veins
>> ”Rolling” veins
>> Delicate veins e.g. women / children
>> Dehydration
>> Pre-shock / Shock
>> Brittle veins
>> Long steroid use
>> Cachexia

>> The above list includes some of the unfavourable factors for
venipuncture, however, this is not a complete list and other
hindrances could be experienced. It is no secret that there are
numerous situations that can lead to difficulties in blood
collection.
>> Every event that leads to a difficult blood collection can be
unfortunate. However, comments such as ”you have bad veins”
will help little and only express helplessness. Of prime impor-
tance, is to reduce the patient’s anxiety, which is the overall
mediator for vasoconstriction. A quiet atmosphere is the most
important requirement to achieving a successful venipuncture.
A hectic atmosphere as well as a room which is too cold, or
cold hands of the personnel performing the venipuncture, can
all lead to vasoconstriction. Consider patient requests such as
puncture site, body positioning and in all cases try to fulfil
these as much as possible.
>> Nevertheless, even skilled personnel can run into difficul-
ties, such as when the bevel of the needle point is held against
the vein wall and blood flow doesn’t occur. In a situation such
as this, the remedy is simply to slightly rotate the needle until
the bevel lies within the lumen of the vein.

13
Blood Collection Techniques

>> If this is not succes-

sful, then the vacuum
tube must be pulled
backwards into the hol-
der until the rubber cap
is no longer penetrated
by the needle. Thus the
suction effect is remo-
ved from the vein and
the bevel end of the
needle should release the vein wall. Reapply the same vacuum
tube and venipuncture should be achieved.

>> If difficulties are still

encountered, then attempt
the venipuncture with
the aid of a blood
collection set.

Helpful hints for blood collection

>> Following removal of the rear protective cover of a double-
ended needle, and seating of the needle in a holder, remove the
forward protective cover. In select cases it is recommended to
bend the needle therefore optimising the needle angle for the
individual situation. With the aid of the forward protective cover
apply slight finger pressure to bend the needle. On grounds of
hygiene and also for self-protection against infection, sterile dis-
posal gloves should always be used.
>> The holder should be held between the pointer, middle finger
and thumb.
>> The hand used for puncturing the skin should not be changed
thus fixing of the system in the patient’s hand/arm is ensured.

14
After placement of the
needle in the vein, use
the free hand to push the
vacuum tube into the hol-
der. With correct needle
positioning, blood should
flow into the tube. When
no blood flows, the need-
le point obviously is not
within the lumen of the
vein. In this case, slightly pull back the needle and correct the
needle positioning.

B l o o d c o l l e c t i o n f ro m a v e n o u s o r a r t e r i a l
catheter
>> Blood collection from catheters is possible, however it is
only conditionally recommended. A well-defined procedure
and care are prerequisites for blood collection from catheters.

>> Approximately 10 ml of blood are removed with a single

syringe and then disposed of; therefore undertaking a safety
measure to ensure that the line is free from flushing solution,
etc. When the manual
aspiration with the
needle is successful,
then the following
collection with the vacu-
um tubes should also be
possible. The vacuum
tube can be directly
connected to a catheter
with a Luer Adapter.

>> After the collection, the catheter should be thoroughly

rinsed and cleaned with a physiological saline solution (20 ml
NaCI 0.9%) to prevent blockage.

15
Blood Collection Techniques

P ro c e d u re f o l l o w i n g b l o o d c o l l e c t i o n
>> Nothing is worse than a ’bruise’ after blood collection.
A phlebotomist is finally judged after a successful blood
collection by the extent of bruising that is evident.

>> Bruising is widely

avoidable! Before re-
moving the needle
from the vein, the
blood collection tube
should be withdrawn
and the tourniquet
should be completely
released. Compression
should follow with a
sterile swab.

>> A compression that is too hard during the process of remo-

ving the needle from the vein, can damage the vein wall and
can lead to an injury to the vein. When this is the case, then a
large haematoma at the puncture site is highly probable. Com-
pression must immediately follow the removal of the needle.
Correspondingly, normal coagulation time requires 2 to 4 minu-
tes and with adequate compression, a haematoma should not
develop.
It should be explained to
the patient what actions
are beneficial following
blood collection.
In the situation of the
patient being weak and
unable to assist, then a
helper must guarantee
appropriate compression.
When compression is
complete, cover the pun-
cture site with a sterile
adhesive bandage.
With a puncture of the
antecubital area of the
arm (inner elbow), the

16
arm should be held above the head, without bending. A bend
can lead to blood congestion and may result in a haematoma.

>> For patients undergoing anticoagulation therapy, a good

manual compression is essential. ”Better a minute too long
than a minute too short!”
Physical exertion such as sawing, hammering or even fast
movement up or down a staircase too soon after blood collec-
tion can lead to the development of a haematoma.

B l o o d c o l l e c t i o n f ro m s m a l l c h i l d re n
>> Blood collection from small children, from about 2 years of
age, follows the same general principles as adult blood collec-
tion, with the exception that the equipment may consist of
smaller dimensions.
Of principal importance when working with small children is to
provide a quiet and friendly atmosphere.

>> Children cooperate much better when it has been clearly

explained to them as to what is going to happen. The applica-
tion of an anaesthetic patch to the anticipated puncture region
about one hour beforehand is an essential prerequisite for a
harmonious puncture procedure. Placement of the child on the
lap of its mother or a helper can generally contribute to sim-
plifying the situation.
For punctures on the dorsal side of the hand or the antecubital
area of the arm, utilisation of a small gauge blood collection
set is necessary. Vacuum tubes with lower volumes are also
required.
Of major importance is to firmly hold the arm, so that the
”flight” reflex motion is prevented.

Dorsal side of the hand puncture

An assistant holding firmly a hands-width above the wrist joint
achieves restriction of blood flow. Use the left hand to grasp
the fingers and pull the skin taut.

17
Blood Collection Techniques

>> Angle the needle at 10 – 20 degrees to the skin. During the

whole procedure, the extremity should be held firmly so move-
ment cannot occur accidentally resulting in removal of the
needle from the vein.

Antecubital area of the arm puncture

>> For elbow punctures, an assisting person holds the upper
arm of the child and simultaneously stops blood flow. When
the arm circumference is large enough, a small tourniquet or
blood pressure cuff suitable for children can be used to stop
blood flow through the veins.
With the left hand, pull the skin taut over the inner elbow regi-
on. Using the right hand insert the needle at 15 degrees to the
skin. The vein area should have been anaesthetised via the use
of an anaesthetic patch.
Release the grip of the left hand (or remove the tourniquet) as
soon as blood begins to flow into the plastic tubing of the
blood collection set. Insert a low volume VACUETTE ® tube into
the holder and proceed with blood collection. The assisting
person is responsible for keeping the child quiet and
motionless throughout the procedure and providing ample
reassurance for the child.

Dorsal side of the foot puncture

>> Venous circulation through the foot of the child can be
stopped with pressure from the hand of an assisting person.
Push the toes of the foot
under and span the skin
of the foot. Use a blood
collection set to tangenti-
ally puncture the foot
vein. As soon as blood
begins to flow, connect a
low fill volume VACUETTE ®
tube.

18
B l o o d c o l l e c t i o n f ro m i n f a n t s a n d
neonates
Scalp vein puncture
>> With the aid of a
nappy (diaper), fasten
the arms of the infant to
the body to prevent
movement. By ’com-
bing’ through the hair
on the scalp, locate a
suitable vein.

>> An assistant should

hold the infant’s head
firmly but gently. With
both hands, part the hair
to expose the underlying
skin and vein, compress
the vein with the fingers.

>> The skin over the

puncture site should be
held taut with the left
hand. Disinfect the pun-
cture site, then insert
the needle from a small
gauge blood collection
set at a 5 – 10 degree
angle to the skin.

19
Blood Collection Techniques

>> As soon as blood begins to flow, connect a VACUETTE ®

tube. Once the tube is filled, remove it from the holder, and
remove the blood collection set from the scalp vein. Using a
sterile swab, place light pressure on the puncture site until
bleeding stops (minimum 2 minutes). Support the infant in an
upright body position and keep the infant calm and quiet.

Safety aspects of blood collection

>> As a result of increased infection risk (e.g. HIV, Hepatitis),
special care should be taken to avoid improper use of equip-
ment and/or deviations or carelessness during routine blood
collection.

VACUETTE ® PET tubes

>> Through the use of thick walled plastic tubes (PET) instead
of glass, tube breakage and injuries resulting from glass splin-
ters can be practically eliminated.

Winged safety blood

collection set
>> Following use of the
safety blood collection
set, depress the sides of
the stopper section and
slide the winged section
forwards until a ’click’ is
heard. The needle should
be fully enclosed within
the protective cover,
thus eliminating the risk
of needlestick injuries and can be safely disposed of.

20
Speedy quick-release
holder
The Speedy is a reusable
holder with an automatic
needle disposal mecha-
nism. After blood collec-
tion, hold the Speedy
vertically above a sharps
disposal container and
depress the extended part
of the release mechanism.
The needle is automati-
cally released into the
disposal container.

21
Blood Collection Techniques

L a b o r a t o r y R e q u i re m e n t s
>> The general view of the laboratory is that the tourniquet
should only be in place for the shortest period possible during
blood collection. (Risk: possible falsifying of results with longer
tourniquet time). A longer period of time, can lead to changes
in albumen values, cell count, lipids and other protein bound
substances.

Application of a tourniquet which is too tight, can lead to

haemolysis.

To avoid an increase in potassium values, all excessive mani-

pulation of the vein should be avoided. e.g. excessive clen-
ching and unclenching of the hand, too hard tapping of the
vein; those actions that are not routinely called for should be
performed in moderation, and generally limited to genuine pro-
blem cases.

Tubes with anticoagulants should be drawn last, thus preven-

ting contamination of other samples. The recommended order:
blood culture tubes
tubes without anticoagulants
citrate tubes for coagulation diagnosis
other tubes with anticoagulants

>> Immediately follow-

ing blood collection, all
tubes should be invert-
ed 4 – 5 times at appro-
ximately 180 degrees.
For a complete inversi-
on, the air bubble
should move from the
top to the bottom of the
tube. Inverting the tubes
will lead to adequate
mixing of anticoagu-
lants or coagulants and
therefore more accurate
laboratory results.

22
>> Improper collection from venous catheters can lead to con-
tamination from infusion solution or to a dilution effect.

>> Complaints about false laboratory results are frequently a

direct outcome of incorrect techniques at the blood collection
location. Clear labelling with patient data is essential. The label
must be affixed to the tube so that blood flow is clearly visible.
Immediately following completion of blood collection, tubes
should be transferred to the laboratory for processing.

L i t e r a t u re
1 Dörner, K., Böhler, T.: Diagnostische Strategien in der Pädiatrie,
Darmstadt 1997

2 Guder, W.G., Narayanan, S., Wisser, H., Zawta, B.: Proben zwischen Patient
und Labor, Darmstadt 1999

3 Flamm H., Rotter M.: Angewandte Hygiene in Krankenhaus und Arztpraxis,

Wien 1999

23
Blood Collection Techniques

Martin Dittmann
Medical training and graduation at the Free University in
Berlin. Specialist training in Anaesthesia and Intensive Care at
University Hospitals at Basel (Switzerland) and Cardiff (GB).
Assistant Manager of the Surgical Intensive Care Unit at Basel
University Hospital. Postdoctoral lecturing qualification in
Basel. From 1980 to 1999 Head of the Dept. of Anaesthesia
and Intensive Care at Kreiskrankenhaus, Bad Säckingen
(Germany).

24
 Greiner Bio-One GmbH
Bad Haller Strasse 32
P.O. Box 6
A-4550 Kremsmünster
Austria

Tel +43 7583 6791-0

Fax +43 7583 6318
E-Mail: office@at.greiner-bio-one.com

one step ahead