Hematoma with blood draws

Been there,done that, ASN, RN · Aug 12, 2015

She is participating in research. This is not about you or your technique. Please advocate for her! The way to avoid it is either... stop sticking her, or find out what is the root cause of the hematomas.

When you reported this to the physician, what was your direction?

JustBeachyNurse, LPN · Aug 12, 2015

Was it an immediate hematoma? If not, when I worked in clinical research the investigator observed the subjects reporting consistent hematomas.

Any immediate hematomas were reported as AE for investigator or sub investigator physician review. Most participants were not holding direct pressure for an adequate amount of time (very necessary when having multiple or serial blood draws), some were removing the gauze too quick partially dislodging the clot and causing the hematoma, some one holding sufficient pressure (enough to clot at the surface but enough for subcutaneous hemostasis) and one or maybe two out of the hundreds had an undiagnosed mild clotting disorder that did not show on a basic CMP & CBC.

Those participants were barred from subsequent studies and extensive testing was done to rule out adverse effect of the test drug (or it may have been a cocktail interaction study). After coagulation, bleeding time, clotting factor and a genetic test one had a variant of Von wildebrand and the other had an undiagnosed platelet disorder that would not be an issue unless repeated phlebotomy, major surgery or illness. Of course one filed a claim claiming it was the drug seeking compensation...thankfully our documentation was impeccable in this case and ultimately they turned out to be in the placebo arm (double blind placebo controlled) proven once the study code was broken but that's a different story.

CrunchRN, ADN, RN · Aug 12, 2015

I am trying to advocate for her. That is why I was asking for any tips about my technique I might be able to change in order to not cause this.

Your reply is rude and unhelpful Beentheredonethat. However, I am sure you know and intended that so that is not news to you.

This has been worked up in the past with no resolution as to the cause. This elderly subject very much wishes to remain in the study and I am trying to help with her wishes.

The hematoma formation was immediate upon entering the vein with a 23 g. The physician is leaving the choice to the subject. We are not her caregivers so cannot re-do that which her PCP feels was already worked up adequately.

JustBeachyNurse, LPN · Aug 12, 2015

I'm shocked she's permitted to remain in the study! When I did research if someone had a hematoma form upon needle insertion they were dropped. Period. Risk was too great.

Hopefully the PI and study manager have enough forethought to have documentation from the PCP so that later on this is not deemed a possible AE by family or another provider.

Aside from angle adjustment and trying to avoid valves (which may be difficult in an elderly patient) or micro aneurysms there isn't much you can do.

The reason participants were worked up as the hematomas did not occur at the screening visit but were reported after the first draws in the active study. They needed to ensure it wasn't a drug effect.

CrunchRN, ADN, RN · Aug 12, 2015

Well..... it is all still under discussion at this point. In the interim I wanted to find out if there were any modifiable factors I might be able to discover as far as technique.

This is a long standing issue apparently and they are not yet on study drug.

JustBeachyNurse, LPN · Aug 12, 2015

Are you doing straight stick or butterfly? I found more hematomas in elderly using butterfly needles as there was always, even if seemingly negligible, movement when you went to attach the tube/change tube. I'd have less hematomas drawing on seniors using a 22ga straight stick and using pediatric sized tubes/micro vacutainers or 22/23ga on a syringe then transfer to the vacutainers.

Been there,done that, ASN, RN · Aug 12, 2015

Read me wrong, Crunch. Again, this is not about you. I may be a COB, but when I envision a little old lady springing up hematomas, it bothers me.

Now that you explain it has been worked up, I can scratch her off my list of things to worry about. I myself, would not be able to continue sticking her, studies be damned.

JustBeachyNurse, LPN · Aug 12, 2015

Read me wrong, Crunch. Again, this is not about you. I may be a COB, but when I envision a little old lady springing up hematomas, it bothers me.
Now that you explain it has been worked up, I can scratch her off my list of things to worry about. I myself, would not be able to continue sticking her, studies be damned.

I would be reluctant to continue to stick as risk out weighs benefit in a voluntary clinical trial

CrunchRN, ADN, RN · Aug 12, 2015

Again beentherdone that it was not posted because it is "about me" except to the extent that I felt badly causing a hematoma and hoped someone would have some ideas that might prevent them. I haven't had that happen before so thought it would be a good idea to check with other nurses that might have some experience and constructive suggestions.

Obviously I was very wrong about that last part. Luckily I am a tough old nurse and only find you mildly annoying and realize that you do not perceive others as well as you seem to think you do.

Finally, the choice is not mine. It is the potential participant's along with the PI and study sponsor.

icuRNmaggie, BSN, RN · Aug 12, 2015

Draw without a tourniquet ? Is she hypertensive?

Oceanpacific · Aug 12, 2015

Undo tourniquet and remove vacutainer tube before withdrawing the needle. People forget to do that. Also nice compression as others have noted. A coban wrap is nice as well. Some people just bruise easily, are on anticoagulants or have bleeding disorders