Hematoma with blood draws

Been there,done that, ASN, 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.

So glad I can mildly annoy you. Please.. continue to enjoy.

The choice to continue sticking her, is indeed yours. You are the one with the needle.

CrunchRN, ADN, RN · Aug 13, 2015

No HTN.

I am reluctant and this is why I have been asking for suggestions. It did clear quickly after I used the Coban to wrap it according to the subject.

What you need to understand is that when people suffer from an inevitably progressive disease with no other viable treatments other than what may be offered by research the risk vs benefit considerations become much more complex.

It would be easy for me to say "nope, not going to do it", but is that what is truly best in this situation? That is why it is a decision that must be made by the participant and the physician and the study sponsor.

I appreciate all the constructive suggestions that have been made. I always remove the tourniquet while the last tube is filling. If the decision is made to continue I will try without a tourniquet at all.

I have never encouraged any participant to continue in a study just to have people in the study. I am offended that anybody would even think that is a consideration.

JustBeachyNurse, LPN · Aug 13, 2015

If you cannot feel the vein, hang the arm down, palpate, clean, air dry (do not let her pump fist), apply tourniquet, stick (I found straight stick with 22ga more effective than 23ga butterfly. The slight size difference fills tubes a little faster and less needle-in- vein time. Less movement of needle with straight vs. butterfly ), start first vacutainer, release tourniquet once blood flows, finish draw, place gauze and apply pressure as needle withdrawn.

Direct pressure with thumb (found combo of pressure plus warmth from hand equates to better fibrin clot formation). Since many do not hold pressure long or firm enough, I held pressure myself with a count of sixty. Never peak. Don't move gauze to not cause further trauma just secure original gauze in place. Minimal hematomas. Often veins and skin fragile as a part of the aging process resulting in micro tears.

I think the biggest factors that helped in my experience:

1. Straight stick not butterfly

2. No pumping of fist, simple warmth (even a sweater or blanket over arm while waiting for practitioner to prepare for draw)

3. Briefest tourniquet time possible, release as soon as blood flowing into tube

4. Smallest tubes possible to meet minimal sample requirement.

5. Holding direct pressure post draw and NOT lifting gauze to peak just taping gauze in place.

Laurab14 · Aug 13, 2015

"or find out what is the root cause of the hematomas."

I believe that is what she was doing by asking the question. All good nurses question if there is something we could do better- whether it is technique or just by picking other people's brain for more knowledge. It is the nurse that doesn't question or feel the need to improve that thinks their occupation is "all about me."

Starting with the easiest and most correctable solution first (technique) seems most appropriate to me.

Thank you for asking questions and trying to advocate for your patient by improving her venipuncture experience.

CrunchRN, ADN, RN · Aug 13, 2015

Thank you both for the excellent and much appreciated input. We always have butterflies, but I will get some 22G strait needles and give that a try along with all the other suggestions that you made. If she decides and is allowed to be in the study.

Any technique tips shifting from the butterfly to a straight needle>

JustBeachyNurse, LPN · Aug 13, 2015

Thank you both for the excellent and much appreciated input. We always have butterflies, but I will get some 22G strait needles and give that a try along with all the other suggestions that you made. If she decides and is allowed to be in the study.
Any technique tips shifting from the butterfly to a straight needle>

Hard to put into words. I was always taught only use butterflies if blood cultures needed (they cost 10x more than straight stick needles!!!) and was shocked when so many techs and nurses lean towards butterflies! I find butterfly needles always move and when used on my son or me actually cause more discomfort. You anchor the vein with non dominant hand, stick at a 30 degree angle careful to not go through the vein. I have my thumb on top index finger bottom and anchor the vacutainer holder with my three fingers. I keep my index finger between skin & folder to reduce changing the angle of the needle (kind of a c-clamp thumb on top, index below). All tube changes are with my nonddominant hand.

(I'm sitting here mimicking a draw trying to describe my technique). I worked phase 1/2 research with studies of up to 30 participants. We'd draw pharmacokinetic and pharmacodynamic labs pre/5 min/15 min/30 min/90 min/.. extended up to 7 days post initial dose intervals.

CrunchRN, ADN, RN · Aug 13, 2015

I get that technique. I will see if I can find a co-worker for a trial run.

I think the only really difficult part will be not seeing the flash. And of course trying something different!

JustBeachyNurse, LPN · Aug 13, 2015

Flash in the tube?

nurseprnRN, BSN, RN · Aug 13, 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.
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.

Suggest that you apply the tourniquet looser-- the vein will still have enough blood in it to retrieve. Also try putting a little roll of gauze against the brachial artery to decrease the blood flow into the arm, thus decreasing pressure on the veins as it tries to leave. Hang the arm over the side of the bed to decrease venous return, and remove the tourniquet the instant you get flash. You could also try the double-tourniquet trick-- apply one more distal to the stick site, then apply the second one proximal to the stick site. Keep using ittybitty needles.

Been there,done that, ASN, RN · Aug 13, 2015

"or find out what is the root cause of the hematomas."
I believe that is what she was doing by asking the question. All good nurses question if there is something we could do better- whether it is technique or just by picking other people's brain for more knowledge. It is the nurse that doesn't question or feel the need to improve that thinks their occupation is "all about me."
Starting with the easiest and most correctable solution first (technique) seems most appropriate to me.
Thank you for asking questions and trying to advocate for your patient by improving her venipuncture experience.

We had not been informed on the basis of the study. That information would have helped. If the patient is indeed in a life or death situation.. then ,hematoma formation would be a negligible side effect.

Just Beachy had all of my suggestions covered. I would always draw without a tourniquet, in these situations. Tourniquets apply so much pressure, a fragile vein can blown, just by their application.

Good luck in your study, Crunch. Please let us know how it turns out.

CrunchRN, ADN, RN · Aug 13, 2015

Thanks Greentea!

BTDT - this is a chronic irreversible inevitably progressive condition that takes years to end a person's life. I did not list many details because I am very hesitant to do that on a public forum. Maybe I was too careful. I don't know.

Been there,done that, ASN, RN · Aug 13, 2015

Thanks Greentea!
BTDT - this is a chronic irreversible inevitably progressive condition that takes years to end a person's life. I did not list many details because I am very hesitant to do that on a public forum. Maybe I was too careful. I don't know.

"this is a chronic irreversible inevitably progressive condition that takes years to end a person's life. ":confused: Can see that the HIPAA gods have you paranoid as well !