Phlebotomy refusing to draw

[Lame]

Last night I received an admit on heparin & amio drips. He had an IV on the right hand & AC. Blood draws couldn't be done on the left because he had a fistula. When the phlebotomist came to draw blood, she informed me that she couldn't draw his blood above his IV even tho I had stopped both infusions for the last 5-10 min. She could try his fingers because they were below the IV but of course the pt refused. She told me it was now a standard of practice that none of the phlebotomists could draw above an IV even if it was saline locked, but didn't know why. Other phlebotomists informed me that it's always been a standard but recently someone actually got fired for drawing above an IV.

I was lucky to be able to use the heparin line. Discarding about 20 cc of blood gave me what seemed to be an accurate PTT.

Has anyone heard of this before? Couldn't find the policy & none of my colleagues knew the reasoning why. I emailed my manager to ask as well. It's just scary especially when the pt is on these life saving drips.

[Double-Helix, BSN, RN]

One potential rationale is that, if the phlebotomist draws from the same vein or an immediate collateral vein distal to an infusing IV, and that vein is damaged in the process, there's potential for whatever is infusing through the line to extravasate, potentially causing tissue damage and, depending on the location of the IV within the extremity, rendering essentially the entire extremity compromised. This would be an even greater concern if a distal IV is infusing amiodarone, which is a known vaso-irritant and vesicant.

[Lame]

One potential rationale is that, if the phlebotomist draws from the same vein or an immediate collateral vein distal to an infusing IV, and that vein is damaged in the process, there's potential for whatever is infusing through the line to extravasate, potentially causing tissue damage and, depending on the location of the IV within the extremity, rendering essentially the entire extremity compromised. This would be an even greater concern if a distal IV is infusing amiodarone, which is a known vaso-irritant and vesicant.

Thank you! This definitely makes sense but is still frustrating as this pt has only 1 extremeity to use.

[Double-Helix, BSN, RN]

Definitely frustrating. I'd be advocating for a PICC line to ensure adequate access and blood drawing ability.

[KatieMI, BSN, MSN, RN]

Antecubital vein is connecting branch between basilic (which becomes brachial) and cephalic DEEP vein systems. Flow from it has little to do with superficial veins used for drawing blood. It is why antecubital vein can be used for almost everything, even for known vesicants and highly concentrated solutions. The risk of extravazation ABOVE the vein if one of small superficial branches is poked is about zero, because blood from antecubital goes directly to deep veins with their high flow and doesn't regurgitate back to superficial veins.

Yet another schmolicy written by ignorant body living under premice that "C means a degree".

[Double-Helix, BSN, RN]

ETA: my first post should say principal. If the phlebotomist is accessing the same vein proximal to the IV, not distal. I can't edit that comment, for some reason.

[Rose_Queen, BSN, MSN, RN]

ETA: my first post should say principal. If the phlebotomist is accessing the same vein proximal to the IV, not distal. I can't edit that comment, for some reason.

Editing is limited to within 5 minutes of the post unless one is a Pro member.

[KatieMI, BSN, MSN, RN]

ETA: my first post should say principal. If the phlebotomist is accessing the same vein proximal to the IV, not distal. I can't edit that comment, for some reason.

That's another thing. If the very same short antecubital branch is accessed proximally, there can be increased risk of extravasation, mixed-up results because the remnants of heparin seeping from the end of the catheter (being a huge and chemically "clingy" molecule, heparin can attach to carrier surfaces), injury to main carrying catheter, etc. But it all makes sense only if the same short antecubital branch is accessed. Small superficial veins proximal to it are totally ok to use - of course, with main infusion being stopped.

I would try to clarify things before it becomes "the way we ALWAYS do it". Pretty often the horror stories about someone fired for this and that can be translated like "I just do not want to do it, for the heck of it".

[Lame]

Thanks for the responses! I'm only 9 months in and still am trying to make sense of things. I sent an email to my manager to see what the actual policy is regarding this and to see what other options may be. In the past when I've stopped any infusion, the phlebotomist has always been able to draw and I've never had any problems or skewed results. I did ask about a picc line but they can't justify doing it for only that reason as the IVs can always be moved

[Julius Seizure]

This is a patient with a fistula, which leads me to believe that he is chronically ill and also by default already has limited IV access because we are down to just one arm. Also, amiodarone can cause phlebitis. It would seem to me that he would somebody who should be considered for a PICC simply based on the fact that we don't want to ruin whatever good vessels that he has left. I don't know much about hemodialysis fistulas, but cant they stop working? Might he need one in the other arm then?

I realize that a PICC line carries an infection risk....but sometimes IVs can't just be moved if there's no where left to move them. I'm surprised they weren't more open to the idea.

[AceOfHearts<3]

I had a patient very similar to the OP's patient recently- dialysis pt, heparin gtt, another cardiac gtt going, very very poor access, etc. We had an issue and an IV team nurse came to help me and when I asked about a PICC she told me the patient couldn't get one- not that he didn't need one or wasn't a candidate because he didn't meet the criteria for needing one, but that he physically couldn't get one (I forget the exact reason as things were so crazy, but it had to do with being a dialysis pt). I suspect it's probably the same for the OP's patient.

[Double-Helix, BSN, RN]

Here's an interesting article on the subject of PICCS and puts with CKD.

http://therenalnetwork.org/qi/resources/HospitalSystemChangeConcept_Tools/GuidelinesForPICCAvoidanceInChronicKidneyDisease-TipSheet.pdf