therapeutic phlebotomy

firstinfamily, RN · Sep 23, 2014

I usually have used a smaller size catheter but for IV fluids, #20/#22/rarely 24. You are using #14 which is a pretty big gauge but you are doing it for drawing off of the blood (?) Your cancer patients may have low platelet counts and therefore are most likely going to have bleeding issues. Use a 2x2 with you when sticking and that way you have gauze to wipe up the extra blood. How much blood are you taking off??

iluvivt, BSN, RN · Sep 23, 2014

You may not have a choice of the needle size that you use because many of the doner kits/therapeutic phlebotomy transfer kits or blood doner kits have a large gauge needle (12 or 14 ) that you cannot detach and add your selected needle. I used to use a kit that you could change the needle and even use an IV catheter but no longer. The kit we use now the needle is attached with tubing and one clamp and there is a collection blood bag attached. By the way you need a large needle to get that viscous blood to keep flowing. It also helps you to collect the desired volume without having to stick the patient more than once (usually).

Now here are some tricks so that does not happen and YES you can try it again just use my tricks and let me know after that what you think...OK. PS..our IV nurses do all the therapeutic phlebotomies

1. The number one trick to prevent the problem you mentioned is to insert the needle BEVEL DOWN, Yes no one ever teaches that but that is exactly what you need to do to prevent that spurting you mentioned . Try that first please.

2. Second option..if it a big juicy vein w/o a tourniquet and you think you can access it without a tourniquet you can access it bevel up without the tourniquet and then put the tourniquet on after you have access the vein and secured the needle (I use a small tegaderm), If you insert bevel up I want you take a look at the cut of the bevel....see how many cms long it use....you must have all of that through the skin and well enough into the vein so it does not leak......so you must carefully advance it a few cms when accessing the vein. You DO NOT need to thread the needle all the way into the vein just thread enough so the all of the bevel is in the vein so after you hit the vein and get a flashback thread it a bit more....you may need to drop your angle before you thread it a bit more

Keep that blood and control the flow moving by the use of gravity (keep patient's arm down)..use of the clamp....adjustment of the tourniquet.

3. You need to make a a very controlled and quick venipuncture into the vein if you go very very slow and you are tentative (even with bevel down) blood will still spurt from the vein upon the puncture because of the large bevel and gauge. It will be less with bevel down. I am very quick and often do not use bevel down all the time anymore but I decide that based upon my assessment and lots and lots of experince. If you are new to the procedure you need to perform the venipuncture bevel down.

4 Have some 2 x2s and 4 by 4s at the ready

Tsatalstrana · Sep 23, 2014

OH WOW...iluvivt...thanks soooo much...this gives me SOMETHING to look forward to now. Yes, I was told to go bevel up, and I inserted very slowly, tentatively. So much appreciate your help. I am going to print off your advice and keep it safely in my pocket! thanks again, and will update on my next attempt! :yes:

iluvivt, BSN, RN · Sep 24, 2014

Yes ..please do so and let me know if it works better you can also just loosen the tourniquet too (if vein is big enough). You can always just tie it after you gain access into the vein. You can also use a BP cuff but keep it below the level of their diastolic number. You will get a MUCH MUCH better fill in vein with the use of a BP cuff so to prevent that spurting and leaking you may need to do a few things....again depending upon your assessment of the veins and their volume. A trick is to just pump it up slightly to 40-50..then clamp it so it stays..then access the vein..secure the needle and pump it up more...get the BP cuff fairly high on the arm especially of you going for a vein in the ACF (which is a good choice for a therapeutic phlebotomy). I like to use the BP cuff for these since many patients find it more comfortable than the tourniquet and that blood just keeps coming and does not clot in the tubing because the flow stays consistent. You can flip it too for easy use since you are using it as an awesome tourniquet.

Did you continue to have oozing after your access or was it just upon venipuncture that you got the spurt and bleeding?