Why am I not getting blood samples with a butterfly needle?

[dsaprog, BSN, RN]

I have a new job that requires me to do phlebotomy for the first time ever. Well today I had a patient who needed a phlebotomy and I did everything as I was taught, I see the flash of blood that let me now I found the vein and everything, I started filling tubes. I filled 3 1/2 tubes and everything was going smoothly and then suddenly I stopped getting blood on the 4th tube. I tried to move the needle around and stuck the needle in like 5 other places on the patient's arm and NO BLOOD. At one point I got a tiny amount of blood that came slowly and stopped before it reached the tube. I don't know if perhaps the needle was dislodged and that is why the blood stopped coming. I am pretty sure I held the needle still. I am having trouble understanding how to do this. Should I stick the needle all the way in? I watched tutorial videos on YouTube and some videos show the clinician putting the needle all the way into the arm while others stick the needle about half way in and then retract it slightly. I have been sticking only about 1/4 of the needle in because I don't want to go deep and puncture the wrong thing. I try to poke the needle in at a 30 degree angle and then narrow it to a 15 degree angle as I advance it. I would love some advice on how to do phlebotomy with a butterfly needle because I will be doing it A LOT in my new job and I hate to torture patients for nothing when I fail to get a blood sample.

[DavidFR, BSN, MSN, RN]

I personally think your problem is going in at too large an angle with 30°.

Try to be a bit more flush with the skin. This guide says 10° - 15° and personally that works for me. 

https://phlebotomycourse.uk/blog/butterfly-blood-draw/

Very easy to say, but don't stress! We all go through these "can't get a vein" periods at some point in our careers; You'll be OK. 

[JKL33]

Can you clarify this portion?

Quote

I tried to move the needle around and stuck the needle in like 5 other places on the patient's arm and NO BLOOD.

Just making sure you are not making multiple pokes with the same needle. Should not be doing that but rather start with new needle if your attempt has failed at any point after the initial poke.

Additionally, many places prefer that if the person performing the phlebotomy is having  that much trouble  (to the extent of making multiple pokes) they would want to have someone else look/attempt after they have made a couple of attempts. 

If your first attempt is unsuccessful or fails at any point such as you describe here, it's okay to do minute repositioning but should not be digging/fishing around at that site—THAT is painful. Instead, if it is clear you're not getting more blood from that site, bandage it and start over (properly assessing for a second suitable vein, getting the vein distended, proper use of tourniquet, proper cleaning on the site, new needle.  You set yourself up for failure on subsequent attempts if not approached properly.  Plus it is just not good patient care. 
 

The other thing I have found occasionally is just a vacutainer that doesn't want to work

/is defective. If I've already filled a few tubes with no problem but the next tube I put on gets zero, I would change out the tube for a new one, then proceed as described above. But in my career I've had quite a few times where I got a new tube and was  back to working just fine, so I've deduced that sometimes it's just the vacutainer. 

 

[dsaprog, BSN, RN]

JKL33 said:

Can you clarify this portion?

Just making sure you are not making multiple pokes with the same needle. Should not be doing that but rather start with new needle if your attempt has failed at any point after the initial poke.

Additionally, many places prefer that if the person performing the phlebotomy is having  that much trouble  (to the extent of making multiple pokes) they would want to have someone else look/attempt after they have made a couple of attempts. 

If your first attempt is unsuccessful or fails at any point such as you describe here, it's okay to do minute repositioning but should not be digging/fishing around at that site—THAT is painful. Instead, if it is clear you're not getting more blood from that site, bandage it and start over (properly assessing for a second suitable vein, getting the vein distended, proper use of tourniquet, proper cleaning on the site, new needle.  You set yourself up for failure on subsequent attempts if not approached properly.  Plus it is just not good patient care. 
 

The other thing I have found occasionally is just a vacutainer that doesn't want to work

/is defective. If I've already filled a few tubes with no problem but the next tube I put on gets zero, I would change out the tube for a new one, then proceed as described above. But in my career I've had quite a few times where I got a new tube and was  back to working just fine, so I've deduced that sometimes it's just the vacutainer. 

 

Yes I know to use a different needle I meant to say "needles (plural)" but I don't have anyone to help me because it's street medicine and I am the only nurse out there. I am trying to get more practice and find tips and tricks online for getting into the vein.

[offlabel]

After 3 and a half tubes, you probably just exhausted the blood in the venous system you were plugged into. Just waiting a minute before trying to aspirate anymore blood is all you'd need to do. Also, if your tourniquet is on too tight, you'll impede arterial flow and won't get venous filling into the arm and you'll briefly run out of blood if you have to take a lot. 

[VeraRN]

I recommend initially studying your anatomy and physiology of the vascular system. When knowledge of the anatomical position and the physiological state of a vein is learned to a very high level, this knowledge becomes the first step to gaining confidence to carry out the task. However, the next step, prior to needling, is to learn how to needle. And as a nurse, there is the process of assessment that is incorporated into all this learning. So learn first about phlebotomy, learn it's definition, learn everything there is to learn, and take a qualification that is recognised by the Nurse Authority in your country? There is so much to learn, please ask questions to your supervisors. Hopefully they can help with learning too.