To ensuring proper disposal of sharps, activating the safety

To sum up, many
complications and subsequently, injuries, can arise from a venipuncture
procedure. In order to minimize the risk of complications or injuries, extra
attention and precaution should be given by the phlebotomist during the
procedure. Phlebotomists should bear in mind to never be over complacent and
take things for granted during the procedure which can result
in complications or injuries of varying severity. Causing a patient permanent
injury for life or causing a needle stick injury to the phlebotomist themselves
is irreversible and apologizing or being filled with regret then will be too
late. Additionally, the safety of both the patients
and phlebotomists is of utmost importance and should never be compromised at
any point of time. Not only should phlebotomists be vigilant, but also be aware of the complications that may arise from
or during the procedure, make informed decisions, and to think on their feet
and react promptly to different situations. Phlebotomists plays a
crucial role in medical diagnosis, preventive healthcare and treatment of
diseases. It is of great importance to keep in mind these points to ensure that
the entire procedure is performed successfully and the risk of complications or
injuries are minimized.

The Centers for Disease
Control and Prevention (CDC) estimates that about 385,000 sharps-related and
needle-stick injuries have occurred to hospital-based healthcare personnel (Cdc.gov,
2015). These injuries are primarily associated with the transmission of
infectious diseases such as, hepatitis B virus (HBV), hepatitis C virus (HCV),
and human immunodeficiency virus (HIV), as well as other pathogens (Cdc.gov,
2015). In 2011, 52% of percutaneous injuries happened during the usage of
hollow-bore needles and 41% occurred after usage and the disposal of needles (Cdc.gov,
2011). 30% of the percutaneous injuries using hollow-bore needles happened due
to percutaneous blood sampling and 27% of that was during venipuncture (Cdc.gov,
2011). It has been estimated that 56% of the injuries that occurred could be
prevented by using safer devices that are available, using needles only when
necessary, ensuring proper disposal of sharps, activating the safety device
after usage and having safer work practices (Cdc.gov, 2011).

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Apart from the
complications that may arise, the nature of the job places phlebotomists
continuously in potential needle-stick situations, and they may experience a
high absolute number of injuries.

Consequently,
partially filled tubes will result from these instances. The amount of
anticoagulant manufacturers place in their tubes is calculated to provide the
proper blood-to-anticoagulant ratio when completely filled.  Therefore, all tubes should be filled to
their stated volume. Short draws disrupt the physiology of the specimen and
alter the anticoagulant-to-blood ratio, resulting in hemolysis and producing
spurious results. Phlebotomists who submit a tube that does not reach the
stated volume put the patient at risk of being diagnosed, medicated and/or
treated according to erroneous results especially in the case of coagulation tests.
The tube most sensitive to underfilling is the sodium citrate tube used for
coagulation studies. Any citrate tube filled less than 90 percent of its stated
volume will yield falsely lengthened activated
partial thromboplastin time test results and can result in the physician
adjusting anticoagulant dosage to a degree that risks serious complications.
Additionally, underfilling a EDTA tube leads to erroneous results due to
excessive anticoagulation. When the ratio of EDTA to blood is too high, the red
cells tend to shrink. As a result, hematocrit, mean cell volume (MCV), and the
mean corpuscular hemoglobin concentration (MCHC) will be affected.

Failure
to draw blood or a short draw, where insufficient blood is collected, may be
due to several factors such as improper insertion of needle, loss of vacuum in
tube and vein collapse. Not inserting the needle deep
enough, inserting the needle through the vein or movement of the needle
out of the vein while the tube is filling will result
in no blood flow, while holding the needle bevel against the vein wall will
result in reduced blood flow. Occasionally, tubes may have no vacuum because of
manufacturer’s error or a defect in the tube. Loss of tube vacuum can
result from exposing the bevel of the needle to the air when collecting from
very superficial veins. Small or fragile veins, such as those seen in elderly
patients, may collapse in response to the suction of the tube vacuum or
excessive force in drawing back on the syringe plunger.  If this occurs, veins will seem to
disappear.  It is best to carefully
evaluate the patient’s veins before venipuncture and select the appropriate
equipment for the vein selected.

Among
complications associated with phlebotomy, nerve damage can occur which is
potentially serious and often results in lawsuits. Occasionally, even when
proper technique and equipment are used, a patient may sustain nerve damage.
Damage to nerves can be permanent. Nerve damage can occur when the needle hits
a nerve that runs close to the vein identified, causing a sharp, pain electric
tingling sensation. This is caused by excessive probing, selection of
inappropriate insertion sites or convulsions by the patient during phlebotomy.
Additionally, if the side or backwall of the vein is ruptured, blood may flow
out and press on the nerve(s) resulting in a compression nerve injury.
Compression nerve injuries can be very subtle compared to direct punctures and
may take days before signs of damage are recognized.

The
U.S. National Library of Medicine explains that a risk of infection is present
whenever the skin is broken (Boyd, 2017). Inadequate cleaning of the insertion
site, poor aseptic techniques or using contaminated equipment can lead to
infections which may be localized or systemic. Cellulitis is an inflammation or
infection in the tissue below the skin surface. It is a rare complication of
venipuncture. Cellulitis is more likely to occur when fluids are given than
during a blood draw. Phlebitis is an inflammation of a vein, which is another
complication of the venipuncture procedure. Sepsis–a serious blood
infection–is also possible following venipuncture. Sepsis is more likely to
occur in patients who have a compromised immune system. This includes the
elderly, patients with immune system disorders and those taking drugs to
suppress the immune system. Burned areas on the arm should be avoided as it is
very sensitive and susceptible to infection. Properly cleaning the site prior
to venipuncture, good aseptic techniques and keeping any dressing over the
venipuncture site clean greatly reduces the risk of infection-related
complications.

Hemolysis
results from the breakdown of red blood cells and the release of hemoglobin
into the plasma/serum portion of the specimen. 
Severe hemolysis may affect test results and is often due to improper
technique. Several factors may contribute to hemolysis such as drawing blood
from a hematoma, not allowing alcohol to dry before beginning venipuncture, not
wiping away the first drop of blood from skin puncture, using small gauge
needles, excessive force on syringe plunger, excessive probing, forcing blood
from a syringe into vacuum tubes, inappropriate blood-to-anticoagulant ratio
due to underfilling, vigorous mixing of tubes and rough handling during
transport. Hemolysis may also result in falsely elevated
potassium, magnesium, lactate dehydrogenase, iron, phosphorous, ammonia and
total protein levels. Hemolyzed samples may show decreased red cell count and
hematocrit.

 

As
mentioned previously, hemoconcentration is another complication that can arise.
Prolonged application of the tourniquet can result in
stagnation of the normal blood flow: this is known as venous stasis. When
venous stasis occurs, the plasma portion of the blood filters into the
surrounding tissues leaving behind larger molecules such as red blood cells,
enzymes, iron, and calcium. This change in balance is known as
hemoconcentration. Hemoconcentration can also be caused by other situations
where extensive blood pooling occurs, such as vigorous clenching of the fist,
long-term IV therapy, probing, sclerosed or occluded veins, edematous areas and
hematomas. Hemoconcentration may result in falsely elevated potassium,
magnesium, lactate dehydrogenase, phosphorus, ammonia and total protein levels.

Hematoma
formation is the most common complication of venipuncture. This occurs when the
needle is improperly inserted or partially inserted into the vein, allowing the
leakage of blood from the vein into the surrounding tissues and accumulation
under the skin during or following venipuncture. A primary indication is
swelling around the venipuncture site while the needle is being inserted which
will result in a bruise. Blood collection from these areas is not painful to
the patient but may result in the collection of old hemolyzed blood rather than
circulating venous blood, due to a slowdown of blood flow to the area.  Additionally, pressure from the blood
collected in the tissues may apply pressure to the blood vessels in this area,
interfering with blood flow and resulting in hemoconcentration in samples
collected from this area. Hematoma can be caused by excessive probing, large
gauge needles, small fragile veins, partial insertion of needle into the vein
allowing leakage, penetration of needle through the vein, removal of needle
prior to releasing the tourniquet, insufficient pressure not applied following
venipuncture and bending the arm up at the elbow while applying pressure. The
elasticity of vein walls is usually sufficient to prevent blood leakage during
venipuncture; however, older patients and patients with small or difficult
veins may be more susceptible to the formation of a hematoma. Additionally, the
University of Maryland Medical Center reports that, occasionally, a patient
will bleed longer than normal after a venipuncture (Boyd, 2017). This
is more common in patients with certain bleeding conditions such as hemophilia.
Patients on anticoagulant therapy, blood thinners, certain drugs (eg. aspirin) or with low platelet count are also at increased
risk of this complication.

Venipuncture
is the act of puncturing the vein as part of a medical procedure, typically to
withdraw a blood sample or for an intravenous injection. Venipuncture has been
practiced for centuries and is the most common invasive medical procedure
performed by trained medical professionals known as phlebotomists. This
procedure requires skills in identifying a vein, inserting a needle into that
vein and then extracting blood without any complications. Despite the care
taken and prior training, a variety of adverse complications may arise from
venipuncture collection. There are many complications that can surface, however,
more common complications in venipuncture include hematoma formation,
hemoconcentration, hemolysis, infection, nerve damage and failure to draw blood
or short draw. Additionally, not only can patients sustain injuries through the
procedure but phlebotomists are at high risk of sustaining injuries too, due to
the nature of their job.

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