Venipuncture

Kenneth R. Harbert , in Essential Clinical Procedures (Second Edition), 2007

BACKGROUND AND HISTORY

Venipuncture evolved from the practice of phlebotomy. The word phlebotomy is derived from ii Greek words referring to "veins" and "cut"; thus, phlebotomy tin be defined as the incision of a vein for bloodletting or collection. Since early times, humans have appreciated the association betwixt blood and life itself. Many medical principles and procedures take evolved from this belief. Hippocrates (460-377 bc) stated that disease was the effect of backlog substances such as blood, phlegm, black bile, and yellowish bile inside the body. It was believed that removal of the excess of these substances would restore balance (McCall, 1998). From this belief arose the practise of bloodletting—the kickoff form of phlebotomy. By the 17th and 18th centuries, phlebotomy was a major therapy for those practicing the healing arts. Lancets were amidst the principal instruments used by clinicians in the 18th century.

Methods and procedures associated with phlebotomy today are dramatically improved. But rarely today is phlebotomy used as a therapeutic modality (due east.yard., for patients with polycythemia). Instead, the chief purpose of phlebotomy is to obtain a sample of claret for diagnostic testing. The evolution of sophisticated laboratory equipment has reduced the need for venipuncture past requiring smaller quantities of blood for diagnostic assessments, amounts that often can be obtained by simply puncturing the skin without directly accessing the veins. There are many ways to obtain a blood sample using the venipuncture method. The procedures in this affiliate describe techniques using Vacutainers, syringes, and infusion sets.

Read full affiliate

URL:

https://www.sciencedirect.com/science/commodity/pii/B9781416030010500095

Extraction Techniques and Applications: Biological/Medical and Environmental/Forensics

K. Lew , in Comprehensive Sampling and Sample Grooming, 2012

3.05.4.1 Venipuncture

Venipuncture is when a vein is pierced by a needle for either intravenous injection or the removal of blood. Veins are favored over arteries considering they have thinner walls, and thus they are easier to pierce. In that location is also lower blood pressure level in veins so that haemorrhage can be stopped more than quickly and easily than with arterial puncture. The nigh site for venipuncture is the antecubital fossa located in the anterior elbow at the fold. This expanse houses three veins: the cephalic, median cubital, and basilic veins (Figure 1). The veins may exist visible in some individuals simply non others, or more easily felt in some, depending on the amount of muscle and fat tissue they accept. Vein patterns may also run differently between individuals. Generally, the cephalic vein runs along nigh the entire length of the arm and the median cubital vein connects the cephalic vein with the basilic vein. Of these three veins, the preferred one for venipuncture is the median cubital vein because it is larger and has a lower tendency to move or roll when the needle is inserted. There are also fewer nerve endings surrounding this vein making venipuncture less painful at this site. In some people the cephalic and/or basilic veins may be more easily located than the median cubital vein and may exist a more than appropriate vein to depict claret from. The phlebotomist must have intendance in anchoring those veins well to prevent rolling.

Figure 1. Major arm veins used for phlebotomy. The median cubital vein is the larger and more stable vein and is preferred for venipuncture. The cephalic and basilic veins have a greater trend to curl and veinpuncture may be more painful from these sites.

Sometimes venipuncture is performed on hand veins when the veins in the antecubital fossa are not appropriate. Blood is collected from the dorsal or dorsum side of the hand (Figure 2). Like to veins in the antecubital fossa, they are prominent in different positions on different individuals. Veins in the hand have a tendency to motility or gyre; thus, the phlebotomist should ensure that the skin is pulled taut and the vein is well anchored down prior to needle insertion.

Effigy 2. Distended veins on the dorsal side of the paw. Phlebotomy is washed on the hand when veins from the antecubital fossa are non bachelor nor suitable.

Read full chapter

URL:

https://www.sciencedirect.com/science/commodity/pii/B9780123813732000685

The Laboratory Woodchuck (Marmota monax)

Christine A. Bellezza DVM , ... Bud C. Tennant DVM, DACVIM , in Laboratory Animal Medicine (Third Edition), 2015

a Venipuncture

Venipuncture in woodchucks can exist challenging considering they lack readily accessible peripheral veins and general anesthesia is usually required. Woodchcucks tin be routinely bled from the femoral vein or artery (Fig. 8.5). Following anesthesia, the venipuncture site is clipped and scrubbed with alcohol and an antiseptic. The femoral pulse is palpated in the inguinal region and is used equally a reference bespeak since the vessels are not visible. A vacutainer tube and a 22-estimate, i" needle may be used. Direct pressure is practical following venipuncture to minimize hematoma formation.

Effigy 8.v. Bleeding the anesthetized woodchuck from the femoral culvert.

Samples can too be obtained from the maxillary or linguifacial veins (Fig. viii.six) which run in close proximity to the clavicle. Here, the woodchuck is placed on its back, head toward the phlebotomist, and a 22-estimate, ane" needle is directed straight into the notch formed where the clavicle meets the sternum. Intendance must be taken to avert entering the thorax. Cardiac puncture has been used and is the easiest and quickest method to obtain large amounts of blood, but complications such as cardiac tamponade and death may occur. Small amounts of claret can be obtained from the cephalic veins (on the medial aspect of the front legs) or tarsal veins (on the dorsal attribute of the rear feet).

Effigy 8.6. Haemorrhage from the anesthetized woodchuck from the linguofacial vein.

Read full chapter

URL:

https://www.sciencedirect.com/science/article/pii/B9780124095274000080

Clinical Biochemistry and Hematology

Ida M. Washington , Gerald Van Hoosier , in The Laboratory Rabbit, Republic of guinea Pig, Hamster, and Other Rodents, 2012

Blood

Venipuncture in guinea pigs is difficult because the peripheral veins in this species are minor and often covered by layers of fat. It is oftentimes necessary to shave the skin and use alcohol to help visualize peripheral veins in this species (Dyer and Cervasio, 2008).

Small volumes of blood can be obtained in unanesthetized guinea pigs from a variety of peripheral veins using a sterile lancet or a 23G–27G needle. A marginal ear vein can be nicked with a 25G needle and blood drops collected straight into a microhematocrit tube. The lateral saphenous vein runs across the tarsal joint and tin exist sampled with a 1-ml syringe on a 23G–27G needle after applying digital force per unit area on the thigh to hold off the vein. The cephalic vein and tarsal vein are also attainable on the republic of guinea pig, although merely small volumes tin can be obtained from these sites, and bruising and hemorrhage frequently result. Alternatively, a toenail can be cut short using a nail clipper to yield small-scale volumes of blood (Clifford and White, 1999).

Larger volumes of claret can be obtained from anesthetized guinea pigs using large central veins, including the jugular vein, cranial vena cava, and femoral vein. The curt cervix of the republic of guinea sus scrofa makes the jugular vein and cranial vena cava difficult to admission, but shaving and proper positioning allow optimal exposure (Pilny, 2008). In the republic of guinea pig, the correct jugular vein is larger than the left and will yield upward to 2.v   ml of claret. A 24G needle on a 1-ml syringe can be directed caudally to enter the jugular vein just cranial to the clavicle (Shomer et al., 1999). The cranial vena cava can exist accessed with a 22G or 23G needle on a iii- or vi-ml syringe that is directed caudally into the sternal notch under the commencement rib. A ketamine–xylazine mixture has been described as the preferable method of anesthesia for this road of blood sampling (Dang et al., 2008). However, the cranial position of the heart makes cardiac hemorrhage a significant risk when claret is sampled from the cranial vena cava (Joslin, 2009). The femoral vein tin be used to collect up to 3   ml of blood with the guinea pig nether anesthesia, in dorsal recumbency, and with the rear leg abducted. A 23G needle on a 1–iii-ml syringe tin exist directed at a 45–90° angle to the skin and inserted just ventral to the pulsing femoral artery inside the femoral triangle (Joslin, 2009).

Alternative sites for claret collection in a guinea pig under anesthesia include an interdigital vein and the retro-orbital sinus. The interdigital vein technique in the guinea pig is adapted from that described in the rat (Snitily et al., 1991). The pes is disinfected with booze and stimulated by rubbing with a methyl salicylate soaked gauze. Approximately 0.4   ml of blood is collected into a capillary tube later puncturing the interdigital vein with a 20G needle. The sample is then transferred into a sodium citrate solution, and pressure is applied to the sampling site for hemostasis (Keino et al., 2002). The retro-orbital sinus volition likewise yield small volumes of blood in an anesthetized guinea grunter (Joslin, 2009).

Cardiocentesis tin can be performed every bit a concluding procedure in an anesthetized republic of guinea pig. The animal is placed in dorsal recumbency, and a 20G–25G needle is advanced toward the heart nether the xiphoid cartilage to enter the left ventricle. Alternatively, up to fifteen   ml of blood can be obtained from the descending aorta or caudal vena cava following a laparotomy as a terminal procedure in an anesthetized republic of guinea pig (Joslin, 2009). Decapitation, performed by a trained individual, may yield ten–15   ml of body blood (Clifford and White, 1999).

Read total chapter

URL:

https://www.sciencedirect.com/science/article/pii/B9780123809209000031

Booze | Blood

B. Hodgson , in Encyclopedia of Forensic Sciences, 2000

Drove

Venepuncture of a cubital vein in an arm is the standard technique used clinically for extracting venous blood. This procedure offers the nigh convenient yet relatively safest way to draw blood from a alive subject. The alcohol content of these samples will represent the systemic claret concentration of alcohol, and the measured value can exist readily correlated with the behavioral effects of alcohol.

An alternative to venous blood is capillary blood obtained past finger-tip puncture. This blood, obtained from the fleshy tissue of the finger-tips, represents a transition from arterial to venous blood. Equally such, the booze concentration more closely represents the concentration in arterial claret. The major disadvantage of finger-tip blood is the very limited quantity that tin can be extracted. The amounts extracted are usually just sufficient to perform an initial analysis with no adventure of repeat if subsequently required. Thus, venous blood has go the predominant choice for forensic purposes, since the extraction is relatively more comfy for the subject field, allows more than sufficient quantity of blood for repeated analyses, and easy correlation with behavioral furnishings.

In deceased subjects, a wider selection of sites for claret collection becomes available. However, the wider selection is counterbalanced by the complications in estimation arising from the differences in booze concentration among the sites. Equally for living subjects, venous blood extracted from a vein in the arm or leg provides the optimum sample for interpretive purposes. The least desirable site is an open breast crenel that results from an autopsy examination.

Claret of uncertain origin (heart, vein or artery) may gather in the chest and mix with the interstitial fluid that bathes the organs of the chest. This mixed fluid is often scooped up and submitted for booze analysis equally a 'claret' sample. The alcohol analysis produces a effect which presents difficulties in interpretation since the sample does not truly reflect a genuine blood origin.

In forensic work, the drove of a blood sample must discover certain precautions related to the integrity and security of the sample. This is particularly so when the result will be used in the prosecution of an crime charged against an individual, such every bit the operation of a motor vehicle while under the influence of alcohol. Precautions are nearly crucial when the offense is that of exceeding a specified statutory blood alcohol concentration (BAC) in the operation of motor vehicles.

Swabbing the injection site with an alcoholic antiseptic solution is a common do in clinical settings. Booze swabbing compromises the integrity of a blood sample taken for booze analysis and is discouraged for forensic purposes. Unfortunately, microorganisms residing on the skin, potentially on the surfaces of apparatus used for taking the blood, or suspended in the ambient air, can contaminate the blood sample. Such microorganisms utilizing blood sugars can produce alcohol through a fermentation procedure. Conversely, microorganisms could as well utilize alcohol present in the blood from drinking equally an free energy source. Either fashion, the true BAC of the person is compromised, leading to difficult interpretations.

Blood alcohol kits, such as pictured in Fig. 1, have been developed expressly for forensic purposes. These kits are self-independent, requiring no boosted apparatus whose cleanliness and alcohol-costless status may be open to question. The kits contain tubes that are sterile and incorporate a preservative, such as sodium fluoride with an anticoagulant. Tubes used in Canada comprise sodium fluoride to produce a terminal concentration of 1% w/v and potassium oxalate as anticoagulant to produce a final concentration of 0.two% w/v. The preservative stabilizes the blood sample for an indefinite menstruation of up to several months, if required. The anticoagulant prevents clotting, an undesirable characteristic when analyzing the blood. Although non essential, the anticoagulant all the same simplifies the analysis by eliminating the step of homogenizing clotted blood. This step would otherwise require the use of homogenizing appliance, a messy and somewhat cumbersome procedure when dealing with whole claret. Refrigeration of the blood samples at approximately 4°C is recommended for prolonged storage. Experimental information have shown that claret concentrations decrease slightly over time when stored at room temperatures. The exact cause of the subtract is non certain simply is thought to exist either evaporation of the alcohol effectually the rubber stopper, or oxidation to acetaldehyde using oxygen from oxyhemoglobin (the ruddy pigment in the blood). Refrigeration stabilizes the blood alcohol for periods of up to six months. The preservative, sodium fluoride, and the commonly used anticoagulants, practise not interfere with the analytical procedures in current forensic use.

Figure i. Blood collection kit with two vacuum blood tubes (a, b), sterile needle (c), needle holder (d), nonalcoholic swab (e), seals (f) and packaging (1000, h).

It should exist noted that analysis for forensic purposes requires whole blood. Hospital and clinical labs routinely separate the fluid portion, plasma, from the blood. The plasma tin exist conveniently analyzed for a number of chemicals, including booze, using automated equipment specifically designed for that purpose. Forensic or toxicology laboratories, however, are more than likely to analyze whole blood for booze since statutory limits for legal operation of motor vehicles are expressed in terms of whole blood, due east.g. 80 mg of alcohol in 100 ml of blood. Alcohol concentrations expressed in terms of plasma have to be converted into the equivalent concentration in whole claret. Since this conversion is directly related to the water content of the blood of the individual, a degree of uncertainty is introduced at this indicate. The water content, or hematocrit value, varies non only amid individuals but inside the same individual. Hence, the equivalent whole blood concentration cannot exist predicted precisely, but only within a range of values with acknowledgment to possible values outside that range.

Read full chapter

URL:

https://www.sciencedirect.com/science/article/pii/B0122272153004029

Arterial and Venous Access and Hemostasis for PCI

Connie North. Hess , ... Mitchell W. Krucoff , in Interventional Cardiac Catheterization Handbook (Third Edition), 2013

Percutaneous Femoral Vein Puncture

Femoral vein puncture is performed like the arterial puncture, equally described in The Cardiac Catheterization Handbook, 5th edition, chapter 2. Indications for femoral venous sheath placement in patients undergoing PCI include the need for additional intravenous access for fluids and medications, a temporary pacemaker, or pulmonary artery force per unit area monitoring. Caution should be used to avert inadvertent additional arterial punctures. For this reason, if femoral vein admission is needed, start with the vein access before arterial puncture. If the artery is inadvertently accessed, place the arterial sheath and and so angle slightly more medially with the side by side puncture.

Read full chapter

URL:

https://world wide web.sciencedirect.com/scientific discipline/commodity/pii/B9780323080576000021

Intravenous Moderate Sedation

In Sedation (Sixth Edition), 2018

Disadvantages

one.

Venipuncture is necessary. Although most developed patients tolerate venipuncture with fiddling or no difficulty, some patients are psychologically unable to "handle" needles anywhere in their torso. Children may be particularly difficult to manage via this route considering veins are proportionally smaller in smaller patients, making venipuncture itself more than difficult. Younger children requiring IV moderate sedation will normally pose astringent management problems (the "precooperative" patient) or be physically unable to control themselves. Non all patients, fifty-fifty adults, have veins that are easy to visualize and gain access to with a needle. Probably the most significant claiming facing the dentist learning 4 moderate sedation is to develop a degree of proficiency at venipuncture. Venipuncture is a learned skill, one that becomes easier to perform as feel is gained.

2.

Complications may ascend at the venipuncture site. As discussed in Chapter 27, a variety of pocket-sized and some major complications tin develop at the venipuncture site. These include hematoma, phlebitis, and intraarterial injection of a drug.

three.

Monitoring of the patient receiving IV moderate sedation must be more intensive than that required in about other moderate sedation techniques. Because intravenously administered drugs act rapidly, the unabridged dental team must be trained to assess the concrete and mental status of the patient throughout the procedure. The greater the depth of sedation (deep > moderate > minimal), the greater is the need for increased patient monitoring.

4.

Recovery from intravenously administered drugs is not complete at the end of the dental treatment. All patients receiving whatsoever intravenously administered CNS depressant must exist escorted from the dental office past a responsible adult companion.

5.

Although the depth of sedation provided by intravenously administered drugs can exist increased rapidly (by administration of boosted drug), the antipodal is not true. Many intravenously administered drugs cannot be reversed past specific drug antagonists. Although antagonists practise exist for several drug groups, specifically opioids, benzodiazepines, and anticholinergics, they are not recommended for routine administration. three–5 Should a patient become overly sedated (deep instead of moderate; moderate instead of minimal), the initial, and about effective, direction in all situations is the maintenance of basic life back up: appraise the patient'southward airway, assist or back up ventilation, and provide for the constructive circulation of oxygenated blood. Post-obit these steps (P-C-A-B [basic life support]), consideration may be given to antidotal drug therapy.

Box 21.one summarizes the advantages and disadvantages of the Iv route of drug administration.

Read full chapter

URL:

https://www.sciencedirect.com/science/commodity/pii/B9780323400534000214

Left-Atrial Bagginess Occluders

Arwa Younis , ... Michael Glikson , in Cardiovascular Thrombus, 2018

Anticoagulation During Device Implantation

Femoral venous puncture does not necessitate withdrawal of anticoagulant therapy. Nevertheless, nigh operators aim to perform the procedure with normal-level INR at baseline and then use intravenous antithrombotic agents (more often than not unfractionated heparin) during the procedure (Table 36.4). The antithrombotic protocol of the PROTECT AF report [43] mandated an INR   <   2.0 at the onset of the procedures. ASA 81–325   mg was initiated at least 1   day before the procedure (nosotros recommend a loading dose if the patient is non on chronic aspirin therapy). In patients who are candidates for postprocedure therapy with DAPT, a loading dose of aspirin and clopidogrel is indicated unless they are already receiving this treatment. Weight-adjusted heparin (seventy–100   IU/kg) is administered after transseptal puncture to maintain an activated clotting time (ACT)   >   200   s for the procedure duration [sixty]. However, some operators perform the procedure while the patient receives OAC with a therapeutic level of the INR, a practise analogous to the widespread employ of warfarin during AF ablation. Several small studies showed that the combined procedures of catheter ablation for AF and Watchman LAA implant—while warfarin or NOACs are onboard—announced to be viable and safe, with first-class rates of LAAO and an observed stroke rate of 0.v% per twelvemonth during midterm follow-up; this without a significant increment in bleeding risk [89,xc]. Intravenous administration of antithrombotic agents is generally provided (at the latest) immediately after traversing the interatrial septum. A weight-adjusted bolus of unfractionated heparin (70–100   IU/kg) is most commonly used, thus maintaining an Deed   ≥   250   southward. LAAO may be performed as office of a combined procedure while a different type of antithrombotic medication is used, e.g., the straight thrombin inhibitor bivalirudin. This approach requires no further anticoagulation. Upon completion of the procedure the heparin is not reversed and various hemostatic techniques are used for rubber sheath removal.

Read full chapter

URL:

https://world wide web.sciencedirect.com/scientific discipline/article/pii/B9780128126158000363

ALCOHOL | Claret and Body Fluid Assay

D.K. Hunsaker , J.C. HunsakerIII, in Encyclopedia of Forensic and Legal Medicine, 2005

Specimen Choice and Collection in Living Subjects

Currently accepted venepuncture consists of cutaneous awarding of a nonalcoholic antiseptic (e.thousand., povidone iodine) and withdrawal of a sufficient aliquot of cubital venous or fingertip capillary whole blood by a sterile needle to a sealed sterile vial. Anticoagulants and microorganism-inhibiting chemicals are typically added. Importantly, venous blood does not precisely reflect the cerebral BAC, which ultimately defines the biochemical effects of EA, unless absorption and distribution of EA are complete at drove (Table 6).

Table 6. Accepted drove, transport, and storage of blood from living persons

Cutaneous awarding of nonvolatile antiseptic
Percutaneous venepuncture of cubital vein or fingertip capillary
Withdrawal of sample by sterile needle to sterile container
Vacuum glass collection tubes are acceptable legally
Filling container sufficiently to avoid evaporation
Use of clean container without anticoagulant assuasive blood to clot (for serum)
Use of preservatives/anticoagulants (for whole blood and plasma):
  1–2% sodium fluoride
  EDTA or potassium oxalate
Proper labeling, laboratory asking course, and chain of custody on or with container
Refrigeration (4 °C) or prompt delivery to analytical laboratory
Recording receipt and disposition of specimen by receiving analyst
Analysis or storage (refrigeration or frozen: −twenty °C) of specimen

EDTA, ethylenediaminetetraacetic acid.

Randomly collected, first-voided urine is by and large valuable just in confirming the presence of EA, considering the urine alcohol concentration (UAC) is subject field to multiple uncontrolled variables. Since the 1990s saliva, or oral fluid, has gained acceptance as a satisfactory matrix for on-the-spot testing for EA, both qualitative and semiquantitative, applicable to workplace or clinical settings such equally emergency departments.

Read full chapter

URL:

https://www.sciencedirect.com/science/commodity/pii/B0123693993000082

Alcohol: Claret and Body Fluid Analysis

J.C. Hunsaker , ... One thousand.D. Dukes , in Encyclopedia of Forensic and Legal Medicine (2d Edition), 2016

Specimen Pick and Collection – Living Subjects

Currently accepted venipuncture (World Health Organization, 2010) consists of cutaneous application of a nonalcoholic antiseptic (e.yard., povidone iodine) and withdrawal of a sufficient aliquot of cubital venous or finger tip capillary whole claret past sterile needle to a sealed sterile vile (Tabular array six). Anticoagulants and microorganism-inhibiting chemicals are typically added. Importantly, venous claret does not precisely reflect the cognitive BAC, which ultimately defines the biochemical effects of EA, unless absorption and distribution of EA is complete at collection (Williams and Leikin, 1999a,b; Earth Health Organization, 2010).

Table six. Accepted collection, ship, and storage of blood from living persons

•

Cutaneous application of nonvolatile clarified

•

Percutaneous venipuncture of cubital vein or finger tip capillary

•

Withdrawal of sample past sterile needle to sterile container

•

Vacuum glass collection tubes are adequate legally

•

Filling container sufficiently to avoid evaporation

○

Use of clean container without anticoagulant allowing blood to jell (for serum)

○

i–2% NaF

•

EDTA or potassium oxalate

•

Proper labeling, laboratory request form, and chain of custody on or with container

•

Refrigeration (4   °C) or prompt delivery to analytical laboratory

•

Recording of receipt and disposition of specimen past receiving annotator

•

Analysis or storage (refrigeration or frozen (−20   °C)) of specimen

Abbreviations: C, centigrade; EDTA, ethylenediaminetetraacetic acid; NaF, sodium fluoride.

Randomly collected, showtime-voided urine is mostly valuable only in confirming the presence of EA considering the concentration (UAC) is subject to multiple uncontrolled variables (Jones, 2006; Payne et al., 1967). Over the last decade saliva, or oral fluid (Choo and Huestis, 2004), has gained credence equally a satisfactory matrix for on-the-spot testing for EA, both qualitative and semiquantitative, applicable to workplace or clinical settings such equally emergency departments.

Read full affiliate

URL:

https://www.sciencedirect.com/science/article/pii/B9780128000342000124