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Phlebotomy Technique

  • Author: Gil Z Shlamovitz, MD, FACEP; Chief Editor: Vincent Lopez Rowe, MD  more...
 
Updated: Nov 25, 2015
 

Approach Considerations

Phlebotomy is commonly done with an evacuated tube system (eg, Vacutainer; BD, Franklin Lakes, NJ) or a syringe and needle or winged butterfly needle device (see the videos below).

Phlebotomy. Vacutainer(R).
Phlebotomy. Butterfly needle.
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Phlebotomy

Apply a tourniquet 10 cm proximal to the chosen site (see the image below), and have the patient lower the arm while clenching and releasing the fist repeatedly for 15-30 seconds so as to engorge the veins.

Phlebotomy. Tourniquet application. Phlebotomy. Tourniquet application.

Gently tapping on the vein may facilitate its identification. On palpation (see the image below), the vein should be soft and bouncy, it should refill after being depressed, and ideally, it should be well supported by the surrounding tissue.

Phlebotomy. Vein palpation. Phlebotomy. Vein palpation.

Use a skin disinfectant to prepare the skin (see the image below), and apply firm pressure to the skin with the swab. Allow the skin to dry for 30 seconds. You may not repalpate the skin after it has been disinfected.

Phlebotomy. Antiseptic solution application. Phlebotomy. Antiseptic solution application.

Assemble the blood collection device (see the image below), inspect it for any breaks or irregularities, and expose the needle.

Phlebotomy. Assembly of Vacutainer(R) device. Phlebotomy. Assembly of Vacutainer(R) device.

With your nondominant thumb, apply traction to the skin a few centimeters distal to the chosen site of needle insertion (see the image below).

Phlebotomy. Application of traction. Phlebotomy. Application of traction.

Inform the patient that you are about to introduce the needle, then insert the needle, with the bevel facing up (see the image below), at an angle of 15-30°. Once the needle has entered the vein (as signaled by decreased resistance), reduce the angle further, and advance the needle another 3-5 mm into the vein.

Phlebotomy. Insertion of needle (bevel up). Phlebotomy. Insertion of needle (bevel up).

If a winged butterfly device is used, grasp it by the wings and introduce the needle into the vein, with the bevel facing up, at an angle of 10-15° (see the first image below). Once the needle is in the vein, a flashback of blood will be visible in the device’s chamber and tubing (see the second image below). Reduce the angle further, and advance the needle another 3-5 mm into the vein.

Phlebotomy. Insertion of winged butterfly device. Phlebotomy. Insertion of winged butterfly device.
Phlebotomy. Insertion of winged butterfly device, Phlebotomy. Insertion of winged butterfly device, flashback of blood.

Switch hands, and hold the vacuum adapter device or the syringe with your nondominant hand so that you can use your dominant hand to pull the plunger or insert and release the vacuum tubes (see the image below).

Phlebotomy. Holding device in place and filling tu Phlebotomy. Holding device in place and filling tubes.

Once a tube has filled up with blood, invert it slowly a couple of times to ensure that the blood mixes with the anticoagulant or additive without causing mechanical hemolysis (see the image below).

Phlebotomy. Blood sample tube inversion. Phlebotomy. Blood sample tube inversion.

Release the tourniquet, apply gauze over the needle entry site, and withdraw the needle (see the image below). Either cover the needle with the safety needle cover or immediately place the device and needle in a sharps container.

Phlebotomy. Removal of needle. Phlebotomy. Removal of needle.

Instruct the patient to keep the arm straight, and apply—or have the patient apply—direct pressure on the gauze for at least 5 minutes (see the image below).

Phlebotomy. Application of pressure on straight ar Phlebotomy. Application of pressure on straight arm for 5 minutes.

If a syringe was used for drawing blood, use the needle remover on the sharps container to remove the needle, then use an adapter to transfer the blood into the sample tubes (see the image below).

Phlebotomy. Transfer of blood from syringe to vacu Phlebotomy. Transfer of blood from syringe to vacuum tube.

Finally, verify the patient’s identity again, and compare it to the preprinted labels. Apply the correct labels to the blood collection tubes while at the patient’s bedside or in the room. Inspect the phlebotomy site. If no bleeding is observed, apply a paper tape over the gauze, or place an adhesive bandage over the puncture site. Discard waste and single-use items, and send the collected blood tubes to the lab.

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Complications

Complications of phlebotomy include the following:

  • Hematoma formation - To prevent this complication, keep the arm straight, and have the patient apply direct pressure to the gauze for at least 5 minutes (patients receiving anticoagulant therapy might require longer application of pressure)
  • Nerve injury - Severe pain is a sign that a nerve was touched by the needle; if this occurs, remove the needle and apply direct pressure
  • Arterial puncture - If this occurs, remove the needle and apply direct pressure for at least 10 minutes; if a pulsatile mass persists, consider arterial duplex ultrasonography
  • Syncope - Some patients manifest a vasovagal response during or just after phlebotomy; thus, phlebotomy in a patient with a history of periphlebotomy should be done in the supine position; using a topical anesthetic and having the patients look away from the phlebotomy site, equipment, and blood filled tubes may be helpful
  • Phlebitis or cellulitis (rare when aseptic technique is used for phlebotomy)
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Contributor Information and Disclosures
Author

Gil Z Shlamovitz, MD, FACEP Associate Professor of Clinical Emergency Medicine, Keck School of Medicine of the University of Southern California; Chief Medical Information Officer, Keck Medicine of USC

Gil Z Shlamovitz, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association

Disclosure: Nothing to disclose.

Chief Editor

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Society for Vascular Surgery, Vascular and Endovascular Surgery Society, Society for Clinical Vascular Surgery, Pacific Coast Surgical Association, Western Vascular Society

Disclosure: Nothing to disclose.

Acknowledgements

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

References
  1. Lavery I, Ingram P. Venepuncture: best practice. Nurs Stand. 2005 Aug 17-23. 19(49):55-65; quiz 66. [Medline].

  2. Phlebotomy. WebPath. Available at http://library.med.utah.edu/WebPath/TUTORIAL/PHLEB/PHLEB.html. Accessed: 11/18/2011.

  3. Ernst, Dennis. Flawless phlebotomy: Becoming a great collector. Nursing. Oct/1995. 25(10):54. [Full Text].

  4. Wollowitz A, Bijur PE, Esses D, John Gallagher E. Use of Butterfly Needles to Draw Blood Is Independently Associated With Marked Reduction in Hemolysis Compared to Intravenous Catheter. Acad Emerg Med. 2013 Nov. 20(11):1151-1155. [Medline].

 
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Antecubital veins, left arm.
Antecubital veins, right arm. Note variable anatomy; median cubital vein is not visible.
Metacarpal veins.
Phlebotomy equipment.
Blood collection tubes.
Vacutainer(R) needle and adapter.
Pediatric blood collection tubes.
Phlebotomy. Tourniquet application.
Phlebotomy. Vein palpation.
Phlebotomy. Antiseptic solution application.
Phlebotomy. Assembly of Vacutainer(R) device.
Phlebotomy. Application of traction.
Phlebotomy. Insertion of needle (bevel up).
Phlebotomy. Insertion of winged butterfly device.
Phlebotomy. Insertion of winged butterfly device, flashback of blood.
Phlebotomy. Holding device in place and filling tubes.
Phlebotomy. Blood sample tube inversion.
Phlebotomy. Removal of needle.
Phlebotomy. Application of pressure on straight arm for 5 minutes.
Phlebotomy. Transfer of blood from syringe to vacuum tube.
Phlebotomy. Vacutainer(R).
Phlebotomy. Butterfly needle.
Antecubital veins, right arm.
 
 
 
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