Some input on this would be appreciated:
One of my nurses was called to draw blood from a child because the phlebots and peds nurses could not get it. Needless, to say, when she arrived, the child had been poked mulitple times and was pretty bruised up. The only vein she could find that was not abused was in the AC above the IV site in the hand. So, she turned off the IV, disconnected it, and flushed the site. After waiting 10 minutes, she drew the samples from the AC.
Even though she took these precautions, the results were skewed. The lab has taken the stance that you can never draw above an IV site, even if there is nothing running.
Of course, this would always be the best situation, but the nurse did what she felt was best for the patient.
I am confident that this nurse does thorough and appropriate assessments. Any feedback or suggestions on what to do in such a situation. i know it won't be the last time we face this.
IMHO, the goal is patient comfort and parent satisfaction. So limiting the number of total sticks before the infusion team is called would be the first step. I am speaking on escalating VADs at AVA next month. I strongly believe that we need venous access tools, with these tools assessing the venipuncture sites of the patient, vein condition, skin condition, etc. And that these tools should merge the experience of the operator (usually a nurse) with the patient score. This would get the most appropriate person for the dificulty level of the patient. Such tools do not exist yet but I am hoping that this presentation will jump start some work on this issue. In the meantime, I would set a firm policy that no one is to stick any patient more than 2 times before calling someone else. Also set a max total number of sticks before the infusion team is called. For a peds patient with difficult veins, if it were my child I would want the infusion team to do the first and hopefully only stick required. I have never seen any research on how long to wait after turning off an infusion before drawing a blood sample proximal to an infusing site. 10 minutes sounds adequate but I guess not always. How old was the child? Could a vein in the foot have been used? Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
This has been an ongoing argument with our lab. The main issue has been how much various circumstances skew the results. The lab is arguing for accuracy, although when pressed for specifics on how much results are being skewed they aren't producing numbers that are clinically significant, just statiscally significant. (We don't really care if the ptt is skewed to 43.8 when it's actually 43.2, it makes no difference clinically), but the lab disagrees, arguing for asbolutely no skewing. Is there reliable data regarding how much skewing typically occurs under various conditions?
I'm all for some sort of tool that grades IV start/blood draw difficulty and hope that project succeeds. It wouldn't help determine who gets seen by the Infusion team where I work since we don't have one and our PICC Nurses are no longer allowed to do peripherals, but it would at least help give us some numbers on the volume of difficult starts we have to help justify getting some equipment that could be used with difficult starts/draws (we had one accuvein but it grew legs, there are no plans to get another, we don't use U/S to assist peripheral placement).
There is some information mainly in the critical care literature about the differences in studies of lab work taken from catheters vs peripheral venipuncture. There is statistically significant differences but those small differences, even though they are significant from a statistical standpoint, do not always make a difference clinically. I have never found data to address your question about how much difference is required before there is clinically significant differences. I think that would depend upon the specific test. For potassium, 3.3 vs 3.8 might make a clinical difference while a glucose of 256 bs 243 would still receive the same treatment. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I completely agree with Lynn in that if it were my child I would insist on the IV team being the ones to attempt venapuncture on my child. First let me say I do not work for and am not associated with any medical supply companys. I do keep our venouscope with me and it has made phlebotomy and staring peripheral IVs MUCH easier. Rarely do I have to attempt a second time. My hand held device runs around $200. There are tools on stands that I am sure would be much easier to keep track of in a hospital but I would think an IV team should be able to keep track of the small hand held if they have some sort of cart with supplies. Valorie
Valorie Dunn,BSN, RN, CRNI, PLNC
I disagree about calling IV for all kids. As an IV nurse, I had to bring my infant for lab draws. no way would I bring them to my IV team. We cover the pedi areas, but volume is so low we don't do many kids. The pedi phlebotomy team ont he other hand is awsome and way better that us. as for the location. 10min with the iv disconnected is deffinatly sufficient. that blood had circulatd the entire body by then. result could have been skewed from a number of other factors. Could it have been inadvertant arterial, could it have been partly hemolyized from slow draw? could be a short draw on a big tube, additives in the tubes and based on full blood volume of tube. pedi draws are often not full adult tubes.