How You Know Whether Needle Has Punctured Vessel

Vasc Health Gamble Manag. 2013; 9: 381–390.

Clarification of the characteristics of needle-tip move during vacuum venipuncture to improve condom

Chieko Fujii

Kinesthesia of Nursing and Medical Care, Keio University, Kanagawa, Japan

Abstract

Groundwork

Complications resulting from venipuncture include vein and nerve impairment, hematoma, and neuropathic pain. Although the bones procedures are understood, few analyses of actual data be. Information technology is important to ameliorate the safety standards of this technique during venipuncture. This study aimed to obtain information on actual needle movement during vacuum venipuncture in guild to develop appropriate educational procedures.

Methods

Half dozen experienced nurses were recruited to collect blood samples from 64 subjects. These procedures were recorded using a digital photographic camera. Software was so used to track and analyze motility without the employ of a marking in social club to maintain the sterility of the needle. Movement along the Ten- and Y-axes during claret sampling was examined.

Results

Approximately 2.5 cm of the needle was inserted into the torso, of which 6 mm resulted from advancing or moving the needle following puncture. The hateful calculated puncture angle was xv.two°. Given the hazards posed by attaching and removing the blood drove tube, as well as by manipulating the needle to fix its position, the needle became unstable whether information technology was fixed or not fixed.

Conclusion

This report examined venipuncture procedures and showed that the method was influenced past increased needle move. Focusing on skills for puncturing the skin, inserting the needle into the vein, and changing easily while being conscious of needle-tip stability may be essential for improving the safety of venipuncture.

Keywords: claret drove, nerve impairment, motility assay, patient safety, puncture angle, clinical education

Introduction

Venipuncture is a mutual procedure for reaching the venous bloodstream and plays an instrumental role as a special technique of phlebotomy in diagnosis and parenteral therapy.

All invasive procedures carry some degree of risk of damage to the normal structures in the proximity of the region at which the process is performed.¹ Venipuncture is also an invasive process involving needle puncture. The complications resulting from venipuncture include nerve harm and neuropathic hurting, local and systematic infections, vein damage, and hematoma, which may vary in seriousness. The epidemiology of needlestick and sharps injuries was investigated in a complete cantankerous-section of 1,162 nurses in a large infirmary in southern Nihon. The prevalence of the devices used was twenty.6% for syringe needles and 3.8% for butterfly needles.^two The toll of such accidents likewise needs to be calculated.

The immediate onset of symptoms with needle movement suggests direct needle-induced nerve trauma.^three Newman and Waxman,⁴ Newman et al,^five and Newman⁶ reported that the incidence of nerve impairment caused by venipuncture during claret donation varies. Venipuncture-induced nervus injuries are rare; factors other than directly nervus contact announced necessary for the chronic pain syndrome to occur.⁷ Such injuries are typically mild or transient, and resolve spontaneously. Rarely, venipuncture-induced nervus injuries can be more severe, resulting in long-term disabling consequences, including Complex Regional Pain Syndrome type 2.⁸ Nerve compression injury may issue from large infiltrations and extravasations that can crusade compartment syndrome.^ix The importance of an authentic understanding of anatomy to prevent nerve harm and appropriate training from individuals experienced in venipuncture has previously been emphasized.¹⁰

Venipuncture is a serious medical procedure that should be carried out only by appropriately trained and competent medical staff.^x However, the procedure may oft be performed not only by specialized technicians but as well by novice practitioners.

The civilization in which nurses and doctors take traditionally worked has often made it hard for nurses to become competent at such skills. Notwithstanding, the boundaries of medical and nursing roles continue to evolve, and a culture of shared roles that may confer substantial benefits for patients, medical staff, and nurses is emerging.¹¹

Iatrogenic nerve injuries are not rare and occur in near all branches of medicine, with malpositioning under general anesthesia and venipuncture every bit leading causes. Some of these injuries may be unavoidable, but greater sensation of which nerves are at take a chance and in what context should facilitate the development and/or wider implementation of preventive strategies.¹² As for intramuscular injection, sciatic nerve injury in the upper outer quadrant of the buttock is an avoidable simply persistent global trouble. The consequences of this injury are potentially devastating, and should exist promoted more than widely by medical and nursing organizations.¹³

In addition, in that location are reports¹⁴ of infections beingness introduced into the blood by venipuncture. It is therefore important to improve safety standards for this technique in order to subtract the number of complications. To date, only a few studies^fifteen have evaluated venipuncture techniques in detail. Accordingly, this study aimed to obtain data on actual needle movement during a venipuncture process using a vacuum collection organization. This data could be used to develop appropriate educational practice programs.

Materials and methods

The study was conducted on three wellness check-up days scheduled during December 2011. If a subject was unwilling to cooperate on a detail day or the time was inconvenient, the check-up was scheduled for another mean solar day.

This study was approved past the ethics commission of the Graduate School of Health Management, Keio University, Kanagawa, Japan (June 23, 2010). The study objectives were explained to all participants. In addition, the participants were informed that they would not be penalized if they withdrew from the study and that only the researchers would view the video images. All participants signed a written consent form, which further explained that personal identification and individual evaluations would not be used and that questionnaire responses would exist stored separately from the written consent forms.

Subjects

Sixty-four staff members, including health intendance workers and administrative staff, were subjected to venipuncture after providing consent for the examination to be recorded.

Six nurses who had worked in the infirmary for longer than 10 years collected the claret samples. Simply ii nurses performed the venipunctures each day. The nurses performing the venipuncture were asked if the vacuum venipuncture technique was their start choice. They were also asked to select the best device for each individual.

The age and sex of the subjects undergoing venipuncture and other details of the procedure were recorded by the nurses. The circumference of the puncture site in the arm was measured afterwards each venipuncture.

Venipuncture equipment

Four nurses used a tube holder (XX-VP010HD01) manufactured by Terumo Corporation, (Tokyo, Nippon) for the vacuum tube procedures, with straight 21-estimate needles (MN-HD2138MS; Terumo Corporation). Two nurses used holders with straight 21-guess needles (35209002; Nipro Corporation, Osaka, Nippon). Blood collection tubes with conventional cap covers (NP-SP0725 or NP-EK0205; Nipro Corporation) were besides used.

Video recording

A Digital HD Video photographic camera recorder (HDR-HC9; Sony, Tokyo, Nihon) mounted on a tripod and Hello-vision MiniDV tapes were used for recording the procedures. The maximum telephoto zoom (10 times) allowed a altitude of l cm from the photographic camera lens to the puncture point. This allowed optical prototype stabilization revision to avert vibration. The puncture signal was fix directly under a pipage fluorescent lamp.

The claret collection procedure was captured using the video editing software EDIUS Pro 5 (Grass Valley KK, Hyogo, Japan), and the generated AVI files were transferred to a PC. The frame rate of the AVI file was 59.94 frames/second. To facilitate the conquering process, nosotros then converted these files into 24-scrap true color with a video capture of 720 × 480 pixels whilst matching them on a monitor. A solid-state drive (SSD)-correlation tracking algorithm was activated during acquisition to adapt the quality of the prototype sequence and account for differences in colour.

Video analysis

WINanalyze (v two.i; Mikromak GmbH, Berlin, Germany) is a software awarding that assists in analyzing movements during video recording. This plan uses calculations to generate assay windows. The software is suitable for Windows AVI.

The needle movement can be visualized as a trajectory formed by using objects from all frames, in which the object sequences of the current image sequence are displayed in diagrammatic form with respect to time domain or converted to the tabulating data. It tin can be analyzed with other statistical programs. Data obtained from the X and Y coordinates were saved in an Excel spreadsheet (Microsoft Corporation, Redmond, WA, USA) and the data used for graphic making. The still images that emphasized the movement were shown using PowerPoint (Microsoft Corporation).

Venipuncture steps and measurements

The video assessed whether the nurses used their ascendant hand to grasp the blood collection tube holder while puncturing the skin and so switched the tube holder to the nondominant hand, so that they were able to use their ascendant hand to remove the tourniquet.

The welded part of the needle at the needle base was cream-colored and easy to distinguish from the surrounding materials (Figure 1). This was designated as point A and was used to track needle movements. Despite being covered by transparent light-green plastic, the needle base of operations attached to the holder was recognizable and therefore designated equally point B, which was used to measure distance. A seal two mm wide and 4 mm long was placed on the holder and was designated as point C. It was connected then that the needle hole was adjusted to the upper part of the seal and turned to the top.

Location of the marking used and itemization of vacuum blood collection tube move in the venipuncture procedure.

Notes: (A) The welded part of the needle at the needle base; (B) the needle base attached to the drove tube holder; (C) a point indicating where the blood drove tube holder was placed; (D) the point where the needle punctured the peel; (Due east) temporary point, interior angle of AED at xc°. The venipuncture process was divided into the following iv steps based on the sequence of events: S-1: puncture; S-2: needle enters the vein; South-3: first collection tube; S-4: removal and insertion of collection tube.

Using WINanalyze, point D was assigned to the point where the needle punctured the skin, and betoken E was set every bit a temporary point at an bending of 90° to find the provisional value of the interior bending of ADE.

The vacuum venipuncture technique was assessed using video images and characterized by the point A trajectory. The procedure was subdivided into four steps (S-i–4), based on the following events:

• S-1 – Puncture: commencement contact of the needle with the skin to entry of the needle into the vein.

• S-ii – Needle enters the vein: entry of the needle into the vein to insertion of the first claret drove tube into the holder.

• S-3 – Kickoff collection tube: insertion of the showtime blood collection tube into the holder and collection of claret to removal of the blood drove tube.

• S-4 – Removal and insertion of collection tube: removal of the first blood collection tube to insertion of the second blood collection tube into the holder.

Measurement of movement during the venipuncture procedure

Given the size differences among the images obtained the written report identified the coordinate representing the least divergence between points A and B. The absolute value of the trajectory spanning from A to B was 0.nine cm. The altitude in each pic was not always the same and therefore calculation bias was corrected using the distance between A and B. The X- and Y-axes represented backward-forwards and upward-downward movements, respectively and the corporeality of motility occurring from 1 frame to the next was calculated and expressed as an absolute value.

Adjustments were made on the footing of the trajectories formed by points A and B calculated for each field of study to derive the mean values for each step. The distance was calculated by the post-obit formula:

 √((X₂−X₁)^two + (Y₂−Y_i)^two).

[1]

Techniques with maximum movement values

For each step, the absolute values of the differences in measurements between frames were summed using [ane] and expressed as movement distances. The maximum values for both the X and Y coordinates of each motion occurring during each step, as well equally their characteristics, were extracted from the video images.

Observations of searching techniques

In one instance, where the blood collection tube was inserted into the holder iii times, point A and bespeak C coordinates were extracted. The distance was measured, and the positional relationship of the coordinates was recorded.

Statistical analysis

Forty-six participants evaluated by video imaging were included in the analysis. If video imaging was blocked by placement of a finger over the needle during venipuncture, data from that section of the video recording were excluded from analysis. The recordings were reliable to a resolution of 1/x mm. Descriptive statistics were summarized with SPSS for Windows (version 19.0; IBM Corporation, Armonk, NY, USA).

Results

Contributions

The mean age of the subjects was 42.three years (standard deviation [SD] 12.2 years), and the mean circumference of their arm at the puncture site was 23.4 cm (SD 2.5 cm).

Vi nurses performed the venipuncture, two of whom were aged in their 30s and iv in their 40s. 4 nurses always inverse hands, whereas i nurse did not alter hands at all. During the venipuncture procedures in 46 subjects, the nurses changed hands 82.half-dozen% of the time subsequently puncture and 69.6% of the fourth dimension when removing the tourniquet.

The needle travelled from the puncture site to the vein through a hateful distance of one.nine cm (SD 1.0 cm) in 29 subjects. This decrease in field of study number was due to the video images existence blocked by placement of a finger. The needle moved a mean distance of 0.six cm (SD 0.3 cm) while entering the vein in 31 subjects. The mean puncture angle was 15.two° (SD 3.1°), with maximum and minimum angles of 21.8° and 10.7°, respectively (Table one).

Table i

Subjects undergoing venipuncture, altitude of needle movement, and puncture angle

	Nurse A		Nurse B		Nurse C		Nurse D		Nurse E		Nurse F		Full
Number of subjects	n = 13		n = 11		n = 9		due north = 7		n = 4		n = two		n = 46
Sex
Male	iv	(xxx.eight%)	4	(36.4%)	4	(44.4%)	3	(42.9%)	one	(25.0%)	0	(0.0%)	xvi	(34.viii%)
Female	9	(69.2%)	5	(45.5%)	4	(44.4%)	4	(57.ane%)	three	(75.0%)	2	(100%)	27	(58.vii%)
No mention	0	(0.0%)	two	(eighteen.2%)	1	(11.1%)	0	(0.0%)	0	(0.0%)		(50.0%)	4	(eight.seven%)
Age (years, mean ± standard deviation)	41.7 ± 12.5		42.three ± 13.7		43.three ± 10.three		43.4 ± fourteen.7		35.8 ± 7.6		52.0 ± 17.C		42.3 ± 12.2
Circumference puncture site (cm, mean ± standard difference)	23.ii ± ane.6		23.9 ± 1.8		23.five ± 1.four		22.viii ± 1.seven		25.0 ± vii.2		21.iii± one.1		23.4 ± 2.5
Changed easily
Later puncture	thirteen	(100%)	11	(100%)	9	(100%)	0	(0.0%)	3	(75.0%)	2	(100%)	38	(82.6%)
Tourniquet removal	eleven	(84.6%)	eleven	(100%)	v	(55.6%)	0	(0.0%)	3	(75.0%)	2	(100%)	32	(69.6%)
Distance of the needle (cm, hateful ± standard deviation)
From puncture to entry into vein	north = 3		n = 8		n = 8		northward = 6		n = four				north = 29
	two.4 ± 0.iii		ane.3 ± 0.4		2.viii ± one.one		1.9 ± 0.6		0.9 ± 0.iii				i.ix ± one.0
From entry into vein to entry into first tube	north = three		n = 10		n = 8		n = 6		n = four				n = 31
	0.8 ± 0.2		0.6 ± 0.2		0.viii ± 0.4		0.3 ± 0.two		0.3 ± 0.ane				0.6 ± 0.3
Bending of puncture (mean ± standard deviation)	northward = 11		n = 10		n = 9		n = 7		northward = four		n = 2		due north = 43
Mean (°)	14.4 ± 3.0		16.six ± 2.8		16.2 ± two.8		12.3 ± one.1		xv.3 ± 3.7		18.four ± 4.ix		15.two ± 3.one
Maximum (°)	20.eight		nineteen.vii		21.4		13.nine		19.eight		21.8		21.eight
Minimum (°)	ten.eight		eleven.1		13.ane		10.seven		11.4		14.9		10.vii

Of the 33 subjects for whom all steps could be analyzed by video imaging, the needle moved a hateful distance of 4.9 cm (SD 2.2 cm) along the X-centrality and 3.2 cm (SD 1.4 cm) along the Y-axis. The needle moved a maximum of 12.iv cm and a minimum of 0.4 cm forth the X-axis, whereas the Y-axis movement ranged from a minimum of 0.7 cm to a maximum of 10.iii cm.

In the instance requiring insertion of the blood collection tube 3 times, the needle moved 6.3 cm forth the X-axis and 3.7 cm along the Y-centrality (Table 2).

Table 2

Summation of full needle movement distance

	S-1		S-two		S-3		Southward-4		Total
Motion distances (cm)	n = 33		north = 35		north = 46		n = 46		n = 33
X-axis
Hateful (Standard deviation)	2.iii	(1.3)	1.ii	(0.6)	0.half dozen	(0.3)	1.i	(ane.seven)	iv.9	(ii.2)
Maximum	v.3		2.8		i.v		11.8		12.4
Minimum	0.8		0.3		0.1		0.ii		0.4
Y-centrality
Mean (Standard departure)	ane.ane	(0.six)	1.1	(0.6)	0.5	(0.3)	0.eight	(1.4)	3.2	(ane.iv)
Maximum	iii.2		2.four		1.4		ix.half-dozen		10.3
Minimum	0.iv		0.4		0.2		0.2		0.6
Movement distances (a field of study case) cm
X-axis	3.0		1.4		0.eight		one.1		6.3
Y-centrality	0.9		1.seven		0.v		0.six		three.7

Minimum and maximum needle motion

Figures 2 and ​ 3 show the maximum accumulated motility that occurred at each step on the X- and Y-axes, respectively. Maximum movement was acquired when the needle or holder was pressed from the height to the bottom, with the needle dropping less than 0.half-dozen cm. In other cases, the blood drove tube contacted the opening of the holder. The needle-tip remained in the vein whilst the holder was raised to insert or remove the blood drove tube.

X-axis: maximum of accumulated movement. (a) shows the start and (b) shows the end of the movement.

Notes: S-1: Needle was pressed from top to bottom by the get-go finger of the left manus. Southward-2: Holder traveled up and down during use of the first collection tube with the collection tube attached to the upper opening of the holder. Due south-3: Nurse changed hands later on inserting the blood collection tube into the holder using the nondominant hand. S-iv: The holder was pushed downwardly during removal of the blood collection tube from the upper opening of the holder.

Y-centrality: maximum of accumulated movement. (a) shows the start and (b) shows the end of the movement.

Notes: S-ane: The needle moved upward and downward. Due south-ii: The holder was pressed from the height to the lesser using the first finger of the left hand. Southward-3: Needle was pushed by the left thumb with the collection tube fastened to the upper opening of the holder. South-4: The holder was pushed down during removal of the blood collection tube from the upper opening of the holder.

Searching movements

A positional relationship was shown between points A and C in cases where claret flowed into the 3rd blood drove tube that had been placed in the holder later puncture. The welded part of the needle moved 0.7 cm from the starting time to the second tube and 0.3 cm from the second to the tertiary tube, as shown in Figure four.

Searching: location of the welded function of the needle at the point where the blood collection tube entered the tip of the holder, and the location of the sticker placed on the holder. (one) the first puncture is not successful; (2) the second puncture is not successful; (iii) the third puncture is successful.

A case in which the hands were not changed

Notably, once, pulling of the peel or angle of the needle was observed during insertion and removal of the blood drove tubes. The needle area could exist visualized clearly in cases in which the hands were non changed, as shown in Effigy v.

A instance in which the hands were not changed.

Notes: Pulling of the skin or bending of the needle was observed. The position of the holder is unstable.

Discussion

Successful venipuncture is characterized as reaching the venous bloodstream and not resulting in complications. This invasive process contains two critical steps: venipuncture site and vein choice, and venipuncture operation. In this report, we evaluated venipuncture performance from puncture to removal of the needle, which is especially related to venipuncture complications.

Unsuccessful venipuncture performance, which leads to complications, is related to improper movement of the needle. Therefore, the actual needle movement data for venipuncture performance are of import to developing appropriate educational do programs. The needle motility at the fourth dimension of puncture is described as a puncture made at an approximate angle of 10°–30°.¹⁶ The needle is laid apartment such that i–2 mm of its tip tin be inserted into the vein.¹⁷ These movements occur in a similar way during venipuncture worldwide.

The length of the 21-guess needle used in this written report was 3.viii cm. When needle puncture occurred, the distance from the two coordinate points equally the needle moved forward at an angle was calculated. Every bit a result, approximately one.9 cm of the needle was inserted after puncture, and information technology moved around 0.half-dozen cm afterward insertion. Therefore, approximately 2.5 cm of the needle was inserted into the body. Equally the mean circumference of the puncture site was 0.half dozen cm, the distance for advancing the needle after the backflow of blood observed in this study was relatively longer than a altitude of 1–2 mm.

This study calculated the puncture bending, ie, the interior bending of the needle and the puncture site. Although the puncture angles represented provisional values (Figure 1) due to differences in the position and orientation of the mitt performing venipuncture, the hateful, minimum, and maximum angles were 15.ii°, 10.7°, and 21.8°, respectively. Information technology is not feasible to bank check whether the needle has entered the vein during vacuum venipuncture until the claret collection tube is inserted. To the author'south knowledge, no other experimental studies are bachelor; therefore, no comparisons with this written report could be made. However, these findings indicate a puncture bending of approximately 15°. This estimate falls within the same range of standard teaching.

Moving the needle-tip to locate the vein under the skin following an unsuccessful puncture is termed "searching." This problem occurs in oftentimes accessed venipuncture sites and also with errors when selecting the vein, but rarely equally a result of venipuncture performance.

When the needle-tip did not enter the claret vessel, the nurse decided whether it was better to remove the needle or motion the needle-tip to locate the blood vessel rather than repeat the puncture numerous times. When the needle-tip is moved, the holder moves at the aforementioned time. Observing the welded function of the needle, the study noted that a 0.7 cm movement occurred betwixt the get-go and second tubes, whereas a 0.three cm movement transpired between the second and 3rd tubes, equaling a total of 1 cm. However, when the point marked on the holder was observed, the holder seemed to rotate. The needle bore may non have rotated to the top. Rotation changes the needle orientation, and blood does non menses back even if the needle has entered the vein. This leads to the notion that the needle has non entered the vein, irrespective of whether the vein was entered or non. At this phase, vein and nerve damage can occur if the needle is moved back and along.

Vein and nerve damage during the bodily puncture of the vein is an of import concern. However, it should be emphasized that attaching and removing the blood collection tube besides as manipulating the needle to set its position as well bear risks.

The maximum summation of frontward–backward movement in this study was 12.iv cm, whereas the maximum up–downwardly movement was 10.3 cm, including motility during needle puncture. This summation value may be influenced of vibrations for the shaking of photographic camera, tracking of data or back period of claret. Movements were large when the needle was pressed downward from acme to bottom later its tip had entered the vein and when the blood collection tube was being prepared for insertion into the holder. In that location were also potential hazards for vein and nerve impairment through attaching and removing the blood collection tube as well equally past manipulating the needle to fix its position.

The problem of using the ascendant versus nondominant paw remains. Collecting blood involves puncturing the skin, changing easily, grasping the holder, and inserting and removing blood collection tubes with the ascendant mitt, followed by removing the tourniquet when the easily are inverse once again. Alternatively, collection may involve puncture and insertion or removal of the blood collection tube with the nondominant mitt without irresolute easily. In these cases, the needle-tip moved backward, and the skin looked visibly stretched while the blood collection tube was inserted and removed.

There are also individuals who hold the needle and needle base, which is a mutual practice in venipuncture. Belongings the needle stops it from shaking and produces less movement which, in plough, presumably reduces the corporeality of stress on the patient. Nevertheless, care must be taken to forestall infection when holding the needle.

Inserting or removing a blood collection tube caused the holder to movement upwardly and downward when the tube contacted the expanse around the opening of the holder. If the blood collection tube contacted the holder, the point where the needle was held became a pivot point for raising the entire holder. Pushing the needle or needle base may crusade the holder to appear raised. Therefore, inserting or removing the blood collection tube increases the take chances of moving the needle-tip. In this regard, improving the quality of blood drove techniques is conspicuously needed, particularly in infirmary wards.¹⁸ Training that focuses on needle stability during manipulation may be particularly beneficial.

Venipuncture is also used for diagnosis during an emergency. It is a skill that is required of nurses on duty at any time, and it may be expected even for dehydrated patients and patients in whom a vein cannot be located. Therefore, the high frequency of claret testing lone means that vein and nerve damage caused by venipuncture can potentially occur in anyone.

The participant hoped to undergo a wellness check-upwards at an early time in the day. Therefore, the number of participants that each nurse is involved with is only partially important. This study evaluated simply a blood collection system. The number of nurses was not sufficient, and there were differences in venipuncture equipment. Variation between subjects, including where to place the fingers during venipuncture and motility of the mitt, decreased with an increase in the number of videos analyzed.

Conclusion

This report examined the characteristics of techniques by reviewing the cases producing movements; individual differences and variations in techniques may have existed among the six nurses included in this written report. Although an identical method was used, participants undergoing venipuncture may have moved at the time of puncture but otherwise may not have moved significantly. This study could therefore non determine the optimal technique. Further studies on how to appraise venipuncture techniques are needed.

Footnotes

Disclosure

The author reports no conflicts of interest in this work.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3726589/

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