3.3 Difficult Draws & Complications

Even experienced phlebotomists encounter difficult draws and complications. Knowing how to prevent, recognize, and manage these situations is essential for patient safety and specimen quality.

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Common Complications

1. Hematoma (Most Common Complication)

A hematoma is a bruise caused by blood leaking from the vein into surrounding tissue.

Causes:

• Needle inserted through both walls of the vein
• Needle partially in the vein
• Tourniquet left on too long
• Inadequate pressure applied after needle removal
• Fragile or small veins

Prevention:

• Use proper needle insertion technique (15-30 degree angle)
• Anchor the vein well before puncture
• Apply firm pressure for 3-5 minutes after the draw
• Do not bend the arm after the draw — this does NOT help and can worsen bleeding

Management:

• If a hematoma forms during the draw: immediately remove the needle, apply firm pressure, and elevate the arm
• Apply cold compress for 15-20 minutes to reduce swelling
• Document the occurrence

2. Syncope (Fainting)

Signs of impending syncope:

• Lightheadedness, dizziness
• Pale, cool, clammy skin
• Nausea
• Tunnel vision or loss of vision

Management:

1. Stop the draw immediately and remove the needle safely
2. Apply pressure to the puncture site
3. If seated: lower the patient's head between their knees (or recline the chair)
4. If supine: elevate the legs
5. Apply cold compress to the forehead or back of the neck
6. Loosen tight clothing
7. Call for help (the designated first-aid trained personnel, per facility policy); if the patient loses consciousness, place them in the recovery position and keep the airway clear
8. Never leave a fainting patient unattended
9. Document the incident

Do not use ammonia inhalants (smelling salts). CLSI's 2007 venipuncture standard (H3-A6, quoted by CAP Today) said they "may be associated with adverse effects" and are not recommended, and the Center for Phlebotomy Education gives the same advice. Follow your facility's procedure.

3. Nerve Injury

Signs:

• Sharp, shooting, electric-like pain radiating down the arm or into the fingers
• Numbness or tingling
• This is DIFFERENT from the normal brief sting of needle insertion

Management:

• IMMEDIATELY remove the needle — do NOT redirect or reposition
• Apply pressure to the site
• Document the incident and notify the patient's physician
• Nerve injuries can result in long-term pain, numbness, or loss of function

4. Hemolysis (Red Blood Cell Destruction)

Hemolysis is the #1 cause of specimen rejection in laboratories.

Causes of hemolysis:

Visual Sign: Hemolyzed serum/plasma appears pink to red (cherry-colored) instead of the normal straw-yellow color.

5. Accidental Arterial Puncture

Signs:

• Bright red blood (vs. dark red/maroon for venous blood)
• Pulsating blood flow — tube fills rapidly
• Patient may report unusual pain

Management:

• Remove the needle immediately
• Apply firm, direct pressure for at least 5 minutes (longer than venous bleeding)
• Do NOT apply a tourniquet — this can worsen bleeding
• Monitor the site after pressure release
• Document and report the incident

6. Petechiae

Petechiae are tiny, pinpoint red spots that appear on the skin (often above the tourniquet site).

Causes:

• Tourniquet too tight or applied too long
• Platelet disorders (thrombocytopenia)
• Fragile capillaries (common in elderly patients or those on anticoagulants)

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The Two-Attempt Rule

Most facilities follow a two-attempt rule:

• If a phlebotomist is unsuccessful after two venipuncture attempts, they must stop and ask another qualified phlebotomist to try
• Making more than two attempts increases patient discomfort, anxiety, and risk of complications
• Document all failed attempts
• Never attempt a draw more than twice on the same patient

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Failed Venipuncture: Troubleshooting

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Vein Assessment Techniques

Proper vein assessment is a critical skill that improves first-stick success rates:

Palpation Technique

• Always use your index finger for palpation — NEVER your thumb (your thumb has its own pulse and you may confuse it with an artery)
• A healthy vein feels bouncy, resilient, and spongy — it compresses when pressed and rebounds when released
• An artery pulsates rhythmically — never puncture a pulsating vessel
• A tendon feels hard, cord-like, and does NOT rebound — tendons do not contain blood

Difficult-to-Find Veins

For patients with difficult-to-find veins, try these techniques:

Veins vs. Arteries vs. Tendons

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Documentation

Proper documentation is essential for every blood collection. The phlebotomist should document:

• Patient identification verification
• Date and time of collection
• Tests ordered and tubes collected
• Site used (e.g., right median cubital, left hand dorsal)
• Number of attempts (including failed attempts)
• Complications (hematoma, syncope, nerve pain, refusal)
• Disposition — specimen sent to lab, transported by (method)
• Phlebotomist signature/ID

Incident Reporting

• Any adverse event (needlestick, patient injury, syncope, nerve pain) must be documented in an incident report
• Include: date, time, description of event, patient and staff involved, actions taken, and follow-up plan
• Incident reports are used for quality improvement and are NOT punitive documents

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Anticoagulant Therapy and Phlebotomy Considerations

Many patients seen by phlebotomists are on anticoagulant therapy. Understanding these medications helps ensure safe blood collection:

Critical Clinical Tip: Always ask patients if they are taking any blood thinners or anticoagulants before the draw. Apply firm pressure for at least 5 minutes (or longer) after the venipuncture to prevent hematoma formation. DO NOT apply a bandage until bleeding has completely stopped.