VACUETTE®

Blood Collection Techniques

Guidelines and
instructions for venous
blood collection

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Contents
Introduction...................................................................................................... 3
Requirements for blood collection.................................................................. 3
Materials required for blood collection........................................................... 4
Introduction
To this day, venipuncture is barely dealt with during study courses; however, it is pre-
cisely in this area where medical staff are subject to particularly critical evaluation by
patients. Therefore, it is important to adopt the best and most stable technique possible
for taking blood samples in all situations.

Positioning the patient.................................................................................... 4
Puncture sites: priority list.............................................................................. 5
Routine puncture sites.................................................................................... 6
Inspection of the puncture site....................................................................... 7
Before taking a blood sample, the top priority is to be fully familiar with the respective
collection system and products used. Handling equipment that you are not familiar
with not only comes across as unprofessional, but also increases the patient's anxi-
ety, which in turn has a negative effect on the condition of the patient's veins. For
training purposes, demo arms are provided so that venipuncture can be practiced as
often as necessary.

Optimal view of the veins using the example of the inside of the elbow...... 7 This guide is intended to
help you to correctly per-
Tourniquet........................................................................................................ 9 form blood collection and
make proper use of the
Disinfection of the puncture site................................................................... 11 various collection sys-
tems. With thorough
Venipuncture.................................................................................................. 12
training, you will soon
Needle insertion........................................................................................... 12
develop the required
Recommended hand position...................................................................... 13
skills.
Inserting the tube ....................................................................................... 13
Corrective action in the event of weak or no blood flow............................... 14
These guidelines are recommended by Greiner Bio-One. The content of the guide-
Correct cannula positioning and solution possibilities................................... 15
lines is based on international standards and current specialist literature. Please
Pulling out the tube..................................................................................... 16
comply with the regulations in your facility and in your country.
Order of draw.............................................................................................. 16
Inversions.................................................................................................... 17
Removing the cannula................................................................................. 17
Activating the safety mechanism.................................................................. 18
Disposal ���������������������������������������������������������������������������������������������������� 19
Requirements for blood collection
Caring for the insertion site.......................................................................... 19
Patient's responsibilities
Tube labelling and sample transport............................................................ 20

Special instructions for collecting blood...................................................... 21 gg Many tests require the patient to fast.
Blood collection from venous catheters....................................................... 21 gg The patient should not smoke prior to blood collection.
Complicating factors for venipuncture.......................................................... 21
gg No sport or major physical exertion.
Blood collection in small children................................................................. 22 gg Consult the doctor before taking any medication.

Blood collection in newborns and infants.................................................... 24 gg For better comparability with previous laboratory results, blood
collections should always be carried out at the same time of day.
Safety aspects when collecting a blood sample.......................................... 25

References..................................................................................................... 27 Patient preparation may vary depending on requirements.

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Medical staff responsibilities Puncture sites: priority list
Prior to the venipuncture, the puncture site must be selected. The veins on the inside
gg Making contact of the elbow are almost always suitable for blood collection; the veins in the back of
gg Patient identification the hand should be considered as a second choice. Puncture in these regions is
successful in about 95% of patients.
gg Documentation of special diets and allergies

gg Explanation and consent The course of the veins can be made visible by using special vein visualization equipment.
gg Hand disinfection

1. Inside of the
The next steps are described below. elbow

Positioning the patient

For venous blood collec-
tion, a venipuncture chair
with armrests is recom-
mended.

This way, it is possible to

2. Back of the
position the patient in
hand
both a sitting and reclin-
ing position and thereby
ensure the patient's
safety.

Materials required for blood collection

gg Blood collection system: VACUETTE® 3. Alternative

puncture sites
gg Tourniquet

gg Gloves

gg Swabs

gg Disinfectant

gg Dressing material/sticking plasters

gg Sharps-proof disposal container

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Routine puncture sites Inspection of the puncture site
Before you decide on a puncture site, the limb must be inspected for injuries. Exclu-
Puncture: Inside of the elbow sion criteria include thick scar tissue, bruises and lymph blockages following mastec-
tomies.
Prior to the puncture, both arms must be examined and one vein selected, if possible
on the non-dominant arm. A suitable puncture site is selected on the basis of these criteria. In this region, an
If the patient prefers to have the puncture on a certain arm, this request should be initial palpation (feel) is carried out, as a vein should not be selected solely based on
granted. It is important that the patient does not make any rapid movements a few its appearance. The condition of the vein to be punctured is vital when selecting which
minutes before blood collection, but calmly sits or lies down. product to use, the position of the person taking the blood sample and the angle of
needle insertion.
The inside of the elbow is
positioned on a stable
support. The elbow joint
should not be fully
extended. When the
elbow is fully extended Optimal view of the veins using the
the veins are suppressed
by the meeting of the joint example of the inside of the elbow
and the skin tension.
There are various ways of making the veins easier to find.

Tourniquet
(see page 9)

Puncture: Back of the hand

As a right-handed person, use your left hand to take the patient's hand to be punc-
tured, which is in a neutral position. The skin is gently stretched in a distal direction.

Slightly bent arm

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Arm hanging down
and positioned on
Tourniquet
stable support
Purpose

The use of a tourniquet is recommended to prioritise a vein and select a puncture site
for the needle. A tourniquet is not necessary if the vessel is large and easy to feel and,
therefore, also easy to puncture.

Application
Stretching the skin
The tourniquet is applied with a little
pressure 7.5–10 cm above the punc-
ture site. With optimal application of
the tourniquet, the pulse should be
easy to feel.

Ball the hand into Tourniquet pressure

a fist (do not pump)
The tourniquet pressure can be measured using a blood pressure cuff. This should
be 40 mmHg. A higher pressure would impair the arterial blood flow to the limb.
This also applies to commercially available tourniquets.

Practical tip: to develop a good feel for the correct pressure, we recommend applying
a tourniquet to one arm and a blood pressure cuff on the opposite side at 40 mmHg.
The blocked veins can now be compared on both arms.
The pressure in the arteries is 120/80 mmHg; in the veins it fluctuates between -5 to
20 mmHg.

Warmth (arm bath

or heat cushion)

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 A tourniquet pressure of 40 mmHg is higher than the venous vascular pressure, but
an almost undisturbed arterial blood flow is still possible. A low tourniquet pressure is
also essential for the differentiation and prioritisation of the vessels. When feeling the
vessels, the pulse can be felt on an artery, but not on a vein. The higher the tourniquet
pressure, the shallower the pulsation wave becomes, until it is not palpable at all once
it reaches or exceeds the systolic blood pressure.
With an optimal tourniquet pressure, the vein to be punctured will be completely filled
by the arterial blood flow. Following a successful puncture, the blood collection tube
fills up easily.
In the case of poor vein conditions,
the tourniquet is often applied too
tightly, so that the tourniquet pressure
gets close to or exceeds the arterial
blood pressure. This leads to prob-
lems when collecting venous blood.
If the systolic blood pressure is
exceeded, the vein to be punctured
can no longer be filled with blood, as
a stricture occurs.
Palpation
The vein should be felt with the fore-
finger and/or middle finger. The
thumb is not suitable, as it has its
own pulse. The vessel should not
pulse at all, otherwise it is an artery.
Using a low tourniquet pressure, the
vein will be well filled, easily palpable
and easy to puncture. A fully filled
vein feels elastic and has a springy
resistance upon palpation. The vein
is normally penetrated in the centre
of the angular point.
It is often difficult to differentiate the vein from a nearby tendon as tendon tissue feels
hard upon palpation. For more accurate differentiation, the patient should move the
lower arm and hand. If the right muscles are tensed, the tendon clearly moves with
them.

If a blood collection tube is used in

such a situation, it sucks the vein
empty, the vessel collapses and the
tip of the needle adheres to the vein Disinfection of the puncture site
wall.
The puncture site must
be thoroughly and care-
Duration fully disinfected immedi-
ately prior to the punc-
The tourniquet should not be applied for longer than one minute in total. If the steps ture. The skin is wiped
for the vein selection, disinfection and puncture last longer than one minute while a with disinfectant in a spi-
tourniquet is applied, the tourniquet must be released for two minutes to avoid ralling motion from the
haemoconcentration. Once blood enters the tube following a successful puncture, inside towards the out-
the tourniquet should be released. side.
Ideally, the vein blockage should last for the shortest possible amount of time and can Please note the (mini-
be applied with a tourniquet or blood pressure cuff. mum) application time in
the product description
A vein blockage time that is too long particularly affects the protein values, cell counts, of the skin antiseptic.
lipids and other substances associated with proteins. In addition, long vein blockage
times can lead to haemolysis and thereby alter the red blood cell indices. The wearing of gloves is mandatory for each procedure carried out (caution:
hepatitis, HIV).

Always observe the manufacturer's instructions and the regulations in your facility.
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 Venipuncture
The skin and the vein are held
in place by being stretched
with the thumb.
This enables accurate pene-
tration of the skin and pre-
vents the vein from "rolling".
Needle insertion
The needle is inserted at an
angle of about 10–30 degrees
with the preferred hand of the
person taking the blood.
When doing this, the needle
tip is facing upwards.
The patient should be made
aware of the imminent needle
insertion.
In a successful puncture, a decrease in resistance is felt when penetrating the vein
wall. The insertion depth can vary depending on the patient and the selected vein.
Practical tip: For a visual
puncture check, use our
VACUETTE® VISIO PLUS
cannula with transparent
viewing window.
12
Recommended hand position
Hold the tube holder
using your preferred
technique. However,
always ensure that the
rear opening and the
grips of the tube holder
are freely accessible, so
that the blood collection
tube can be easily insert-
ed and pulled out later.
Practical tip: hold the tube holder
with the thumb and forefinger in the
10–30 ° preferred puncturing hand. Using
your free fingers, you can support
the patient's arm and hold it in place.
This way, the tube holder and the
cannula can be easily inserted and
accurately adjusted. This avoids
making any further movements of
the cannula in the vein, which can
cause pain and injury.
Inserting the tube
Using your free hand,
push the blood collection
tube into the holder. Any
unnecessary hand chang-
es should be avoided.
The forefinger and middle
finger are positioned on
the gripping strip of the
tube holder, while the tube
is inserted with the thumb.
The rear end of the can-
nula pierces the stopper in the cap and the blood flows into the tube. This hand
position prevents any cannula movement while inserting and pulling out the blood
collection tube.
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 Correct cannula positioning and solution possibilities
If the cannula is correctly
positioned in the vein,
blood will flow unimped- 1 Cannula outside 2 Needle tip partly
the vein outside tissue 
ed into the evacuated
Insert the cannula loss of vacuum
blood collection tube.
further Insert cannula
further; use a new
The tube is used in such tube.
a way that the blood flow
can be seen.

Once the blood is in the

VACUETTE® blood collec-
3 Needle tip not fully 4 Needle tip not fully
tion tube, the tourniquet inside vein  inside vein 
can be removed or haematoma haematoma; possi-
loosened. Insert the cannula ble nerve damage
further; possibly Gently withdraw
If blood is only flowing stop procedure the cannula;
possibly stop the
into the tube hesitantly or not at all, there may be various reasons for this. There is no
procedure
general solution for this problem; it must be responded to individually. By implement-
ing a routine, you develop a feel for the particular situation and can act appropriately.

5 Needle tip com- 6 Needle tip is on the

pletely penetrated vein wall
through vein Gently alter the
Corrective action in the event of weak or no blood flow Slowly withdraw cannula position;
cannula (possibly possibly remove
Minimal re-positioning of under vacuum) tube
the cannula under suc-
tion (with the tube insert-
ed) can often be suffi-
cient to activate the
blood flow.
7 Needle tip is on the 8 Cannula next
vein wall and is to vein
However, in the event of incorrectly facing Stretch the skin,
bigger manipulations, it is downwards hold the vein in
necessary to remove the Gently alter cannu- place; alter cannula
tube from the holder. In la position; possibly position
remove tube accordingly
this way, the suction
from the vacuum is inter-
rupted and no longer acts on the cannula opening in the tissue.

The utmost caution is required for any kind of manipulation. 9 Needle tip is on 10 Collapsed vein
a vein valve Loosen tourniquet;
Gently alter the remove tube; wait
Various images of incorrect cannula positions are shown below. cannula position; a short time
possibly remove
the tube.

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 Pulling out the tube Inversions

When pulling the tube Each tube must be

5x
out of the holder, it must inverted immediately on
be ensured that the can- removal. Coagulation
nula is kept in the same tubes should be inverted
position. around 180 degrees 4–5
This is achieved by plac- times and all other tubes
ing the thumb on the 5–10 times.
grips of the holder and
grasping the filled tube
with the remaining fin- Practical tip: If you invert
gers. The tube is then each tube five times, you
pushed out of the holder cannot go wrong.
with the thumb.

A steady hand position is also important, as several blood collection tubes are usually For anticoagulants or coagulants to take effect, good mixing is required by completely
used. These should be taken in the following sequence. inverting – not shaking. The air bubble should be clearly visible going from top to
bottom and vice versa when inverting the tube.

Order of draw
* If no blood culture is
Blood culture* or discard tube required, a discard tube
(without additives) should be
used first briefly (not fully
Coagulation** filled) and discarded.
** If a citrate tube is used for
coagulation diagnostics as
the first or only tube, a tube
Serum (with or without gel) without additives should be
used shortly beforehand and
discarded to avoid contami-
Heparin (with or without gel) nation due to tissue throm-
boplastin.
EDTA
Glucose
Other tube types
Removing the cannula
Before the cannula is removed from the vein, the tube must be removed.
A clean swab is placed over the
puncture site and held in place with a
finger. Without applying pressure at
the puncture site, the cannula is
withdrawn in one smooth movement.
Pressure is only applied once the can-
nula has been completely removed.
IMPORTANT: While the cannula is
being removed from the vein, pres-
sure must not be applied on the
swab. The cannula tip would cut open
the rear vein wall and cause pain as
well as a large haematoma.

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 Activating the safety mechanism Disposal

In order to prevent needle injuries, the safety mechanism of the used product must The secured product is disposed of in
be activated immediately. a sharps-proof container specifically
provided for this purpose.
There are two different ways to activate this with the VACUETTE® QUICKSHIELD
safety tube holder:

With the help of a stable

supporting surface or the
thumb, the cannula is

or
securely sealed with the
protective shield attached Caring for the insertion site
to the holder.
The patient can normally take over the
The user will know that compression themselves. The pres-
the safety mechanism sure should be maintained for 3–5
has been activated after minutes – or until the bleeding has
or

a clearly audible "click". stopped.

If the patient is too weak, the person
carrying out the puncture or an assis-
tant must ensure appropriate com-
With the safety blood collection set activation is carried out whilst withdrawing the pression is maintained.
cannula:
When doing this, the arm is extended and may be positioned facing upwards.
The winged cannula is held still using your preferred Bending the arm may lead to blockage of the vessel again and cause a haematoma
technique. Greiner Bio-One recommends fixing one to form. The formation of a haematoma after blood collection is unpleasant for both
wing and the swab in place on the patient with the the patient as well as the person taking the blood and is a complication that can
thumb or another finger, without applying pressure at generally be avoided.
the puncture site.

The safety mechanism is unlocked by applying side- The wound dressing is only applied
ways pressure on the clear part of the product with the once bleeding has stopped.
free hand. Then, the shaft is withdrawn until the can-
nula is completely enclosed within the product and the
safety mechanism engages. For patients receiving anticoagulation
The user knows that the safety mechanism has been treatment, good manual compression
correctly activated upon hearing a clearly audible is vital. One minute too many is better
"click". than one minute too few!
Now, pressure can be applied to the puncture site.
Physical exertion or strain on the
With correct handling, the person taking the blood will affected limb too soon can cause
never come into contact with a contaminated cannula. bleeding or bruising.

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 Tube labelling and sample transport Special instructions for
Clear labelling with the patient's reference data and the information required for the collecting blood
laboratory is essential.
In order to avoid mix-
ups, you should try to Blood collection from venous catheters
label the tube in the
presence of the patient. Collection from inserted catheters is possible, but is only conditionally recommended
If a tube is labelled with from venous catheters. It must be ensured that the catheter is suitable for blood
an adhesive label, it collection and is also compatible with the collection system.
must be applied in such
a way that the blood Improper collection from venous catheters can lead to contamination through infusion
flow remains visible and solutions, dilution effects as well as to false laboratory results.
the filling level can be
checked.

As an alternative to sticking a label on Complicating factors for venipuncture

the tube, pre-barcoded blood collec-
tion tubes can be used. In conjunction There are many unfavourable factors which negatively impact on blood collection.
with the corresponding software, all Stress can lead to vasoconstriction in anxious patients. It is therefore important to
the necessary information for the labo- create a pleasant atmosphere. Even if just the room temperature is too low, there
ratory is automatically documented. could be a negative effect on venipuncture.
Errors are reduced, working steps are
reduced and complete traceability is
ensured.
Additional factors:

gg thin veins gg anxiety

After blood collection, the tubes should
be sent to the laboratory without delay gg delicate veins in children gg cold temperature
for further processing. gg brittle veins gg vasoconstriction

gg veins punctured gg volume deficiency

multiple times
gg pre-shock/shock
gg sclerosed veins
gg long-term treatment
gg rolling veins with steroids

gg cachexia

These guidelines are recommendations.

You should always comply with the guidelines of your facility.

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 Blood collection in small children Puncture on the inside of the elbow

There is barely any technical difference in blood collection in small children aged from When puncturing the inside of the
about two years of age in comparison to the procedure for adults. However, it is elbow, the accompanying person
especially challenging in small children and requires experience and sensitivity. holds down the child's arm. The can-
nula is inserted into the vein at a
Principally, a quiet and friendly atmosphere is important for very young patients. Chil- maximum angle of 30 degrees.
dren cooperate much better when they are given an explanation of what is going to VACUETTE® blood collection tubes are
happen to them. then used in the recommended order
of draw. The accompanying person
For safety reasons and to keep the closely observes the child during the
limb steady, it is recommended that blood collection and reacts to sponta-
the child sits on the lap of the person neous movements.
accompanying them. Reflex move-
ments can be counterbalanced in this
way.
Puncture on the back of the hand
The use of local anaesthetics and
agents to stimulate the blood flow can The puncture hardly differs at all from
make the procedure easier. the procedure with adults, except that
the accompanying person keeps the
The collection system must be adapt- child's lower arm steady during the
ed to the small size of the vessels. whole procedure. As a right-handed
The puncture is made using a fine person, the person taking the blood
safety blood collection set or safety uses their left hand to take the hand
tube holder. Greiner Bio-One recom- to be punctured, which is in a neutral
mends the use of 22G or 23G can- position. The skin is gently stretched
nulae with viewing window and blood in a distal direction. The needle is
collection tubes with a reduced vol- inserted at a shallow angle.
ume. In order to avoid iatrogenic
anaemia, the blood volume taken
should be kept low and documented.
Puncture on the back of the foot
If required, a children’s tourniquet or a
child-sized blood pressure cuff can be The accompanying person keeps the
used. child's leg steady during the whole
procedure. As a right-handed person,
the person taking the blood uses their
left hand to hold the foot to be punc-
tured. The toes are gently pulled
downwards. This provides the
required skin tension for optimal nee-
Practical tip: dle insertion. The puncture is made at
Inform the young patient about the forthcoming "stick". a shallow angle.

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 Blood collection in newborns and
infants
In addition to capillary blood collection in newborns or infants, venous puncture may
also be necessary. This can prove difficult due to the condition of the veins. The usual
puncture sites are scalp veins which are easily visible. Needle insertion on the head
may be perceived as dangerous by the parents, which is why it is helpful to explain
the procedure to them in a sensitive manner.
Safety aspects when collecting
a blood sample
The topic of health and safety in the workplace should be important to all people
working in the hospital and health sector. The main objective of social policies in the
European Union is an improvement in working conditions.
For this purpose, COUNCIL DIRECTIVE 2010/32/EU was drawn up for the prevention
of injuries from sharp/pointed instruments in the hospital and healthcare sector.

The health and safety of employees is of utmost importance and is closely associated
Head vein puncture with the health of the patient.

The baby's head can be positioned and restrained by an accompanying person in The purpose of this framework agreement is:
various ways and depends on the venipuncture site. When doing this, it is important
• to create the safest possible working environment
that the head is well restrained, but spontaneous body movements are also pre-
vented. • to avoid injuries to employees by sharp/pointed medical instruments (including
needlestick injuries)
By "combing", the head hairs can be • to protect exposed employees
parted and the best vein for puncture
can be selected. Fine hairs can be
fixed in place during disinfection. The use of sharp/pointed medical instruments with integrated protection
In the case of a thick head of hair, it is mechanisms is therefore an important point.
recommended that the puncture site is
shaved. The principle "...never assume that no risk exists" is equally as important.

The training and instruction of medical staff regarding the correct use of sharp/
The skin under the puncture site is pointed medical instruments with integrated protection mechanisms is the focus of
stretched with one finger on the free the EU Directive.
hand. The puncture is made at a very
shallow angle.

Use of plastic tubes

By using plastic (PET) tubes instead of glass, tube breakage – and therefore the risk
of injury due to broken glass – is virtually eliminated.

Just like with small children, the blood collection system must be adapted to the small
size of the vessels. The puncture is made using a fine safety blood collection set or
safety tube holder. Greiner Bio-One recommends the use of 22G or 23G cannulae
with viewing window and blood collection tubes with a reduced volume. In order to
avoid iatrogenic anaemia, the blood volume taken should be kept low and docu-
mented.

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 Notes References

Clinical and Laboratory Standards Institute: Procedures for the Collection of

Diagnostic Blood Specimens by Venipuncture; Approved Standard - Sixth Edition.
CLSI document GP41-A6, Wayne 2007

Dennis J. Ernst MT (ASCP), Catherine Ernst RN: Phlebotomy for Nurses and Nursing
Personnel, 2005

Dörner K.: Klinische Chemie und Hämatologie, Thieme Verlag, 8. Auflage, 2013

Guder, W.G., Narayanan, S.l., Wisser, H., Zawta, B.: Samples: From the Patient to
the Laboratory, Darmstadt 2000

McCall R.; Tankersley C. M.: Phlebotomy Essentials. Baltimore, Wolters Kluwer |

Lippincott Williams & Wilkins, 2012

Robert Koch Institut: Disinfection requirements in punctures and injections.

Springer-Verlag, 2011

The National Association of Phlebotomists: Phlebotomy Manual & Assessment

Book, 3. Auflage, London 2010

World Health Organization: WHO guidelines on drawing blood: best practices in

phlebotomy, WHO Document Production Services, Geneva 2010

Responsible for content/copyright: Greiner Bio-One GmbH

8th edition 2015
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