Atlas of Procedures in Neonatology, 4th Edition
Dawn M. Walton
Billie Lou Short
- Blood sampling
- Routine, particularly if a large volume of blood is needed
- Blood culture
- Central hematocrit
- Preferred (over capillary sample) for certain studies (1,2 and 3)
- Ammonia (arterial optimal)
- Drug levels
- Cross-matching blood
- Lactate and pyruvate levels (arterial optimal)
- Administration of drugs
- Use of deep vein in presence of coagulation defect
- Local infection at puncture site
- Femoral or internal jugular vein (see G)
- External jugular vein in infants with respiratory distress, intracranial hemorrhage, or raised intracranial pressure
- Observe universal precautions. Wear gloves.
- When sampling from neck veins, place infant in head-down position to avoid cranial air embolus. Do not use neck veins in infants with intracranial bleeding or increased intracranial pressure, except as a last resort.
- Remove tourniquet before removing needle, to minimize hematoma formation.
- Apply local pressure with dry gauze to produce hemostasis (usually 2 to 3 minutes).
- Avoid using alcohol swab to apply local pressure (painful, impairs hemostasis).
- Special Considerations for Neonates
- Conserve sites to preserve limited venous access by using distal sites first whenever possible.
- Use small needle or scalp vein butterfly. A 23-gauge needle is best. Hemolysis or clotting may occur with a 25 gauge or smaller.
- Choice of veins (Fig. 13.1) in order of preference:
- Antecubital fossa
- Dorsum of hands
- Dorsum of feet
- Greater saphenous vein at the ankle
- Vein in center of the volar aspect of the wrist
- Proximal greater saphenous vein
- Recent studies show that adequate pain control can be achieved during venipuncture with EMLA (Astra Pharmaceuticals, L.P., Wayne, PA, USA) cream applied 1 hour prior to procedure, if time allows (4,5).
- Oral sucrose solution (24% to 25%) provides quick and effective pain control for venipuncture (6,7).
- Heel lancing can be more painful and require more punctures than venipuncture in infants (4,8).
- A 23- to 25-gauge venipuncture needle (a safety-engineered needle should be used) (Fig. 13.2).
- Syringe with volume just larger than sample to be drawn
- Prepared alcohol swabs
- Gauze pads
- Appropriate containers for specimens
- For blood culture:
- Povidone-iodine solution preparation (three swabs)
- Sterile gloves
- Blood culture bottle(s)
- Transfer needle
- Tourniquet or sphygmomanometer cuff
FIG. 13.1. The superficial venous system in the neonate.
FIG. 13.2. Safety-engineered needles for venipuncture.
- Technique (See Procedures DVD for Video)
- Locate the appropriate vessel. Use transillumination if necessary (see Chapter 12). Warm extremity with heel warmer or warm washcloth if circulation is poor.
- Apply anesthetic cream if time permits, and/or administer sucrose solution if possible.
- Restrain infant appropriately.
- Prepare area with antiseptic (see Chapter 4).
- Occlude vein proximally using either:
- Tourniquet or cuff inflated to level between systolic and diastolic pressure (Fig. 13.3)
- Direct pressure over vessel
- Rubber band (loop two bands together, tied as in Fig. 13.3)
FIG. 13.3. Correct application of a tourniquet for quick release.
FIG. 13.4. Anterior wall of vein removed. Needle penetrating skin a short distance from site of venipuncture.
- Remove occlusion device and replace to promote optimal vein distension.
- Check syringe function and attach to needle. Alternative method is to use Microlance needle (0.9 x 40 mm) (Becton Dickinson, Franklin Lakes, NJ, USA) without a syringe to collect samples by drip method. Drip method cannot be used for blood culture or coagulation studies (8).
- Penetrate skin first and position for entry of vein (Fig. 13.4).
- Angle of entry 25 to 45 degrees
- Bevel up preferred for optimal blood flow (less chance of needle occlusion by vein wall)
- Direction of entry with or against direction of blood flow
- If possible, insert needle at area where vessel bifurcates to avoid “rolling” of veins.
- Collect sample by gentle suction
- To prevent occlusion by vein wall
- To avoid hemolysis
- If Microlance needle is used, collect sample by drip directly into specimen container.
- Release tourniquet.
- Remove needle and apply local pressure with dry gauze for 3 minutes or until complete hemostasis.
FIG. 13.5. A: Anatomy of the femoral triangle as defined in the text. (Adapted from
Plaxico DT, Bucciarella RL. Greater saphenous vein venipuncture in the neonate. J Pediatr. 1978;93:1025
, with permission.) B: Position of the femoral triangle on the abducted thigh.
- Shave adequate area of frontal or parietal scalp.
- Use scalp vein needle set or 23-gauge butterfly.
- Occlude vein proximally with finger, or place a rubber band around head circumference, avoiding eye area.
- Feel for a pulse to avoid tapping an artery.
- Use a shallow angle (15 to 20 degrees).
- See technique for general venipuncture.
Proximal Greater Saphenous Vein (9)
- Have assistant hold infant's thighs abducted with knees and hips slightly flexed.
- Locate femoral triangle (Fig. 13.5A).
- Proximal boundary: inguinal ligament
- Lateral boundary: medial border of sartorius muscle
- Medial boundary: lateral border of adductor longus muscle
- Enter skin and then vein at point approximately two-thirds along line from inguinal ligament to apex of triangle (Fig. 13.5B).
- Use relatively steep angle (60 to 90 degrees).
- After entering skin, advance while applying gentle suction 1 to 4 mm until blood return is achieved.
- See F, “General Venipuncture.”
External Jugular Vein
- Position infant in head-down position with head extended and rotated away from selected vessel (Fig. 13.6).
- Prepare skin over sternocleidomastoid muscle with antiseptic.
- Flick infant's heel to induce crying and optimize vein distension.
- Visualize external jugular vein running from angle of jaw to posterior border of sternocleidomastoid in its lower third.
- Puncture vessel where it runs across the anterior border of the sternocleidomastoid muscle.
- See F, “General Venipuncture.”
FIG. 13.6. Infant positioned for puncture of external jugular vein.
- Complications (10,11,12 and 13)
- Hemorrhage with
- Coagulation defect
- Puncture of deep vein
- Venous thrombosis or embolus, with puncture of large, deep vein (11)
- Laceration of adjacent artery
- During femoral vein puncture:
- Reflex arteriospasm of femoral artery with gangrene of extremity (12)
- Penetration of peritoneal cavity
- Septic arthritis of hip (13)
- During internal jugular puncture:
- Laceration of carotid artery
- Pneumothorax/subcutaneous emphysema
- Interference with ventilation owing to positioning for jugular vein puncture
- Raised intracranial pressure owing to head-down position aggravating intraventricular hemorrhage
- During scalp vein puncture:
- Laceration of artery
- Corneal abrasion or other eye damage if rubber band used improperly
- Baral J.Use of a simple technique for the collection of blood from premature and full-term babies. Med J Aust. 1968;1:97.
- Shohat M.Preterm blood counts vary with sampling site [Letter]. Arch Dis Child. 1987;62:1193.
- Thurlbeck SM, McIntosh N.Preterm blood counts vary with sampling site. Arch Dis Child. 1987;62:72.
- Shah VS, Taddio A, Bennett S, et al. Neonatal pain response to heel stick vs venipuncture for routine blood sampling. Arch Dis Child Fetal Neonat Ed.1997;77:F143.
- Larsson BA, Tannfeldt G, Lagercrantz H, et al. Alleviation of the pain of venipuncture in neonates. Acta Paediatr.1998;87:774.
- Archarya AB, Annamali S, Taub NA, Field D.Oral sucrose analgesia for preterm infant venipuncture. Arch Dis Child Fetal Neonat Ed. 2004;89:F17.
- Stevens B, Yamada J, Ohlsson A.Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev. 2004;(3):CD001069.
- Larsson BA, Tannfeldt G, Lagercrantz H, et al. Venipuncture is more effective and less painful than heel lancing for blood tests in neonates. Pediatrics.1998;101:882
- Plaxico DT, Bucciarelli RL.Greater saphenous vein venipuncture in the neonate. J Pediatr. 1978;93:1025.
- McKay RJ Jr.Diagnosis and treatment: risk of obtaining samples of venous blood in infants. Pediatrics. 1966;38:906.
- Nabseth DC, Jones JE.Gangrene of the lower extremities of infants after femoral venipuncture. N Engl J Med. 1963;268:1003.
- Kantr RK, Gorton JM, Palmieri K, et al. Anatomy of femoral vessels in infants and guidelines for venous catheterizations.Pediatrics.1989;33:1020.
- Asnes RS, Arendar GM.Septic arthritis of the hip: a complication of venipuncture. Pediatrics. 1966;38:837.