Difficult Access After Mastectomy With a Running IV
A 68-year-old woman arrives at the outpatient lab with orders for a CBC, PT/INR, and two sets of blood cultures. She reports a right modified radical mastectomy with axillary lymph node dissection three years ago. Her left antecubital fossa has a peripheral IV infusing normal saline; the site is clean and without redness. Both hands have visible veins, but the left hand veins are small and fragile. The patient is anxious and says she fainted during a previous draw. The lab has 23-gauge butterflies, 21-gauge straight needles, and 10 mL discard tubes. The requisition is marked STAT, and the nurse asks you to draw above the IV to save time. You must obtain all specimens with minimal hemolysis and no contamination.
1. Which venipuncture site do you select, and why are the alternatives unacceptable? Include how you would modify the draw for fragile veins.
Read the worked answer
Select a vein on the left hand distal to the IV, not the left antecubital vein above the IV. The right arm is contraindicated because axillary node dissection increases lymphedema and infection risk. Drawing proximal to a running IV can dilute the sample, introduce infusate, and increase hemolysis; the nurse's suggestion is unsafe for the ordered tests.
Use the 23-gauge butterfly for the fragile hand veins, warm the hand, release the tourniquet within 1 minute, and use a syringe if the vacuum collapses the vein. If no distal vein can be obtained, ask the nurse to pause the IV briefly and flush per policy, or escalate to a clinician; do not draw above the IV. For two culture sets, use separate venipuncture sites if possible; if access is limited, document the sites clearly. Because the patient has a syncope history, draw with her supine or reclined and keep her observed.
2. State the order of draw for these tests and explain how you would prevent hemolysis and culture contamination when using a butterfly set.
Read the worked answer
Order: blood cultures first, then light-blue citrate, then serum/red-gold, then lavender EDTA. Cultures are sterile and must not be contaminated by tube additives. With a butterfly, the first culture bottle primes the tubing; if the light-blue tube is the first tube after the butterfly, draw a discard tube first so the citrate tube fills correctly.
For hemolysis: use a 23-gauge butterfly, avoid vigorous pulling, do not draw from a hematoma, let the antiseptic dry, invert gently, and transport upright. For culture contamination: cleanse the site with the approved antiseptic and let it dry; do not palpate after cleansing; inoculate bottles before other tubes; use separate sites for the two sets. Label at the bedside. If a syringe is used, transfer blood gently, avoid needle recapping, and fill the citrate tube to its line.
3. During the second culture set, the patient becomes pale and diaphoretic. What immediate actions, reporting, and documentation are required?
Read the worked answer
Stop the draw, remove the needle, apply pressure, and help the patient to a supine position with legs elevated if possible. Check responsiveness, airway, breathing, and pulse; loosen tight clothing; apply a cool cloth; monitor until she recovers. Do not leave her alone. If she does not regain consciousness quickly, call for emergency help per clinic protocol.
Record the time, symptoms, vital signs if obtained, interventions, and outcome. Notify the nurse or clinician and complete an incident report. Do not attempt the remaining cultures until she is stable and cleared; the STAT order does not justify continuing during syncope. Reassess whether the remaining specimen can be collected later or at another site. Document that the patient was advised to remain seated or lying for 10 to 15 minutes and to drink fluids.