• Blood sampling in a baby without indwelling arterial line, or when sampling from arterial line or capillary sampling is inappropriate

• Cleaning solution or cleaning swab – follow local infection control policy
• Appropriately labelled blood bottles and request cards
• Non-sterile gloves 
• Adhesive dressing
• 23 G blood sampling needle or needle-safe cannula
• Do not use a broken needle
• Sterile gauze/cotton wool to apply to wound post-procedure
• Sharps container

Preparation

• Wash hands and wear gloves (see Infection prevention guideline)
• Second person employs containment holding and gives sucrose
  
  • immobilisation is crucial to baby’s safety whilst undergoing phlebotomy, and to success of procedure
• Identify suitable vein (typically back of hand or foot)
• Place paper towels under limb to avoid blood dripping onto bed linen

Insertion and sampling

• Apply hand pressure around limb to distend vein
• Clean the puncture site then do not touch again
• Place thumb on skin slightly distal to proposed puncture site
• Hold needle at 10–20° angle and puncture skin
• Advance needle toward vein. Resistance may diminish slightly as needle enters vein and blood will be seen to flow
• Collect required volume taking care to mix but not shake blood
• When sampling complete, release the pressure from around the limb, place gauze/cotton wool over insertion point and withdraw needle
• Maintain pressure on site until bleeding ceases 

Complications

• Inability to obtain specimen due to: 
  
  • inappropriate choice of vein 
  • thrombosed vein (due to previous/repeated attempts) 
  • inexperienced operator 
  • baby shocked, cold or dehydrated causing vasoconstriction

Unsuccessful attempts

• Adhere strictly to a limit on number of attempts
• If no satisfactory sample collected after 2 attempts, seek second opinion as to whether to make a further attempt or cancel procedure 
• Defer to a more experienced operator
• Venous distension:
  
  • use warm pack to encourage vasodilation and venous filling 
• Transillumination of limb can help identify suitable vein

Avoid:

• Veins close to an infection, bruising and phlebitis
• Thrombosed veins 
• Oedematous limbs – danger of stasis of lymph, predisposing to complications e.g. phlebitis and cellulitis
• Areas of previous venepuncture – build-up of scar tissue can cause difficulty accessing vein and result in pain 
• Sampling from potential IV infusion site or long line vein (e.g. cubital fossa or long saphenous) whenever possible

Haemolysis risk factors

• Use of <23 G needle, or too large a gauge for vessel
• Drawing blood specimens from IV or central line
• Under-filling tube – ratio of anticoagulant to blood >1:9
• Reusing tubes that have been refilled by hand with inappropriate amounts of anticoagulants 
• Mixing tube too vigorously 
• Failing to let alcohol/disinfectant dry
• Using too great a vacuum, e.g. using too large a tube or syringe
• Squeezing can cause haemolysis and elevate serum potassium

Completion and organisation

• Keep track of all needles used and dispose of them in sharps container
  
  • do not re-sheath needle 
• Dispose of rubbish and clean tray
• Remove gloves and wash hands
• Label all samples and investigation forms at cot side
• Arrange for transfer of samples to laboratory
• Document in patient notes

• Wear well-fitting gloves during procedure to prevent contamination from potential blood spills

  • gloves will not prevent needle stick injury, but the wiping effect of glove on needle may reduce volume of blood to which hand exposed

• Discard used needles directly into sharps container – do not re-sheath

• Report any incident/accident linked to needle or sharp injury immediately, and seek assistance; start PEP as soon as possible, following protocols (>72 hr, PEP not effective)