Pediatric and Geriatric Venipuncture

• Collecting blood by venipuncture from infants and children may be necessary for tests that require large amounts of blood (i.e., cross-matching and blood cultures) and tests that cannot normally be performed by skin puncture (i.e., ammonia levels and most coagulation studies).
• Venipuncture in children under the age of two should be limited to superficial veins and not deep, hard to find veins.
• The most accessible veins of infants and toddlers are the veins of the antecubital fossa and forearm.
• Other potential venipuncture sites include the

  • medial back side of the wrist
  • the dorsum of the foot
  • the scalp
  • medial ankle
• Capillary collection is normally recommended for pediatric patients, especially newborns and infants up to 12 months, because their veins are small and not well developed and there is a considerable risk of permanent damage.
• Removing more than 10% of an infant’s blood volume at one time

  can lead to anemia, shock, and cardiac arrest.
• Many facilities do not allow more than 3% of a child’s blood volume to be collected at any one time and allow no more than 10% in an entire month.
• Parents or guardians may give the best prediction of how cooperative the child will be. Anxiety on the part of a parent can negatively influence the child’s coping mechanisms.
• Venipuncture in children that results in a traumatic experience can have lasting negative consequences, including increased sensitivity to pain, a decreased capacity to cope with it, and a lifelong fear of needles.
• Interventions to minimize pain transmission or ease the pain of venipuncture include the use of cold or vibration, EMLA, a eutectic (easily melted) mixture of local anesthetics for newborns through adults, and oral sucrose and pacifiers for infants and toddlers.
• Eutectic mixture of local anesthetics is a topical anesthetic containing lidocaine and prilocaine. It is available in a cream that must be covered with a clear dressing or a patch after application.
• EMLA takes approximately 1 hour (a major drawback to its use) for it to anesthetize the area to a depth of approximately 5 mm. It cannot be used on patients who are allergic to local anesthetics.
• EMLA cannot be used on patients who are allergic to local anesthetics, infants with a gestational age of less than 37 weeks, or infants under 12 months of age who are receiving treatment with methemoglobin inducing agents.
• Use of a 12-24% solution of oral sucrose has been shown to reduce the pain of procedures such as heel puncture and venipuncture in infants up to 6 months of age.
• A 24% solution of sucrose (prepared by mixing 4 teaspoons of water with 1 teaspoon of sugar) can be administered by dropper, nipple, oral syringe, or on a pacifier provided that it will not interfere with the tests

  to be collected or diet restrictions.
• The sucrose must be given to the infant 2 minutes before the procedure, and its pain-relieving benefits last for approximately 5 minutes.
• Studies have shown that infants given sucrose or even a regular pacifier by itself cry for a shorter time and are more alert and less fussy after the procedure.
• Immobilization of the patient is a critical aspect in obtaining an adequate specimen from infants and children while ensuring their safety.
• A newborn or young infant can be wrapped in a blanket, but physical restraint is often required for older infants, toddlers, and younger

  children.
• Venipuncture of an antecubital vein is most easily accomplished using a 23-gauge butterfly needle attached to an evacuated tube holder or syringe.
• In addition to reducing the risk of iatrogenic anemia, minimizing the volume of blood drawn shortens the duration of the draw and the time the patient is under stress.
• Geriatric means relating to old age.
• Skin changes include loss of collagen and subcutaneous fat, resulting in wrinkled, sagging, thin skin with a decreased ability to stay adequately hydrated.
• Aging skin cells are replaced more slowly, causing the skin to lose elasticity and increasing the likelihood of injury. Blood vessels also lose elasticity, becoming more fragile and more likely to collapse, resulting in an increased chance of bruising and the failure to obtain blood.
• Skin changes make veins in the elderly easier to see; however, sagging

  skin combined with loss of muscle tone may make it harder to anchor veins and keep them from rolling.
• Antinuclear antibodies, Rheumatoid Arthritis, or Rheumatoid Factor- Diagnose lupus and rheumatoid arthritis, which can affect nervous system function
• Complete blood count- Determine hemoglobin levels, detect infection, and identify blood disorders
• Blood urea nitrogen/creatinine- Diagnose kidney function disorders that may be responsible for problems such as confusion, coma, seizures, and tremors
• Calcium/magnesium- Identify abnormal levels associated with seizures and muscle problems
• Electrolytes- Determine sodium and potassium levels, critical to proper nervous system function
• Erythrocyte sedimentation rate- Detect inflammation; identify collagen vascular (i.e., connective tissue) diseases
• Glucose- Detect and monitor diabetes; abnormal levels can cause confusion, seizures, or coma or lead to peripheral neuropathy
• Prothrombin time/Partial thromboplastin time Monitor blood-thinning medications; important in heart conditions, coagulation problems, and stroke management
•  Serum protein electrophoresis- Identify protein or immune globulin disorders that lead to nerve damage
• Venereal Disease Research Laboratory/Fluorescent treponemal antibody absorption test- Diagnose or rule out syphilis, which can cause nerve damage and dementia
• Effects of aging include loss of auditory hair cells, resulting in a hearing loss in upper frequencies and trouble distinguishing sounds such as ch, s, sh, and z.
• Effects of aging on the eyes include a diminished ability of the lens to adjust, causing farsightedness; clouding of the lens or cataract formation resulting in dim vision; and other changes that lead to light intolerance and poor night vision.
• Slower nerve conduction associated with aging leads to slower learning, slower reaction times, and a diminished perception of pain, which, in turn, can lead to an increase in injuries.
• Reduced cerebral circulation can lead to loss of balance and frequent falls.
• Alzheimer disease and other forms of dementia can render a patient unable to communicate meaningfully, requiring you to communicate through a relative or other caregiver.