Take the guesswork out of venipunctures

April 1, 2009

Superman would make
a great phlebotomist. With his X-ray vision, he would never miss a vein,
or have to apologize to a patient, or send in another superhero to try
to draw blood. STAT draws would take half the time, and morning
collections would be completed faster than a speeding bullet.

Unfortunately, most of us are not from Krypton.
While the jobs of other healthcare professionals have been infinitely
simplified by robotics, nanotechnology, and digital imaging, those who
draw blood are resigned to relying on old technology like instinct and
the human fingertip. But just when you think you have the only job in
healthcare that cannot be improved by technology, someone shouts, “Look!
Up in the sky. It's a bird! It's a plane! It's a vein-detection device!”
Not just one device but a veritable bevy … a flock … a gaggle, even … so
many that it requires an entire magazine article to summarize them all.
Here is that article:

Standard eyes

What follows is a
summary of devices designed to locate veins from which blood can be
drawn. They utilize a variety of technologies, designs, and applications
for patients of all ages and skin pigmentation. Although phlebotomy will
never be automated, these devices bring today's technological
advancements into one of the last otherwise entirely manual
procedures in healthcare. Why is it important to see all options beneath
the skin? It is all about the standards.

Being able to see the exact location of veins not
only makes the procedure more frequently successful but also facilitates
a lab's compliance with standards established by the Clinical and
Laboratory Standards Institute (CLSI). According to the organization's
venipuncture standard (H3), a thorough survey of available veins must be
conducted to minimize the risk of injury to the patient. This
recommendation is based on the close proximity of the medial
antebrachial cutaneous nerves to the basilic vein, which lies in the
inside or medial aspect of the antecubital area. If pierced by a
misguided needle, these nerves can be permanently injured, subjecting
the patient to long-term pain and complications. Failure to comply with
this standard requirement can translate to a laboratory's liability for
those injuries. Because the standards require an avoidance of the
basilic vein unless no safer vein can be located, any device that lets
the user see the available veins beneath the skin not only manages the
risk of injury but also facilitates compliance with the standards.

Devices that utilize laser/infrared technology
The AV300 is the size of a cordless phone.

AV300 (AccuVein, Cold Spring Harbor, NY):

According to the manufacturer, the AV300 relies on the physical property
of hemoglobin in that it absorbs infrared light. When the device is held
about seven inches above the skin and activated, it detects the
difference in the hemoglobin concentration between the veins and
surrounding tissue. Once detected, the reflected infrared light
indicates the size and position of veins beneath the surface of the skin
by instantly projecting a precise map of the veins on the skin above
them. The device, the size of a cordless phone, can be hand-held or
positioned on a hands-free accessory so the procedure can be performed
while the map is projected.

“It is portable and works in any kind of ambient
light and on any color of skin,” says Vinny Luciano, vice president of
Marketing for Accuvein. “The AV300 never comes in contact with the
patient, so it does not need to be sterilized between uses. It operates
on batteries or can be plugged into a wall outlet, whichever is most
convenient for the user. Once the device is activated, there is no lag
time before you know precisely where the veins lie.”

The VeinViewer is a mobile biomedical device using near infrared light.

VeinViewer (Luminetx, Memphis, TN): Using
near infrared light and “other technologies,” the VeinViewer is a mobile
biomedical device that illuminates subcutaneous veins, then projects an
image of the vasculature onto the surface of the skin. According to the
manufacturer, the VeinViewer uses a flexible head unit that positions
the infrared light over any part of the anatomy. The light makes veins
visible to a digital video camera, which then transmits live video to an
image processor. The processor then enhances and aligns the images for
output through a projector that displays the enhanced image in real
time. By imaging the vasculature, the company's website states “…
clinicians have the ability to visualize the location of the target area
and observe any movement of the vasculature regardless of a patient's
age, body type, or skin tone.”

Luminetx has created a subsidiary to adapt its
vein-finding technology to other applications within and outside of
healthcare. Using vein-pattern recognition technology, a tabletop device
captures the vein pattern present in the palm of a person's hand, then
generates a numeric biometric “key,” which is unique to every
individual. The key is used to enroll the person in a biometric system
as a fraud-proof method for verifying identity. Any attempt to use a
biometrically enabled system generates a new key that is matched against
the person's enrolled key.

Devices that illuminate tissue
The Venoscope II can be attached to a patient with a Velstretch strap.

Venoscope (Venoscope, Lafayette, LA):
The Venoscope II Transilluminator is a hand-held device used to locate
veins using high-intensity red and white LEDs that penetrate deep into
the subcutaneous tissue. When placed on the patient's skin, the device
illuminates the subcutaneous tissue with an array of high intensity LED
lights highlighting the veins, which
the light rather that reflect it. While directing
light into the subcutaneous tissue, the manufacturer recommends dimming
the ambient lighting as much as possible to provide the contrast needed
to see veins. A white light provides definition between the tissue,
which is lighter in intensity; and the veins, which appear as dark lines
or shadows between the device's two illuminating arms. The unit is
powered by three AA alkaline batteries and has a built-in low-battery
indicator that signals when batteries need to be changed. The Venoscope
II can be attached to the patient's arm by attaching a Velstretch strap
(provided), effectively stabilizing the vein to prevent rolling and
liberating both of the user's hands for the venipuncture. After use, the
device may be wiped with an alcohol or bleach solution.

For neonatal applications, Venoscope also offers
the Neonatal Transilluminator, which functions under the same principle
in a smaller and more portable design. The illuminating lights are cool
and bright enough to illuminate without burning.

Wee Sight allows one person to both operate the device and perform the prodedure.

Wee Sight (Children's Medical Ventures,
Monroeville, PA):
Also designed for neonatal patients, the Wee Sight
Transilluminator utilizes a strong LED light to reveal vein location
without emitting heat. The device is designed to lie flat on a surface
to allow users to position the baby's arm or leg over it for enhanced
illumination. Alternatively, it can be held in the hand of the user and
positioned against the patient's limb. According to the company's
website, the design allows one person to both operate the device and
perform necessary procedure.

The Vein Locator is disgarded after use.

Vein Locator (Sharn Inc., Tampa, FL): The
Vein Locator is a portable, battery-operated device that uses three LED
lights to transilluminate the patient's tissue, highlighting veins.
Limited for neonatal, pediatric, and frail adult patients, the Vein
Locator is self-contained and can be cleaned as needed. The device's
batteries provide 40 hours of use and are not replaceable. Once
exhausted, this device is discarded.

The Veintector runs on two oxyride batteries and includes a strap for hands-free use.

Veintector (Carolina Liquid Chemistries, Brea,
The Veintector uses 38 red and yellow LED lights to illuminate
the tissue beneath the skin upon which it rests. A protective sheet is
placed between patient and device to prevent patient-device contact. A
color-adjustment button allows the user to change settings for optimal
contrast. The device runs on two oxyride batteries and includes a strap
for hands-free use. Lights can be disinfected with alcohol.

Veinlite Transilluminators offer haolgen-light fiber-optic units and battery-operated, LED-based pocket models.

Veinlite Transilluminators (TransLite LLC,
Sugar Land, TX):
TransLite uses the side-transillumination method in
all its Veinlite models. A bright ring of light is placed against the
skin, and light is focused into the tissue and towards the center of the
ring creating a virtual light source under the skin that uniformly
illuminates the superficial tissues within the ring. The deoxygenated
blood in veins causes them to show up as dark lines in contrast with the
surrounding tissue. An opening in the ring facilitates blood draws or
injections. Veinlites can either be halogen-light fiber-optic units or
battery-operated, LED-based pocket models.

Halogen-light Veinlites have a variable intensity
light source and a metal ring illuminator with a fiber-optic cable. A
large ring illuminator is used for adult vein access, whereas a small
ring illuminator is used for pediatric venous access. LED-based
Veinlites achieve the best contrast for vein imaging by using a
combination of bright orange LEDs (for strong illumination), combined
with deep red light (for high penetration of dark pigmented skins).
Light shields snap on to the units to stop interference from overhead
light. Pediatric or neonate adapters can be used to enhance the light
area for use with babies and children. All LED-based models come with
disposable plastic covers to prevent infection. Veinlite LED is
rechargeable and has 24 LEDs (12 orange and 12 red). Two switches are
used to select either or both colors for optimum vein imaging in all
skin types.

TransLite offers two other models for use in
phlebotomy: the Veinlite EMS and the Veinlite PEDI. Veinlite EMS is a
simpler version of the Veinlite LED but uses 16 LEDs (eight orange and
eight red). According to the manufacturer, it provides a lower-cost
option for venous access and is well suited to emergency response teams.
It uses two AA alkaline batteries and has a single switch to illuminate
both orange and red LEDs. The Veinlite PEDI the smallest vein
transilluminator and is designed for babies and neonates. It has 12 LEDs
(eight orange and four red) and one CR2 lithium battery. Two switches
allow for selection of either or both colors for optimum vein imaging. A
snap-on neonatal adapter is designed to shine six closely packed LEDs
through a small opening for safe through-the-body transillumination of
small limbs in neonates.

The magic of veinfinders

Whether you use supernatural powers, the
technologies of Planet Earth, or the good old-fashioned
fingertip, locating the best vein for venipuncture is critical
to patient satisfaction, specimen integrity, staff productivity,
and compliance with the standards. Arthur Clarke, author of
2001: A Space Odyssey
, once wrote, “Any sufficiently
advanced technology is indistinguishable from magic.” Some of
these devices may seem to be employ magic, but healthcare
professionals should use them as supplements to their keenly
developed senses of vision, palpation, and instinct, not
substitutes for them.

Vein finders may not enable a laboratory's staff
to leap tall buildings in a single bound or make them more powerful than
a locomotive. But if they can draw on the first stick, they might just
become super heroes to difficult patients.

Dennis J. Ernst, MT(ASCP), is
the director of the Center for Phlebotomy Education in Corydon, IN. The
author of several books on phlebotomy, Ernst also chairs the revisions
of several CLSI specimen-collection standards and serves as the editor
of the Phlebotomy Today family of e-newsletters. As an industry
consultant, Ernst consults with companies serving the preanalytical
market, including Accuvein.



Sharn Inc.



Carolina Liquid Chemistries




Children's Medical Ventures



[In order of appearance in
this article]

“It seems to me
that the motto of our profession as always been 'YES, WE CAN!' It
continually astonishes me how much we accomplish under the most
challenging of circumstances. Not just doing business as usual or more
with less, but the intelligence, resourcefulness, creativity, and
tenacity characteristic of laboratory professionals. We are still
largely unknown by name to the general public but the passion and
commitment to excellence that typify our contribution to healthcare are
reward enough. We are professionals in every sense of the word!”—
Sharon M. Miller, PhC, MT(ASCP), CLS(NCA), Professor Emerita, Clinical
Laboratory Sciences, College of Health & Human Sciences, Northern
Illinois University, DeKalb, IN.