Medical Vein

CLINICAL ISSUES

Take the guesswork out of venipunctures

I NEVER MISS A VEIN.

By Dennis J. Ernst, MT(ASCP)

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uperman 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 AV300 (AccuVein, Cold Spring Harbor, NY): According to 18

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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 The AV300 is the size of a cordless phone. 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.” 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 The VeinViewer is a mobile biomedical processor. The processor device using near infrared light. 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.” www.mlo-online.com

CLINICAL ISSUES 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.

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 (Children’s Medical Ventures, Monroeville, PA): Also designed for neonatal patients, the

Devices that illuminate tissue 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, The Venoscope II can which absorb the be attached to a pa- light rather that tient with a Velstretch reflect it. While strap. 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. 20

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

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. Vein Locator (Sharn Inc., Tampa, FL): The Vein Locator is a portable, battery-operated device that uses

The Vein Locator is disgarded after use.

three LED lights to transilluminate the patient’s tissue, highlighting veins. Limited for neonatal, pediatric, and frail adult patients, the Vein Locator is selfcontained 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. Veintector (Carolina Liquid Chemistries, Brea, CA): The Veintector uses 38 red and yellow LED lights to illuminate the tissue beneath the skin upon which it rests. A protective sheet

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

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 (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 Veinlite Transilluminathat uniformly tors offer haolgen-light illuminates the fiber-optic units and batsuperficial tis- tery-operated, LED-based pocket models. sues 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 batteryoperated, 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 www.mlo-online.com

v ein SfUinB Jd Ee Cr Ts 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. www.mlo-online.com

Accuvein 816-298-6991 www.accuvein.com Luminetx 910-252-3752 www.luminetx.com Venoscope 800-284-7655 www.venoscope.com Children’s Medical Ventures 800-345-6443 http://weesight.respironics.com

Sharn Inc. 800-325-3671 www.sharn.com Carolina Liquid Chemistries 336-722-8910 http:/www.carolinachemistries. com/CLC/index.dfm/hurl/idsPageID=154/Type=39/Helps-to-findthose-hard-to-find-veins TransLite 281-240-3111 www.veinlite.com

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“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.