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Butterfly needles reduce the incidence of nerve injury during phlebotomy.

To the Editor.--Among complications associated with phlebotomy, nerve injury is relatively rare but is potentially serious and often results in malpractice lawsuits. (1-3) However, to the best of our knowledge, no effective measures that have been verified systematically to minimize this particular health care risk have been published.

Our outpatient clinic decided to facilitate the use of butterfly needles in late 2006 based on a report showing that these devices could increase success rates while reducing patients' discomfort during phlebotomy. (4) Because other phlebotomy procedures have remained basically unchanged, the introduction of this policy provided us an opportunity to have insight into the effect of using butterfly needles on the incidence of nerve injury in phlebotomy.

We retrospectively reviewed our computer-based phlebotomy records of observed complications as well as of patients' complaints and compared the incidence of nerve injury before and after the introduction of the new policy. It is often difficult to precisely diagnose nerve injury during phlebotomy, because there are no definite diagnostic criteria.

Therefore, we restricted the definition of nerve injury to cases with pain and/or numbness of the fingers and/or hands during and/or after phlebotomy, because such symptoms are confined to nerve injury. Among these, severe nerve injury was defined as having symptoms that persisted for more than 7 days and that was confirmed by medical neurologists. Differences between the values in categoric data were statistically analyzed using the [chi square] test or Fisher exact test.

Among 1 057471 patients who underwent phlebotomy between January 2003 and December 2010, nerve injury occurred in 89 cases (8.4 per 100000 cases). Of these, 7 cases were judged to be severe nerve injury. The overall incidence of nerve injury was significantly lower between 2007 and 2010 than between 2003 and 2006 (5.81 versus 11.28 per 100000 cases, P = .002; Figure). The incidence of severe nerve injury between 2007 and 2010 was also significantly lower-than that between 2003 and 2006 (0.17 versus 1.23 per 100000 cases, P = .03).

These observations suggest that butterfly needles reduce the incidence of nerve injury during phlebotomy, although we cannot exclude a potential bias due to training practices at the time of switchover to butterfly needles. In contrast to the conventional needle, the impact generated at the time of tube insertion into the holder is not directly transmitted to the needle when butterfly needles are used in the evacuated-tube method of phlebotomy, which prevents the needle from moving. In addition, the butterfly needle is usually shorter than the conventional needle. These structural features of butterfly needles may have made it possible to minimize the deep insertion of the needle, thereby resulting in a reduction of nerve injury, because the major nerves frequently underlie very close to the major superficial vein or the skin. (5) Furthermore, the increased success rate when using butterfly needles may have contributed to the reduction of nerve injury. (4)

In conclusion, the use of butterfly needles is recommended at least when puncturing sites with a high risk of causing nerve injury. A prospective controlled study is warranted to confirm the feasibility of this strategy, although the low incidence of nerve injury might make this type of study difficult to complete.

HIROAKI OHNISHI, MD, PHD

MITSUKO WATANABE, BSC

TAKASHI WATANABE, MD, PHD

Department of Laboratory Medicine

Kyorin university school of Medicine

Tokyo, Japan

(1.) Sander HW, Conigliari MF, Masdeu JC. Antecubital phlebotomy complicated by lateral antebrachial cutaneous neuropathy. N Engl J Med. 1998;339(27):2024.

(2.) Berry PR, Wallis WE. Venepuncture nerve injuries. Lancet. 1977;8024(1):1236-1237.

(3.) Ernst DJ. Phlebotomy on trial. MLO Med Lab Obs. 1999;31(4):46-50.

(4.) Hefler L, Grimm C, Leodolter S, Tempfer C. To butterfly or to needle: the pilot phase. Ann Intern Med. 2004;140(11):935-936.

(5.) Ohnishi H, Urata T, Kishino T, Takano M, Watanabe T. A novel maneuver to prevent median nerve injury in phlebotomy. Ann Intern Med. 2009; 151(4):290-291.

The authors have no relevant financial interest in the products or companies described in this article.

doi: 10.5858/arpa.2011-0431-LE
Incidence of nerve injury before and after
recommending the use of butterfly needles.
White and black bars represent the respective
incidence of overall and severe nerve injury.
The numbers above the bars describe the
actual rate per 100000 venipunctures.

Incidence of Nerve Injury/1000 000 Venipunctures

Year Overall Severe

 P = .002 P = .03

2003-2006 11.28 1.23
2007-2010 5.81 0.17

Note: Table made from bar graph.
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Title Annotation:Letters to the Editor
Author:Ohnishi, Hiroaki; Watanabe, Mitsuko; Watanabe, Takashi
Publication:Archives of Pathology & Laboratory Medicine
Article Type:Letter to the editor
Date:Apr 1, 2012
Words:752
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