UNIVERSITY OF MALTA
FACULTY OF MEDICINE & SURGERY
PHARMACY DEPARTMENT
Ref. No.
SOP/PD/232_01
STANDARD OPERATING PROCEDURE
ADVANCED VENEPUNCTURE ARM
Page 1 of 22
Valid for:
2 years from
approval
UNIVERSITY OF MALTA
FACULTY OF MEDICINE & SURGERY
PHARMACY DEPARTMENT
Ref. No.
SOP/PD/232_01
STANDARD OPERATING PROCEDURE
ADVANCED VENEPUNCTURE ARM
Valid for:
2 years from
approval
1. Scope
This Standard Operating Procedure (SOP) applies to staff and students using the
Advanced Venepuncture Arm in the Pharmacy Practice Resource Unit (PPRU) at the
Pharmacy Department, University of Malta.
2. Objective
To describe the procedure for set-up and use of the Advanced Venepuncture Arm.
3. Definitions
a. Red reservoir selector lever: Situated on the front of the fluid unit.
b. Venepuncture: Collection of blood from a vein; veins being the best source
from which to obtain blood.
c. Cannulation: Insertion of a hollow, narrow tube with a sharp, retractable
inner core (cannula) into a vein, artery, or another body cavity.
d. Median Cubital Vein: Vein of choice for venepuncture of the upper limb. It
is located in the preferred site which is the antecubital fossa, where the
arm bends at the elbow (SOP/PD/231_01/A1).
e. Mock Blood: A synthetic solution made to the correct colour and viscosity of
venous blood.
f. Injections: Sterile solutions, suspensions or emulsions, presented in a suitable
aqueous or non-aqueous vehicle intended for parenteral administration into
body tissues.
g. Intravenous Injection: Injection of a substance directly into the vein
(SOP/PD/231_01/A2). The intravenous route (IV) uses a hypodermic
injection for the purpose of instilling a single dose of medication, injecting a
contrast medium or beginning an IV infusion of blood, medication, or a fluid
solution, such as saline or dextrose in water.
h. Antecubital Fossa (ACF): A tiny cavity in the shape of a triangle located in
the elbow joint which is vital for blood samples because there are the three
main veins running through it. These are the cephalic vein, basilic vein and
median vein (SOP/PD/231_01/A3).
Page 2 of 22
UNIVERSITY OF MALTA
FACULTY OF MEDICINE & SURGERY
PHARMACY DEPARTMENT
Ref. No.
SOP/PD/232_01
STANDARD OPERATING PROCEDURE
ADVANCED VENEPUNCTURE ARM
Valid for:
2 years from
approval
4. Responsibility
4.1.
4.2.
The members of the Department of Pharmacy (staff and students) are
responsible for following this SOP.
The designated Laboratory Officer or Laboratory Assistant is responsible for
ensuring that this SOP is followed.
5. Procedure
5.1.
a.
b.
c.
d.
Diagram of Advanced Venepuncture Arm
Advanced Venepuncture Arm Skin – Light
Advanced Venepuncture Arm Rest
Fluid Unit
Mock blood
Page 3 of 22
UNIVERSITY OF MALTA
FACULTY OF MEDICINE & SURGERY
PHARMACY DEPARTMENT
Ref. No.
SOP/PD/232_01
STANDARD OPERATING PROCEDURE
ADVANCED VENEPUNCTURE ARM
5.2.
Basic Fluid Unit Operations
5.2.1.
5.2.2.
5.2.3.
5.2.4.
5.3.
Connect the refill bottle or the arm to the fluid unit, ensuring that the
tube with the black sleeve attaches to the left connector with the black
ring on it.
Slide the red reservoir selector lever to the left to pressurise the left
reservoir or slide the red reservoir selector level to the right to
pressurise the right reservoir.
Turn the release valve clockwise to close it, before pressurising the
fluid unit, by squeezing the pressure bulb.
Turn the release valve anticlockwise to open; this will depressurise the
fluid unit.
Filling the Fluid Unit
5.3.1.
5.3.2.
5.3.3.
5.3.4.
5.3.5.
5.3.6.
5.3.7.
5.3.8.
5.4.
Valid for:
2 years from
approval
Feed the blood into the left hand reservoir when filling the fluid unit.
Slide the reservoir selector to the right.
Connect the refill bottle.
Close the valve on the pressure bulb.
Pressurise the fluid unit into the grey zone.
Keep the pressure in the grey zone to ensure that the reservoir fills
quickly.
Open the pressure valve once the blood reaches a maximum level of
300ml to depressurise the fluid unit and the blood stops transferring.
Disconnect the bottle; the fluid unit is full and ready to be attached to
the arm.
Priming the Veins
5.4.1.
5.4.2.
5.4.3.
5.4.4.
5.4.5.
5.4.6.
Slide the red reservoir selector lever to the left after carrying out the
steps in Section 5.3.
Connect the arm.
Ensure that both white clips on the arm tubes are open.
Close the valve on the pressure bulb.
Pressurise the fluid unit into the green zone. Do not overpressurise
(into the grey zone) as this will cause blood to leak from the puncture
sites in previously used veins creating a mess under the skin. Air
pressure in the left reservoir forces the blood out through the arm and
into the right reservoir.
Close the white clip on the right hand tube after there are no more air
bubbles coming out of the arm. This will maintain the correct pressure
in the arm during training and the arm is ready to use.
Page 4 of 22
UNIVERSITY OF MALTA
FACULTY OF MEDICINE & SURGERY
PHARMACY DEPARTMENT
Ref. No.
SOP/PD/232_01
STANDARD OPERATING PROCEDURE
ADVANCED VENEPUNCTURE ARM
5.5.
Fitting the Skin
5.5.1.
5.5.2.
5.5.3.
5.5.4.
5.5.5.
5.5.6.
5.6.
Lubricate the arm with the supplied water-based lubricant to make the
skin easier to attach; the hand, forearm and upper arm must be well
lubricated.
Align the skin with the underlying anatomy of the arm.
Work the skin up the arm gently.
Pull the fingers onto the hand.
Slide the skin up to the top of the arm; the ridge around the inside must
engage with groove at the top.
Slide the skin around slightly so that it fits the arm anatomy properly.
Using the Arm
5.6.1.
5.6.2.
5.6.3.
5.6.4.
5.6.5.
5.6.6.
5.6.7.
5.7.
Valid for:
2 years from
approval
Take the blood by using vacuum collection devices, or a needle and
syringe or by cannulation.
Maintain the pressure in the green zone during training since as the
blood level decreases in the left reservoir the pressure will drop.
Release the clip on the right hand tube occasionally during training and
allow blood to flow through the arm to remove any air bubbles that
might have been introduced.
Pressurise the arm from the right reservoir when there is a sufficient
volume of blood in it.
Slide the red reservoir selector lever to the right.
Open the clip on the right tube and close the clip on the left tube
ensuring the pressure is in the green zone.
Squirt the contents of the syringe into a container so that at the end of
the training session the blood can be poured back into the refill bottle.
Emptying the Veins Prior to Replacement
5.7.1.
5.7.2.
5.7.3.
5.7.4.
5.7.5.
5.7.6.
5.7.7.
Slide the red reservoir selector to the right.
Connect the arm.
Ensure both white clips on the arm tubes are open.
Close the valve on the pressure bulb.
Pressurise the fluid into the green zone. Air pressure in the right
reservoir forces the blood out through the arm and into the left
reservoir.
Release the pressure and disconnect the arm once the amount of blood
coming out is minimal; the right reservoir will eventually empty and
air will flow through the veins.
Disconnect the arm.
Page 5 of 22
UNIVERSITY OF MALTA
FACULTY OF MEDICINE & SURGERY
PHARMACY DEPARTMENT
Ref. No.
SOP/PD/232_01
STANDARD OPERATING PROCEDURE
ADVANCED VENEPUNCTURE ARM
5.8.
Emptying the Fluid Unit Prior to Storage/Transport
5.8.1.
5.8.2.
5.8.3.
5.8.4.
5.8.5.
5.8.6.
5.9.
Valid for:
2 years from
approval
Remove the blood from the fluid unit only when it is in the left hand
reservoir.
Slide the red reservoir selector lever to the left.
Connect the refill bottle.
Close the valve on the pressure bulb.
Pressurise the fluid unit into the grey zone and keep the pressure in the
grey zone to ensure that the bottle fills quickly.
Release the pressure and disconnect the bottle once most of the blood
has been removed and only air is bubbling through the left tube.
Removing the Skin
5.9.1.
5.9.2.
5.9.3.
5.9.4.
5.9.5.
Roll the upper part of the skin down over onto itself, as far as it will
go, using both hands. Do not force the skin.
Fold the skin down over onto itself again.
Gently pull the skin down onto the wrist.
Gently pull the skin off the wrist onto the hand; the hand should
gradually go floppy as the skin is worked off the arm.
Hold the skin by the upper part once most of the skin is off the arm,
and remove it.
5.10. Changing the Veins
5.10.1. Follow the procedures in Sections 5.7 and 5.9 before changing the
veins.
5.10.2. Remove and discard the strips of tape running around the thumb, wrist,
and the upper antecubital fossa (ACF) area.
5.10.3. Disconnect the two upper connectors first.
5.10.4. Pull the lower connector gently out of the palm.
5.10.5. Hold the transparent tube and pull the vein out from it.
5.10.6. Remove the vein and discard it. Avoid spilling any residual blood left
in the veins.
5.10.7. Lay the new vein on the work surface in the correct position (two veins
at the top, small hand veins at the bottom and the slant of the median
cubital matches the groove in the vein module).
5.10.8. Attach the top two veins and push the transparent tubes back into the
arm so that the connectors fit well.
5.10.9. Fit the veins into the grooves and wrap the supplied tape around the
upper ACF area to hold them in place.
5.10.10. Attach the palm connector and push the transparent tube back into the
arm so that the connector fits well.
Page 6 of 22
UNIVERSITY OF MALTA
FACULTY OF MEDICINE & SURGERY
PHARMACY DEPARTMENT
Ref. No.
SOP/PD/232_01
STANDARD OPERATING PROCEDURE
ADVANCED VENEPUNCTURE ARM
Valid for:
2 years from
approval
5.10.11. Fit the veins into the grooves of the forearm and tape them in place.
5.10.12. Tape the vein into the thumb area ensuring that the veins around the
hand fit in the grooves correctly.
5.10.13. Settle the veins into the grooves correctly; the arm is now ready to
have the skin fitted.
Page 7 of 22
UNIVERSITY OF MALTA
FACULTY OF MEDICINE & SURGERY
PHARMACY DEPARTMENT
Ref. No.
SOP/PD/232_01
STANDARD OPERATING PROCEDURE
ADVANCED VENEPUNCTURE ARM
5.11. Flow Charts
5.11.1. Basic Fluid Operations
Start
Connect the refill bottle or the arm to the fluid
unit, ensuring that the tube with the black
sleeve attaches to the left connector with the
black ring on it.
Slide the red reservoir selector lever, situated
on the front of the fluid unit, to the left to
pressurise the left reservoir or slide the red
reservoir to the right to pressurise the right
reservoir.
Turn the release valve clockwise to close it,
before pressurising the fluid unit, by squeezing
the pressure bulb.
Turn the release valve anticlockwise to open;
this will depressurise the fluid unit.
End
Page 8 of 22
Valid for:
2 years from
approval
UNIVERSITY OF MALTA
FACULTY OF MEDICINE & SURGERY
PHARMACY DEPARTMENT
Ref. No.
SOP/PD/232_01
STANDARD OPERATING PROCEDURE
ADVANCED VENEPUNCTURE ARM
5.11.2. Filling the Fluid Unit
Start
Feed the blood into the left hand reservoir
when filling the fluid unit.
Slide the red reservoir selector lever to the
right.
Connect the refill bottle.
Close the valve on the pressure bulb.
Pressurise the fluid unit into the grey zone.
Keep the pressure in the grey zone to ensure
that the reservoir fills quickly.
Open the pressure valve once the blood
reaches a maximum level of 300ml to
depressurise the fluid unit and the blood stops
transferring.
Disconnect the bottle; the fluid unit is full and
ready to be attached to the arm.
End
Page 9 of 22
Valid for:
2 years from
approval
UNIVERSITY OF MALTA
FACULTY OF MEDICINE & SURGERY
PHARMACY DEPARTMENT
Ref. No.
SOP/PD/232_01
STANDARD OPERATING PROCEDURE
ADVANCED VENEPUNCTURE ARM
5.11.3. Priming the Veins
Start
Slide the red reservoir selector lever to the left
after carrying out the procedure in Section
5.11.2
Connect the arm
Ensure that both white clips on the arm tubes
are open
Close the valve on the pressure bulb.
Pressurise the fluid unit into the green zone.
Do not overpressurise (into the grey zone) as
this will cause blood to leak from the puncture
sites in previously used veins creating a mess
under the skin. Air pressure in the left
reservoir forces the blood out through the arm
and into the right reservoir.
Close the white clip on the right hand tube
after there are no more air bubbles coming out
of the arm. This will maintain the correct
pressure in the arm during training and the arm
is ready to use.
End
Page 10 of 22
Valid for:
2 years from
approval
UNIVERSITY OF MALTA
FACULTY OF MEDICINE & SURGERY
PHARMACY DEPARTMENT
Ref. No.
SOP/PD/232_01
STANDARD OPERATING PROCEDURE
ADVANCED VENEPUNCTURE ARM
5.11.4. Fitting the Skin
Start
Lubricate the arm with the supplied waterbased lubricant to make the skin easier to
attach. The hand, forearm and upper arm must
be well lubricated.
Align the skin with the underlying anatomy of
the arm.
Work the skin up the arm gently.
Pull the fingers onto the hand.
Slide the skin up to the top of the arm. The
ridge around the inside must engage with
groove at the top.
Slide the skin around slightly so that it fits the
arm anatomy properly.
End
Page 11 of 22
Valid for:
2 years from
approval
UNIVERSITY OF MALTA
FACULTY OF MEDICINE & SURGERY
PHARMACY DEPARTMENT
Ref. No.
SOP/PD/232_01
STANDARD OPERATING PROCEDURE
ADVANCED VENEPUNCTURE ARM
5.11.5. Using the Arm
Start
Take the blood by using vacuum collection
devices, or a needle and syringe or by
cannulation.
Maintain the pressure in the green zone during
training since as the blood level decreases in
the left reservoir the pressure will drop.
Release the clip on the right hand tube
occasionally during training and allow blood
to flow through the arm to remove any air
bubbles that might have been introduced.
Pressurise the arm from the right reservoir
when there is a sufficient volume of blood in
it.
Slide the red reservoir selector lever to the
right.
Open the clip on the right tube and close the
clip on the left tube ensuring the pressure is in
the green zone.
Squirt the contents of the syringe into a
container so that at the end of the training
session the blood can be poured back into the
refill bottle.
End
Page 12 of 22
Valid for:
2 years from
approval
UNIVERSITY OF MALTA
FACULTY OF MEDICINE & SURGERY
PHARMACY DEPARTMENT
Ref. No.
SOP/PD/232_01
STANDARD OPERATING PROCEDURE
ADVANCED VENEPUNCTURE ARM
5.11.6. Emptying the Veins Prior to Replacement
Start
Slide the red reservoir selector lever to the
right
Connect the arm
Ensure both white clips on the arm tubes are
open.
Close the valve on the pressure bulb.
Pressurise the fluid into the green zone. Air
pressure in the right reservoir forces the blood
out through the arm and into the left reservoir.
Release the pressure and disconnect the arm
once the amount of blood coming out is
minimal. Eventually the right reservoir will
empty and air will flow through the veins.
Disconnect the arm
End
Page 13 of 22
Valid for:
2 years from
approval
UNIVERSITY OF MALTA
FACULTY OF MEDICINE & SURGERY
PHARMACY DEPARTMENT
Ref. No.
SOP/PD/232_01
STANDARD OPERATING PROCEDURE
ADVANCED VENEPUNCTURE ARM
5.11.7. Emptying the Fluid Unit Prior to Storage/Transport
Start
Remove the blood from the fluid unit only
when it is in the left hand reservoir.
Slide the red reservoir selector lever to the left.
Connect the refill bottle.
Close the valve on the pressure bulb.
Pressurise the fluid unit into the grey zone and
keep the pressure in the grey zone to ensure
that the bottle fills quickly.
Release the pressure and disconnect the bottle
once most of the blood has been removed and
only air is bubbling through the left tube.
End
Page 14 of 22
Valid for:
2 years from
approval
UNIVERSITY OF MALTA
FACULTY OF MEDICINE & SURGERY
PHARMACY DEPARTMENT
Ref. No.
SOP/PD/232_01
STANDARD OPERATING PROCEDURE
ADVANCED VENEPUNCTURE ARM
5.11.8. Removing the Skin
Start
Roll the upper part of the skin down over onto
itself, as far as it will go, by using both hands.
Do not force the skin.
Fold the skin down over onto itself again.
Gently pull the skin down onto the wrist.
Gently pull the skin off the wrist onto the
hand; the hand should gradually go floppy as
the skin is worked off the arm.
Hold the skin by the upper part once most of
the skin is off the arm, and remove it.
End
Page 15 of 22
Valid for:
2 years from
approval
UNIVERSITY OF MALTA
FACULTY OF MEDICINE & SURGERY
PHARMACY DEPARTMENT
Ref. No.
SOP/PD/232_01
STANDARD OPERATING PROCEDURE
ADVANCED VENEPUNCTURE ARM
5.11.9. Changing the Veins
Start
Follow the procedures in Sections 5.11.6. and
5.11.8. before changing the veins.
Remove and discard the strips of tape running
around the thumb, wrist, and the upper
antecubital fossa (ACF) area.
Disconnect the two upper connectors first.
Pull the lower connector gently out of the
palm.
Hold the transparent tube and pull the vein out
from it.
Remove the vein and discard it. Avoid spilling
any residual blood left in the veins.
Lay the new vein on the work surface in the
correct position (two veins at the top, small
hand veins at the bottom and the slant of the
median cubital matches the groove in the vein
module).
Attach the two top veins and push the
transparent tubes back into the arm so that the
connectors fit well.
1
Page 16 of 22
Valid for:
2 years from
approval
UNIVERSITY OF MALTA
FACULTY OF MEDICINE & SURGERY
PHARMACY DEPARTMENT
Ref. No.
SOP/PD/232_01
STANDARD OPERATING PROCEDURE
ADVANCED VENEPUNCTURE ARM
1
Fit the veins into the grooves and wrap the
supplied tape around the upper ACF area to
hold them in place.
Attach the palm connector and push the
transparent tube back into the arm so that the
connector fits well.
Fit the veins into the grooves of the forearm
and tape them in place.
Tape the vein into the thumb area ensuring that
the veins around the hand fit in the grooves
correctly.
Settle the veins into the grooves correctly. The
arm is now ready to have the skin fitted.
End
Page 17 of 22
Valid for:
2 years from
approval
UNIVERSITY OF MALTA
FACULTY OF MEDICINE & SURGERY
PHARMACY DEPARTMENT
Ref. No.
SOP/PD/232_01
STANDARD OPERATING PROCEDURE
ADVANCED VENEPUNCTURE ARM
Valid for:
2 years from
approval
6. Precautions
6.1. Always set the arm up on a wipe clean surface since the process is potentially
messy.
6.2. If mock blood gets into the eyes flush with plenty of cold water.
6.3. Do not wear ‘good’ clothes when training with this product since contact with
mock blood will permanently stain them. It can be washed out using a
biological detergent.
6.4. Observe normal hygiene procedures after handling the product and mock
blood.
6.5. Do not overpressurise into the grey zone when priming the veins as this will
cause blood to leak from the puncture sites in previously used veins creating a
mess under the skin.
6.6. Maintain the pressure in the green zone during training since as the blood level
decreases in the left reservoir the pressure will drop.
6.7. When emptying the fluid unit the blood to be removed must always be in the
left hand reservoir.
6.8. Do not force the skin when rolling the upper part of the skin down over onto
itself to remove it.
6.9. The fluid unit should always be emptied before storing the arm in its
appropriate case, especially if the product is being transported long distances.
6.10. Avoid spilling any residual blood left in the veins whilst removing to discard
them.
7. References
Advanced Venepuncture Arm User Guide. Issue 2. UK; Limbs & Things Ltd;
2008.
The Venipuncture From an Arm Vein. So You’re Going to Collect a Blood
Specimen: An Introduction to Phlebotomy. [Online]. 2013 [cited 2013 Oct
15];21-23.
Available
from:
URL:
http://www.cap.org/apps/docs/cap_press/bloodSpecimenBook/Venipuncture.p
df
Venepuncture Year 2 Dental Students Practical Skill Session. University
Section of Anaesthesia, Pain & Critical Care Medicine. Clinical Skills in
Venepuncture & IV Cannulation. [Online]. [cited 2013 Nov 20]. Available
from: URL: http://www.gla.ac.uk/media/media_109798_en.pdf
Page 18 of 22
UNIVERSITY OF MALTA
FACULTY OF MEDICINE & SURGERY
PHARMACY DEPARTMENT
Ref. No.
SOP/PD/232_01
STANDARD OPERATING PROCEDURE
ADVANCED VENEPUNCTURE ARM
Valid for:
2 years from
approval
8. Appendices
SOP/PD/231_01/A1 – Diagram showing the median cubital vein
SOP/PD/231_01/A2 – Diagram showing the desired angle and site for venepuncture
SOP/PD/231_01/A3 – Diagram showing The Antecubital Fossa
9. Revision History
Version Number
01
Amendments/ Reasons for change
Initial Release
Page 19 of 22
UNIVERSITY OF MALTA
FACULTY OF MEDICINE & SURGERY
PHARMACY DEPARTMENT
Ref. No.
SOP/PD/232_01
STANDARD OPERATING PROCEDURE
ADVANCED VENEPUNCTURE ARM
SOP/PD/231_01/A1 - Diagram showing the median cubital vein
Page 20 of 22
Valid for:
2 years from
approval
UNIVERSITY OF MALTA
FACULTY OF MEDICINE & SURGERY
PHARMACY DEPARTMENT
Ref. No.
SOP/PD/232_01
STANDARD OPERATING PROCEDURE
ADVANCED VENEPUNCTURE ARM
Valid for:
2 years from
approval
SOP/PD/231_01/A2 - Diagram showing the desired angle and site for venepuncture
Page 21 of 22
UNIVERSITY OF MALTA
FACULTY OF MEDICINE & SURGERY
PHARMACY DEPARTMENT
Ref. No.
SOP/PD/232_01
STANDARD OPERATING PROCEDURE
ADVANCED VENEPUNCTURE ARM
SOP/PD/231_01/A3 - Diagram showing The Antecubital Fossa
Page 22 of 22
Valid for:
2 years from
approval