Tips from the Field…

Handling Difficult Blood Draws in Substance Using Research Populations: Experience of the Russia ARCH Team

By Tatiana Yaroslavtseva and Anna Kazishvilly

The presence of HIV infection and the absence of antiretroviral treatment are the principal inclusion criteria for the Russian ARCH study. The primary transmission method of HIV infection in Russia is injection drug use, and the majority of ARCH study participants are people who have injected drugs (heroin and/or street methadone).

The Russia ARCH study protocol calls for 24 ml (3 tubes) of blood at enrollment. As of July 2014, 205 participants have been enrolled in the study and 28 participants (14%) were unable to provide 24 ml of blood. More than a third of subjects (72/205, 35%) have had a blood draw with complications (e.g., excessive duration, multiple sticks). Even when enough volume is drawn, complicated blood draws can introduce hemolysis, which may impact test results.

Given the participants’ long history of injecting drugs, many have problems with peripheral vein access. Injection drugs are prepared using a variety of chemical substances that affect veins’ integrity, and the use of non-sterile needles and syringes leads to inflammatory vascular complications, such as thrombophlebitis. All of these issues lead to vascular sclerosis, the eventual consequence of which is difficulty with peripheral venous access.

Having a research nurse who has experience with drawing blood from people who inject drugs can help a study obtain successful draws. The Russia ARCH phlebotomist, Anna, has been working with injection drug using populations since 2003 has been resourceful when dealing with difficult draws. For example, she uses a syringe for blood collection during difficult draws instead of a standard butterfly clip. Anna uses the specialty 364810 BD Vacutainer® 50/200 to avoid problems with the contactless transfer of blood from the syringe cylinder.

Anna is also able to attempt blood draws from a number of venipuncture sites. Standard venipuncture uses the median cubital, basalic, and cephalic veins from the antecubital region of the arm. If the usual blood sampling locations are damaged and cannot be used for phlebotomy, then Anna looks for other locations, such as the veins of the posteromedial surface of the forearm, wrist, and rear foot.

However, even with a skilled and resourceful phlebotomist, there are still times when blood cannot be collected. Faced with this challenge and given the importance of serum and plasma for the study, it was decided to amend the Russia ARCH blood draw protocol to institute a minimum draw. If at baseline, the minimum amount is not collected following multiple attempts, consented participants are disenrolled from the study and compensated for that study visit.

The described procedures have mitigated this challenge in the Russia ARCH study.