Heel Sticks
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Heel stick is a minimally invasive and easily accessible way of obtaining capillary blood samples for various laboratory tests, especially newborn screens and glucose levels. However, thanks to improved laboratory techniques that require smaller sample volumes and improved automated heel lancing devices that minimize trauma and pain, [1] heel stick is a viable method of obtaining blood for many routine blood tests. [2] Heel stick sampling can also help preserve venous access for future intravenous (IV) lines.
Some evidence exists that in term neonates, skilled venipuncture may result in fewer total punctures and less pain than heel stick. A Cochrane review first published in 1999 and updated in 2011 suggests that it may in fact be the procedure of choice in this population. [3] However, these results may not be extrapolatable to preterm infants or infants who require multiple or frequent blood sampling. [4] In addition, the development of newer, more effective, and less painful lancing devices may increase the relative utility of heel stick.
Heel stick blood sampling is indicated whenever capillary blood is an acceptable source. Such situations include the following:
The sample required is relatively small
Another acceptable source of blood (eg, central venous catheter, umbilical catheter, arterial line) is not already available
Heel stick samples can be used for general chemistries and liver function tests, complete blood counts (CBCs), toxicology, newborn screening, bedside glucose monitoring, and blood gas analysis. [5, 6, 7, 8]
Heel stick should not be performed if any significant injury, infection, anomaly, or edema is present on the sampling area of the heel. [9]
At present, coagulation studies may not be performed with capillary samples. Blood tests that require relatively larger sample volumes may not be feasible with heel stick samples. Blood cultures require perfectly sterile technique and, therefore, may not be done with samples obtained via heel stick. Certain other sophisticated tests may also not be performed on heel stick samples (eg, chromosomal analyses and certain immunoglobulins and titers).
When ordering a laboratory test that is sent to another facility or is out of the ordinary, check with the laboratory to determine which type of blood sample is required.
The materials required for a heel stick include the following:
Gloves
A heel-warming device (if desired)
Antiseptic solution (eg, povidone-iodine, chlorhexidine, or alcohol, depending on the local facility’s policy)
A heel-lancing device (eg, Tenderfoot [ITC Medical, Edison, NJ] or Quikheel Lancet
[BD, Franklin Lakes, NJ]), sized appropriately for the infant’s weight – A 0.65 mm incision depth is appropriate for infants weighing 1 kg or less; a 0.85 mm incision depth is appropriate for small-for-gestational-age (SGA) infants and premature infants who weigh more than 1 kg; and a 1 mm incision depth is appropriate for term infants aged 6 months or younger
A towel or pad to cover bed linens
An appropriate blood collecting apparatus, including a hematology tube, a capillary blood gas tube, filter paper, a serum separator tube, and a capillary tube
A bandage or gauze to dress the wound after the procedure
Anesthesia
Standard local or systemic pharmacologic anesthesia is not required for heel stick sampling. Local anesthetics may interfere with the quality of the blood sample.
Anesthesia for heel stick in infants can involve oral sucrose, ambient light and noise reduction, and swaddling. Sucrose has been shown to have a substantial anesthetic effect in multiple trials, though an optimal dose has not been definitively established. [10] It may be administered with a dropper, a needleless syringe, or a pacifier dipped in a dose of approximately 0.1-1 mL.
Swaddling, bringing the infant’s hands to the midline, and minimizing environmental stimulation has also been shown to have an effect on how infants tolerate this painful procedure. [5]
Positioning
Developmentally appropriate positioning, should be implemented when possible. The heel stick sample is obtained most easily with the infant supine (see the image below).
Proper site selection (see the image below) is important for minimizing pain and avoiding contact with the calcaneus. The posterior pole of the heel should not be used for a heel stick, because this site is where the calcaneus is in its most superficial position. [11]
If heel warming is desired, apply a heel warmer according to the manufacturer’s directions for approximately 5 minutes before performing the heel stick. (Some studies have found heel warming to offer no improvement in blood volume collected. [12] )
Put on gloves. Prepare the automated heel-lancing device according to the manufacturer’s directions. Prepare an adequate area around the heel stick site with antiseptic solution.
Position the heel between thumb and forefinger, with the fingers underneath the calf and posterior ankle and the thumb over the ball of foot or arch (see the image below). Apply a small amount of pressure to place the foot in a comfortable dorsiflexed position.
Place the automated lancing device on the appropriate area on the side of the heel (see the image below), then activate it.
Apply mild pressure with thumb and fingers. Avoid excessive squeezing or milking of the heel; this may lead to greater hemolysis and more pain.
Wipe away the first drop of blood, and collect the sample. Fill the capillary tube by touching the open tip of the tube to a blood drop, which is drawn into the tube by capillary action. Collect blood drops into hematology or chemistry tubes (see the image below), taking care to avoid excessive scooping of blood from the adjacent skin with the lip of the collection tube, which can interfere with test results.
Blot blood drops onto appropriate areas on the filter paper according to the laboratory’s instructions; methods of collecting filter paper samples for newborn screens have strict guidelines and vary between laboratories. If blood stops flowing, try to wipe away any clot that may have formed at the incision site with gauze or an alcohol wipe. Release pressure to allow capillary refill, then reapply pressure to allow a blood drop to form again.
When sampling is complete, apply pressure to the incision site until bleeding stops. Apply gauze or a bandage.
Complications of heel stick include the following:
Infection (cellulitis, abscess, osteomyelitis)
Scarring
A too-deep incision (potentially making contact with calcaneus)
Inaccurate results (eg, hemolysis causing hyperkalemia, air bubbles causing erroneous blood gas results, platelet clumping)
Vertanen H, Fellman V, Brommels M, et al. An automatic incision device for obtaining blood samples from the heels of preterm infants causes less damage than a conventional manual lancet. Arch Dis Child Fetal Neonatal Ed. 2001 Jan. 84(1):F53-5. [Medline].
American Association for Respiratory Care. Capillary Blood Gas Sampling for Neonatal & Pediatric Patients. Respiratory Care. 2001. 46(5):506-513. [Full Text].
Shah VS, Ohlsson A. Venepuncture versus heel lance for blood sampling in term neonates. Cochrane Database Syst Rev. 2011 Oct 5. CD001452. [Medline].
D’Apolito KC. State of the science: procedural pain management in the neonate. J Perinat Neonatal Nurs. 2006 Jan-Mar. 20(1):56-61. [Medline].
Folk LA. Guide to capillary heelstick blood sampling in infants. Adv Neonatal Care. 2007 Aug. 7(4):171-8. [Medline].
Bardakdjian-Michau J, Bahuau M, Hurtrel D, Godart C, Riou J, Mathis M, et al. Neonatal screening for sickle cell disease in France. J Clin Pathol. 2009 Jan. 62(1):31-3. [Medline].
Algeciras-Schimnich A, Cook WJ, Milz TC, Saenger AK, Karon BS. Evaluation of hemoglobin interference in capillary heel-stick samples collected for determination of neonatal bilirubin. Clin Biochem. 2007 Nov. 40(16-17):1311-6. [Medline].
Patton JC, Akkers E, Coovadia AH, Meyers TM, Stevens WS, Sherman GG. Evaluation of dried whole blood spots obtained by heel or finger stick as an alternative to venous blood for diagnosis of human immunodeficiency virus type 1 infection in vertically exposed infants in the routine diagnostic laboratory. Clin Vaccine Immunol. 2007 Feb. 14(2):201-3. [Medline].
Folk L. Capillary heelstick blood sampling. MacDonald MG, Ramasethu J, eds. Atlas of Procedures in Neonatology. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2007. 93-6.
Stevens B, Yamada J, Ohlsson A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev. 2010 Jan 20. CD001069. [Medline].
Arena J, Emparanza JI, Nogues A, et al. Skin to calcaneus distance in the neonate. Arch Dis Child Fetal Neonatal Ed. 2005 Jul. 90(4):F328-f331. [Medline].
Janes M, Pinelli J, Landry S, et al. Comparison of capillary blood sampling using an automated incision device with and without warming the heel. J Perinatol. 2002 Mar. 22(2):154-8. [Medline].
Liaw JJ, Yang L, Katherine Wang KW, Chen CM, Chang YC, Yin T. Non-nutritive sucking and facilitated tucking relieve preterm infant pain during heel-stick procedures: A prospective, randomised controlled crossover trial. Int J Nurs Stud. 2011 Oct 14. [Medline].
Morrow C, Hidinger A, Wilkinson-Faulk D. Reducing neonatal pain during routine heel lance procedures. MCN Am J Matern Child Nurs. 2010 Nov-Dec. 35(6):346-54; quiz 354-6. [Medline].
Badr LK, Abdallah B, Hawari M, Sidani S, Kassar M, Nakad P, et al. Determinants of premature infant pain responses to heel sticks. Pediatr Nurs. 2010 May-Jun. 36(3):129-36. [Medline].
Johnston C, Campbell-Yeo M, Fernandes A, Inglis D, Streiner D, Zee R. Skin-to-skin care for procedural pain in neonates. Cochrane Database Syst Rev. 2014 Jan 23. 1:CD008435. [Medline].
Herrington CJ, Chiodo LM. Human touch effectively and safely reduces pain in the newborn intensive care unit. Pain Manag Nurs. 2014 Mar. 15 (1):107-15. [Medline].
Timothy G Vedder, MD Neonatology Staff, St Cloud Hospital, CentraCare Health, St Cloud, MN; Assistant Clinical Professor of Pediatrics, University of Hawaii, John A Burns School of Medicine; Associate Professor of Pediatrics, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine
Timothy G Vedder, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Bioethics and Humanities, Minnesota Medical Association, Society of US Army Flight Surgeons
Disclosure: Nothing to disclose.
Taylor L Sawyer, DO, MEd, FAAP, FACOP Associate Professor of Pediatrics, University of Washington School of Medicine; Director, Neonatal-Perinatal Fellowship, Seattle Children’s Hospital
Taylor L Sawyer, DO, MEd, FAAP, FACOP is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American College of Osteopathic Pediatricians, American Medical Association, American Osteopathic Association, Association of American Medical Colleges, International Pediatric Simulation Society, Society for Simulation in Healthcare
Disclosure: Nothing to disclose.
Dharmendra J Nimavat, MD, FAAP Associate Professor of Clinical Pediatrics, Department of Pediatrics, Division of Neonatology, Southern Illinois University School of Medicine; Staff Neonatologist, Clinical Director, NICU Regional Perinatal Center, HSHS St John’s Children’s Hospital
Dharmendra J Nimavat, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association of Physicians of Indian Origin
Disclosure: Nothing to disclose.
Ted Rosenkrantz, MD Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine
Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, Eastern Society for Pediatric Research, American Medical Association, Connecticut State Medical Society, Society for Pediatric Research
Disclosure: Nothing to disclose.
Acknowledgments
The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Army, the Department of Defense, or the US Government.
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