RevBrasAnestesiol.2014;64(2):131---133
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
OfficialPublicationoftheBrazilianSocietyofAnesthesiologywww.sba.com.br
CLINICAL
INFORMATION
Venipuncture-related
lateral
antebrachial
cutaneous
nerve
injury:
what
to
know?
Juan
A.
Ramos
DepartmentofAnesthesiology,MayoClinic,CollegeofMedicine,Jacksonville,FL,UnitedStates
Received23January2013;accepted10June2013 Availableonline11October2013
KEYWORDS
Peripheralnerve injuries; Phlebotomy; Informedconsent
Abstract
Backgroundandobjectives: Venipunctureisoneofthemostcommonproceduresperformed
indailyanestheticpractice.Thoughusuallyinnocuous,peripheralnerveinjurieswithserious sequelae have been describedfollowing venipuncture. We presenta case of venipuncture-related lateral antebrachialcutaneous nerve injury, alongside the essential diagnostic and prognosticinformationfordaytodaypractice.
Case: 27-Yearoldmalewhounderwentvenipunctureoftherightantecubitalfossawitha 20-gaugeneedle,forroutinemetabolicassessment.Thepatientsufferedashooting,electric-type pain traveling onthelateralside ofthe forearm,from theantecubitalfossa proximally, to therightlateralwristandbaseoftherightthumb.After24h,thepatientstillexperienced shooting,electric-typepainthatwasratedas8/10attherightdistallateralarm,rightlateral wristandbaseofthethumb,accompaniedbyparesthesia.Theliteraturewasreviewedandthe patientwas counseledregardingpublishedoutcomesofthesetypeofinjuries.Atfollow-up, thepatientstatedthatthedysesthesiasubsidedapproximately3---4weeksafterinitialinjury, andreportednoremainingneurologicdeficits.
Conclusions: Peripheralnerveinjurieshavebeendescribedaftervenipuncture,butthe liter-ature islimited.Nervesintheantecubitalfossaclassically lieonaplane justbeneath, and incloseproximityto,theveins,makingthemsusceptibletoinjuryduringphlebotomy;alsoit hasbeenshownthatthereisalargerangeofanatomicvariation,suggestingthatevena non-traumatic,satisfactoryvenipuncturecandirectlydamagethesenerves.Anesthesiologistsmust beawareofthispossiblecomplication,diagnosisandprognosticationtoadequately counsel patientsintheeventthatthiscomplicationoccurs.
© 2013SociedadeBrasileirade Anestesiologia.Publishedby ElsevierEditoraLtda.Allrights reserved.
E-mail:[email protected]
Introduction
Venipuncture,includingintravenouscannulation, isoneof themostcommonproceduresperformedindailyanesthetic practice.It is universallyimplied that proper intravenous
132 J.A.Ramos
accessshouldbeobtainedinordertoadequatelyandsafely perform general anesthesia. Though usually innocuous, peripheralnerveinjurieswithmoreseriousandlong-lasting sequelaehavebeendescribedasrarecomplications follow-ingvenipuncture1;thesecomplicationsproduceunnecessary
angstand physical suffering inaffected patients andmay resultindebilitatingoutcomes.
Case
Ourcase,a27-yearoldmalewithoutsignificantpast medi-calhistory,underwentvenipunctureoftherightantecubital fossawitha20-gaugeneedle,forroutinemetabolic assess-ment.Atthetimeoftheblooddraw,thepatientsuffereda shooting,electric-typepaintravelingonthelateralsideof theforearm,fromtheantecubitalfossaproximally,tothe rightlateralwristandbaseoftherightthumb.Shortlyafter theneedlewasremoved,thepainfadedgradually.
After 24h, the patient noticed shooting, electric-type pain that was rated (on an 11-point visual analog scale, VAS, anchored with 0=no pain and 10=worst pain ever experienced)as8/10at theright distal lateralarm, right lateral wristand base of the thumb. The pain was exac-erbatedbyflexionatthe elbow,lastingfor afewseconds andsubsidingoncearmflexionwasdiscontinued.The pain wasaccompaniedbymildparesthesia(describedas percep-tion of pins and needles) of the area but therewere no motordeficits.Intervalexaminations24hand7daysafter theincident,revealednohematomaorlocalsignsof infec-tion.The sensorydeficitsclearlyfollowedthe distribution of the lateral antebrachial cutaneous nerve, electromyo-graphic(EMG)testingwasdeferred,butwasofferedasan optiontothepatientifdeficitsdidnotsubsideby4weeks. Atthetime,theliteraturewasreviewedandthepatient wasreassured that most commonly, 70%, 90% and 96% of venipuncture-relatednerveinjuriesresolvewithin1,3and 6 months,respectively.1 Follow-up was arranged4 weeks
postoperativelyfor furtherassessment andpossible treat-ment.
At follow-up, the patient stated that the dysesthesia subsidedapproximately3---4weeksafterinitial injury,and reportednoremainingneurologicdeficits.
Discussion
Peripheral nerve injuries have been described both after venipuncture and blood donations, but the literature is limited. This injury is defined by a persistent burning, shooting, electrical-type pain or paresthesia in a specific peripheral nerve distribution, which begins immediately while the needle is in situ, or can be delayed for sev-eralhoursthereafter.Commonly,historicalevidenceatthe timeof the procedure suggests a difficult (e.g., multiple attempts),traumaticorsepticphlebotomy(e.g.,formation ofhematomaor,rarely,abscess).2
Its incidence in blood donor population has been described between 1 in 21,000 and 1 in 26,000 venipunctures.1,3 Most of the injuries resolve
sponta-neously.Chronicdisabling deficitshave been described (1 in1.5 millionphlebotomies),4but permanentdamagehas
beenreportedin asmanyas87%ofpatients whorequired
1
2 A
2
A B
C
Figure1 Antecubitalfossa.Reproducedwithpermissionfrom
Venipuncture-relatedperipheralnerveinjury 133
care by painmanagement specialists.2 Hematoma
forma-tionispresent at thevenipuncturesitein 24%ofpatients withvenipuncture-relatednerveinjuries, suggestingsome degree of puncture trauma.1 The majority of the times,
however,hematomasareabsent.
Nervesintheantecubitalfossaclassicallylieonaplane justbeneath,andincloseproximityto,theveins(Fig.1), makingthemsusceptibletoinjuryduringphlebotomy.5
Addi-tionally, Horowitz2 showed in dissected cadaveric upper
extremities thatin 6 of 14 specimens,major branchesof cutaneous nerves were superficial to or overlaying veins: medialandlateralantebrachialcutaneousnervesinrelation tothebasilic,medianbasilic,mediancephalic,orcephalic veinsintheantecubitalfossa.Thissuggeststhatevena non-traumatic, satisfactory venipuncture can directly damage thesenerves.
Phlebotomy best practice has suggested that for venipuncturetheinsertedneedleshouldbeplaced superfi-cially,andthemedialaspectoftheantecubitalfossashould beavoided.3 Minimizingneedlemovement while insituis
probablyalsowise;however,takingthehighanatomic vari-abilityintoaccount,theriskofinadvertentnervedamageis stillapossibility.Asanesthesiologists,weneedtobeaware oftheserisksinordertoavoidthiscomplication,andequally importantly,weshouldbereadytodiscusswiththepatient thepotentialoptionsfordiagnosisandtreatmentaswellas theprognosis.
Conclusion
Anesthesiologists routinely administer medications requiring an intravenous route of delivery. Although
venipuncture-related nerve injuries are infrequent, anesthesiologists must be aware of this possible compli-cation, and advise patients properly during acquisition of inform consentif the possibility of antecubital venous access is contemplated. Familiarization with prognosis in venipuncture-related nerve injuries is also advocated to adequately counsel patients in the event that this complicationoccurs.
Conflicts
of
interest
Theauthordeclaresnoconflictsofinterest.
Acknowledgments
TheauthorwouldliketoexpresshisgratitudetoDr.SorinJ. Brullforhisguidanceandintellectualcontributionstoward themakingofthismanuscript.
References
1.NewmanBH,WaxmanDA.Blooddonation-relatedneurologic nee-dleinjury:evaluationof2years’worthofdatafromalargeblood center.Transfusion(Paris).1996;36:213---5.
2.Horowitz SH. Venipuncture-induced causalgia: anatomic rela-tionsofupperextremitysuperficialveinsandnerves,andclinical considerations.Transfusion(Paris).2000;40:1036---40.
3.BerryP.Venipuncturenerveinjuries.Lancet.1977;1:1236---7. 4.NewmanB.Venipuncturenerveinjuriesafterwhole-blood
dona-tion.Transfusion(Paris).2001;41:571---2.
