Venipuncture-related lateral antebrachial cutaneous nerve injury: what to know?

Abstracts

Background and objectives:

Venipuncture is one of the most common procedures performed in daily anesthetic practice. Though usually innocuous, peripheral nerve injuries with serious sequelae have been described following venipuncture. We present a case of venipuncture related lateral antebrachial cutaneous nerve injury, alongside the essential diagnostic and prognostic information for day to day practice.

Case:

27-Year old male who underwent venipuncture of the right antecubital fossa with a 20-gauge needle, for routine metabolic assessment. The patient suffered a shooting, electric-type pain traveling on the lateral side of the forearm, from the antecubital fossa proximally, to the right lateral wrist and base of the right thumb. After 24 h, the patient still experienced shooting, electric-type pain that was rated as 8/10 at the right distal lateral arm, right lateral wrist and base of the thumb, accompanied by paresthesia. The literature was reviewed and the patient was counseled regarding published outcomes of these type of injuries. At follow-up, the patient stated that the dysesthesia subsided approximately 3-4 weeks after initial injury, and reported no remaining neurologic deficits.

Conclusions:

Peripheral nerve injuries have been described after venipuncture, but the literature is limited. Nerves in the antecubital fossa classically lie on a plane just beneath, and in close proximity to, the veins, making them susceptible to injury during phlebotomy; also it has been shown that there is a large range of anatomic variation, suggesting that even a nontraumatic, satisfactory venipuncture can directly damage these nerves. Anesthesiologists must be aware of this possible complication, diagnosis and prognostication to adequately counsel patients in the event that this complication occurs.

Peripheral nerve injuries; Phlebotomy; Informed consent

Justificativa e objetivos:

a venipuntura é um dos procedimentos mais comuns na prática anestésica cotidiana. Embora geralmente inócuas, lesões de nervos periféricos com sequelas graves foram descritas após venipuntura. Apresentamos um caso de lesão de nervo cutâneo antebraquial lateral relacionada à venipuntura, juntamente com as informações de diagnóstico e prognóstico essenciais para a prática cotidiana.

Relato de caso:

paciente do sexo masculino, 27 anos, submetido à venipuntura de fossa antecubital direita, com uma agulha de calibre 20, para avaliação metabólica de rotina. O paciente sofreu uma dor aguda, tipo choque elétrico, que percorreu a face lateral do antebraço desde a fossa antecubital proximal até o pulso lateral direito e a base do polegar direito. Após 24 horas, o paciente ainda sentia a dor semelhante a choque elétrico que foi classificada como 8/10 no braço distal lateral direito, no pulso lateral direito e na base do polegar, acompanhada de parestesia. Fizemos uma revisão da literatura e o paciente recebeu orientação sobre os resultados publicados a respeito desse tipo de lesão. Durante o acompanhamento, o paciente relatou que a disestesia diminuiu cerca de 3-4 semanas após a lesão inicial e que não restou déficit neurológico.

Conclusões:

lesões de nervos periféricos foram descritas pós-venipuntura, mas a literatura é limitada. Os nervos da fossa antecubital estão classicamente localizados em um plano logo abaixo - e muito próximos - das veias, o que os torna susceptíveis a lesões durante a flebotomia; além disso, sabe-se que existe uma extensa variação anatômica, o que sugere que mesmo uma venipuntura satisfatória não traumática pode danificar diretamente esses nervos. O anestesiologista deve estar ciente dessa possível complicação e também do diagnóstico e prognóstico para orientar os pacientes de forma adequada, caso essa complicação ocorra.

Lesões de nervos periféricos; Flebotomia; Consentimento informado

Justificación y objetivos:

la venopunción es uno de los procedimientos más comunes en la práctica anestésica cotidiana. Aunque en general es inocua, se han descrito lesiones de los nervios periféricos con secuelas graves después de la venopunción. Presentamos un caso de lesión de nervio cutáneo antebraquial lateral relacionada con la venopunción, conjuntamente con la información de diagnóstico y pronóstico que son esenciales para la práctica cotidiana.

Caso:

paciente del sexo masculino, de 27 años, sometido a venopunción de la fosa antecubital derecha con una aguja de calibre 20 para evaluación metabólica de rutina. El paciente sufrió un dolor agudo de tipo descarga eléctrica, recorriendo el lateral del antebrazo desde la fosa antecubital proximal hasta la muñeca derecha y la base del pulgar derecho. Después 24 h, el paciente todavía sentía un dolor parecido a una descarga eléctrica que fue clasificado como 8/10 en el brazo distal lateral derecho, en la muñeca derecha y en la base del pulgar, acompañado de parestesia. Hicimos una revisión de la literatura y el paciente recibió orientación sobre los resultados publicados respecto a ese tipo de lesión. Durante el seguimiento, el paciente relató que la disestesia disminuyó aproximadamente 3-4 semanas después de la lesión inicial y no informó déficit neurológico.

Conclusiones:

se han descrito lesiones de nervios periféricos tras venopunción, pero la literatura es limitada. Los nervios de la fosa antecubital están clásicamente localizados en un plano inmediatamente inferior (y muy cercanos) a las venas, lo que los hace susceptibles a lesiones durante la flebotomía. Además, se sabe que existe una extensa variación anatómica, sugiriendo que incluso una venopunción satisfactoria no traumática puede perjudicar directamente esos nervios. El anestesiólogo debe ser consciente de esa posible complicación y también del diagnóstico y del pronóstico para orientar a los pacientes de forma adecuada en el caso de que ocurra esa complicación.

Lesiones de nervios periféricos; Flebotomía; Consentimiento informado

Introduction

Venipuncture, including intravenous cannulation, is one of the most common procedures performed in daily anesthetic practice. It is universally implied that proper intravenous access should be obtained in order to adequately and safely perform general anesthesia. Though usually innocuous, peripheral nerve injuries with more serious and long-lasting sequelae have been described as rare complications following venipuncture¹; these complications produce unnecessary angst and physical suffering in affected patients and may result in debilitating outcomes.

Case

Our case, a 27-year old male without significant past medical history, underwent venipuncture of the right antecubital fossa with a 20-gauge needle, for routine metabolic assessment. At the time of the blood draw, the patient suffered a shooting, electric-type pain traveling on the lateral side of the forearm, from the antecubital fossa proximally, to the right lateral wrist and base of the right thumb. Shortly after the needle was removed, the pain faded gradually.

After 24 h, 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) as 8/10 at the right distal lateral arm, right lateral wrist and base of the thumb. The pain was exacerbated by flexion at the elbow, lasting for a few seconds and subsiding once arm flexion was discontinued. The pain was accompanied by mild paresthesia (described as perception of pins and needles) of the area but there were no motor deficits. Interval examinations 24 h and 7 days after the incident, revealed no hematoma or local signs of infection. The sensory deficits clearly followed the distribution of the lateral antebrachial cutaneous nerve, electromyographic (EMG) testing was deferred, but was offered as an option to the patient if deficits did not subside by 4 weeks.

At the time, the literature was reviewed and the patient was reassured that most commonly, 70%, 90% and 96% of venipuncture-related nerve injuries resolve within 1, 3 and 6 months, respectively.¹ Follow-up was arranged 4 weeks postoperatively for further assessment and possible treatment.

At follow-up, the patient stated that the dysesthesia subsided approximately 3-4 weeks after initial injury, and reported no remaining neurologic deficits.

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 several hours thereafter. Commonly, historical evidence at the time of the procedure suggests a difficult (e.g., multiple attempts), traumatic or septic phlebotomy (e.g., formation of hematoma or, 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 spontaneously. Chronic disabling deficits have been described (1 in 1.5 million phlebotomies),⁴ but permanent damage has been reported in as many as 87% of patients who required care by pain management specialists.² Hematoma formation is present at the venipuncture site in 24% of patients with venipuncture-related nerve injuries, suggesting some degree of puncture trauma.¹ The majority of the times, however, hematomas are absent.

Nerves in the antecubital fossa classically lie on a plane just beneath, and in close proximity to, the veins (Fig. 1), making them susceptible to injury during phlebotomy.⁵ Additionally, Horowitz² showed in dissected cadaveric upper extremities that in 6 of 14 specimens, major branches of cutaneous nerves were superficial to or overlaying veins: medial and lateral antebrachial cutaneous nerves in relation to the basilic, median basilic, median cephalic, or cephalic veins in the antecubital fossa. This suggests that even a non-traumatic, satisfactory venipuncture can directly damage these nerves.

Figure 1
Antecubital fossa. Reproduced with permission fromD’Alessandro M. Anatomy Atlases. Curated by Ronald Bergman,Ph.D. http://www.anatomyatlases.com. 1 - median basilicvein, 2 - median cephalic vein, A - lateral antebrachial cuta-neous nerve, B - palmar branch of the medial antebrachialcutaneous nerve, C - ulnar branch of the medial antebrachialcutaneous nerve.

Phlebotomy best practice has suggested that for venipuncture the inserted needle should be placed superficially, and the medial aspect of the antecubital fossa should be avoided.³ Minimizing needle movement while in situ is probably also wise; however, taking the high anatomic variability into account, the risk of inadvertent nerve damage is still a possibility. As anesthesiologists, we need to be aware of these risks in order to avoid this complication, and equally importantly, we should be ready to discuss with the patient the potential options for diagnosis and treatment as well as the prognosis.

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 complication, and advise patients properly during acquisition of inform consent if 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 complication occurs.

Acknowledgments

The author would like to express his gratitude to Dr. Sorin J. Brull for his guidance and intellectual contributions toward the making of this manuscript.

Referências

• ¹
  Newman BH, Waxman DA. Blood donation-related neurologic needle injury: evaluation of 2 years' worth of data from a large blood center. Transfusion (Paris). 1996;36:213-5.
• ²
  Horowitz SH. Venipuncture-induced causalgia: anatomic relations of upper extremity superficial veins and nerves, and clinical considerations. Transfusion (Paris). 2000;40:1036-40.
• ³
  Berry P. Venipuncture nerve injuries. Lancet. 1977;1:1236-7.
• ⁴
  Newman B. Venipuncture nerve injuries after whole-blood donation. Transfusion (Paris). 2001;41:571-2.
• ⁵
  Horowitz SH. Peripheral nerve injury and causalgia secondary to routine venipuncture. Neurology. 1994;44:962-4.

Publication Dates

• Publication in this collection
  Mar-Apr 2014

History

• Received
  23 Jan 2013
• Accepted
  10 June 2013