Diagnosis and Treatment of Nerve Injury Following Venipuncture

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, 1,2 ]. 4 [ 1,2 Case Report Case Report ]. However, the antecubital fossa fossa the antecubital ]. However, 3 , Yong Hee Park , Yong [ 1 ]. While most of these patients fully re fully of these]. While most patients 6 , 5 , 2 [ , and Hwa-Yong Shin , and Hwa-Yong 4 Department of Anesthesiology and Pain Medicine, Medicine, and Pain Department of Anesthesiology 4 , Myung Sub Yi 1 The incidence of nerveThe varies injury during venipuncture

in different reports, ranging from 1/21,000–1/25,000 to as as 1/21,000–1/25,000 to from ranging reports, in different as 1/67,000 low experience se they may exists possibility that a rare cover, criteria met the diagnostic of CRPS. that pain chronic vere, antecubital fossa include the cephalic vein, basilic vein, and vein, basilic vein, the cephalic include fossa antecubital vein median antebrachial the neurovascular in which area, complex is an anatomically the making lie very other, may close each to structures Moreover, nerves injury to during vulnerable venipuncture. between fossa in the antecubital variations the anatomical the riskindividuals add to of nerve injury 304

299 - - - - , Hana Cho eISSN 2383-7977 1 • Ultrasonography is important for the early and confirmative diagnosis of a a of diagnosis confirmative and early the is important for Ultrasonography Venipuncture is one of the one of the most commonly performed, minimal performed, commonly most the of one the of is one Venipuncture , Duk Kyung Kim 3 Department of Radiology, Chung-Ang University Hospital, Chung-Ang Chung-Ang Chung-Ang University Hospital, Department of Radiology, 3 Anesthesiologists; Peripheral nerve injuries; Ultrasonography; Venipuncture. Ultrasonography; injuries; nerve Peripheral Anesthesiologists; : Two anesthesiologists in our hospital experienced an injury of the lateral antebrachial antebrachial lateral the of injury an experienced hospital our in anesthesiologists Two : Department of Anesthesiology and Pain Medicine, Chung-Ang University College of of Chung-Ang University College Medicine, and Pain Department of Anesthesiology Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, Hospital, Medicine, Chung-Ang University and Pain Department of Anesthesiology recovery. recovery. Conclusions: Moreover, block. with a nerve treatment immediate for and venipuncture, during injury nerve possible the compli of aware be to patient the and practitioner the both for it is imperative venipuncture. after injury nerve of cation Keywords: University College of Medicine, University College Sungkyunkwan University, Seoul, Korea Samsung Medical Center, School of Medicine, the describe we Here, injury. nerve peripheral to lead may it however, procedures; ly-invasive veni during injury nerve cases of self-reported two of prognosis and treatment, diagnosis, injuries. nerve possible needle-related to attention drawing aim of with the puncture Case they Immediately, venipuncture. during nerve musculocutaneous the of branch cutaneous in full resulting medication, oral with blocks nerve and examinations ultrasound underwent In Jung Kim Sujin Kim 1 2 Medicine, Background: Diagnosis and treatment of nerve injury following nerve injury of and treatment Diagnosis venipuncture two cases - - A report of Anesth Pain Med 2021;16:299- Med Pain Anesth https://doi.org/10.17085/apm.21010 pISSN 1975-5171 ]. 2 , 1

April 12, 2021 12, 2021 April January 18, 2021 2021 18, January April 10, 2021 2021 10, April A vein in the antecubital fossa is one of the first choices for choices is one of the first fossa in the antecubital A vein Venipuncture, or phlebotomy, is one of the most com is one of the most or phlebotomy, Venipuncture, This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits which (http://creativecommons.org/licenses/by-nc/4.0) License Non-Commercial Attribution Commons Creative the of terms the under Access article is an Open This distributed cited. is properly work original the provided in any medium, reproduction and distribution, use, non-commercial unrestricted 2021 Anesthesiologists, Society of Korean © the Copyright cubital vein, located between the cephalic and basilic vein, between vein, and basilic located vein, cubital the cephalic com veins Other for blood sampling. suitable vein is a large in the also located are usedmonly that for blood sampling routine blood sampling in adults. Specifically, the median the median Specifically, in adults. blood sampling routine tively harmless in most cases, it may be associated with a with be associated a it may cases, in most harmless tively nervecritical peripheral injury as complexion regional such (CRPS) [ syndrome pain monly performed minimally-invasive procedures, essential essential procedures, performedmonly minimally-invasive trans fluid therapy, intravenous blood sampling, for routine is rela this procedure Although and bloodfusion, donation. Tel: 82-2-6299-3164 Tel: 82-2-6299-2585 Fax: [email protected] E-mail: Pain Medicine, Chung-Ang University University Chung-Ang Medicine, Pain Heukseok- 102 Medicine, of College Korea 06973, Seoul Dongjak-gu, ro, Corresponding author Corresponding CIPS Shin, FIPP, M.D., Ph.D., Hwa-Yong and Anesthesiology of Department Received Received Revised Accepted Anesth Pain Med Vol. 16 No. 3

Here, we present two self-reported cases of anesthesiologists arm level (Fig. 1A), between the biceps brachii tendon and experiencing nerve injury during blood sampling. Written the punctured cephalic vein at the antecubital level, com- consent for publication was obtained from the patients. We pared with contralateral side, suggestive of neuritis with also discuss the importance of ultrasonography for the early perineural hemorrhage (Fig. 1B). diagnosis and prompt treatment of nerve injury following Low amplitudes in the left lateral and medial antebrachial venipuncture. cutaneous nerves were observed on a sensory nerve conduction study (NCS) performed on the same day, suggesting CASE REPORTS left lateral and medial antebrachial cutaneous neuropathy. Consequently, a nerve block of the injured nerve was Case 1 promptly performed on the same day. After local infiltration with 2% mepivacaine, a mixture of 0.75% ropivacaine (1 ml) A 28-year-old male patient undergoing venous blood sam- , triamcinolone (20 mg) , and normal saline (2.5 ml) was in- pling was punctured in the middle of the antecubital fossa of jected around the nerve (Fig. 2). The patient experienced the left arm with a 21-gauge needle. During the procedure, he felt a sharp, electrical pain throughout his arm, extending from the venipuncture site to the tip of the fingers. The intensity of the pain was rated as 8/10 in the visual analog scale (VAS). After the needle was withdrawn, he experienced dysesthesia and burning pain in the anterior wrist and the anterior, lower half of his forearm, which was rated as 7–8/10 on the VAS and lasted for more than 24 h. Since the pain and discomfort did not subside even after 24 h, he visited the pain clinic for evaluation and management. After a brief medical interview and physical examination to rule out peripheral neuropathy, ultrasonographic examination of the venipuncture site was performed to accu- rately assess the nerve. It revealed segmental swelling and Fig. 2. Ultrasound guided peripheral nerve block for the lateral perineural echogenic changes in the lateral antebrachial cu- antebrachial cutaneous nerve at the elbow. BrM: brachialis muscle, BT: biceps tendon, CV: cephalic vein, ECRL: extensor carpi taneous branch of the musculocutaneous nerve at the fore- radialis longus muscle, H: humerus, RN: radial nerve.

Fig. 1. Ultrasonography at the antecubital level. (A) Left, injured arm; it shows the soft tissue swelling and prominent echogenicity around the lateral antebrachial cutaneous nerve (asterisks), adjacent to the cephalic vein (V), implying either direct nerve injury or compressive neuritis due to the surrounding hematoma. A hyoechoic linear line indicated with ‘▲’ symbol shows the trajectory of the needle coming out. (B) A contralateral, right, uninjured arm; it shows the lateral antebrachial cutaneous nerve (asterisk) with normal sono-archtitecture. (C) Follow-up ultrasonographic image of the first case done at three weeks after the injury, showing improvement in the segmental swelling and perineural echogenic changes around the affected nerve (asterisks).

300 www.anesth-pain-med.org KSRA ------301 ]. Even ]. Even 8 , 7 [ ). She was pain free, both at rest rest both at free, pain was ). She Fig. 1C Fig.

DISCUSSION This study is a report of two anesthesiologists’ self-report of two anesthesiologists’ is a report study This nerve injury prevent to it is important and foremost, First The pain around the puncture site worsened (6–7/10 in worsened site in (6–7/10 the puncture around pain The shooting experience to intermittent continued patient The ultrasonographic a follow-up weeks later, and a half Three relationships between nerves and cutaneous veins relationships in the of median side cu the radial that suggest fossa antebrachial for venipuncture site safe is a relatively bital vein and maneuvering delicate site, puncture withsafest the to is essential of the needle or catheter handling careful risking injuries of the nerve deep penetration, lying avoid in the attempts multiple deep Additionally, behind the vein. left arm, which had been noted in the previous examination examination been noted in the previous had which left arm, with findings (similar and with movement. arm and hand nerve injury. They were ed of venipuncture-related cases of the condi describe to able features the detailed clinical perspective through and the patient’s the doctor’s tion from of the injury. the course out site selecting puncture the carefully by during venipuncture withrisk least the nerveof site injury. venipuncture typical A of fossa superficialis chosen in the antecubital among veins nerve cutaneous is seen lateral deep The along the forearm. Risk of nerve is cases. in most damage vein the cephalic in the is punctured vein especially when the cephalic higher area it a dangerous making partlower fossa, of the cubital nerve medial cutaneous The descends for venipuncture. the or under over either passing medial vein, the basilic to portion anatomical These ulnar of the median vein. cubital She was prescribed prednisolone (5 mg), pregabalin (75 (75 pregabalin (5 mg), prednisolone prescribed was She es and (325 mg), acetaminophen (37.5 mg), tramadol mg), per a week. os bis in die for (20 mg) omeprazole nerve the after h 24 with further worsening block, VAS) the the Following (8/10 in the VAS). day the following through sub gradually the pain medication, of oral administration of a week. course the over sided the VAS 1–2/10 on to without but during site arm movement, puncture the at pain pregab including sensoryany medications, oral The deficit. (20 mg) and esomeprazole (500 mg), naproxen alin (75 mg), had prescribed for another week. She per die were os bis in 2 weeks the injury after at without any relief pain complete and numbness. sensation tingling a decreased revealed performed. results was examination Its the nerve to in the of the echogenic adjacent lesion extent ------Nerve injury during venipuncture during injury Nerve ). The patient no longer ex no longer patient ). The Fig. 1C Fig. in Case 1. in Case B , Fig. 1A Fig.

After the ultrasonographic examination of the nerve examination inju the ultrasonographic After Ultrasonographic examination of the antecubital area was was area of the antecubital examination Ultrasonographic A 32-year-old female patient was punctured with a with a punctured was patient female A 32-year-old A follow-up ultrasonographic examination at three weeks three at examination ultrasonographic A follow-up The patient experienced an intermittent shooting, electri shooting, experienced an intermittent patient The www.anesth-pain-med.org and normal saline (2.5 ml) was injected around the nerve. the nerve. injected ml) was (2.5 and normal saline around the nerve after to Immediately reduced her pain block, in the affected forearm. with hypesthesia 1–2/10 on the VAS, ry, skin infiltration with 2% mepivacaine was performed was ry, with 2% mepivacaine and infiltration skin nervea nerve performed was of the injured block with a (1 ml), triamcinolone (20 mg), of 0.75% ropivacaine mixture with ous nerve, which lies adjacent to the median cubital vein, the median vein, to cubital nerve, lies adjacent which ous with the con as compared infiltrates, with mild surrounding findings ultrasonographic showed similar It side. tralateral performed to further evaluate the puncture site. Its results results Its site. performed the puncture further to evaluate cutane antebrachial injury of the lateral probable suggested of her first four fingers, and dull pain rated 7–8/10 on the the 7–8/10 on rated and dull pain fingers, four of her first clinic visited the pain She area. the punctured around VAS afternoon. that ness after the needle was removed. Subsequently, she com she Subsequently, the needle removed. after ness was the tips to elbow her from extending plaineddysesthesia of a left arm for venous blood sampling. She felt an electrical felt an electrical She left arm blood sampling. for venous for a few the tip of her fingers to her forearm from sensation numb followed by seconds punctured, was when her skin 21-gauge needle in the middle of the antecubital fossa of the fossa needle the antecubital in the middle of 21-gauge Case 2 fected nerve, suggesting an improvement in the neuritis and fectedan improvement nerve, suggesting ( hemorrhage perineural perienced discomfort, pain, or paresthesia. after the injury showed an improvement in the segmental in the segmental the injuryafter an improvement showed the af around echogenic and perineural changes swelling os were prescribed for another week. In the following two two the following week. for another prescribed In os were weeks the injury, after re and discomfort his pain gradually ignorable. was that duced a degree to block. The medications, including pregabalin (75 mg), (75 mg), pregabalin including medications, The block. bis in die per (20 mg) and esomeprazole (500 mg), naproxen cal pain (2–3/10 in the VAS) extending anteriorly from his his from anteriorly extending (2–3/10 in the VAS) pain cal his wrist to for a weekforearm the nerve administering after mg), pregabalin (75 mg), tramadol (75 mg), acetaminophen acetaminophen mg), (75 tramadol (75 mg), pregabalin mg), a for die in bis peros mg) (20 esomeprazole and mg), (650 week. immediate pain relief, with no adverse effect. After the pro the with After effect. no adverse relief, pain immediate of 1/10 on the intensity a pain reported the patient cedure, prescribed with (5 he was prednisolone Additionally, VAS. Anesth Pain Med Vol. 16 No. 3 same site should be avoided. ripheral nerve is further differentiated from the surrounding Despite an appropriate and satisfactory venipuncture, a muscles and tendons, which are relatively more hypoechoic. possibility of a nerve injury still exists. When venipunc- Once the nerve of interest is identified in a cross-sectional ture-related nerve injury is suspected, one should first elicit view, the probe should be moved along the nerve to scan the a history of recent venipuncture through history taking and nerve throughout its course. Ttracing the nerve of interest physical examination, and rule out any underlying diseases enables identifying any abnormalities in size and appear- that might cause peripheral neuropathy, such as diabetes. ance, or discontinuation of the nerve. Turning the probe For a more accurate and objective diagnosis, other tools can 90-degrees around can show a longitudinal image of the le- be used, including electromyography (EMG), NCS, magnetic sion. Longitudinal images can show changes in the nerve di- resonance imaging (MRI) and ultrasonography. ameters or discontinuation of the nerves. EMG and NCS are useful to localize and confirm periph- Ultrasonographic findings of a nerve injury include en- eral nerve injuries [9]. Decreased conduction velocity or largement of nerve diameter indicating nerve swelling or conduction block in the affected nerve on NCS is also indic- neuroma, focal disorganization of its fascicular structure, or ative of nerve injury. However, electrodiagnostic studies transection of the nerve. In a first-degree Sunderland nerve cannot provide detailed information regarding the anatomy injury, or neurapraxia, the nerve retains its normal appear- of the injured area or determine the severity of the injury, ance with or without minor swelling of the nerve. A sec- and the patients experience major discomfort during these ond-degree Sunderland nerve injury, or axonotmesis, shows studies. a clearly enlarged diameter of the nerve due to axonal swell- MRI can also aid in assessing nerve injuries. It is helpful in ing and edema. Focal swelling and the surrounding edema directly evaluating the changes in the nerve signals and peri- can be shown with hyper-echogenicity. A third-degree or neural tissues, especially in the deeper structures that are fourth-degree Sunderland nerve injury, or neurotmesis, hard to evaluate through ultrasound [9]. However, its expen- shows loss of normal fascicular pattern due to involvement sive and time-consuming nature make MRI a less attractive of the endoneurium. Hypo-echogenicity and marked en- diagnostic tool. In addition, MRI is contraindicated for some largement of the nerve can also be noted. A fifth-degree patients, including uncooperative children, patients with Sunderland nerve injury is a complete transection of the mechanical devices such as a pacemaker, or patients admit- nerve. In this kind of transection injury, ultrasound can de- ted to the intensive care unit. tect discontinuation of the nerve, showing interruption of Ultrasonography can be useful for localizing and diagnos- the epineurium and enlarged, hypo-echoic nerve stump. ing iatrogenic peripheral nerve injuries. Additionally, it can Distance between the lesion site, the affected muscles, and be used to assess the surrounding structures and detect ab- the skin can be measured and can help guide decision-mak- normalities, such as hematoma. Doppler imaging can be ing in treatment course. used to assess the blood vessels and vascular changes in the Ultrasound scanning of the lesion site can not only detect area surrounding the injured nerve. Bedside ultrasonogra- abnormalities of the nerve itself, but also reveal abnormali- phy is useful in the real-time assessment of nerve injuries, ties in the surrounding areas. Such findings include scars, and can be performed in an acute phase of the injury with- foreign bodies, or hematoma. Sharp scars associated with out causing any pain to the patient, making it one of the laceration with a knife or glass, needle or catheter related in- most preferred tools for diagnosing peripheral nerve injury. jury can be seen as hypoechoic, linear lines penetrating the Injection treatment can also be performed simultaneously skin, subcutaneous tissues, or interrupting nerve sheaths. with the diagnosis [10]. Foreign bodies can be usually found as scattering sound- The first step in diagnosing an iatrogenic peripheral nerve waves from their surfaces. A hematoma can be seen as a dif- injury through ultrasonography is identifying the lesion. A fuse, hypo-echoic area on the image. normal peripheral nerve is sheathed with an outer epineuri- Diagnosis of iatrogenic nerve injury and identification of um, which contains several fascicles composed of axons. A the lesion site should lead to prompt treatment. The initial transducer should be placed at the nerve of interest at a general management of nerve injury is similar to that of oth- 90-degree angle, and a cross sectional view of a normal pe- er nerve lesions. Conservative management includes the ad- ripheral nerve will show hyper-echoic epineurium with a ministration of oral medications, including opioids, NSAIDs, few hypo-echoic fascicles within the epineurium. The pe- adjuvant analgesics, such as gabapentin or pregabalin [11],

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Kyung Duk Shin, Hwa-Yong sion: Kim, Jung In Cho, Hana Yi, Sub Myung Park, Hee Yong Kim, Sujin Kim, Kyung Duk Shin, Hwa-Yong sonography for the early detection and prompt diagnosis of diagnosis detection and prompt for the early sonography as nerve procedures injury related during needle or catheter nervewell as immediate of the affected block nerve of are and shortening pain the importanceutmost in alleviating of the injury.course reported. report. a case is This cluded article. in this published ------Nerve injury during venipuncture during injury Nerve ], or under general anesthesia. Cen anesthesia. ], or under general 14 ], aiding in a quicker recovery time. time. recovery in a quicker ], aiding ]. 13 12 [ ]. Such catheter related nerve injuries during procedures nerve injuries during related procedures catheter ]. Such In conclusion, it is crucial to avoid nerve it is crucial conclusion, injury avoid to In during ve Needle or catheter related nerve injury may also occur nerve also occur injury related may or catheter Needle With the probe in the exact lesion site, the practitioner practitioner the site, lesion exact the in probe the With Additionally, immediate nerve blockade upon diagnosis nerve immediate upon diagnosis blockade Additionally, 15 www.anesth-pain-med.org during seemingly harmless procedures, such as venipunc as such procedures, harmless seemingly during nerve When a peripheral blood sampling. routine for ture of ultra application injury efforts, many is suspected despite ultrasonography for procedures with a risk of nerve for procedures injury. ultrasonography and for both it is important the practitioner Furthermore, of the possibility of nerve injury be to aware the patient nipuncture or catheter related procedures in the first place place in the first procedures related or catheter nipuncture as well site as the using selecting the puncture carefully by inspecting the vein that is to be cannulated and its surround be is to cannulated that the vein inspecting structures. ing under regional or general anesthesia can be prevented by by be prevented can anesthesia or general under regional during these proce of ultrasound application the routine nerve carefully by injuries avoid can practitioner The dures. anesthesia. The incidence of nerve The anesthesia. injury during subclavian been as 0.6% reported has catheterization venous central [ tral venous catheterization is among one of the most com one of the most is among catheterization venous tral under general performedmonly procedures catheterization during the administration of regional anesthesia, such as as such anesthesia, of regional during the administration [ block plexus brachial ticoid injection is also used to inhibit the release of local in ticoid injection of local is also used inhibit the release to dis ectopic neuronal and decrease flammatory mediators [ charges tures. Thus, the use of ultrasonography results in fewer com results the use of ultrasonography Thus, tures. with Local a shorterplications performance glucocor time. can be observedcan with the help of ultrasonogra in real-time it all times, needlethe of the course at Because visible is phy. struc other nearby avoid to is possible for the practitioner vanced, until the tip is placed desirably around the injured the injured around the tip is placed desirably until vanced, injected through are anesthetics local nerve. Pre-measured nerve, which the injured around the needle and infiltrate should carefully puncture the skin near the affected area. the affected near the skin area. puncture carefully should needle be while the needle visible The should tip is ad raphy also servesraphy superior as a nerve peripheral toolthe for block eral nerve pain eral in immediate injury. result Nerve can block confirm of can which the diagnosis of the affected area, relief a nerve Ultrasonog injury site. of the lesion and the location of a nerve injury is crucial. A nerve anes local using block tool for periph and therapeutic thetics is both a diagnostic and systemic glucocorticoids, along with physiotherapy to to with along physiotherapy glucocorticoids, and systemic the affected supplied by muscles of the atrophy prevent nerve. Anesth Pain Med Vol. 16 No. 3

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