Dear Sir,
Peripheral venous cannulation (PVC) is a routine procedure in the perioperative setting, intensive care unit, and emergency departments. Large-bore intravenous cannulas (16G, 18G) and peripherally inserted central lines (PICC) are most commonly inserted in the cephalic vein, basilic vein, or the great saphenous vein. However, these veins share intimate anatomical proximity with peripheral nerves and often show anatomical variations.[1] Peripheral nerve injury (PNI) is a reported complication of venous cannulation, frequently at the cubital fossa and other forearm locations, such as anatomical snuff box, wrist, and lower one-third.[12] Surprisingly, PNIs following PVCs are less often reported in the literature than the actual incidences.[2] These injuries amount to considerable morbidity and bring forth long-term impairment.[3] However, to date, no precise preventive strategy for their occurrence has been documented in the literature. The point-of-care ultrasonography (POCUS) has become an endorsed standard for central venous cannulation as it improves the success rate and minimizes the associated complications. POCUS can be a safety tool for preventing PNI during PVC/PICC, at high-risk anatomical locations.
The areas in upper and lower extremity where peripheral nerve is in close proximity to veins with high chances of nerve injury are depicted in sonoanatomy Figure 1b–e. The commonly chosen sites of peripheral veins for cannulation in upper extremity at areas of risk are depicted in Figure 1a.
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Figure 1: (a) High-risk areas for nerve injury during venous cannulation in upper extremity showing corresponding veins (b–e) the sonoanatomy at high-risk areas for peripheral nerve injury in upper and lower extremity
Injuries to the superficial radial nerve, median nerve, and lateral and median cutaneous nerves of the forearm were mostly reported following PVCs.[123] Varying grades of venepuncture–induced PNIs are documented in the literature ranging from mild neurapraxia to even permanent injuries such as neurotmesis.[123] The most distinctive symptoms that are suggestive of PNIs include sharp radiating pain, numbness, tingling, and paraesthesia of the extremity area supplied by those specific peripheral nerves.[24] The nerve conduction studies and electromyography are used to localize and confirm PNIs besides MRI and ultrasonography.
Kim et al.[4] reported iatrogenic lateral cutaneous nerve of forearm injuries following venepuncture in the cubital fossa and demonstrated that ultrasound can detect and confirm such PNIs. Matsuo et al.[5] in their cadaveric study demonstrated that a proximal distance of ≥4.6 cm to be considered from the venous confluence for cannulation of the cephalic vein at the wrist joint to prevent injury to the superficial radial nerve. The PNIs following PVCs may resolve spontaneously, but the recovery is often incomplete, and few patients may develop complete loss of neuronal function resulting in permanent deficits.[2]
The POCUS has been suggested for improving the success rate of PVC, especially for difficult PVC, which reduces need for a central venous line. POCUS can be a dynamic tool to guide PVC in areas close to the peripheral nerve, thereby preventing accidental nerve injuries. Earlier literature documented that precise knowledge of the regional anatomy of cannulation sites is an essential part of the prevention.[1] Some frequent cannulation sites such as the cubital fossa carry a higher risk of PNI because of their variable and often intimate proximity to veins.[12] POCUS can help for proper catheter size selection, insertion angle, cannulation technique, and post procedure evaluation.
The precise knowledge of sonoanatomy and the use of POCUS for large bore PVC at high-risk areas can reduce iatrogenic PNI. The POCUS should be the standard of care for ensuring safety during peripheral intravenous cannulation as it is currently endorsed for central venous cannulation.
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References
1. Horowitz SH. Venipuncture-induced causalgia: Anatomic relations of upper extremity superficial veins and nerves, and clinical considerations Transfusion. 2000;40:1036–40
2. Boeson MB, Hranchook A, Stoller J. Peripheral nerve injury from intravenous cannulation: Acase report AANA J. 2000;68:53–7
3. Stevens RJ, Mahadevan V, Moss AL. Injury to the lateral cutaneous nerve of the forearm after venous cannulation: A case report and literature review Clin Anat. 2012;25:659–62
4. Kim IJ, Cho H, Yi MS, Park YH, Kim S, Kim DK, et al Diagnosis and treatment of nerve injury following venipuncture-A report of two cases Anesth Pain Med (Seoul). 2021;16:299–304
5. Matsuo M, Honma S, Sonomura T, Yamazaki M. Clinical anatomy of the cephalic vein for safe performance of venipuncture JA Clin Rep. 2017;3:50
