Unintentional arterial puncture during cephalic vein cannulation: case report and anatomical study †

Characterization of the Difficult Peripheral IV in the Perioperative Setting: A Prospective, Observational Study of Intravenous Access for Pediatric Patients Undergoing Anesthesia

Background

Various criteria exist for defining difficult intravenous access (DIVA) in infants and children. The current study evaluated the factors associated with DIVA in a prospective cohort of over 1000 infants and children presenting for anesthetic care.

Methods

This was a prospective, observational study of patients aged 0 to 18 years undergoing elective surgical or radiologic procedures under general anesthesia. Prior to the initial attempt at peripheral intravenous (PIV) cannulation, the anticipated difficulty of PIV catheter placement was determined by the provider using a visual analogue scale (VAS) from 1 to 10. The number of attempts was recorded as well as the time required to achieve PIV access. DIVA was defined as requiring three or more attempts. After successful cannulation, the actual difficulty of the PIV placement was assessed by the provider and recorded using the same VAS. Patient characteristics, including age, race, body mass index (BMI), American Society of Anesthesiologists (ASA) physical classification, and history of difficult PIV placement, were evaluated as covariates.

Results

In our cohort of 1002 pediatric patients, 78% of patients were successfully cannulated in a single attempt and 91% of patients were successfully cannulated in two or fewer attempts. Factors associated with requiring three or more PIV attempts included younger age (OR 8.73; 95% CI: 3.38, 22.6 for age <1 year and OR 4.93; 95% CI: 2.05, 11.8 for age 1-3 years), higher ASA physical classification (OR 1.95; 95% CI: 1.10, 3.46 for ASA II), and prior history of difficult PIV placement (OR 3.46; 95% CI: 1.70, 7.08). BMI, racial category or gender were not independent predictors of DIVA.

Conclusion

We found that approximately 9% of patients required three or more attempts at IV placement in the operating room. Patients that required multiple PIV attempts were more likely to be younger, have a higher ASA classification or a history of difficult PIV placement.

Four patients with a clinically significant radial artery anomaly

The superficial radial artery is an anatomic variant in which the radial artery passes superficial to the tendons of the anatomic snuffbox. Cadaver studies have shown its incidence to be 0.5% to 1%. Four patients with this anatomic variation were encountered in our practice, and their clinical courses and anatomy are described. One patient presented with digital ischemia after catheter placement in the anomalous radial artery. Three patients with end-stage renal disease were found to have a superficial radial artery incidentally, and this was used for inflow in the creation of hemodialysis fistulas.

Unintended intra-arterial injection of contrast of an intracranial CT angiography

Computed tomography angiography (CTA) is widely used to evaluate intracranial vascular disease. We report a case of intracranial CTA with unintended intra-arterial (IA) injection of contrast due to IA placement of an intravenous cannula, which results in a selective left vertebral artery IA CTA. Knowledge of anatomy is essential in analyzing the whole study and identifying the error. In clinical practice, it is important to avoid and recognize a wrongly placed intravenous cannula. And bolus tracking protocol might play a role as a gatekeeper.

The venous patterns of the cubital fossa in subjects from Brazil

Venous punctures are among the most common procedures performed by healthcare professionals. In particular, the cubital fossa is the site where the venous accesses are frequently made due to the number of superficial veins and the numerous anastomoses in this region. The arrangement of these venous connections is of particular interest for clinical application in several areas, thus, the healthcare professional must possess knowledge about these vessels and their anatomical relationships. The present study aims to analyze the venous pattern of the cubital fossa among individuals from Brazil. This study was approved by a Research Ethics Committee. The sample had 100 healthy individuals (50 men and 50 women). The superficial veins of the cubital fossa were analyzed with the aid of a sphygmomanometer. When inflated, the pressure in the forearm increased and the veins became prominent. It was observed that in the selected sample the types with the highest prevalence were the Type I and Type VII, both with 22% in 200 limbs studied. The chi² test showed a significant statistical difference between the anastomosis pattern and the sex of the studied sample. The anastomotic pattern of the superficial veins of the studies sample is similar to African, European and Asian populations. The study of these variations is necessary to provide scientific basis for the healthcare professional during a venipuncture in order to avoid iatrogenic errors and damages in cutaneous nerves or neighboring arteries.

Clinical anatomy of the cephalic vein for safe performance of venipuncture

Background

The aims of this study were to elucidate why the cephalic vein provides a reliable cannulation site from a morphological viewpoint and identify an effective landmark for avoiding injury to the superficial branch of the radial nerve (SBRN), allowing for safe venipuncture of the cephalic vein.

Findings

We examined 32 forearms and wrists from 18 cadavers. The cephalic vein was a constant structure containing a branch communicating with a collateral vein of the deep palmar arch via the first dorsal interossei muscle. The metacarpal vein from the medial two digits flowed into the cephalic vein. The venous confluence formed 5.8 ± 1.2 cm proximal to the radial styloid process. The SBRN passed 0.4 ± 0.3 cm volar to the venous confluence. The distance between the venous confluence and subcutaneous emergence of the SBRN was 2.6 ± 1.0 cm.

Conclusions

These observations suggest that the cephalic vein is a constant structure that serves as a drainage vein of the hand and provides a reliable cannulation site in the forearm. The venous confluence may serve as a novel landmark to predict the running course of the SBRN.

Mapping of the snuffbox and cubital vessels for percutaneous arterial venous fistula (pAVF) in dialysis patients

PURPOSE

Report on the anatomic qualification of the snuffbox radial artery (SBRA) and proximal radial artery (PRA) for pAVF.


METHODS

Retrospective analysis of upper extremity mapping in 64 limbs in 55 dialysis patients was performed. The radial artery was assessed for diameter, patency, flow and proximity to the adjacent vein to SBRA and PRA. Sites qualified for pAVF on a binary basis when the in situ radial artery and adjacent vein were straight, parallel, greater than 2 mm in diameter and within 1.5 mm of each other. Effect of age, sex, diabetes, systolic blood pressure and obesity were assessed with logistic regression. Mean, median and frequency distribution of vessel diameter and distance were analyzed.


RESULTS

Radial artery sites were qualified for pAVF in 47.6% (30/63) at the SBRA and 87.9% (29/33) at the PRA. SBRA sites were disqualified for vessel size in 36.4% (12/33 overall, usually vein 11/12), distance in 24% (8/33) and both 36.4% (12/33). All (4/4) PRA sites were disqualified for vessel size alone. The adjacent vein was the median vein or cephalic vein for the SBRA, and the perforating vein or vena comitans for the PRA. Effects of age, sex, diabetes, systolic blood pressure, obesity and prior fistula did not attain statistical significance.


CONCLUSIONS

Most dialysis patients meet the anatomic requirements for pAVF in the SBRA or PRA. Vessel size is the most common limiting variable followed by distance between vessels.

Necrosis caused by intra-arterial injection of promethazine: case report

Promethazine injections have led to necrosis and gangrene of the distal upper extremity when inadvertently injected into an artery. There have been few case reports of this alarming complication in the literature. We report on 2 cases of intra-arterial promethazine injection that led to amputation.