Prevention and Management of Nerve Injury in Vascular Access

Understanding Nerve Injury Risk

Nerve injury during vascular access procedures, while relatively uncommon, represents a significant clinical concern with potentially lasting consequences for patients. Anatomical variations in veins, arteries, and nerves occur frequently across the population, meaning that even experienced clinicians cannot rely solely on expected anatomy when performing these procedures (Pires et al., 2018; Yammine, 2021; Mikuni et al., 2013).

Peripheral Venous Access Sites

Certain anatomical locations carry elevated risk for nerve damage during peripheral venous access. The cephalic vein at the radial wrist poses a particular hazard due to its proximity to the superficial radial nerve. Similarly, the volar (inner) aspect of the wrist places the median nerve at risk of injury. At and above the antecubital fossa, multiple neural structures may be affected, including the median nerve, anterior interosseous nerve, and both the lateral and medial antebrachial nerves (Kim et al., 2014; Ramos, 2014; Voin et al., 2017; Wu & Liu, 2018; Mikuni et al., 2013; Rayegani & Azadi, 2014; Samarakoon et al., 2011; Mukai et al., 2020; Matsuo et al., 2017; Serra et al., 2018; Ohnishi, 2009; Moore et al., 2012; Oven & Johnson, 2017; Shields et al., 2021; Yeak et al., 2021; Wallis et al., 2020; Tsukuda et al., 2019; McCall, 2021; Desai et al., 2019; Becciolini et al., 2021).

Peripheral Arterial Access Sites

Arterial catheterization carries its own set of neurological risks. The brachial artery lies in close anatomical relationship with the median nerve, making this site particularly hazardous. Radial artery access may result in injury to either the median nerve or the radial nerve (Imbrìaco, 2022; Wang, 2020).

Central Vascular Access Devices

Although nerve injuries associated with CVADs occur rarely, documented cases involving axillary, subclavian, and internal jugular insertion sites have resulted in phrenic nerve injury, brachial plexus damage, and Horner’s syndrome. These complications, while infrequent, demand vigilant clinical awareness (Moore et al., 2012; Desai et al., 2019; Björkander et al., 2019; Lenz et al., 2019; Butty et al., 2016; Zou, 2020; Lindgren et al., 2019; Yang et al., 2014; Paraskevas, 2011; Gozubuyuk et al., 2017).

Strategies for Risk Reduction

Minimizing Venipuncture Attempts

Multiple venipuncture attempts significantly increase the probability of nerve injury. Repeated peripheral and central venous access attempts, subcutaneous probing techniques, and multiple needle passes have all been associated with heightened risk (Rayegani & Azadi, 2014; Serra et al., 2018; Oven & Johnson, 2017; Desai et al., 2019; Zou, 2020; Gozubuyuk et al., 2017). Clinicians should therefore approach each access attempt with careful planning and appropriate resources to maximize first-attempt success.

Ultrasound Guidance

Ultrasound-guided insertion represents a primary strategy for improving first-time insertion success while simultaneously allowing visualization of veins, arteries, and associated structures including nerves. This technology is particularly valuable when placing short or long peripheral catheters in patients with difficult intravenous access, when inserting peripheral arterial catheters, CVADs, and midline catheters (Ohnishi, 2009; Shields et al., 2021; Yeak et al., 2021; Imbrìaco, 2022; Wang, 2020; Zou, 2020; Paraskevas, 2011; Millington et al., 2019; Wang et al., 2018; Bardin-Spencer, 2020; Braverman, 2021; Flumignan et al., 2021; Raphael et al., 2023).

Insertion Angle Considerations

When inserting a phlebotomy needle or peripheral intravenous catheter without ultrasound guidance, clinicians must assess vein depth and select an appropriate insertion angle. Steep angles increase the risk of penetrating the posterior vein wall and damaging underlying structures. For shallow veins and the veins of older adults, an angle of 5° to 15° is generally appropriate. Deeper veins may require steeper angles, but this should be approached cautiously (Ramos, 2014; McCall, 2021; Coulter, 2016).

Preferred Phlebotomy Sites

For routine phlebotomy, the median cubital vein and the cephalic vein (excluding the first quarter of the forearm above the wrist) represent preferred sites. These veins are positioned closer to the skin surface and in anatomical locations where nerve damage and brachial artery puncture are less likely to occur (Ramos, 2014; Voin et al., 2017; Mikuni et al., 2013; Ohnishi, 2009; McCall, 2021).

Conversely, the medial and lateral portions of the antecubital fossa—specifically the basilic and median basilic veins—should be avoided due to their proximity to the median nerve and brachial artery. Injury to the median nerve in this region can result in loss of extension, flexion, and sensation in the hand and forearm.

The cephalic vein in the first quarter of the forearm (the region immediately above the wrist) should also be avoided (Kim et al., 2014; Samarakoon et al., 2011; Matsuo et al., 2017).

Needle Stabilization During Phlebotomy

Needle movement during blood collection procedures increases the risk of neural contact and injury. Clinicians should use appropriate technique to minimize needle movement while attaching and removing blood collection tubes (Ramos, 2014; McCall, 2021; Fujii, 2013).

Recognizing and Responding to Nerve Injury

Immediate Response to Paresthesia

When a patient reports symptoms consistent with direct puncture nerve injury—including paresthesia, radiating electrical pain, tingling, burning, prickly sensations, or numbness—the clinician must immediately stop the insertion procedure and carefully remove the VAD or phlebotomy needle. The procedure should also be discontinued upon patient request or when patient behavior indicates severe pain (Voin et al., 2017; Wu & Liu, 2018; Oven & Johnson, 2017; Desai et al., 2019).

Following such an event, the responsible provider must be promptly informed of the patient’s symptoms. Early recognition and intervention substantially improve prognosis for nerve injury. Consultation with an appropriate specialist, such as a hand specialist or neurologist, may be required. Importantly, the majority of venipuncture-related nerve injuries resolve within six months (Oven & Johnson, 2017; Shields et al., 2021; Tsukuda et al., 2019; Desai et al., 2019).

Nerve Compression and Compartment Syndrome

Nerve compression injuries can develop through several mechanisms, and prevention requires attention to multiple factors. Infiltration and extravasation must be detected early to limit the volume of solution entering surrounding tissue. Bleeding at attempted and successful access sites must be controlled to prevent hematoma formation, which can compress adjacent nerves. Patients receiving anticoagulant therapy face elevated hematoma risk and require additional vigilance (Serra et al., 2018; Zou, 2020; Gozubuyuk et al., 2017; Blake et al., 2013).

Any VAD should be removed immediately when a patient reports pain, neuropathy, or weakness in the affected extremity during dwell time. Nerve injury following peripherally inserted central catheter (PICC) insertion has been documented in the literature. Nerve compression can result from infiltrated intravenous solutions, hematoma, and edema associated with the inflammatory process of phlebitis and thrombophlebitis (Wu & Liu, 2018; Janakos et al., 2017; Seligman & Woodman, 2019; Pare & Moore, 2018).

The classic signs and symptoms of compartment syndrome include pain, pallor, paresthesia, paralysis, and pulselessness, with pain typically progressing from paresthesia to paralysis. Pallor and loss of peripheral pulse indicate advanced compartment syndrome. This condition constitutes a surgical emergency requiring fasciotomy within hours to prevent loss of the affected extremity. Clinicians should be aware that the hand contains numerous anatomical compartments compared to the wrist or forearm (Blake et al., 2013; Kistler et al., 2018; Wilson, 2011).

Risk factors for compartment syndrome from intravenous infiltration, while the condition itself is rare, include contrast media administration, pressurized infusion delivery, and patients with communication barriers such as those younger than three years old, patients with impaired sensation, and those with altered mentation (Pare & Moore, 2018).

Special Clinical Considerations

Phrenic Nerve Injury

Subclavian and jugular insertion sites can produce damage to the phrenic nerve, which manifests on chest radiograph as an elevated right hemidiaphragm. Associated findings may include right shoulder and neck pain, distended neck veins, and hiccups. Phrenic nerve injury can result from direct trauma associated with multiple needle insertions, compression from the catheter itself, intraventricular tip locations, hematoma, and infiltration or extravasation of infusing solutions. When phrenic nerve injury is identified, CVAD removal is indicated (Lindgren et al., 2019; Paraskevas, 2011).

Horner’s Syndrome

PICCs and catheters inserted via the internal jugular vein have been associated with vision-related changes suggestive of cervical sympathetic nerve inflammation, a constellation of findings known as Horner’s syndrome. Clinical indicators include pupil constriction (miosis) and upper eyelid drooping (ptosis) (Butty et al., 2016; Zou, 2020).

Risk reduction strategies for Horner’s syndrome include ultrasound-guided insertion, avoiding excessive head rotation during skin puncture, minimizing repeated insertion attempts, avoiding steep needle-to-skin angles during insertion, and applying appropriate compression to prevent hematoma formation following inadvertent carotid artery injury.

Complex Regional Pain Syndrome

Complex regional pain syndrome (CRPS) represents a chronic, debilitating condition characterized by ongoing neuropathic pain over a regional area. The pain is typically disproportionate to the original injury and progressively incorporates sensory, motor, and autonomic changes. Venipuncture-induced CRPS, while rare, presents diagnostic challenges because this syndrome frequently spreads to extremities that were not directly traumatized. Affected patients may require lifelong management including multiple pain medications, corticosteroids, nerve blocks, physical therapy, and surgical interventions such as sympathectomy (Elahi & Reddy, 2014; Pruthi et al., 2016).

References

Bardin-Spencer, A. (2020). Ultrasound-guided peripheral arterial catheter insertion by qualified vascular access specialists or other applicable health care clinicians. Journal of the Association for Vascular Access, 25(1), 48-50. https://doi.org/10.2309/j.java.2019.003.008

Becciolini, M., Pivec, C., Raspanti, A., & Riegler, G. (2021). Ultrasound of the radial nerve: A pictorial review. Journal of Ultrasound in Medicine, 40(12), 2751-2771. https://doi.org/10.1002/jum.15664

Björkander, M., Bentzer, P., Schött, U., Broman, M. E., & Kander, T. (2019). Mechanical complications of central venous catheter insertions: A retrospective multicenter study of incidence and risks. Acta Anaesthesiologica Scandinavica, 63(1), 61-68. https://doi.org/10.1111/aas.13214

Blake, S., Dean, D., & Chance, E. A. (2013). Antecubital venipuncture resulting in compartment syndrome of the anterior brachium: A case report. JBJS Case Connector, 3(1), e12. https://doi.org/10.2106/JBJS.CC.K.00165

Braverman, J. (2021). Bedside ultrasound for procedural assistance in pediatrics. Pediatric Annals, 50(10), e404-e410. https://doi.org/10.3928/19382359-20210914-01

Butty, Z., Gopwani, J., Mehta, S., & Margolin, E. (2016). Horner’s syndrome in patients admitted to the intensive care unit that have undergone central venous catheterization: A prospective study. Eye, 30(1), 31-33. https://doi.org/10.1038/eye.2015.181

Coulter, K. (2016). Successful infusion therapy in older adults. Journal of Infusion Nursing, 39(6), 352-358. https://doi.org/10.1097/NAN.0000000000000196

Desai, K., Warade, A. C., Jha, A. K., & Pattankar, S. (2019). Injection-related iatrogenic peripheral nerves injuries: Surgical experience of 354 operated cases. Neurology India, 67(7), S82-S91. https://doi.org/10.4103/0028-3886.250703

Elahi, F., & Reddy, C. G. (2014). Venipuncture-induced complex regional pain syndrome: A case report and review of the literature. Case Reports in Medicine, 2014, 613921. https://doi.org/10.1155/2014/613921

Flumignan, R. L., Trevisani, V. F., Lopes, R. D., Baptista-Silva, J. C., Flumignan, C. D., & Nakano, L. C. (2021). Ultrasound guidance for arterial (other than femoral) catheterisation in adults. Cochrane Database of Systematic Reviews, 10(10), CD013585. https://doi.org/10.1002/14651858.CD013585.pub2

Fujii, C. (2013). Clarification of the characteristics of needle-tip movement during vacuum venipuncture to improve safety. Vascular Health and Risk Management, 9(1), 381-390. https://doi.org/10.2147/VHRM.S47490

Gozubuyuk, E., Buget, M. I., Akgul, T., Altun, D., & Kuçukay, S. (2017). Brachial plexus injury associated with subclavian vein cannulation: A case report. A&A Case Reports, 9(7), 207-211. https://doi.org/10.1213/XAA.0000000000000566

Imbrìaco, G. G. (2022). Preventing radial arterial catheter failure in critical care—Factoring updated clinical strategies and techniques. Anaesthesia Critical Care & Pain Medicine, 41(4), 101096. https://doi.org/10.1016/j.accpm.2022.101096

Janakos, M., Haustein, D., & Panchang, P. (2017). Musculocutaneous neuropathy due to PICC line insertion: A case report. PM&R, 9(9), S202. https://doi.org/10.1016/j.pmrj.2017.08.159

Kim, K. H., Byun, E. J., & Oh, E. H. (2014). Ultrasonographic findings of superficial radial nerve and cephalic vein. Annals of Rehabilitation Medicine, 38(1), 52-56. https://doi.org/10.5535/arm.2014.38.1.52

Kistler, J. M., Ilyas, A. M., & Thoder, J. J. (2018). Forearm compartment syndrome: Evaluation and management. Hand Clinics, 34(1), 53-60. https://doi.org/10.1016/j.hcl.2017.09.006

Lenz, H., Myre, K., Draegni, T., & Dorph, E. (2019). A five-year data report of long-term central venous catheters focusing on early complications. Anesthesiology Research and Practice, 2019, 6769506. https://doi.org/10.1155/2019/6769506

Lindgren, S., Gustafson, P., & Hammarskjöld, F. (2019). Analysis of central venous access injuries from claims to the Swedish Patient Insurance Company 2009-2017. Acta Anaesthesiologica Scandinavica, 63(10), 1378-1383. https://doi.org/10.1111/aas.13430

Matsuo, M., Honma, S., Sonomura, T., & Yamazaki, M. (2017). Clinical anatomy of the cephalic vein for safe performance of venipuncture. JA Clinical Reports, 3(1), 50. https://doi.org/10.1186/s40981-017-0121-6

McCall, R. E. (2021). Phlebotomy Essentials (7th ed.). Jones & Bartlett Learning.

Mikuni, Y., Chiba, S., & Tonosaki, Y. (2013). Topographical anatomy of superficial veins, cutaneous nerves, and arteries at venipuncture sites in the cubital fossa. Anatomical Science International, 88(1), 46-57. https://doi.org/10.1007/s12565-012-0160-z

Millington, S. J., Lalu, M. M., Boivin, M., & Koenig, S. (2019). Better with ultrasound: Subclavian central venous catheter insertion. Chest, 155(5), 1041-1048. https://doi.org/10.1016/j.chest.2018.12.007

Moore, A. E., Zhang, J., & Stringer, M. D. (2012). Iatrogenic nerve injury in a national no-fault compensation scheme: An observational cohort study. International Journal of Clinical Practice, 66(4), 409-416. https://doi.org/10.1111/j.1742-1241.2011.02869.x

Mukai, K., Nakajima, Y., Nakano, T., et al. (2020). Safety of venipuncture sites at the cubital fossa as assessed by ultrasonography. Journal of Patient Safety, 16(1), 98-105. https://doi.org/10.1097/PTS.0000000000000441

Ohnishi, H. (2009). A novel maneuver to prevent median nerve injury in phlebotomy. Annals of Internal Medicine, 151(4), 290-291. https://doi.org/10.7326/0003-4819-151-4-200908180-00023

Oven, S. D., & Johnson, J. D. (2017). Radial nerve injury after venipuncture. Journal of Hand and Microsurgery, 9(1), 43-44. https://doi.org/10.1055/s-0037-1599220

Paraskevas, G. (2011). Variable anatomical relationship of phrenic nerve and subclavian vein: Clinical implication for subclavian vein catheterization. British Journal of Anaesthesia, 106(3), 348-351.

Pare, J. R., & Moore, C. L. (2018). Intravenous infiltration resulting in compartment syndrome: A systematic review. Journal of Patient Safety, 14(2), e6-e8. https://doi.org/10.1097/PTS.0000000000000233

Pires, L., Ráfare, A. L., Peixoto, B. U., et al. (2018). The venous patterns of the cubital fossa in subjects from Brazil. Morphologie, 102(337), 78-82. https://doi.org/10.1016/j.morpho.2018.02.001

Pruthi, P., Arora, P., Mittal, M., Nair, A., & Sultana, W. (2016). Venipuncture induced complex regional pain syndrome presenting as inflammatory arthritis. Case Reports in Medicine, 2016, 8081401. https://doi.org/10.1155/2016/8081401

Ramos, J. A. (2014). Venipuncture-related lateral antebrachial cutaneous nerve injury: What to know? Brazilian Journal of Anesthesiology, 64(2), 131-133. https://doi.org/10.1016/j.bjan.2013.06.004

Raphael, C. K., El Hage Chehade, N. A., Khabsa, J., Akl, E. A., Aouad-Maroun, M., & Kaddoum, R. (2023). Ultrasound-guided arterial cannulation in the paediatric population. Cochrane Database of Systematic Reviews, 3(3), CD011364. https://doi.org/10.1002/14651858.CD011364.pub3

Rayegani, S., & Azadi, A. (2014). Lateral antebrachial cutaneous nerve injury induced by phlebotomy. Journal of Brachial Plexus and Peripheral Nerve Injury, 2(1), e43-e45. https://doi.org/10.1186/1749-7221-2-6

Samarakoon, L. B., Lakmal, K. C., Thillainathan, S., Bataduwaarachchi, V. R., Anthony, D. J., & Jayasekara, R. W. (2011). Anatomical relations of the superficial sensory branches of the radial nerve: A cadaveric study with clinical implications. Patient Safety in Surgery, 5(1), 28. https://doi.org/10.1186/1754-9493-5-28

Seligman, C., & Woodman, K. (2019). Proximal median neuropathy with brachial plexitis after PICC placement; a case study and review of neurologic complications associated with central venous catheter placement. Neurology, 92(15 Supplement), P2.4-013.

Serra, R., Ielapi, N., Barbetta, A., et al. (2018). Adverse complications of venipuncture: A systematic review. Acta Phlebologica, 19(1), 11-15. https://doi.org/10.23736/S1593-232X.18.00408-3

Shields, L. B. E., Sutton, B., Iyer, V. G., Shields, C. B., & Rao, A. J. (2021). Venipuncture-related median nerve palsy disguised as intraoperative brachial plexus injury. Case Reports in Neurology, 13(2), 361-368. https://doi.org/10.1159/000515474

Tsukuda, Y., Funakoshi, T., Nasuhara, Y., Nagano, Y., Shimizu, C., & Iwasaki, N. (2019). Venipuncture nerve injuries in the upper extremity from more than 1 million procedures. Journal of Patient Safety, 15(4), 299-301. https://doi.org/10.1097/PTS.0000000000000264

Voin, V., Iwanaga, J., Sardi, J. P., et al. (2017). Relationship of the median and radial nerves at the elbow: Application to avoiding injury during venipuncture or other invasive procedures of the cubital fossa. Cureus, 9(3), e1094. https://doi.org/10.7759/cureus.1094

Wallis, K. A., Hills, T., Barfoot, S., & Mirjalili, S. A. (2020). Nerve injuries in primary care: Clarifying the anatomical course and surface anatomy of at-risk nerves to improve future clinical outcomes. Clinical Anatomy, 33(2), E22. https://doi.org/10.1002/ca.23370

Wang, A. (2020). Better with ultrasound: Arterial line placement. Chest, 157(3), 574-579. https://doi.org/10.1016/j.chest.2019.08.2209

Wang, J., Liu, F., Liu, S., & Wang, N. (2018). An uncommon cause of contralateral brachial plexus injury following jugular venous cannulation. American Journal of Case Reports, 19, 289-291. https://doi.org/10.12659/AJCR.908125

Wilson, B. G. (2011). Contrast media-induced compartment syndrome. Radiologic Technology, 83(1), 63-77.

Wu, A., & Liu, H. (2018). Persistent median nerve injury probably secondary to prolonged intravenous catheterization at antecubital fossa. Journal of Clinical Anesthesia, 46, 61-62. https://doi.org/10.1016/j.jclinane.2018.01.024

Yammine, K. (2021). Patterns of the superficial veins of the cubital fossa. Phlebology, 32(6), 403-414. https://doi.org/10.1177/0268355516655670

Yang, C. W., Bae, J. S., Park, T. I., et al. (2014). Transient right hemidiaphragmatic paralysis following subclavian venous catheterization: Possible implications of anatomical variation of the phrenic nerve—a case report. Korean Journal of Anesthesiology, 65(6), 559-561. https://doi.org/10.4097/kjae.2013.65.6.559

Yeak, R. D. K., Yap, Y. Y., & Nasir, N. M. (2021). A rare case of posterior interosseous nerve palsy post-venepuncture. Journal of the College of Physicians and Surgeons Pakistan, 31(11), 1357-1358. https://doi.org/10.29271/jcpsp.2021.11.1357

Zou, Z. (2020). Horner syndrome caused by internal jugular vein catheterization. Journal of Cardiothoracic and Vascular Anesthesia, 34(6), 1636-1640. https://doi.org/10.1053/j.jvca.2019.06.031

This clinical guideline is intended for use by qualified healthcare professionals. Clinical judgment should always be exercised in individual patient care situations.