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Venipuncture nerve injuries after whole‐blood donation

Horowitz dissected the arms of seven randomly chosen cadavers and found a great deal of variation in the anatomy of the antecubital nerves relative to the antecubital veins.1 While, classically, the nerves are supposed to be deep to the veins, in his study the nerves often overlaid the veins or were intertwined with them. This suggests that even a nontraumatic, straightforward venipuncture can directly cause damage to a cutaneous nerve. Two other pieces of evidence support the concept that local nerve injuries from phlebotomy are not totally preventable. We reviewed a total of 28 reported nerve injury cases from 194,000 blood donations in 1999. The form we used captured donor demographics, the name of the phlebotomy nurse, clinical symptoms, and specific evidence of venipuncture trauma, such as adjustment of the needle, difficult venipuncture, and presence of a hematoma. In 40 percent of the cases (8/20), there was no evidence of venipuncture trauma. Furthermore, more than 100 nurses were not associated with a nerve injury, 22 nurses were associated with one nerve injury, and three nurses were associated with two nerve injuries during the year. These data suggest that even an uncomplicated needle venipuncture can cause a nerve injury and that the association with these injuries is widespread and not limited to a few nurses. Common sense dictates that less probing will minimize these injuries, but they will occur sometimes, even if the best phlebotomy technique is used. Horowitz also reported on 24 referred cases that had a high incidence (87%) of permanent damage. The prognosis is just the opposite in the blood center setting.2,3 Almost all affected whole-blood donors do well. In our experience, only one permanent, disabling injury out of 1.5 million blood donations was seen. During this period, we had approximately 240 reported cases that were consistent with a nerve injury. As Horowitz correctly noted, the difference is that he saw a referred population and also included intravenous cannulations, while our experience represents the incidence in a blood donor population undergoing wholeblood phlebotomy, with a 16-gauge needle in the antecubital fossa. Finally, it is of interest that all reported studies have found postphlebotomy nerve injuries to be more common in females. Two studies found that 79 percent (19/24)1 and 65 percent (43/66)2 of such injuries occurred in females, and, in our 1999 data, 82 percent (23/28) of injured donors were female. Possible explanations are that the veins in females are of poorer quality and therefore require more probing to cannulate them, that females have a smaller arm size, and that females have a higher rate of reporting. Bruce Newman, MD American Red Cross Blood Services Southeast Michigan Region 100 Mack Detroit, MI 48034 e-mail: newmanb@usa.redcross.org