Journal of Society of Anesthesiologists of Nepal. Inadvertent arterial cannulation during intravenous cannulation of the cephalic vein

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1 Journal of Society of Anesthesiologists of Nepal JSAN 2015; 2 (1) AN OFFICIAL PUBLICATION OF SAN A PEER REVIEWED JOURNAL JSAN Volume 2, Issue 1, February 2015 ISSN JSAN 2015; 2 (1) JOURNAL OF SOCIETY OF ANESTHESIOLOGISTS OF NEPAL Available online at Journal of Society of Anesthesiologists of Nepal Letter to the editor Inadvertent arterial cannulation during intravenous cannulation of the cephalic vein Parineeta Thapa, Balkrishna Bhattarai BP Koirala Institute of Health Sciences, Dharan, Sunsari, Nepal A R T I C L E I N F O Article history Received Accepted Published Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgment of the work s authorship and initial publication in this journal. To the Editor, Cephalic vein in the wrist is a common choice for peripheral venous cannulation due to easy access and splinting as well as consistent anatomy. Unintentional radial artery cannulation during cephalic venous access over the radial styloid process is unlikely and rare. Here we report such a case while securing venous access. A 43 year-old lady was planned for total abdominal hysterectomy. The cephalic vein at her wrist was made prominent by manual compression and the skin was prepared with antiseptic solution. Cannulation of the vein over the right radial styloid process was started with an 18G cannula. The needle was withdrawn and the cannula advanced once blood was seen in the flash back chamber. Intravenous fluid transfusion set was connected. It was noted that there was a back flow of bright red blood into the transfusion set rather than free flow of fluid into the vein. We suspected arterial cannulation. On palpation, the tip of the cannula was felt anteromedially where a distinct arterial pulse was palpable (Figure 1). The cannula was removed and compression was applied over the puncture site to prevent bleeding and hematoma. No further problems like pain, distal ischemia or hematoma were noted in the limb. Anaesthesia and surgery were commenced after securing a new intravenous line in her left hand. At the insertion site of the cannula a distinct arterial pulse could be palpated revealing the presence of an artery near the cephalic vein. Figure 1: Cannula in the wrist with its tip (marked) anteromedially Inadvertent arterial cannulation during central venous cannulation is a common complication but is rare during peripheral venous cannulation. A few incidences have been reported during cephalic, basilic, cubital and saphenous vein cannulation. The most likely reason of arterial puncture during cephalic vein cannulation at the level of wrist is the presence of superficial radial artery. Normally the radial artery runs several millimeters deeper than the cephalic vein, so the risk of arterial cannulation is rare. 1 But in 0.5 to 1% of individuals, there is superficial radial artery, where the radial artery at the level of wrist crosses over the tendons which define the snuff box, rather than Corresponding author: Parineeta Thapa, MD, Assistant Professor, Department of Anaesthesiology and Critical Care, B. P. Koirala Institute of Health Sciences, Dharan, Sunsari, Nepal, parithapa2002@yahoo.com, Telephone Journal of Society of Anesthesiologists of Nepal 37

2 JSAN 2015; 2 (1) running deep to it. 2 Unidentified arterial cannulation and injection of drugs into an artery can cause devastating complications like arterial thrombosis and ischemia of the limb distal to the injection site. Need for thrombectomy and surgical repair of the artery has also been reported. 3 Anticipation and early identification of this situation is important in preventing further harm to the patient. Use of arterial blood gas analysis and pressure transducer may be required at times when clinical judgement alone may fail, as in cases with hypovolemia. In our case we could trace the tip of the cannula going anteromedially into the direction of radial artery confirming its intraarterial location. Peripheral venous cannulation is performed after making the vein prominent and possibility of inadvertent arterial cannulation is seldom thought of. Our and similar other cases prompt us to routinely palpate the venipuncture site for arterial pulse prior to venous cannulation to avoid this potentially harmful situation. References 1. Lirk P, Keller C, Colvin J, Colvin H, Rieder J, Maurer H, et al. Unintentional arterial puncture during cephalic vein cannulation: case report and anatomical study. Br J Anaesth 2004;92: Rodriguez-Niedenfuhr M, Vazquez T, Nearn L, Ferreira B, Parkin I, Sanudo JR. Variations of the arterial pattern in the upper limb revisited: a morphological and statistical study, with a review of the literature. J Anat 2001;199: Beale EW, Behnam A. Injection injury of an aberrant superficial radial artery requiring surgical intervention. J Hand Microsurg 2012;4: Journal of Society of Anesthesiologists of Nepal

3 Journal of Society of Anesthesiologists of Nepal (JSAN) Authors Guidelines Introduction Journal of Society of Anaesthesiologists of Nepal (JSAN) is an official publication of the Society of Anaesthesiologists of Nepal (SAN). It is a peer-reviewed, open-access medical journal that is published with the aim of highlighting the scientific advances in the field of anaesthesia, intensive care, pain medicine and allied sciences. The journal provides platform for anesthesiologists, intensivists and pain practitioners to share their views, finding of their scientific research, and experiences. Type of articles published: JSAN has planned to publish articles under following headings: Editorials Special article Original article Case reports Audits Review articles Letter to the editor Manuscripts submitted must be within the area of interest of JSAN. It should provide knowledge, be original in authorship, be based on adequate records, and must have significant finding. Reviewers will evaluate the suitability of the manuscript for publication. The language of publication is English. The author should clearly specify the type of article being submitted. However, the category under which the article will be published will be decided by the editorial board. Preparation of Manuscripts: Manuscripts should be prepared according to the Uniform Requirements for Manuscripts Submitted to Biomedical Journals, at 1 Single-space manuscripts with 1-inch margins on all sides. Number all pages consecutively, beginning with the title page. Submit all materials in a single file *.docx format only. Word limit for articles The manuscript should not exceed 3000 words and 30 references for an original article and audits, 4000 words I and 50 references for a review article, 1000 words and 10 references for a case report, and 500 words and 5 references for a letter to the editor. Guidelines on Use of Language Use of Language Uniformity in English Language is required. There should be no abbreviation in Abstract Abbreviation spelt out in full for the first time Avoid repetition of same words and waste words Do not use & in the text Running title provided should be not more than 50 characters Format the manuscript in a single column Do not use any special typeface for emphasis Use of Numbers Numbers less than 10 should be written in words. Numbers 10 or more should be written in numbers. Words should begin a sentence. Numbers less than 1 and greater than -1 should begin with 0 (e.g ) Do not use a space between a number and its percent sign. Use one space between a number and its unit. Report percentages to two decimal place if the sample size is larger than 100. Do not use decimal places if the sample size is less than 10. Do not use percentages if the sample size is less than 20. Do not imply greater precision than your measurement instrument. For ranges use to but not to avoid confusion with a minus sign and use the same number of decimal places as the summary statistic. It is important for authors and reviewers to know that our

4 journal follows double blind peer review process. To ensure the integrity of the blind peer-review for submission to this journal, every effort should be made to prevent the identities of the authors and reviewers from being known to each other. This involves the authors, editors, and reviewers (who upload documents as part of their review) should check the document to remove any identifying information from the Research Article document. Cover letter and Title page should be uploaded as supplementary files. For further detail on how to remove identity from document, please visit: JSAN/help/view/editorial/topic/ A complete manuscript includes the following elements. The elements should be prepared in separate *.docx files. The files are listed below. 1. File 1. Cover Letter: Provide a cover letter. Briefly describe the article and its unique contribution to the literature. List any previous presentations of the work and any related manuscripts. (Related manuscripts must be attached as supplemental files.) 2. File 2. Title Page. List on the title page: Title of the manuscript. Provide a title that is concise, specific, and informative. A running title (50 characters max) Authors full names (First, Middle and Last) Authors Advanced degrees and institutional affiliations Corresponding author s full name, address, telephone and fax numbers, and address. Support: List all sources of financial or other material support received for the work reported. Prior presentations. Give the name, date, and location of any conferences at which portions of the manuscript content have been presented. Word count for abstract Word count for the text excluding title page, abstract, references, tables and figures. Numbers of tables and numbers of figures. 3. File 3 Research Article Title (Repeat) Abstract. Abstracts are required for all manuscript submissions. Abstracts should summarize main points. Do not include tables, figures, or references. Abstracts for original research, audits are limited to 250 words and usually contain the following headings. Background: One sentence describing the problem being addressed and one sentence stating the objective of the study. Methods: Describe study design, setting, participants, interventions, measures, main outcomes, and analyses. Results: State the main findings of the study. Conclusions: Two sentences that 1) summarize the main finding/interpretation of the study and, 2) provide context by stating the main implications of the findings for practice, policy, or research. Case reports, review articles, guidelines or theory articles may use an unstructured abstract that states the problem addressed or purpose, summarizes the major points, and ends with one to two short sentences on the major conclusion and implication. Key words. Provide at least 3 key words from the list of MeSH database available at mesh. Abbreviations. Standard abbreviations may be used for frequently encountered terms. Place abbreviations in parentheses after the first appearance of the term in the text. They should not be used in the abstract. Text. Research articles will usually include the sections listed below; subheadings may be used to identify major content areas. Systematic reviews, case reports, and articles describing new methods or theory may use different formats as needed. Introduction: States clearly and concisely the article s unique contribution within the context of prior work conducted by the authors or others, and relevant bodies of theory. Methods: Enables the study to be assessed for validity and trustworthiness. Include a statement of approval by the appropriate institutional review board. Statistical test used should be clearly mentioned. Results: Conveys the study findings. Tables and figures should be self explanatory and should not be repeated in words. Statistical results should include confidence intervals or exact p values, even for non-significant results. Qualitative results should focus on the main domains and interpretive findings; consider using an appendix to convey more detailed qualitative findings and quotations. Discussion: Interprets the findings in the context of the study s strengths and limitations, prior knowledge, published literature, and implications for practice, policy, or future research. Acknowledgments. Before the references, list those who have made substantive contributions to the work but do not meet the criteria for authorship according to the Uniform Requirements for Manuscripts Submitted to Biomedical Journals, at Authors should retain written permission from each person they acknowledge. Conflict of Interest Statement. At the end of the text, after any acknowledgments, include a statement of all potential, II

5 perceived, or real conflicts of interest for each author. If an author has no potential conflicts, that should be stated. References. Authors are responsible for ensuring the accuracy of references. Format references in accordance with the Vancouver Style. For further reference please visit ca/downloads/vcc_vancouverstyleguide.pdf. Number citations with superscript Arabic numerals in order of appearance in the text, tables, and figures. Journal titles should be abbreviated using NLM abbreviations in Index Medicus. Cite articles accepted for publication as forthcoming with the journal title and year. Cite unpublished articles or personal communications with name and date in parentheses. Authors must obtain prior written permission to cite a personal communication. Tables Tables should be double-spaced with a short descriptive title. Include footnotes as needed to allow readers to interpret it independent of the article text. Present tables on the same place as in the text numbered in the order it appears in the text. Figures Each figure should include a brief descriptive title. Number figures in the order they appear in the text and place them accordingly. When a manuscript that includes a graph is accepted for publication, authors will be asked to supply actual numbers for each data point on the graph. Appendices. (Optional) Material that is not essential to the article, but is useful to some readers, may be published in appendices, e.g., detailed quotations from qualitative studies, supplemental tables, and research instruments. Refer to appendices in the main text and follow the same standards and style as the body of the article. Submit appendices with the manuscript file during the submission process. Duplicate/Prior Publication. If there is any possible duplicate or prior publication of any content of the manuscript, notify the editors and describe in the cover letter. Provide copies by of all related materials that have been previously published or are under consideration or in press elsewhere. Style We encourage authors to write in the active voice and first person. We want a clear, brief description of the essential methods and key findings of your study. Please provide just enough background to set the context and enough discussion to disclose the limitations and declare the importance of your work. Each table must add important information to the text. Figures should be used when pictures convey more than words and numbers. Refer to drugs by their generic names. Quantitative values should be expressed in units with Systeme International (SI). The JSAN will be published both in print and online. Mailing Address: Editorial Office The Society of Anaesthesiologists of Nepal (SAN) NMA building (Siddhi Sadan), Exhibition Road, Kathmandu, Nepal. GPO Box: jsan2070@gmail.com Manuscript Submission Process All manuscripts are submitted online at only. Accepted file formats: Text. Microsoft Word *.docx format. Tables. Microsoft Word, Excel embedded in Word. Graphs for publication. When a manuscript that includes a graph is accepted for publication, the authors will be asked to supply actual numbers for each data point on the graph. Graphics. JPEG or PDFformat. Line art must have a resolution of 1200 dpi (dots per inch) and digital photographs (such as radiographs and scanned images) should be at least 300 dpi. They must be created at a high resolution. Mixed text and graphics. If a graphics file includes text, the text must be on a separate layer of the TIFF or EPS file to allow conversion to our font style. Checklist before submission Submit all materials online. 1. First *.docx file : Cover letter 2. Second *.docx file: Title page 3. Third *.docx file: Research article Abstract Key words Abbreviations Article text Acknowledgments Conflict of interest statements References Appendices, if any Preparing for submission: III

6 Review the Requirements for Submission, above. If applicable, submit hard copies of the following by mail: Permission to republish previously published material Consent of individual to publish material Copies of related publications for evaluation of possible duplicate publication. Manuscript Review Process We make every effort to complete the peer review process and notify the corresponding author as soon as possible after receiving a complete submission. All articles are evaluated by at least two editors. Selected manuscripts undergo further review, typically by 2-4 peer reviewers. Manuscripts are assessed based on their originality, importance of results, clarity of discussion, contribution of new knowledge, and potential impact on health, health care, policy, and future inquiry. We encourage authors to share their expertise by becoming a peer reviewer. Express your interest with an to the executive editor. Information submitted or accepted for publication in the JSAN may be released to the media or the public only after it has been published in the JSAN, or after the corresponding author has been notified that the JSAN will not publish it. If the research represents thesis work of a residency program, it should be clearly mentioned in the disclosures. However, even before research is published in JSAN, authors may present the results at scientific meetings or conferences. 1 International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals. Ann Intern Med. 1997;126(1):36-47 IV