Median Cubital Vein

Effect of Patient Preparation, Specimen Collection, Anticoagulants, and Preservatives on Laboratory Test Results

Leland Baskin , ... Christopher Naugler , in Accurate Results in the Clinical Laboratory, 2013

Venipuncture

The median cubital vein in the antecubital fossa is the most commonly used site due to its accessibility and size, followed by the neighboring cephalic and basilic veins [13,49,51,52]. Veins on the dorsal surface of the hand and wrist, radial aspect of the wrist, followed by dorsal and lateral aspects of the ankle are also used, but these should only be used if one can demonstrate good circulation [51,52]. Sites to be avoided include arms ipsilateral to a mastectomy; scarred skin and veins; fistulas; sites distal to intravenous (IV) lines; and edematous, obese, and bruised areas [13].

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Variables affecting endocrine tests results, errors prevention and mitigation

Hossein Sadrzadeh PhD , ... Gregory Kline MD , in Endocrine Biomarkers, 2017

1.6.2.1 Venous blood collection

The collection of blood specimens typically occurs at venous sites on the body, with the median cubital vein in the antecubital fossa being the typical collection site because this vein is relatively large and easily accessible [12]. Other veins, cephalic and basilic, as well as veins on the dorsal surface on the hand, wrist and ankle, can also be used for venous blood collection. It is important to avoid collecting blood from scarred skin and veins, sites distal to IV lines, bruised areas, and arms ipsilateral to a mastectomy site [12].

Application of the tourniquet 3–4   in. above the site of collection applies pressure to the vein, impeding its flow of blood back to the heart and increasing the peripheral vein's definition making them easier to locate and pierce during blood collection. Improper application of a tourniquet, however, can introduce numerous preanalytical errors. For example, creating a pressure >76   mmHg with a tourniquet induces anaerobic metabolism, increasing lactate and ammonia concentrations while decreasing pH [13]; most laboratories do not apply a tourniquet for the collection of blood for lactate testing. Application of a tourniquet for longer than 1   min can cause hemoconcentration with destruction of tissue and release of intracellular components such as potassium, enzymes, proteins, and protein-bound substances. In addition, application of tourniquet for 3   min can result in the increase of proteins (4.9%), lipid (4.7%), cholesterol (5.1%), iron (6.7%), bilirubin (8.4%), and aspartate aminotransferase (9.3%) [14]. Similarly, repeated fist clenching, increased muscle contraction, or high stress can increase the concentrations of many analytes such as potassium, cortisol, glucose, free fatty acids, and muscle enzymes [13]. Therefore it is critical to maintain the venous occlusion during the blood collection to <1   min [13].

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Sample Collection, Including Participant Preparation and Sample Handling

Colin Wilde , ... Douglas A. Granger , in The Immunoassay Handbook (Fourth Edition), 2013

Puncture Site

There are a number of veins in the arm that may be used, but the larger median cubital and cephalic veins are used most frequently. The puncture site should be carefully chosen avoiding any area of hematoma and any area of extensive scarring. A specimen taken from the side on which a mastectomy has recently been done may not be truly representative because of lymphostasis; specimens should never be taken from an arm being used for intravenous therapy because hemodilution is likely. Lowering the arm over the side of the armrest or bed will cause the veins to distend. Stroking in an upward direction usually makes the veins more visible. The veins become more prominent and easier to enter when the patient forms a fist, but vigorous hand exercise should not be allowed as this may change some blood constituent levels. The puncture site should be cleaned with an isopropanol swab and wiped dry to minimize contamination of the specimen.

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Hemodialysis Access

Brendon Quinn MD , ... Christopher G. Carsten MD , in Comprehensive Vascular and Endovascular Surgery (Second Edition), 2009

Brachial-Basilic Transposition Technique

The basilic vein courses along the ulnar aspect of the forearm, passing 1 to 2 cm anterior to the medial epicondyle. The vein converges with the median cubital vein above the antecubital crease. The basilic vein usually lies in the deep subcutaneous tissue at the antecubital crease and pierces the brachial fascia in the distal third of the upper arm; however, occasionally it lies beneath the fascia at the antecubital crease. In the upper arm, the basilic vein parallels and is superficial to the course of the brachial artery in the bicipital groove. Proximally, it drains into the axillary vein.

The vein is exposed through an incision that extends from the antecubital crease to the axilla. This dissection begins in the middle of the upper arm and proceeds distally. At the confluence of the basilic and median basilic veins, the incision and dissection proceed along the larger of the two veins to the antecubital crease. It may be necessary to extend the dissection to the proximal forearm to achieve adequate mobilization in obese patients. Mobilization of the basilic vein is carried proximally to its junction with the axillary vein. Venous tributaries are ligated with fine silk suture and divided. Several large, short venous branches may lie between the basilic and the brachial veins that must be divided and closed with 6-0 polypropylene suture. Care is taken to avoid injury to the medial antebrachial cutaneous nerve, a sensory nerve that is draped over the basilic vein. The brachial artery is exposed proximally to its entry into the antecubital fossa. Exposure of the artery can usually be accomplished through the same incision used to mobilize the vein. The basilic vein is transected and gently flushed with heparinized saline. A gently curving subcutaneous tunnel is created with a tunneling device over the anterior upper arm. The basilic vein is brought through this tunnel. Care is taken to avoid twisting or kinking the vein during tunneling. Systemic heparin is administered. An end-to-side anastomosis is created using 6-0 polypropylene suture. To minimize the risk of steal, the length of the arteriotomy is limited to 5 mm. The wound is closed in two layers (Figure 26-8).

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Access for Renal Replacement Therapy

James P. Hunter , ... Michael L. Nicholson , in Kidney Transplantation–Principles and Practice (Seventh Edition), 2014

Brachiobasilic Arteriovenous Fistula

The basilic vein originates on the medial aspect of the forearm at the wrist from the dorsal venous network of the hand. It runs superficially in the forearm and usually communicates with the cephalic vein via the median cubital vein at the elbow. It only remains superficial for a short distance in the arm before coursing beneath the deep fascia to run up the medial aspect of the arm alongside the medial cutaneous nerve of the forearm. Broadly, brachiobasilic fistula formation can be split into one-stage and two-stage procedures. A one-stage procedure is usually performed under GA and requires an extensive incision from the cubital fossa running longitudinally along the medial aspect of the arm towards the axilla. The basilic vein is mobilized from beneath the deep fascia and all tributaries are ligated and divided. Once an appropriate length has been exposed, the vein is divided and placed superficial to the medial cutaneous nerve of the forearm. The vein can then either be tunneled subcutaneously, or, as is preferred in our unit, the lateral skin flap can be undermined and the vein placed in a suitable position for needling. The vein can then be anastomosed to the brachial artery in an end-to-side disposition. The deep fascia is then closed beneath the vein to ensure that it remains superficial. The advantages of a one-stage procedure are that it only requires one operation and a single hospital stay and the fistula can be used more quickly. The disadvantage is that, if the fistula fails, the patient has undergone a significant procedure, with a substantial incision, usually under GA ( Figure 5-6). A two-stage procedure comprises a first stage, during which the basilic vein is anastomosed to the brachial artery under local anesthetic, through a small cubital fossa incision. The fistula is then assessed for maturation 4–6 weeks following formation and, if deemed adequate, the more extensive second stage can be performed. The second-stage procedure is usually performed under GA, although a regional block with local anesthetic infiltration can be used. The incision is as described above in the one-stage procedure. The vein is mobilized from its bed beneath the deep fascia, all the branches are ligated, and it is then transposed as described above. If the medial cutaneous nerve of the forearm is coursing across the fistula and at risk of damage during needling, then the fistula should be divided, positioned superficial to the nerve, and reanastomosed. Recent data support the use of brachiobasilic AVF ahead of prosthetic grafts, demonstrating improved long-term patency and a lower frequency of intervention. 61, 71 The patency rates at 2 years range from 50% to 80%, with one randomized study yielding patency rates of 70% at 3 years. 54 Brachiobasilic fistulas do however have higher wound complication rates due to the extensive incision required. One recent study demonstrated that the two-stage procedure had more favorable patency rates than a one-stage procedure at 1 year (34% versus 88%; P  =   0.047). 92

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CONVENTIONAL WORKHORSE FLAPS

David S. Soutar , in Flaps and Reconstructive Surgery, 2009

Venous anatomy of the region

The radial artery in the intermuscular septum is accompanied by two venae comitantes. They communicate at frequent intervals in a ladder-shaped fashion. The comitantes contain valves but the frequent interconnections allow bypassing of these valves, and this perhaps in part explains retrograde venous flow required, for example, in distally pedicled flaps. The venae comitantes drain into the median cubital vein via a constant branch near the elbow. The superficial forearm veins drain into the cephalic, basilic, and median cubital veins (see Figure 25.3). The deep venae comitantes communicate with the superficial veins via the common branch, going into the median cubital vein proximally and via a network of veins in the region of the radial styloid process distally. This allows the venous drainage of the forearm to be equally effective using either the deep venae comitantes or superficial veins. The median cubital vein connects the cephalic and basilic systems. The basilic vein is the dominant drainage for the dorsum of the hand and passes proximally in the medial bicipital groove. The cephalic vein is superficial between the brachioradialis and biceps at the elbow. The cephalic vein can in fact be dissected out proximally as far as the deltopectoral groove, giving an enormous length of venous pedicle (see Figures 25.1B, 25.3).

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Extraction Techniques and Applications: Biological/Medical and Environmental/Forensics

K. Lew , in Comprehensive Sampling and Sample Preparation, 2012

3.05.4.1 Venipuncture

Venipuncture is when a vein is pierced by a needle for either intravenous injection or the removal of blood. Veins are favored over arteries because they have thinner walls, and thus they are easier to pierce. There is also lower blood pressure in veins so that bleeding can be stopped more quickly and easily than with arterial puncture. The most site for venipuncture is the antecubital fossa located in the anterior elbow at the fold. This area houses three veins: the cephalic, median cubital, and basilic veins (Figure 1 ). The veins may be visible in some individuals but not others, or more easily felt in some, depending on the amount of muscle and fat tissue they have. Vein patterns may also run differently between individuals. Generally, the cephalic vein runs along almost the entire length of the arm and the median cubital vein connects the cephalic vein with the basilic vein. Of these three veins, the preferred one for venipuncture is the median cubital vein because it is larger and has a lower tendency to move or roll when the needle is inserted. There are also fewer nerve endings surrounding this vein making venipuncture less painful at this site. In some people the cephalic and/or basilic veins may be more easily located than the median cubital vein and may be a more appropriate vein to draw blood from. The phlebotomist must take care in anchoring those veins well to prevent rolling.

Figure 1. Major arm veins used for phlebotomy. The median cubital vein is the larger and more stable vein and is preferred for venipuncture. The cephalic and basilic veins have a greater tendency to roll and veinpuncture may be more painful from these sites.

Sometimes venipuncture is performed on hand veins when the veins in the antecubital fossa are not appropriate. Blood is collected from the dorsal or back side of the hand (Figure 2). Similar to veins in the antecubital fossa, they are prominent in different positions on different individuals. Veins in the hand have a tendency to move or roll; thus, the phlebotomist should ensure that the skin is pulled taut and the vein is well anchored down prior to needle insertion.

Figure 2. Distended veins on the dorsal side of the hand. Phlebotomy is done on the hand when veins from the antecubital fossa are not available nor suitable.

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Cord Blood Stem Cells for Clinical Use

Yong Zhao , in Cord Blood Stem Cells and Regenerative Medicine, 2015

2.3 Stem Cell Educator Therapy

Based on the preclinical evidence that CB-SC possess the immune modulations, 10,38,39,41 we have developed the Stem Cell Educator Therapy in clinical trials 40,42,43 (Figure 2 ). Briefly, a 16-gauge IV needle is placed in the median cubital vein to isolate lymphocytes from the patient's blood by using a Blood Cell Separator. The collected lymphocytes are transferred into the device for exposure to CB-SC, and other blood components are automatically returned to the patient. 40 The stem cell educator functions as part of a closed-loop system that circulates a patient's blood through a blood cell separator, briefly cocultures the patient's lymphocytes with CB-SC in vitro, and returns the educated lymphocytes to the patient's circulation. 4,40 CB-SC tightly attached to interior surfaces in the device, and only the CB-SC-educated autologous lymphocytes are returned to the subjects. The Stem Cell Educator Therapy requires only two venipunctures with minimal pain, and does not introduce stem cells or reagents into patients in comparison with other stem cell-based therapies (e.g., MSC and HSC). 40 Additionally, CB-SC display very low immunogenicity, eliminating the need for human leukocyte antigen (HLA) matching prior to treatment. 10,35,38,40 Thus, these advantages of Stem Cell Educator Therapy may provide CB-SC-mediated immune modulation therapy while mitigating the safety and ethical concerns associated with other stem cell-based approaches and conventional immune therapies.

Figure 2. Overview of Stem Cell Educator Therapy.

A T1D participant (left) is connected to a Blood Cell Separator (right) and the Stem Cell Educator (bottom center) to form a closed system. Lymphocytes isolated from the T1D participant by the Blood Cell Separator travel through the Stem Cell Educator where they come in contact with CB-SC attached to the interior surfaces of the device. Educated lymphocytes are returned to the patient's blood circulation.

 Ref. 40.

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Vascular Access

Monnie Wasse MD, MPH, FASN , Gerald A. Beathard MD, PhD, FASN , in Chronic Kidney Disease, Dialysis, and Transplantation (Fourth Edition), 2019

Fistula Types Based on Anatomy

Although a variety of different anatomical types of AVF can be surgically created, most AVF creations fall within three basic configurations (Fig. 23.1). There is a separate category of AVFs sometimes referred to as middle-arm or bidirectional fistulas that have been created when neither of the three basic configurations are possible. These are created using the proximal radial artery with either the median antebrachial vein or the median cubital vein. 7 The suitability of the median antebrachial vein may be contributed to in part by the fact that the venipuncturist does not commonly access it.

According to accepted guidelines, 8,9 the order of preference for the creation of permanent vascular access should start distally in the upper extremity and progress proximally to preserve venous anatomy. According to this approach, the radial-cephalic AVF would be considered primary and the brachial-cephalic and brachial-basilic would be considered secondary choices. Some have advocated that the middle-arm AVFs should be considered tertiary. 10 If it is not possible to create one of the basic configurations of AVF, then reasonable attempts at creating a transposed AVF should be made before consideration is given to the insertion of AVG; however, it is important to consider patient-specific factors (e.g., comorbid conditions, anticipated longevity) at the time a surgical plan is devised. In the event that an AVG is placed, it should ideally be done with the plan that it will be used for the dual purposes of providing dialysis access during its problem-free life and for the development of the upper arm veins for the later creation of a secondary AVF once its use becomes problematic.

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Advanced Floor of Mouth Cancer

Minh Tam Truong , ... Samuel J. Rubin , in Oral, Head and Neck Oncology and Reconstructive Surgery, 2018

Radial Forearm Free Flap

The first reported cases using an RFFF were described by Yang and colleagues in 1981, where they used the flap to resurface contractures in the neck from previous burns. 126 Its use for reconstruction in head and neck cancer patients after resection was first described by Soutar et al. 127

Anatomy

An anatomic description of the radial forearm flap was given by Urken and colleagues in 2012. 127a The blood supply to the lower arm originates from the brachial artery, which divides into the ulnar and radial artery. The radial artery leads into the deep palmar arch, and the ulnar artery leads to the superficial palmar arch. The four vascular systems that supply blood to the forearm skin are perforators from radial, ulnar, and anterior and posterior interosseus arteries. The radial artery, in the lateral intermuscular septum, gives off 9 to 17 fascial branches that supply the skin of most of the forearm. There are few fascial branches in the middle third of the forearm, and the inferior cubital artery supplies the proximal fasciocutaneous flaps. The radial artery also supplies the muscles of the flexor compartment, the palmaris longus, and the radial nerve. The length of the pedicle is limited by the radial recurrent artery or the cephalic vein, which would allow for extension of the dissection above the antecubital fossa.

The venous supply to the radial forearm has a superficial venous supply through the cephalic vein and a deep venous supply through the two paired venae comitantes, which run in the intermuscular septum. There are five different types of connections between the deep venae comitantes and the superficial veins. The type 1 pattern (20%) contains wide communication between the superficial and deep system, and the median cubital vein splits into the basilic median vein and the cephalic median vein. The type 2 pattern (43%) is the same as the type 1 pattern, except that the median cubital vein does not bifurcate. The type 3 pattern (18%) contains a confluence of the two venae comitantes to a common trunk, but does not anastomose with the cephalic vein to form a median cubital vein. In the type 4 pattern (5%), the venae comitantes do not converge or join with the cephalic vein. The type 5 pattern (15%) is similar to type 4, except one of the venae comitantes is dominant to the other. 128

The cutaneous innervation of the forearm is derived from the medial, lateral, and posterior antebrachial cutaneous nerves—the primary sensory nerve to the forearm. The antebrachial nerve branches from the musculocutaneous nerve, runs along the cephalic vein, and continues to the thenar eminence in the hand. The medial antebrachial nerve arises from the medial cord of the brachial plexus, supplies the medial aspect of the forearm, and runs along the basilic vein. Before performing an RFFF, one should check that the ulnar artery supplies blood to the index finger and thumb because of reported cases of an incomplete superficial arch or noncommunication between the superficial and deep arch. 129

Surgical Technique

An Allen test should be performed before and during the surgery to test for patency of the radial artery and prevent hand ischemia. The patient should be positioned in the supine position, and a skin paddle should be traced around the radial artery. A scalpel is used to make a lateral incision along the arm down to the flexor carpi ulnaris, and subfascial dissection is performed until the palmaris longus (if present) and flexor carpi radialis are identified. At this point the dissection is performed from the radial aspect of the flap down to the brachioradialis muscle. The radial nerve is identified and preserved, including its branches along the wrist. Subfascial dissection is performed between the brachioradialis and the flexor carpi ulnaris, which is where the vascular pedicle is found. Sharp dissection is performed underneath the brachioradialis to preserve the vascular pedicle. Dissection is performed in the groove between the brachioradialis and the flexor carpi radialis. Hemostasis is obtained with bipolar electrocautery and hemoclips. Dissection is performed distal to proximal into the antecubital fossa. The superficial vein should be identified and followed to the antecubital fossa. After the entire flap is elevated, the radial artery is identified in the region of the wrist, and a clamp is applied to perform an Allen's test. The vessels are ligated, and the flap is brought to the neck region, where 9-0 nylon sutures are used for anastomosis to either the facial or superior thyroid artery, and the vein is anastomosed to the internal jugular, external jugular, or facial vein. Depending on the size of the defect at the donor site, the donor site can be closed primarily, using an ulnar transposition flap, or with a purse-string suture and split-thickness graft. 130

Complications

Complications that have been reported in cases involving RFFF include total and partial flap loss, venous thrombosis, arterial thrombosis, dehiscence, and fistula formation. 131,132 Venous thrombosis occurs at least twice as often as arterial thrombosis in the case of free flaps. 133 Patient age, smoking history, and presence of comorbid conditions were related to higher rates of complications but were not statistically significant. 131,134 However, arteriovenous thrombosis had significantly worse outcomes than arterial or venous thrombosis alone and multiple takebacks, or takebacks after postoperative day 3, were associated with significantly worse outcomes. Prior radiation therapy is not associated with worse outcomes. 131,135 Venous thrombosis usually occurs from mechanical obstruction, including compression, twisting, kinking, or stretching of the vein. 135 Donor site morbidity includes hand ischemia, 136 tendon exposure, 137 decreased resting temperature in the hand, and subjective impairment in wearing watches or bracelets, numbness, soreness, itching, cold intolerance, and poor cosmetic appearance. There was no significant difference between the RFFF arm and control arm with strength testing and goniometry. 138

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