Q &A : AC PIVs

Q: I know not to but reality is, many nurses use the AC (antecubital fossa) to start and dwell a peripheral IV. It is the easiest place to find a vein so why not use it?

A: The antecubital fossa is in front of the elbow, bounded laterally and medially by the humeral origins of the extensors and flexors of the forearm, respectively, and superiorly by an imaginary line connecting the humeral condyles. This area contains the anterior branches of the medial and lateral cutaneous nerves of the forearm and the median cubital vein, which joins the cephalic and basilic veins. The cephalic, basilic and median cubital veins are usually easily seen and palpated in the roof of the fossa, and becomes a common site for venipuncture as is the case for blood draws. The use of the cubital fossa for intravenous fluid therapy is not recommended because movement of the elbow joint disturbs the catheter and irritates the vein wall with the consequence that thrombosis of the vein quickly occurs. The brachial artery is palpated here when the arterial pressure is being taken using a sphygmomanometer but, because of the bicipital aponeurosis, the elbow should be fully extended so that the artery is pressed back on to the elbow joint to render palpation a little easier. The brachial artery is in close relation to the median nerve, which lies on its medial side. Awareness of this relationship should minimize the incidence of nerve trauma during puncture for blood sampling or the insertion of vascular catheters.

The antecubital fossa is an area of flexion and placement of a peripheral IV in that area in an adult patient is uncomfortable due to the need to keep elbow extended in an unnatural position. In addition, the area is difficult to splint with the use of arm board. The use of the veins in the antecubital fossa should be reserved for blood collection, for the insertion of midline catheters and peripherally inserted central catheters.

In the event of an emergency, if the antecubital vein is used, change the site within 24 hours or sooner. Knowing the risks, if you decide to proceed and dwell a short peripheral catheter in this site, the potential for complications such as phlebitis, thrombosis, infiltration, extravasation, and nerve damage increases. In many cases, the resulting injury will not be obvious until the PIV catheter is removed and a few days/weeks/months has passed. One last thing to remember when puncturing the veins in the antecubital fossa –  unsuccessful insertion attempts will limit the use of the veins below.