The incidence, significance, and management of accidental intra-arterial injection: a narrative review

Causes, risk factors, and complications of accidental intra-arterial administration of medications in a children's hospital: a case series

BACKGROUND

Accidental intra-arterial administration of a medication can lead to serious iatrogenic harm. Most studies have discussed single cases of accidental intra-arterial administration of a medication, but only a few have described multiple cases occurring in a single, pediatric hospital setting.

METHODS

The subjects were pediatric patients with an accidental intra-arterial administration of a medication. After obtaining approval from the institutional review board, the relevant cases were extracted from incident reports submitted to the patient safety office of the study center between November 2016 and April 2023.

RESULTS

A review of 18,204 incident reports yielded 10 cases (patient age: 27 days to 13 years) of accidental intra-arterial administration of a medication. The most common site of the cannulation was the dorsum of the foot followed by the dorsum of the hand. The medications administered were narcotics, sedatives, muscle relaxants, antibiotics, and crystalloids. No serious adverse events occurred after injection. In some cases, the accidental arterial cannulation was not discovered immediately (53 min to 26 days). Seven patients had difficult intravenous access; in two of these, ultrasound-guided peripheral venous cannulation was used.

CONCLUSIONS

We experienced 10 cases of accidental intra-arterial administration of a medication. The dorsalis pedis artery and the radial artery around the anatomical tobacco socket were common sites of unintentional arterial cannulation. Difficult intravenous (IV) access may be associated with unintentional arterial cannulation. If IV access is difficult or the free IV drip is sluggish, strict vigilance and repeated confirmation are needed to prevent unintentional arterial cannulation.

Guidelines for management of actual or suspected inadvertent intra-arterial injection of sclerosants

BACKGROUND

Inadvertent intra-arterial injection of sclerosants is an uncommon adverse event of both ultrasound-guided and direct vision sclerotherapy. This complication can result in significant tissue or limb loss and significant long-term morbidity.

OBJECTIVES

To provide recommendations for diagnosis and immediate management of an unintentional intra-arterial injection of sclerosing agents.

METHODS

An international and multidisciplinary expert panel representing the endorsing societies and relevant specialities reviewed the published biomedical, scientific and legal literature and developed the consensus-based recommendations.

RESULTS

Actual and suspected cases of an intra-arterial sclerosant injection should be immediately transferred to a facility with a vascular/interventional unit. Digital Subtraction Angiography (DSA) is the key investigation to confirm the diagnosis and help select the appropriate intra-arterial therapy for tissue ischaemia. Emergency endovascular intervention will be required to manage the risk of major limb ischaemia. This includes intra-arterial administration of vasodilators to reduce vasospasm, and anticoagulants and thrombolytic agents to mitigate thrombosis. Mechanical thrombectomy, other endovascular interventions and even open surgery may be required. Lumbar sympathetic block may be considered but has a high risk of bleeding. Systemic anti-inflammatory agents, anticoagulants, and platelet inhibitors and modifiers would complement the intra-arterial endovascular procedures. For risk of minor ischaemia, systemic oral anti-inflammatory agents, anticoagulants, vasodilators and antiplatelet treatments are recommended.

CONCLUSION

Inadvertent intra-arterial injection is an adverse event of both ultrasound-guided and direct vision sclerotherapy. Medical practitioners performing sclerotherapy must ensure completion of a course of formal training (specialty or subspecialty training, or equivalent recognition) in the management of venous and lymphatic disorders (phlebology), and be personally proficient in the use of duplex ultrasound in vascular (both arterial and venous) applications, to diagnose and provide image guidance to venous procedure. Expertise in diagnosis and immediate management of an intra-arterial injection is essential for all practitioners performing sclerotherapy.

Inadvertent administration of intravenous anaesthesia induction agents via the intracerebroventricular, neuraxial or peripheral nerve route - A narrative review

Intravenous (IV) medication administration error remains a major concern during the perioperative period. This review examines inadvertent IV anaesthesia induction agent administration via high-risk routes. Using Medline and Google Scholar, the author searched published reports of inadvertent administration via neuraxial (intrathecal, epidural), peripheral nerve or plexus or intracerebroventricular (ICV) route. The author applied the Human Factors Analysis and Classification System (HFACS) framework to identify systemic and human factors. Among 14 patients involved, thiopentone was administered via the epidural route in six patients. Four errors involved the routes of ICV (propofol and etomidate one each) or lumbar intrathecal (propofol infusion and etomidate bolus). Intrathecal thiopentone was associated with cauda equina syndrome in one patient. HFACS identified suboptimal handling of external ventricular and lumbar drains and deficiencies in the transition of care. Organisational policy to improve the handling of neuraxial devices, use of technological tools and improvements in identified deficiencies in preconditions before drug preparation and administration may minimise future risks of inadvertent IV induction agent administration.

Can Currently Available Non-invasive Continuous Blood Pressure Monitors Replace Invasive Measurement With an Arterial Catheter?

Deviations from normal blood pressure (BP) during general anesthesia have been clearly linked to several adverse outcomes. Measuring BP accurately is therefore critically important for producing excellent outcomes in health care. Normal BP does not necessarily guarantee adequate organ perfusion however and adverse events have occurred even when BP seemed adequate. Invasive blood pressure monitoring has recently evolved beyond merely measuring BP. Arterial line-derived pulse contour analysis is used now to assess both cardiac output and stroke volume variation as indices of adequate intravascular volume. Confirmation of acceptable cardiac output with data derived from invasive intra-arterial catheters has become very important when managing high-risk patients. Newer devices that measure BP continuously and non-invasively in the digital arteries via a finger cuff have also become available. Many clinicians contemplate now if these new devices are ready to replace invasive monitoring with an arterial catheter. Unlike non-invasive devices, intra-arterial catheters allow frequent blood sampling. This makes it possible to assess vital parameters like pH, hemoglobin concentration, ionized calcium, potassium, glucose, and arterial partial pressure of oxygen and carbon dioxide frequently. Non-invasive continuous BP measurement has been found to be unreliable in critically ill patients, the elderly, and patients with calcified arteries. Pulse contour-derived estimates of cardiac output and stroke volume variation have been validated better with data derived from arterial lines than that from the newer finger cuff monitors. Significant advances have been recently made with non-invasive continuous BP monitors. Invasive monitoring with an arterial line however remains the gold standard for measuring BP and assessing pulse contour analysis-derived hemodynamic variables in critically ill patients. In the future, non-invasive continuous BP monitors will likely replace intermittent oscillometers in the operating room and the postoperative period. They will however not eliminate the need for arterial catheterization in critically ill patients.

When the course deviates from expected: Misplacement of an epicutaneo-caval catheter in a neonate

Central venous access, a common and essential component of the care of the critically ill neonate, is associated with complications such as infection, thrombosis, and bleeding. Unintentional arterial cannulation of a venous catheter is a rare but potentially dangerous complication. In the report, we describe the accidental cannulation of an artery with an epicutaneo-caval catheter in an extremely low birth weight infant. We discuss the physical and radiological findings that raise the suspicion of an arterial placement of a catheter, the diagnostic tools to confirm the misplacement, the potential complications, and strategies to prevent it.