Acute hand ischemia after intra-arterial injection of meprobamate powder

Acute Limb Ischemia Caused by Inadvertent Arterial Drug Self-Injection: A Case Report

BACKGROUND A predictable consequence of long-term injection drug use is the destruction of the native venous system; as a consequence, people who inject drugs may eventually move to injection into skin and subcutaneous tissue, wounds, muscles, and arteries. These practices put people who inject drugs at risk for injection-related soft-tissue infection, vascular damage, ischemia, and compartment syndrome, all of which have overlapping presenting symptoms. CASE REPORT A 35-year-old man who injects drugs presented with foot swelling and discoloration initially concerning for necrotizing fasciitis or compartment syndrome. After progression despite appropriate antimicrobial and surgical treatment for soft-tissue infection, he was diagnosed with arterial insufficiency and resultant distal ischemia. This diagnosis was discovered only after obtaining additional history of the patient's drug use practices. Just prior to his symptoms, he had unintentionally injected a formed thrombus into his dorsalis pedis artery. CONCLUSIONS Intra-arterial injection of drugs can cause ischemia through a variety of mechanisms, including direct vessel trauma, arterial spasm, toxicity from the drug of abuse or an adulterant, embolism of particulate matter, and as proposed here, direct injection of preformed thrombus. Medical providers should be aware of the steps of injection drug use and their associated risks so that they can ask appropriate questions to focus their differential diagnosis, increase their understanding of common or current local injection practices, and develop rapport with the patient. Patient education on safe injection techniques may also reduce the risk of serious complications.

Acute Digital Ischemia After Arterial Injection of Crushed Zolpidem Tablets: Role of Microcrystalline Cellulose? A Case Report

Literature is scarce on acute ischemia after intra-arterial injection of crushed tablets and no effective medical treatment against the progression of lesions is reported. The only factor able to modify the outcome is the delay between injection and management by a specialized vascular team. Moreover the risk of necrosis seems higher after benzodiazepine intra-arterial injection than with other drugs. We tried to find out mechanistic explanations. We report on the case of a 31-year-old drug addict woman who self-injected into her left brachial artery crushed tablets of zolpidem. She developed an acute ischemia of the left hand, with necrosis of the intermediate and distal phalanges of fingers II, III, and IV. Angiogram of the left upper arm confirmed the distal arterial occlusions with no run-off after the palmar arch in the necrotic fingers. Once she was admitted into our vascular unit, intravenous vasodilator therapy by iloprost, heparin and local protective care were rapidly introduced. After delineation between living and necrotic tissues, she required distal amputations of the affected fingers. The clinical severity of arterial injections of benzodiazepine tablets is linked to the association of several pathophysiological mechanisms. Rather than related benzodiazepine pharmacologic effects with tissue ischemia, by the inhibition of phosphodiesterase, a vasodilator intermediate, or through the peripheral benzodiazepine-type receptor, the predominant mechanism is more likely in relation with microcrystalline cellulose, one component of zolpidem tablets, known as potential embolic agents. They are insoluble and resistant to degradation in water. These properties are probably prominent in the case we described here. Through this case report we want to drag attention of physicians in charge of a patient with acute ischemia after crushed tablet accidental intra-arterial injection, not only to look at the drug injected but also the other components of the tablet and especially to microcrystalline cellulose.

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

This narrative review discusses the incidence, risk factors, mechanisms of injury, complications, and treatment regimens for accidental intra-arterial injection of medications. Despite awareness of the issue and the establishment of safety recommendations by national agencies, accidental iatrogenic intra-arterial injection of medications continues to occur. Most of these injuries are caused by accidental injection into an established arterial cannula or the inadvertent and unrecognized cannulation of an artery instead of a vein. Although many medications have been injected into arteries without significant consequence, a number of drugs are consistently associated with severe morbidity, including the need for amputation, making early incident recognition and treatment vital. Accidental intra-arterial injection of medications has also been increasingly reported in those who use illicit drugs, as these intravenous injection attempts can be misdirected into an artery. These reports have improved understanding of these injuries and possible treatment modalities. While the characteristics of injuries from illicit injections are diverse and the optimal treatment modalities are still uncertain, a regimen that includes anticoagulation and intra-arterial injection of thrombolytics and prostaglandins may improve outcomes. Steroids, vasodilators, and sympathetic blocks do not appear to influence amputation rates. Owing to the small and sporadic number of cases, no definitive clinical trial evidence exists, but the treatment modalities found to be useful in the illicit intra-arterial injection group may benefit treatment of similar iatrogenic injuries.

[Gangrene of the hand due to accidental intra-arterial injection of floxacilline: about a case]

La floxacilline appartient à la classe des pénicillines bêta lactames. Dans notre contexte elle est très utilisée pour lutter contre les infections à germes Gram positif dont le staphylocoque doré. Cependant son utilisation doit être très prudente car elle n’est pas dénuée de complications. Nous rapportons l’observation d’un garçon de 6 ans opéré pour fracture de l’humérus. L’enfant a été mis sous floxacilline injectable après suspicion d’une infection sur matériel 2 mois après son opération. Le lendemain du début de l’antibiothérapie, l’enfant a présenté une ischémie aigue de la main droite. Il nous a alors été adressé pour prise en charge. Les explorations ont objectivé une obstruction de l’artère radiale. Une aponévrotomie de décharge a été réalisée et une héparinothérapie post opératoire a été démarrée. L’évolution a été marquée par une gangrène de toute la main. A travers cette observation nous voulons sensibiliser le personnel soignant sur le risque de survenue de cette complication désastreuse, et les mesures à prendre pour la prévenir.

Evaluation of the effects of intra-arterial sugammadex and dexmedetomidine: an experimental study

BACKGROUND

Intra-arterial injection of medications may cause acute and severe ischemia and result in morbidity and mortality. There is no information in the literature evaluating the arterial endothelial effects of sugammadex and dexmedetomidine. The hypothesis of our study is that sugammadex and dexmedetomidine will cause histological changes in arterial endothelial structure when administered intra-arterially.

METHODS

Rabbits were randomly divided into 4 groups. Group Control (n=7); no intervention performed. Group Catheter (n=7); a cannula inserted in the central artery of the ear, no medication was administered. Group Sugammadex (n=7); rabbits were given 4mg/kg sugammadex into the central artery of the ear, and Group Dexmedetomidine (n=7); rabbits were given 1μg/kg dexmedetomidine into the central artery of the ear. After 72h, the ears were amputated and histologically investigated.

RESULTS

There was no significant difference found between the control and catheter groups in histological scores. The endothelial damage, elastic membrane and elastic fiber damage, smooth muscle hypertrophy and connective tissue increase scores in the dexmedetomidine and sugammadex groups were significantly higher than both the control and the catheter groups (p<0.05). There was no significant difference found between the dexmedetomidine and sugammadex groups in histological scores.

CONCLUSION

Administration of sugammadex and dexmedetomidine to rabbits by intra-arterial routes caused histological arterial damage. To understand the histological changes caused by sugammadex and dexmedetomidine more clearly, more experimental research is needed.

Inadvertent Intra-Arterial Drug Injections in the Upper Extremity: Systematic Review

PURPOSE

To review the literature pertaining to inadvertent intra-arterial drug injection in the upper extremity, explore the various treatment options and their outcomes, and identify risk factors for limb amputation following intra-arterial injection.

METHODS

A systematic review of Medline, EMBASE, and Cochrane databases (inception to March 2013) was completed for patients presenting with intra-arterial drug injection of the upper extremity. Details on intervention and outcome were extracted and subjected to pooled analysis with amputation as the primary outcome.

RESULTS

A total of 25 articles (209 patients) were included for review. Mean patient age was 31 ± 8 years (male, 71%; female, 29%). Prescription opioids (33%) were the most commonly injected substance, and the brachial artery (39%) was the most common site. The overall weighted mean amputation incidence was 29%. Anticoagulants were the most common treatment used (77%). From pooled analysis, conditions requiring antibiotic use were significantly associated with a higher incidence of amputation; whereas use of steroids was associated with a lower incidence of amputation. Patients presenting 14 hours or more after injection and those injecting crushed pills rather than pure substances had significantly higher incidences of amputation.

CONCLUSIONS

Intra-arterial drug injection of the upper extremity carries an amputation incidence of nearly 30%. Conditions requiring adjunctive antibiotic use and delay in receiving care were both significantly associated with higher incidences of amputation. No single treatment protocol to date has established superiority.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

A mimic of soft tissue infection: intra-arterial injection drug use producing hand swelling and digital ischemia

BACKGROUND

Inadvertent intra-arterial injection of illicit substances is a known complication of injection drug use and can lead to severe complications, including infection, ischemia and compartment syndrome. Identifying complications of intra-arterial injection can be difficult, as clinical manifestations overlap with other more common conditions such as cellulitis and soft tissue infection, and a history of injection drug use is frequently not disclosed.

METHODS

A 37-year-old male patient presented with 24 hours of right hand pain, erythema and swelling. Despite classic "track marks", he denied a history of injection drug use, and vascular insults were not initially considered. After failing to respond to three days of aggressive treatment for suspected deep-space infection, an arteriogram demonstrated findings consistent with digital ischemia of embolic etiology.

RESULTS

As a result of the delay in diagnosis, the lesion was not amenable to reperfusion and the patient required amputation of the distal digit.

CONCLUSION

Practitioners should be alert to the possibility of intra-arterial injection and resulting complications when evaluating unusual extremity infections or unexplained ischemic symptoms, even in the absence of a definite history of injection drug use.