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Parsi K, De Maeseneer M, van Rij AM, Rogan C, Bonython W, Devereux JA, Lekich CK, Amos M, Bozkurt AK, Connor DE, Davies AH, Gianesini S, Gibson K, Gloviczki P, Grabs A, Grillo L, Hafner F, Huber D, Iafrati M, Jackson M, Jindal R, Lim A, Lurie F, Marks L, Raymond-Martimbeau P, Paraskevas P, Ramelet AA, Rial R, Roberts S, Simkin C, Thibault PK, Whiteley MS. Guidelines for management of actual or suspected inadvertent intra-arterial injection of sclerosants. Phlebology 2024:2683555241260926. [PMID: 39046331 DOI: 10.1177/02683555241260926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
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.
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Affiliation(s)
- Kurosh Parsi
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Australasian College of Phlebology (ACP), Chatswood, NSW, Australia
- Department of Dermatology, St Vincent's Hospital, Sydney, NSW, Australia
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Dermatology, Phlebology and Fluid Mechanics Laboratory, St Vincent's Centre for Applied Medical Research, Darlinghurst, NSW, Australia
| | | | - Andre M van Rij
- Australasian College of Phlebology (ACP), Chatswood, NSW, Australia
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Christopher Rogan
- Interventional Radiology Society of Australasia (IRSA), Camperdown, NSW, Australia
- Department of Medical Imaging, Sydney Adventist Hospital, Sydney, NSW, Australia
- Macquarie University Hospital, Sydney, NSW, Australia
| | - Wendy Bonython
- Faculty of Law, Bond University, Gold Coast, QLD, Australia
| | - John A Devereux
- University of Queensland Law School, University of Queensland, Saint Lucia, QLD, Australia
| | | | - Michael Amos
- Department of Anaesthesiology, Concord Hospital, Sydney, NSW, Australia
| | - Ahmet Kursat Bozkurt
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Department of Cardiovascular Surgery, Istanbul University, Istanbul, Turkie
| | - David E Connor
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Dermatology, Phlebology and Fluid Mechanics Laboratory, St Vincent's Centre for Applied Medical Research, Darlinghurst, NSW, Australia
| | - Alun H Davies
- European College of Phlebology, Rotterdam, The Netherlands
- Vascular Surgery, Imperial College London, Charing Cross and St Mary's Hospital, London, UK
| | - Sergio Gianesini
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Vascular Surgery, University of Ferrara, Ferrara, Italy
| | | | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Anthony Grabs
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Department of Vascular Surgery, St Vincent's Hospital, Sydney, NSW, Australia
| | - Lorena Grillo
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Vascular Surgery, University of Medical Sciences (UCIMED), San Jose, Costa Rica
| | - Franz Hafner
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - David Huber
- Art of Vein Care, Wollongong, NSW, Australia
| | - Mark Iafrati
- American Venous Forum (AVF), East Dundee, IL, USA
- Vanderbilt University Medical Center, Vanderbuilt University, Nashville, TN, USA
| | - Mark Jackson
- Australian and New Zealand Society for Vascular Surgery(ANZSVS), Melbourne, VIC, Australia
- Department of Vascular Surgery, Gold Coast University Hospital, Gold Coast, QLD, Australia
- School of Medicine, Griffith University, Gold Coast, QLD, Australia
| | - Ravul Jindal
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Vascular Surgery, Fortis Hospital, Mohali, India
| | - Adrian Lim
- Department of Dermatology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Fedor Lurie
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Jobst Vascular Institute, Toledo, OH, USA
- Section of Vascular Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Lisa Marks
- Australasian College of Phlebology (ACP), Chatswood, NSW, Australia
- Brighton Day Surgery, Adelaide, SA, Australia
| | - Pauline Raymond-Martimbeau
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Dallas Non-Invasive Vascular Laboratory and Vein Institute of Texas, Dallas, TX, USA
| | | | | | - Rodrigo Rial
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Vascular and Endovascular Surgery, University Hospital HM Madrid, Torrelodones, Spain
| | | | - Carlos Simkin
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Clínica Simkin, Buenos Aires, Argentina
| | - Paul K Thibault
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Australasian College of Phlebology (ACP), Chatswood, NSW, Australia
- Central Vein and Cosmetic Medical Centre, Newcastle, NSW, Australia
| | - Mark S Whiteley
- The College of Phlebology, Guildford, UK
- The Whiteley Clinic, Guildford, UK
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Muacevic A, Adler JR. An Overview of the Treatment Strategies of Extremities Ischemia in the Intensive Care Unit. Cureus 2023; 15:e33454. [PMID: 36751165 PMCID: PMC9899499 DOI: 10.7759/cureus.33454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2023] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES To investigate the effect of the peripheral block on peripheral ischemia on the extremities of patients in the intensive care unit (ICU). MATERIALS AND METHODS Sixty-two patients with ischemic peripheral vascular disease were divided retrospectively into two groups; Group 1 (patients who underwent USG-guided infraclavicular or femoral block, n=20) and Group 2 (patients who did not experience any block, n=42). The demographic characteristics of the patients, the diagnosis of hospitalization, the day when the circulatory disorder developed, laboratory tests at the time of diagnosis, other medical treatments applied, presence of inotropic support, the response of ischemia on extremities, amputation, duration of hospital stay, discharge and mortality were compared. RESULTS The most common reason for hospitalization was cerebrovascular disease. There was no statistical difference between the groups regarding age, gender, height, body weight, and diagnosis. There was no statistical difference between the groups regarding hematocrit, lactate, creatinine, and albumin values, the day when the peripheral ischemia developed in extremities, inotropic and prednisolone use, presence of cannulation, length of hospital stays, and mortality. The number of patients discharged from the intensive care unit in Group 1 was significantly higher than in Group 2 (p=0.048). Amputation was performed on one patient in Group 1 and two patients in Group 2. There was a decrease in peripheral ischemia in 14 (70%) of the patients in Group 1 and 25 (59.5%) of the patients in Group 2. CONCLUSIONS Targeted peripheral block techniques for peripheral circulatory disorders for selected ICU patients in conjunction with preventive and medical treatments may decrease peripheral ischemia in extremities and increase ICU discharge.
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3
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Intra-arterial injection of Diclofenac by informal health practitioner: A rare complication of a common drug. Ann Med Surg (Lond) 2022; 83:104736. [DOI: 10.1016/j.amsu.2022.104736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/18/2022] [Accepted: 09/18/2022] [Indexed: 11/19/2022] Open
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4
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Technique of Wide-Awake Local Anesthesia No Tourniquet Injection for a Transradial Forearm Amputation in an Ischemic Hand. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 4:432-436. [DOI: 10.1016/j.jhsg.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 04/02/2022] [Indexed: 11/22/2022] Open
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5
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Johnson JG, Chinnadurai SK. Drug Delivery and Safety Considerations. Vet Clin North Am Exot Anim Pract 2021; 25:1-11. [PMID: 34823686 DOI: 10.1016/j.cvex.2021.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Anesthetic drugs must be delivered at the appropriate dose and route of administration to produce the expected anesthetic effects. This is important for patient safety because anesthetic drugs function by depressing the central nervous and cardiovascular systems, which if improperly dosed or administered could cause potentially life-threatening effects. Several routes of administration and different drug delivery methods are available to safely and reliably anesthetize zoologic companion animal patients. Because of the nature of zoologic companion animal practice, anesthetic procedures pose risks that the anesthetist should understand to carefully plan procedures that are as safe and efficient as possible.
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Affiliation(s)
- James G Johnson
- Department of Animal Health, Saint Louis Zoo, One Government Drive, St Louis, MO 63110, USA; Department of Veterinary Preventative Medicine, College of Veterinary Medicine, The Ohio State University, Columbus, OH 43210, USA.
| | - Sathya K Chinnadurai
- Department of Animal Health, Saint Louis Zoo, One Government Drive, St Louis, MO 63110, USA
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6
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Al-Shareef AS, Darweish A, Shirah B. Inadvertent Arterial Cannulation and Norepinephrine Infusion Due to a Misplaced Central Venous Catheter. Cureus 2021; 13:e17757. [PMID: 34659970 PMCID: PMC8494162 DOI: 10.7759/cureus.17757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2021] [Indexed: 11/25/2022] Open
Abstract
Central venous catheter (CVC) insertion is one of the most common procedures done for critically ill patients. The subclavian vein is the particular preferred site. Misplacement of a CVC via the subclavian vein is frequent and can result in life-threatening complications. We aim to report a rare complication of misplaced CVC in the left subclavian vein and norepinephrine infusion that was associated with right upper limb ischemia. Immediate recognition and intervention are key to prevent further complications. The use of ultrasound has proven to reduce such complication, and the hospital implemented the use of ultrasound prior to any CVC placement.
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Affiliation(s)
- Ali S Al-Shareef
- Department of Emergency Medicine, King Abdulaziz Medical City, Jeddah, SAU.,Research Office, King Abdullah International Medical Research Center, Jeddah, SAU.,College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Aida Darweish
- Department of Emergency Medicine, King Abdulaziz Medical City, Jeddah, SAU.,Research Office, King Abdullah International Medical Research Center, Jeddah, SAU.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Bader Shirah
- Research Office, King Abdullah International Medical Research Center, Jeddah, SAU.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, SAU
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7
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Yan G. Extravasation of Concentrated Potassium Chloride: A Case Report. CURRENT THERAPEUTIC RESEARCH 2021; 95:100646. [PMID: 34745392 PMCID: PMC8554452 DOI: 10.1016/j.curtheres.2021.100646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 09/25/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The extravasation of potassium chloride will cause serious harm, especially if it is not diagnosed or treated promptly. Objective:to report the clinical course of a patient who was suffering a potassium extravasation and to discuss steps that can be done to decrease the chances of this event from occurring in other patients. METHODS After discontinuation of infusion device and withdrawal of intravenous catheter, wet packing with magnesium sulfate and local injection of papaverine and lidocaine were applied. RESULTS After 11 days, the extravasation injury had recovered. CONCLUSIONS To avoid a repeat of such an adverse event, proper sites for administering, accurate dilution of potassium chloride solutions, close observation, and increased awareness of trained personnel of extravasation dangers are vital. Once extravasation occurs, timely wet application with magnesium sulfate and local injection of papaverine and lidocaine may have been useful in producing a favorable recovery.
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Affiliation(s)
- Guifang Yan
- Burn and Plastic Department, the First Affiliated Hospital of Chengdu Medical College, Sichuan, China
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8
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Maldarelli ME, Traver EC, Norcross G, Gann D, Kattakuzhy S, Welsh C, Schmalzle SA. Acute Limb Ischemia Caused by Inadvertent Arterial Drug Self-Injection: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e932903. [PMID: 34392302 PMCID: PMC8378779 DOI: 10.12659/ajcr.932903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
| | - Edward Conan Traver
- Department of Infectious Diseases, University of Maryland Medical Center, Baltimore, MD, USA
| | - Gregory Norcross
- Department of Internal Medicine, University of Maryland Medical Center, Baltimore, MD, USA
| | - Donald Gann
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sarah Kattakuzhy
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Christopher Welsh
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sarah Ann Schmalzle
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA.,Division of Infectious Disease, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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9
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Vu M, Wisell J, Wohltmann W. Cutaneous foreign body microemboli-induced occlusive vasculopathy: A complication of illicit intravenous injection of oral opioid tablets. J Cutan Pathol 2021; 48:1173-1177. [PMID: 33934378 DOI: 10.1111/cup.14039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 04/20/2021] [Accepted: 04/28/2021] [Indexed: 10/21/2022]
Abstract
Occlusive nonvasculitic vasculopathy is a process characterized clinically by retiform purpura and potential ulceration and necrosis of affected areas, secondary to blockage of small vessels without associated inflammatory vasculitis. Intravascular injection of foreign material is known to cause distal ischemia and necrosis due to thrombosis, local vasoconstriction, or microemboli formation. A 27-year-old male presented with retiform purpura and worsening distal fingertip necrosis of the right upper extremity accompanied by suspicious intravascular polarizable foreign material identified on skin, muscle, and vascular biopsies. We report a case that highlights concerning complications and dermatopathologic findings of intravascular injection of oral opioid tablets.
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Affiliation(s)
- Marie Vu
- University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Joshua Wisell
- Department of Pathology, University of Colorado, Denver, Colorado, USA
| | - Wendi Wohltmann
- Department of Dermatology, Uniformed Services University of the Health Sciences, San Antonio Military Medical Center, San Antonio, Texas, USA
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10
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Détriché G, Goudot G, Khider L, Galloula A, Guillet M, Lillo-Le Louët A, Messas E, Mirault T. Acute Digital Ischemia After Arterial Injection of Crushed Zolpidem Tablets: Role of Microcrystalline Cellulose? A Case Report. Front Pharmacol 2020; 11:560382. [PMID: 33390940 PMCID: PMC7775664 DOI: 10.3389/fphar.2020.560382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 10/23/2020] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Grégoire Détriché
- Vascular Medicine, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, APHP centre Université de Paris, Paris, France.,INSERM U970, Paris Cardiovascular Research Center, Paris, France
| | - Guillaume Goudot
- Vascular Medicine, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, APHP centre Université de Paris, Paris, France.,Physics for Medicine Paris, INSERM U1273, ESPCI Paris, CNRS FRE 2031, PSL Research University, Paris, France
| | - Lina Khider
- Vascular Medicine, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, APHP centre Université de Paris, Paris, France.,Physics for Medicine Paris, INSERM U1273, ESPCI Paris, CNRS FRE 2031, PSL Research University, Paris, France
| | - Alexandre Galloula
- Vascular Medicine, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, APHP centre Université de Paris, Paris, France
| | - Matthieu Guillet
- Vascular Medicine, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, APHP centre Université de Paris, Paris, France
| | - Agnès Lillo-Le Louët
- Centre Régional de Pharmacovigilance de Paris-Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, APHP centre Université de Paris, Paris, France
| | - Emmanuel Messas
- Vascular Medicine, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, APHP centre Université de Paris, Paris, France.,INSERM U970, Paris Cardiovascular Research Center, Paris, France.,Physics for Medicine Paris, INSERM U1273, ESPCI Paris, CNRS FRE 2031, PSL Research University, Paris, France.,VASC European Research Network, Centre de Référence des Maladies Vasculaires Rares, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, APHP centre Université de Paris, Paris, France
| | - Tristan Mirault
- Vascular Medicine, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, APHP centre Université de Paris, Paris, France.,INSERM U970, Paris Cardiovascular Research Center, Paris, France.,Physics for Medicine Paris, INSERM U1273, ESPCI Paris, CNRS FRE 2031, PSL Research University, Paris, France.,VASC European Research Network, Centre de Référence des Maladies Vasculaires Rares, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, APHP centre Université de Paris, Paris, France
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11
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Haldipur N, Forsyth J, Webster P. Iatrogenic intra-arterial injection in the upper limb: A pragmatic guide for the on-call vascular surgeon. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.4103/ijves.ijves_41_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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12
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Kumar V, Salaria AK, Kumar P, Dogra E, Singh G, Aggarwal S. Digital Ischemia Following Brachial Artery Cannulation in a Polytrauma Patient: A Case-Based Discussion of Etiopathogenesis and Management. J Orthop Case Rep 2020; 10:40-45. [PMID: 32953653 PMCID: PMC7476694 DOI: 10.13107/jocr.2020.v10.i02.1688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Iatrogenic digital ischemia following inadvertent intra-arterial injections is well documented. Most of the culprit drugs are used for sedation or in general anesthesia. Proper understanding of the causative factors and pathophysiology is of utmost importance for adequate treatment. There have been conflicting evidences in the numerous studies and theories proposed regarding pathophysiology. We scoped the available literature to find out the cause of digital ischemia in one of the patients presented to us but could not find a convincing answer. Due to incomplete understanding of the pathophysiology, there is no specific treatment protocol. Most important is vigilance regarding risk factors, knowledge of typical medications, immediate recognition of the situation, assessment of the disease progression, anticoagulation, symptomatic treatment, and specific therapy (which varies from case to case) are mainstay of treatment. Further research is warranted to understand the etiopathogenesis so that proper treatment protocol could be established.
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Affiliation(s)
- Vishal Kumar
- Department of Orthopaedic Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amit Kumar Salaria
- Department of Orthopaedic Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Prasoon Kumar
- Department of Orthopaedic Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ekta Dogra
- Department of Community Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Gaganpreet Singh
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences, Bathinda, India
| | - Sameer Aggarwal
- Department of Orthopaedic Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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13
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Lokoff A, Maynes JT. The incidence, significance, and management of accidental intra-arterial injection: a narrative review. Can J Anaesth 2019; 66:576-592. [PMID: 30877587 DOI: 10.1007/s12630-019-01327-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 12/05/2018] [Accepted: 12/08/2018] [Indexed: 10/27/2022] Open
Abstract
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.
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Affiliation(s)
- Andrew Lokoff
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada. .,Department of Anesthesia, University of Toronto, Toronto, ON, Canada.
| | - Jason T Maynes
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada.,Department of Anesthesia, University of Toronto, Toronto, ON, Canada
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14
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Zhang H, Kumar S. Unintended intra-arterial injection of contrast of an intracranial CT angiography. Radiol Case Rep 2018; 14:41-43. [PMID: 30305864 PMCID: PMC6175775 DOI: 10.1016/j.radcr.2018.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 08/30/2018] [Accepted: 09/03/2018] [Indexed: 12/02/2022] Open
Abstract
Computed tomography angiography (CTA) is widely used to evaluate intracranial vascular disease. We report a case of intracranial CTA with unintended intra-arterial (IA) injection of contrast due to IA placement of an intravenous cannula, which results in a selective left vertebral artery IA CTA. Knowledge of anatomy is essential in analyzing the whole study and identifying the error. In clinical practice, it is important to avoid and recognize a wrongly placed intravenous cannula. And bolus tracking protocol might play a role as a gatekeeper.
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Affiliation(s)
- Han Zhang
- Neuroradiology, Level B1, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore
| | - Sumeet Kumar
- Neuroradiology, Level B1, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore
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Dumps C, Halbeck E, Bolkenius D. Medikamente zur intravenösen Narkoseinduktion: Barbiturate. Anaesthesist 2018; 67:535-552. [DOI: 10.1007/s00101-018-0440-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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16
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Bercovici N, Russomanno K, Santoro F, Scola C, Murphy M, Elaba Z. Cutaneous refractile foreign body microemboli with intravascular injection of oral medication. J Cutan Pathol 2018; 45:365-368. [DOI: 10.1111/cup.13125] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 01/25/2018] [Accepted: 02/06/2018] [Indexed: 11/28/2022]
Affiliation(s)
| | - Kristen Russomanno
- Department of Dermatology, University of Connecticut School of Medicine; Farmington Connecticut
| | - Frank Santoro
- Department of Pathology; Hartford Hospital; Hartford Connecticut
| | | | - Michael Murphy
- Department of Dermatology, University of Connecticut School of Medicine; Farmington Connecticut
| | - Zendee Elaba
- Department of Pathology; Hartford Hospital; Hartford Connecticut
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Bulic K, Antabak A, Lorencin M. Near-Complete Hand Loss Following an Unintentional, Intra-arterial Medicine Injection in an Infant. J Pediatr Intensive Care 2018; 7:43-45. [PMID: 31073466 DOI: 10.1055/s-0037-1601336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 02/18/2017] [Indexed: 10/19/2022] Open
Abstract
Unintentional, intra-arterial administration of medicines can lead to very serious sequelae, including limb loss. We present a case of a 13-week-old boy who was unintentionally given phenobarbital into his right radial artery, which resulted in a near-complete hand amputation. Pediatric patients are under increased risk of such injuries due to their small vessel size and their inability to express immediate complaints, which often leads to a delayed recognition of the condition. As no specific treatment algorithms have been established, the mainstay of therapy is supportive care aimed at maintaining vascular patency. Prompt recognition is imperative in avoiding potentially detrimental effects; therefore, all personnel administering intravenous therapy should be aware of this possibility and be acquainted with the initial supportive measures.
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Affiliation(s)
- Kresimir Bulic
- Department of Surgery, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Anko Antabak
- Department of Surgery, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Mia Lorencin
- Department of Surgery, University of Zagreb School of Medicine, Zagreb, Croatia
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Shon HC, Park JK, Kang SW, Yang JY. Necrosis of the thumb after inadvertent injection of diclofenac in the radial artery: a case report. J Pain Res 2017; 10:2803-2806. [PMID: 29263695 PMCID: PMC5732554 DOI: 10.2147/jpr.s150306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Inadvertent intra-arterial drug injection occurs rarely, but it can cause very serious clinical complications, and thus, awareness of inadvertent intra-arterial drug injection is needed. The complications mainly result from iatrogenic reasons and can occur because of vascular variations in the arteries, under circumstances where normal intravenous injection is difficult, or in drug abusers who perform self-injection. The adverse effect associated with intra-arterial drug injection is serious and may lead to necrosis, requiring amputation of the affected extremity, infection, pseudoaneurysm, rhabdomyolysis, compartment syndrome, and permanent disability. However, the etiology of such adverse effects has not been clearly identified and treatment methods have not yet been established. We encountered a patient who developed necrosis of the thumb after an inadvertent injection of diclofenac sodium in the radial artery due to variations in the forearm arteries. Here, we report the prevention and treatment of, and precautions against, the dangers of intra-arterial drug injection.
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Affiliation(s)
- Hyun-Chul Shon
- Department of Orthopaedic Surgery, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Ji-Kang Park
- Department of Orthopaedic Surgery, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Sang-Woo Kang
- Department of Orthopaedic Surgery, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Jae-Young Yang
- Department of Orthopaedic Surgery, College of Medicine, Chungbuk National University, Cheongju, Korea
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Thillainathan S, Mariyaselvam MZ. Why has NHS England introduced an innovation and technology tariff to improve safer arterial systems in England? Br J Anaesth 2017; 119:1231-1232. [PMID: 29156027 DOI: 10.1093/bja/aex361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Wilson RM, Elmaraghi S, Rinker BD. Ischemic Hand Complications From Intra-Arterial Injection of Sublingual Buprenorphine/Naloxone Among Patients With Opioid Dependency. Hand (N Y) 2017; 12:507-511. [PMID: 28832211 PMCID: PMC5684922 DOI: 10.1177/1558944716672198] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Sublingual buprenorphine/naloxone, a common treatment for opioid dependence, is frequently abused by intravenous injection. Inadvertent intra-arterial injection of buprenorphine/naloxone can produce acute ischemic insult to the hand due to gelatin embolism. Our purpose was to review a series of these patients in order to describe the clinical entity, review the outcomes, and propose a rational treatment algorithm. METHODS Clinical records of all patients evaluated by the hand surgery team between 2011 and 2015 for ischemia of the hand after buprenorphine/naloxone injection were reviewed. Treatment, complications, and amount of tissue loss were recorded. Patients presenting within 48 hours of the injection were treated with intravenous heparin for 5 days, followed by oral aspirin and clopidogrel for 30 days. Those presenting after 48 hours were treated with aspirin and clopidogrel only. RESULTS Ten patients presented during the review period. Average follow-up time was 13 weeks. Eight had ischemia of the radial side of the hand, 1 of the ulnar side, and 1 had bilateral ischemia. Three patients were treated with intravenous heparin and 5 with oral agents. Two presented with dry gangrene and did not receive anticoagulation. All patients experienced tissue loss. There was no difference in outcome regardless of treatment. CONCLUSIONS With the increasing use of sublingual buprenorphine/naloxone in opioid dependency, ischemic hand injuries will be seen with greater frequency. Whereas outcomes did not vary with treatment modality in this series, further study is needed to determine the most effective treatment of these injuries.
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Salama T, Aghoutane EM, Fezzazi RE. [Gangrene of the hand due to accidental intra-arterial injection of floxacilline: about a case]. Pan Afr Med J 2017; 25:221. [PMID: 28293337 PMCID: PMC5337270 DOI: 10.11604/pamj.2016.25.221.10803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 10/17/2016] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Tarik Salama
- Service de Chirurgie Pédiatrique A, Départment des maladies de L'Enfant, CHU Mohammed VI, Université Cadi Ayyad, Marrakech, Maroc
| | - El Mohtadi Aghoutane
- Service de Chirurgie Pédiatrique A, Départment des maladies de L'Enfant, CHU Mohammed VI, Université Cadi Ayyad, Marrakech, Maroc
| | - Rédouane El Fezzazi
- Service de Chirurgie Pédiatrique A, Départment des maladies de L'Enfant, CHU Mohammed VI, Université Cadi Ayyad, Marrakech, Maroc
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Balthasar AJR, van Geffen GJ, van der Voort M, Lucassen GW, Roggeveen S, Bruaset IJ, Bruhn J. Spectral tissue sensing to identify intra- and extravascular needle placement - A randomized single-blind controlled trial. PLoS One 2017; 12:e0172662. [PMID: 28278194 PMCID: PMC5344374 DOI: 10.1371/journal.pone.0172662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 02/08/2017] [Indexed: 11/18/2022] Open
Abstract
Safe vascular access is a prerequisite for intravenous drug admission. Discrimination between intra- and extravascular needle position is essential for procedure safety. Spectral tissue sensing (STS), based on optical spectroscopy, can provide tissue information directly from the needle tip. The primary objective of the trial was to investigate if STS can reliably discriminate intra-vascular (venous) from non-vascular punctures. In 20 healthy volunteers, a needle with an STS stylet was inserted, and measurements were performed for two intended locations: the first was subcutaneous, while the second location was randomly selected as either subcutaneous or intravenous. The needle position was assessed using ultrasound (US) and aspiration. The operators who collected the data from the spectral device were blinded to the insertion and ultrasonographic visualization procedure and the physician was blinded to the spectral data. Following offline spectral analysis, a prediction of intravascular or subcutaneous needle placement was made and compared with the “true” needle tip position as indicated by US and aspiration. Data for 19 volunteers were included in the analysis. Six out of 8 intended vascular needle placements were defined as intravascular according to US and aspiration. The remaining two intended vascular needle placements were negative for aspiration. For the other 11 final needle locations, the needle was clearly subcutaneous according to US examination and no blood was aspirated. The Mann-Whitney U test yielded a p-value of 0.012 for the between-group comparison. The differences between extra- and intravascular were in the within-group comparison computed with the Wilcoxon signed-rank test was a p-value of 0.022. In conclusion, STS is a promising method for discriminating between intravascular and extravascular needle placement. The information provided by this method may complement current methods for detecting an intravascular needle position.
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Affiliation(s)
- Andrea J. R. Balthasar
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- * E-mail:
| | - Geert-Jan van Geffen
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | | | - Ivar J. Bruaset
- Department of Anesthesiology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Joergen Bruhn
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, The Netherlands
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Ali MA, Yahya M. Intentional intra-arterial injection of midazolam in a patient with status epilepticus in the Intensive Care Unit. Saudi J Anaesth 2017; 11:476-478. [PMID: 29033730 PMCID: PMC5637426 DOI: 10.4103/sja.sja_93_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Fundamental medical care includes intravenous (IV) access which provides prompt resuscitation and reliable delivery of analgesics, antibiotics, and vasoactive medication. Difficult access populations, especially in critical area, continue to challenge providers to consider and utilize alternative means to provide IV access. Potential options under such circumstances include intramuscular, intraosseous, and intratracheal drug administration, but in extreme cases where no other options are available, intra-arterial route might be considered. We present a case where midazolam was intentionally injected intra-arterially to abort seizure activity in a patient with status epilepticus in the Intensive Care Unit.
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Affiliation(s)
| | - Muhammad Yahya
- Department of Anaesthesia, Aga Khan University, Karachi, Pakistan
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Abstract
Intravenous injection of drugs is associated with a host of medical complications, notably soft-tissue infections. On the contrary, intra-arterial injections of drugs have also been reported, largely restricted to inadvertent injections. Here we describe a patient who engaged in repeated intra-arterial injections of heroin when she exhausted most of her venous access, and presented acutely with a radial artery occlusion requiring thrombolytic therapy. Clinicians should have a high index of suspicion for intra-arterial injection in injection drug users who present with limb pain, ischemia, and motor/sensory deficits. Given the reluctance patients may have in discussing their injection practices, clinicians should proactively discuss and counsel patients about safe injection practices and the dangers of intra-arterial injections.
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Lim WY, Raghavan KC. Identification and confirmation of suspected unintended peripheral arterial cannulation during anaesthesia. PROCEEDINGS OF SINGAPORE HEALTHCARE 2016. [DOI: 10.1177/2010105816685339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Unintended arterial cannulation and injection of drugs may result in ischaemia and tissue necrosis. Various methods used to differentiate accidental arterial from intravenous cannulation have their own shortcomings. Here we present the case of a 13-year-old girl having an elective procedure under general anaesthesia and the challenges faced in distinguishing suspected intra-arterial cannulation from what was indeed an intravenous cannulation. We recommend the use of an open-ended saline-filled ‘T’ connector–syringe system and pressure transduction as the methods of choice to identify and confirm, respectively, a suspected arterial cannulation during anaesthesia.
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Affiliation(s)
- Wan Yen Lim
- SingHealth Anaesthesiology Residency Programme, Singapore
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Teo MC, Shah VA. Digital ischaemia following inadvertent arterial cannulation of a peripherally inserted central catheter in a very low birth weight infant. Singapore Med J 2016; 56:482-3. [PMID: 26310354 DOI: 10.11622/smedj.2015125] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Min Charmaine Teo
- Department of Paediatric Medicine, National University Hospital, Singapore
| | - Varsha Atul Shah
- Department of Neonatal and Developmental Medicine, Singapore General Hospital, Singapore.
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Pikija S, Pilz G, Gschwandtner G, Rösler C, Schlick K, Greil R, Sellner J. Panitumumab-Associated Encephalopathy after Accidental Intra-arterial Application through Dislocated Central Venous Access Device. Front Neurol 2016; 7:196. [PMID: 27872609 PMCID: PMC5098172 DOI: 10.3389/fneur.2016.00196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 10/24/2016] [Indexed: 11/13/2022] Open
Abstract
Acute central nervous system (CNS) toxicity and immune-related side effects are increasingly recognized with the use of monoclonal antibodies for cancer therapy. Here, we report a patient who developed of acute-onset encephalopathy and coma, which began shortly after administration of panitumumab for the treatment of metastatic colorectal cancer. Echocardiography revealed that the drug had been infused into the left cardiac ventricle via a dislocated central venous line. Diffusion-weighted magnetic resonance imaging disclosed multiple cortical hyperintensities, which were preferentially located in the frontal lobes. While the neurological condition improved within a few days, the patient died 4 weeks later. It seems likely that the administration of the antibody via the intra-arterial route contributed to the development of this condition. Toxic encephalopathy may be a hitherto unrecognized complication of panitumumab treatment and should be taken into consideration in patients developing CNS symptoms undergoing this therapy.
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Affiliation(s)
- Slaven Pikija
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University Salzburg , Salzburg , Austria
| | - Georg Pilz
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University Salzburg , Salzburg , Austria
| | - Gerald Gschwandtner
- Department of Geriatric Medicine, Christian Doppler Medical Center, Paracelsus Medical University Salzburg , Salzburg , Austria
| | - Cornelia Rösler
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University Salzburg , Salzburg , Austria
| | - Konstantin Schlick
- Laboratory of Immunological Molecular Cancer Research, Department of Internal Medicine III with Hematology, Medical Oncology, Hemostaseology, Infectious Diseases, Rheumatology, Oncologic Center, Paracelsus Medical University Salzburg , Salzburg , Austria
| | - Richard Greil
- Laboratory of Immunological Molecular Cancer Research, Department of Internal Medicine III with Hematology, Medical Oncology, Hemostaseology, Infectious Diseases, Rheumatology, Oncologic Center, Paracelsus Medical University Salzburg , Salzburg , Austria
| | - Johann Sellner
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University Salzburg, Salzburg, Austria; Department of Neurology, Klinikum rechts der Isar, Technische Universität München, München, Germany
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Hancı V, Özbilgin Ş, Özbal S, Kamacı G, Ateş H, Boztaş N, Ergür BU, Arıkanoğlu A, Yılmaz O, Yurtlu BS. Evaluation of the effects of intra-arterial sugammadex and dexmedetomidine: an experimental study. Braz J Anesthesiol 2016; 66:456-64. [PMID: 27591458 DOI: 10.1016/j.bjane.2015.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 01/30/2015] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Volkan Hancı
- Dokuz Eylül University, School of Medicine, Department of Anesthesiology and Reanimation, İnciraltı, İzmir, Turkey.
| | - Şule Özbilgin
- Dokuz Eylül University, School of Medicine, Department of Histology and Embryology, İnciraltı, İzmir, Turkey
| | - Seda Özbal
- Dokuz Eylül University, School of Medicine, Department of Histology and Embryology, İnciraltı, İzmir, Turkey
| | - Gonca Kamacı
- Dokuz Eylül University, School of Medicine, Department of Experienced Laboratory Animal Science, İnciraltı, İzmir, Turkey
| | - Hasan Ateş
- Dokuz Eylül University, School of Medicine, Department of Plastic, Reconstructive and Aesthetic Surgery, İnciraltı, İzmir, Turkey
| | - Nilay Boztaş
- Dokuz Eylül University, School of Medicine, Department of Anesthesiology and Reanimation, İnciraltı, İzmir, Turkey
| | - Bekir Uğur Ergür
- Dokuz Eylül University, School of Medicine, Department of Histology and Embryology, İnciraltı, İzmir, Turkey
| | - Ahmet Arıkanoğlu
- Dokuz Eylül University, School of Medicine, Department of Anesthesiology and Reanimation, İnciraltı, İzmir, Turkey
| | - Osman Yılmaz
- Dokuz Eylül University, School of Medicine, Department of Experienced Laboratory Animal Science, İnciraltı, İzmir, Turkey
| | - Bülent Serhan Yurtlu
- Dokuz Eylül University, School of Medicine, Department of Anesthesiology and Reanimation, İnciraltı, İzmir, Turkey
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Avaliação dos efeitos de sugamadex e dexmedetomidina intra‐arterial: estudo experimental. Braz J Anesthesiol 2016; 66:456-64. [DOI: 10.1016/j.bjan.2015.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 01/30/2015] [Indexed: 11/23/2022] Open
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Gaudin A, Andrieux K, Couvreur P. Nanomedicines and stroke: Toward translational research. J Drug Deliv Sci Technol 2015. [DOI: 10.1016/j.jddst.2015.07.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Inadvertent Intra-Arterial Drug Injections in the Upper Extremity: Systematic Review. J Hand Surg Am 2015; 40:2262-2268.e5. [PMID: 26409581 DOI: 10.1016/j.jhsa.2015.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 08/03/2015] [Accepted: 08/03/2015] [Indexed: 02/02/2023]
Abstract
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.
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Foster SD, Lyons MS, Runyan CM, Otten EJ. A mimic of soft tissue infection: intra-arterial injection drug use producing hand swelling and digital ischemia. World J Emerg Med 2015; 6:233-6. [PMID: 26401188 DOI: 10.5847/wjem.j.issn.1920-8642.2015.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 05/29/2015] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Sean D Foster
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Michael S Lyons
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Christopher M Runyan
- Department of Plastic, Reconstructive & Hand Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Edward J Otten
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, USA
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Bushe CJ, Falk D, Anand E, Casillas M, Perrin E, Chhabra-Khanna R, Detke HC. Olanzapine long-acting injection: a review of first experiences of post-injection delirium/sedation syndrome in routine clinical practice. BMC Psychiatry 2015; 15:65. [PMID: 25886006 PMCID: PMC4389990 DOI: 10.1186/s12888-015-0450-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 03/19/2015] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Olanzapine long-acting injection (LAI) for the treatment of schizophrenia was associated with a cluster of symptoms termed post-injection delirium/sedation syndrome (PDSS) in a small percentage (~2%) of patients during clinical trials. The objective of this analysis was to evaluate the rate and clinical characteristics of PDSS since olanzapine LAI entered commercial use. METHODS Cases of PDSS were identified from all reported adverse events during worldwide commercial use of olanzapine LAI through to 1 March 2014. Data sources included two ongoing post-marketing safety studies as well as spontaneously reported adverse events from routine clinical practice over a 5-year period (1 March 2009 to 1 March 2014). RESULTS A total of 338 PDSS events were identified. Of these, 91% occurred within 1 hour of injection, and 52% of these occurred within 15 minutes. None of the PDSS events in this analysis were fatal, and most resolved within 72 hours. The most common symptoms (occurring in >30% of cases) were sedation (61%), confusion (56%), dysarthria (54%), somnolence (46%), dizziness (45%) and disorientation (35%). Overall, PDSS occurred with approximately 0.07% of injections and in 0.46-1.03% of patients (reporting and incidence rates from spontaneous reports and post-marketing safety studies, respectively). CONCLUSIONS The PDSS events reported during routine clinical use of olanzapine LAI are generally similar in incidence and presentation to those reported in clinical trials. Caution should be applied when interpreting spontaneously reported rates of adverse events, however, due to potential under-reporting. Implemented risk-minimisation activities may contribute substantially to the identification and appropriate management of patients with PDSS in clinical practice.
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Affiliation(s)
- Chris J Bushe
- Eli Lilly, Lilly House, Priestly Road, Basingstoke, Hampshire, RG24 9NL, UK.
| | - Deborah Falk
- Eli Lilly, Lilly Corporate Center, Indianapolis, IN, 46285, USA.
| | - Ernie Anand
- Eli Lilly, Erlwood, Windlesham, Surrey, GU20 6PH, UK.
| | - Marta Casillas
- Eli Lilly, Avda. de la Industria 30, 28108, Alcobendas, Madrid, Spain.
| | - Elena Perrin
- Eli Lilly, 13, Rue Pages, 92158, Suresnes Cedex, Paris, France.
| | | | - Holland C Detke
- Eli Lilly, Lilly Corporate Center, Indianapolis, IN, 46285, USA.
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de Armendi AJ, Butt AL. Intra-arterial injection; timely and proper treatment can make all the difference. Eur J Anaesthesiol 2015; 32:284-285. [PMID: 25675287 DOI: 10.1097/eja.0000000000000219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Alberto J de Armendi
- From the Department of Anesthesiology, University of Oklahoma Health Sciences Center Home, Oklahoma City, Oklahoma, USA
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Kumar M, Singh J, Sharma P, Khera A, Singh P. Accidental intra-arterial injection of diclofenac -case report. J Clin Diagn Res 2015; 9:PD16-7. [PMID: 25738031 DOI: 10.7860/jcdr/2015/11205.5430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 11/01/2014] [Indexed: 11/24/2022]
Abstract
Diclofenac sodium is a very common drug used in medical practice for analgesia and is freely available over the counter without any medical prescription. The drug is also the most commonly used or misused by quacks working all over India. Many case reports have been published on upper limb catastrophe of unintentional intra-arterial injection of barbiturates, thiopental sodium, narcotics, and tranquilizers but only two cases of inadvertent intra-arterial injection of diclofenac have been reported till date. Potential serious complication of inadvertent intra-arterial injection of diclofenac sodium leading to gangrene has been recently reported in medical literature. It is a medical emergency and literature has shown that timely diagnosis with early intervention can salvage the limb. We hereby report a case of accidental intra-arterial injection of diclofenac sodium in the ulnar artery by a quack for pain abdomen leading to gangrene of the distal part of affected little, ring and part of middle finger of right hand.
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Affiliation(s)
- Mohinder Kumar
- Associate Professor, Department of Surgery, MMISR, Mullana , Ambala, Haryana, India
| | - Jasdeep Singh
- Senior Resident, Department of Surgery, MMISR, Mullana , Ambala, Haryana, India
| | - Pratibha Sharma
- Post Graduate Resident, Department of Surgery, MMISR, Mullana , Ambala, Haryana, India
| | - Aadhar Khera
- Post Graduate Resident, Department of Surgery, MMISR, Mullana , Ambala, Haryana, India
| | - Puneet Singh
- Post Graduate Resident, Department of Surgery, MMISR, Mullana , Ambala, Haryana, India
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Lokoff A, Lokoff P. Unrecognized arterial cannulation due to the backflow feature of the BD Insyte™ Autoguard™ BC cannula. Can J Anaesth 2015; 62:542-3. [DOI: 10.1007/s12630-015-0319-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 01/13/2015] [Indexed: 11/28/2022] Open
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Freestyle Perforator-Based Fasciocutaneous Flap Reconstruction in Nicolau Syndrome-Related Tissue Necrosis. Indian J Surg 2015; 77:1187-90. [PMID: 27011533 DOI: 10.1007/s12262-015-1239-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 01/20/2015] [Indexed: 12/18/2022] Open
Abstract
The actual pathology of the Nicolau syndrome (NS) is still unknown. It is thought to involve direct vascular damage and vasospasm. Many NS cases were reported in the literature but a treatment protocol is still not established. However, after demarcation of the necrotic tissue, surgical intervention is mandatory. Five NS cases with extensive tissue necrosis on the upper lateral gluteal region were analyzed retrospectively. Operative technique was described in details for freestyle perforator-based fasciocutaneous flaps from the gluteal region to reconstruct defects of NS-related tissue necrosis. Freestyle perforator-based fasciocutaneous flaps were used for defect closure in all patients. All flaps survived totally. No complications occurred during the follow-up period. Although rare, NS is a serious complication of inadvertent intramuscular injections. Prevention is the best treatment. However, in case of large-tissue necrosis, freestyle perforator-based fasciocutaneous flaps harvested from the gluteal region is a satisfactory option for reconstruction.
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Singh A, Sidhu KS, Rai S. Accidental Intra-Arterial Injection during Test Dose of Injection of Benzyl Penicillin: Complications and Management—A Case Report. ACTA ACUST UNITED AC 2015. [DOI: 10.4236/crcm.2015.46043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Hohenstein C, Herdtle S, Hoyme M, Lauten A, Chaudhary T. Rescue of the limb after accidental injection of diazepam into femoral artery. Am J Emerg Med 2014; 32:1149.e5-6. [DOI: 10.1016/j.ajem.2014.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 02/17/2014] [Indexed: 10/25/2022] Open
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Acute Hand Ischemia after Unintentional Intraarterial Injection of Drugs: Is Catheter-Directed Thrombolysis Useful? J Vasc Interv Radiol 2014; 25:963-8. [DOI: 10.1016/j.jvir.2014.03.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 03/14/2014] [Accepted: 03/14/2014] [Indexed: 11/23/2022] Open
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Prabhu R, Shenoy R, Thinda N, Patel A, Sadhu S. Be Careful with an IV Line. J Clin Diagn Res 2014; 8:166-7. [PMID: 24783122 DOI: 10.7860/jcdr/2014/7937.4150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 02/11/2014] [Indexed: 11/24/2022]
Abstract
Obtaining an intravenous (IV) access is a simple procedure which can be done in almost any hospital setting. One of the most dreaded complications of this procedure is an inadvertent intra-arterial cannulation. This can result in an accidental injection of medications intra-arterially, which can potentially lead to life altering consequences. In the hope that these types of events can be prevented, we are presenting a case of a 57-year-old male who underwent bougie dilatation for an oesophageal stricture and was accidentally given medication for pain management intra-arterially through an improperly placed IV line, which resulted in ischaemia, gangrene and subsequent loss of the hand. Those who try to obtain an IV access should always be on the lookout for possible clues that can prevent an inadvertent IA injection, especially if cannulation is in an area where an artery is in close proximity to a vein; these clues include but are not limited to the following: a bright-red flash of blood in the cannula, pulsatile movement of blood in the IV line, and intense pain or burning at the site of injection. These signs, as well as educating the patient on early symptoms of ischaemia, may allow early action to be taken, to prevent irreparable damage. We always have to be careful when we insert an I.V line.
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Affiliation(s)
- Raghunath Prabhu
- Assistant Professor, Department of Surgery, Kasturba Medical College, Manipal University , Manipal, Karnataka, India
| | - Rajgopal Shenoy
- Professor, Department of Surgery, Kasturba Medical College, Manipal University , Manipal, Karnataka, India
| | - Nitin Thinda
- Intern, Department of Surgery, Kasturba Medical College, Manipal University , Manipal, Karnataka, India
| | - Anisha Patel
- Intern, Department of Surgery, Kasturba Medical College, Manipal University , Manipal, Karnataka, India
| | - Sakshi Sadhu
- Intern, Department of Surgery, Kasturba Medical College, Manipal University , Manipal, Karnataka, India
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Anatomical vascular variations and practical implications for access creation on the upper limb. J Vasc Access 2014; 15 Suppl 7:S70-5. [PMID: 24817459 DOI: 10.5301/jva.5000257] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2014] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND A profound knowledge of vascular anatomy and an understanding of vascular access functionality with respect to possible complications are critical in selecting the site for arteriovenous anastomosis. METHODS Outline of vasculature variations of the upper limb with prevalence reported in literature of at least 1%, which may affect access creation, is depicted in this review. RESULTS Over a dozen arterial anatomical anomalies of the upper limb, the most common is "high origin" of the radial artery (12-20%). Superficial positions of brachial, ulnar and radial artery as well as accessory brachial are another possible anatomic variants (0.5-7%). The most variable venous layout on the upper arm is seen in the anatomy of the brachial vein and the basilic vein forming the axillary vein. Three types of basilic vein course on upper arm have been described. CONCLUSIONS The mapping technique to assess vascular variants facilitate site selection for AVF creation even in cases with previously attempted failed access (misdiagnosed vascular variant could force to secondary options). Thus, a thorough understanding and evaluation of anatomy, taking into consideration the possible vascular variations of the forearm and upper arm, are necessary in the planning of AVF creation and increase the success of AVF procedures.
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Gálvez-Martín P, Hmadcha A, Soria B, Calpena-Campmany AC, Clares-Naveros B. Study of the stability of packaging and storage conditions of human mesenchymal stem cell for intra-arterial clinical application in patient with critical limb ischemia. Eur J Pharm Biopharm 2014; 86:459-68. [DOI: 10.1016/j.ejpb.2013.11.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 10/22/2013] [Accepted: 11/05/2013] [Indexed: 12/20/2022]
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Massive Schmerzen und livide Verfärbung des linken Beins nach intravaskulärer Heroininjektion bei einem 32-jährigen Patienten. Internist (Berl) 2014; 55:329-33. [DOI: 10.1007/s00108-014-3446-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Reynolds PM, MacLaren R, Mueller SW, Fish DN, Kiser TH. Management of extravasation injuries: a focused evaluation of noncytotoxic medications. Pharmacotherapy 2014; 34:617-32. [PMID: 24420913 DOI: 10.1002/phar.1396] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Extravasations are common manifestations of iatrogenic injury that occur in patients requiring intravenous delivery of known vesicants. These injuries can contribute substantially to patient morbidity, cost of therapy, and length of stay. Many different mechanisms are behind the tissue damage during extravasation injuries. In general, extravasations consist of four different subtypes of tissue injury: vasoconstriction, osmotic, pH related, and cytotoxic. Recognition of high-risk patients, appropriate cannulation technique, and monitoring of higher risk materials remain the standard of care for the prevention of extravasation injury. Prompt interdisciplinary action is often necessary for the treatment of extravasation injuries. Knowledge of the mechanism of extravasation-induced tissue injury, agents for reversal, and appropriate nonpharmacologic treatment methods is essential. The best therapeutic agent for treatment of vasopressor extravasation is intradermal phentolamine. Topical vasodilators and intradermal terbutaline may provide relief. Intradermal hyaluronidase has been effective for hyperosmotic extravasations, although its use largely depends on the risk of tissue injury and the severity of extravasation. Among the hyperosmotic agents, calcium extravasation is distinctive because it may present as an acute tissue injury or may possess delayed clinical manifestations. Extravasation of acidic or basic materials can produce significant tissue damage. Phenytoin is the prototypical basic drug that causes a clinical manifestation known as purple glove syndrome (PGS). This syndrome is largely managed through preventive and conservative treatment measures. Promethazine is acidic and can cause a devastating extravasation, particularly if administered inadvertently through the arteriolar route. Systemic heparin therapy remains the accepted treatment option for intraarteriolar administration of promethazine. Overall, the evidence for managing extravasations due to noncytotoxic medications is nonexistent or limited to case reports. More research is needed to improve knowledge of patient risk, prompt recognition of the extravasation, and time course for tissue injury, and to develop prevention and treatment strategies for extravasation injuries.
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Affiliation(s)
- Paul M Reynolds
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado; Department of Pharmacy, University of Colorado Hospital, Aurora, Colorado
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Ghatak T, Samanta S. Intra-arterial induction for emergency intubation-Should we use? Saudi J Anaesth 2013; 7:487-8. [PMID: 24348314 PMCID: PMC3858713 DOI: 10.4103/1658-354x.121068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Tanmoy Ghatak
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sukhen Samanta
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Dasgupta M, Adhikari S, Datta M. Inadvertent intraarterial injection leading to gangrene: a rare but devastating postoperative complication. J Obstet Gynaecol India 2013; 62:56-8. [PMID: 24293877 DOI: 10.1007/s13224-013-0359-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Accepted: 06/12/2012] [Indexed: 11/28/2022] Open
Affiliation(s)
- Mandira Dasgupta
- Department of Obstetrics & Gynaecology, Medical College & Hospitals, Calcutta, 559, Block N, New Alipore, Kolkata, 700 053 India
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Axillary-axillary interarterial chest loop graft for successful early hemodialysis access. J Vasc Access 2012; 14:291-4. [PMID: 23172167 DOI: 10.5301/jva.5000121] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2012] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Obtaining adequate vascular access in patients undergoing chronic hemodialysis therapy can be demanding, particularly for those in whom all peripheral venous options have been exhausted. CASE We present a case of a 46-year-old woman with a history of complex vascular access for end-stage renal failure for whom there was no remaining possibility of venous access and had reached a palliative stage. We implanted an emergency loop axillary-axillary interarterial early needling graft. Post-operatively, the patient made a quick and uneventful recovery, resuming hemodialysis after only six days with no interventions necessary up to four months follow-up. To the best of our knowledge, this is the first dedicated case report describing the successful implantation of an axillary-axillary interarterial chest loop graft to re-establish access in a patient with exhausted options. CONCLUSION We recommend the use of this technique to surgeons who find themselves in comparable situations in the future.
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Holland C, Jaeger L, Smentkowski U, Weber B, Otto C. Septic and aseptic complications of corticosteroid injections: an assessment of 278 cases reviewed by expert commissions and mediation boards from 2005 to 2009. DEUTSCHES ARZTEBLATT INTERNATIONAL 2012; 109:425-30. [PMID: 22787504 PMCID: PMC3394381 DOI: 10.3238/arztebl.2012.0425] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 02/02/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND Local corticosteroid injections can have serious septic and aseptic complications. METHODS From 2005 to 2009, medical expert committees and mediation boards reviewed 1528 cases of alleged treatment errors relating to injections. RESULTS 278 cases were identified in which complications arose after local glucocorticosteroid injections. The injections were intra-articular, paravertebral, intramuscular, and at other sites. In 39.6% of cases, treatment errors or patient information errors of the following types were found: aseptic technique was not maintained, injections were performed in the absence of an indication, time intervals between injections were too short, excessive doses were administered, infections were not diagnosed, erroneous injections were performed, patients were not informed of the risks, and there were errors of organization and documentation. CONCLUSIONS Injections of glucocorticosteroids must be performed in strict adherence to the manufacturer's instructions with respect to the composition of the solution to be injected, the quantity per injection, and the intervals between injections. Repeated injections with too little time between them raise the risk of infection. Physicians should pay more attention to this fact, particularly when deciding on the indication for paravertebral injections. Aseptic technique should be strictly maintained. The indication for the injection should be clearly documented. When glucocorticosteroids are injected into small joints and tendon spaces, the introduction of crystals into the subcutaneous tissue and adipose tissue should be avoided. The intramuscular administration of depot glucocorticosteroids should be avoided. Patients should be informed of the risk of infection and/or tissue atrophy, as well as of alternative forms of treatment.
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Affiliation(s)
- Christian Holland
- Expert Commitee for Medical Malpractice Claims of the North Rhine Medical Association, Düsseldorf.
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