Low-concentration, continuous brachial plexus block in the management of Purple Glove Syndrome: a case report

Comparison of Single-Dose Infraclavicular Brachial Plexus Block and Continuous Infraclavicular Brachial Plexus Block Applications in the Treatment of Finger Amputations

Introduction The aim of this study is to evaluate the replantation success of single-dose infraclavicular brachial plexus block and continuous infraclavicular brachial plexus block (CIBPB) applied with bupivacaine and prilocaine in patients with finger amputation. Materials and Methods This prospective randomized nonblinded study was conducted between January 2012 and September 2017, and 47 patients, all male, were included. Patients were randomly separated into two groups as 23 patients CIBPB applied group (group A) and 24 patients single-dose infraclavicular block applied group (group B). In group B, after the effect of block is ceased, intravenous patient-controlled (PC) opioid analgesia and, where necessary, 1 mg/kg meperidine and 75 mg diclofenac sodium intramuscularly were alternately administered at 4 to 6 hours intervals. The average ages were 30.7 ± 10.06 and 29 ± 9.08, respectively. Replantations were applied as being two venous anastomoses to one artery, where possible. Hourly skin temperatures of fingers of the hands in which both surgeries applied and no surgery applied in both the groups were measured for 3 days with an infrared thermometer. Also, Numerical Rating Scale (NRS) evaluations in both the groups were performed in 3-hour intervals for 3 days. Results Replantations were successful in 22 patients in whom CIBPB was applied (95.6%) and in 19 patients in whom single block was applied (79.16%). Regarding the finger temperatures, no significant difference was detected between both the groups for 3 days following the operation. No significant difference was found between the length of hospital stays (4.73 ± 2.21-4.71 ± 1.53) and duration of operations (2.90 ± 0.73-2.83 ± 0.58). There was no significant difference between the temperature values of both the groups. NRS scores of group A were statistically significantly lower than those of group B. Conclusion In this prospective randomized study performed by using bupivacaine and prilocaine on 24 patients, the success rate of finger replantations with CIBPB was found to be higher. CIBPB is a very beneficial method that should be taken in consideration in hand injuries with anastomosis and high risk of vasospasm. Further studies with more number of cases would help reduce the question marks related with the success of this method.

Purple Glove Syndrome after Phenytoin or Fosphenytoin Administration: Review of Reported Cases and Recommendations for Prevention

The aim of our study was to identify all previously reported cases of phenytoin- or fosphenytoin-associated purple glove syndrome (PGS) and summarize the most current understanding of the pathophysiology, clinical presentation, diagnosis, and treatment of the disease. We searched the English language references from MEDLINE, EMBASE, CINAHL, TOXNET, and gray literature that featured one or more case descriptions of phenytoin- or fosphenytoin-associated PGS after administration and provided information on the clinical setting of the event and associated outcome(s). Descriptive statistics were employed to summarize relevant facts about the cases. We identified 82 unique cases of parenteral phenytoin-associated PGS and 5 cases of fosphenytoin-associated PGS that were published from 1984 to 2015. Additionally, we found two cases of PGS associated with oral formulation of phenytoin published from 1999 to 2015. The spectrum of tissue injury ranged from mild local cutaneous reactions around the infusion site to frank limb ischemia. Just over a half of cases reported symptoms after one dose of IV phenytoin. Pathologic findings included evidence for microvascular thrombosis and possible microvascular or subclinical extravasation as a contributing mechanism. Dopper ultrasound and conventional angiography were used in some patients to identify arterial or venous thrombosis. Various treatments were documented including the use of supportive care such as limb elevation and heat or cold application, utilization of systemic antibiotics, anticoagulants, or vasodilators, and local infiltration of hyaluronidase, heparin, or other compounds. In a small number of patients, invasive interventions such as regional anesthesia, thrombectomy, fasciotomy, and debridement were described. Time to resolution varied from days to weeks. Resolution of PGS without deficits was documented in the majority of cases. Skin changes followed by sensory and motor deficits were described in 16, 6, and 5 cases, respectively. Four patients underwent skin grafting and eight patients required limb amputation. Death as a result of PGS was documented in two patients. PGS associated with oral and injectable phenytoin or parenteral fosphenytoin has been documented in the literature and sometimes includes significant vascular thrombosis and potentially limb-threatening ischemia. Avoidance of small hand veins, adherence to recommended IV administration guidelines and monitoring of the infusion site for reactions should be considered to decrease the morbidity of IV phenytoin or fosphenytoin use. Patients with PGS and evidence of decreased distal perfusion should undergo prompt vascular imaging and potential intervention to avoid ischemic sequelae. Alternative anticonvulsant drugs should be considered in patients at risk for PGS when possible.

Phenytoin-Induced Purple Glove Syndrome: A Case Report and Review of the Literature

OBJECTIVE

To present a case report and literature review of phenytoin-induced purple glove syndrome (PGS).

CASE SUMMARY

A 54-year-old African American male presented to our hospital's emergency department (ED) following a seizure episode, cardiac arrest, and loss of consciousness. On arrival to the ED, the patient's total phenytoin level was subtherapeutic at 4.1 mcg/mL and his corrected total phenytoin level was subtherapeutic at 5.1 mcg/mL. In the ED, the patient received a loading dose of intravenous (IV) phenytoin 1,000 mg once via the left cephalic vein, at a rate of 50 mg/min, and was admitted to the medicine service. A day following IV phenytoin administration, a nurse noticed an IV fluid infiltration on the skin tissue around the left cephalic vein. The area appeared dark blue and purple in color, swollen, erythematous, and warm to touch. An ultrasound of the left upper extremity was performed and revealed subcutaneous fluid collection without evidence of thrombosis.

DISCUSSION

The Naranjo Adverse Drug Reaction Probability Scale assigned a score of 7, indicating phenytoin as the probable cause of purple glove syndrome (PGS). The patient's PGS was managed with a combination of dry dressing material, left forearm elevation, collagenase topical cream, 0.1% IV bupivacaine, and IV fentanyl. The patient's injury was resolving at the time of discharge to a rehabilitation facility.

CONCLUSION

PGS is a rare complication of IV phenytoin therapy. The risk of PGS for this patient may have been abated by decreasing the phenytoin infusion rate from 50 mg/min to less than 25 mg/min.