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ПЕРИОПЕРАЦИОННЫЕ ТЕХНОЛОГИИ
Диагностика и тактика ведения пациентов в случае
непреднамеренной внутриартериальной инфузии при введении препаратов в вены локтевой ямки
ДЛЯ КОРРЕСПОНДЕНЦИИ
Ганди Фенил - интерн отделения сосудистой хирургии Медицинского колледжа Прамукхсвами, больница Шри-Кришна (Гуджарад, Индия). E-mail: fenilgandhi@me.com https://orcid.org/0000-0002-2634-5205
Патель Дж., Шах П., Ганди Ф.
Медицинский колледж Прамухсвами, Госпиталь Шри-Кришна, 388325, Гуджарат, Индия
Keywords:
внутриартериальная инфузия, диклофенак натрия, локтевая ямка, ишемия, гангрена, допплерография
Актуальность. Непреднамереннная внутриартериальная инфузия (НВИ) представляет собой редкий, но потенциально серьезный случай, требующий принятия неотложных мер. Как правило, случаи НВИ являются ятрогенными осложнениями внутривенного введения лекарственных препаратов. НВИ происходит при внутривенной инфузии в вены верхней конечности, вне зависимости от того, каким заболеванием обусловлено проведение манипуляции, и сопровождается внезапной сильной болью в руке с последующим цианозом и побледнением любой ее части.
Цель - выявление ранних факторов риска ампутации конечности вследствие НВИ. Кроме того, были рассмотрены различные подходы к лечению этого осложнения и определены протоколы, применение которых позволяет избежать ампутации или необратимой инвалидизации при НВИ. Материал и методы. Настоящее исследование «случай-контроль» проходило в отделении сосудистой хирургии больницы Шри-Кришна. Для оценки эффективности ранней диагностики и тактики ведения больных с этим осложнением были изучены 5 случаев НВИ. Состояние пациентов оценивали на основании классификации Рутерфорда (Rutherford), с использованием данных анамнеза и допплерографии.
Результаты. У 3 из 5 пациентов НВИ удалось диагностировать на раннем этапе, что позволило избежать ампутации и благодаря применению консервативной терапии и проведению фасцио-томии сохранить конечность. Однако у 2 из 5 пациентов наблюдалось почернение пальцев, им не удалось избежать хирургического вмешательства - была проведена ампутация пальцев. Исход операций был удовлеторительным, дальнейшие осложнения отсутствовали. Заключение. Ранняя диагностика и лечение имеют чрезвычайно важное значение при НВИ, ассоциирующейся с возможностью развития серьезных осложнений. Кроме того, особую важность имеет и разработка стандартного протокола, позволяющего в таких случаях не допустить ампутации конечности. И наконец, с целью предотвращения таких ситуаций медицинский персонал должен проходить регулярную тренировку.
Конфликт интересов. Авторы заявляют об отсутствии конфликта интересов.
Для цитирования: Патель Дж., Шах П., Ганди Ф. Диагностика и тактика ведения пациентов в случае непреднамеренной внутриартериальной инфузии при введении препаратов в вены локтевой ямки // Клин. и эксперимент. хир. Журн. им. акад. Б.В. Петровского. 2020. Т. 8, № 1. С. 74-79. 10.33029/2308-1198-2020-8-1-74-79 Статья поступила в редакцию 16.10.2019. Принята в печать 05.02.2020.
Evaluation & management of accidental intra-arterial injection in the ante-cubital fossa
Patel J., Shah P., Gandhi F.
Pramukhswami Medical College, Shree Krishna Hospital, 388325, Gujarat, India
Introduction. Intra-arterial drug injection is a rare but a potentially serious medical emergency. It is most commonly seen as an iatrogenic complication when administering an intravenous medication. Accidental intra-arterial injection was defined as an intravenous injection administered in the upper limb for any illness, which was followed by sudden severe pain in the limb followed by bluish discoloration of any part of the limb.
The aim of the study is to identify the risk factors early on for limb amputation following intra-arte-rial injection. We also wanted to assess efficacy of the various modalities of the treatments administered, and establish a standardized treatment plan for intra-arterial injection for limb salvaging. Since, intra-arterial injections are not a common incidence, it is difficult to follow and establish a standard plan of treatment to prevent an amputation and/or permanent disability. Material and methods. This was a case-control study conducted in the Vascular Surgery department of Shree Krishna Hospital. 5 cases of accidental intra-arterial injection were studied for the efficacy of early evaluation and management of each. The patients were studied based on Rutherford Classification, clinical history, and Doppler findings.
Results. 3 out of the 5 patients presented early and limb salvation was achieved. Conservative treatment and upper limb fasciotomy proved to aid with the limb salvation. However, 2 out of the 5 patients presented with complains of blackening of the digits. In these patients, limb salvation was not achieved and Ray's amputation was performed. All the patients recovered well, with proper functioning of the upper limb. The outcome was satisfactory without further complications. Conclusion. Early evaluation and management of a case of accidental intra-arterial injection is of utmost importance due to its serious complications. Also, it is important to have a standard treatment plan, which can be employed for limb salvation. Lastly, all medical professionals must be regularly trained in order to prevent such mishaps from happening.
CORRESPONDENCE
Gandhi FeniL - Intern, Department of Vascular Surgery, Pramukhswami Medical College, Shree Krishna Hospital (Gujarat, India). E-mail: fenilgandhi@me.com https://orcid.org/0000-0002-2634-5205
Keywords:
intra-arterial injection, diclofenac sodium, ante-cubital fossa, ischemia, gangrene, dopplerography
Conflict of interests. The authors declare no conflict of interests.
For citation: Patel J., Shah P., Gandhi F. Evaluation & management of accidental intra-arterial injection in the antecubital fossa. Clin Experiment Surg. Petrovsky J. 2020; 8 (1): 74-79. doi: 10.33029/2308-1198-2020-8-1-74-79 (in Russian) Received 16.10.2019. Accepted 05.02.2020.
Accidental intra-arterial injection whether being self-administered or iatrogenic, is a medical emergency. The normal vascular anatomy, aberrant vasculature, difficult emergency situations and human error, all contribute to the iatrogenic intra-arterial injections in an attempt of getting an intravenous access. Van der Post first reported the condition in 1942 [1]. It is estimated that accidental intra-arterial injection is revealed in 1:3500-1:56 000 patients visiting the emergency department [2].
Barbiturates, thiopental sodium, narcotics, and tranquilizers are common drugs that have caused medical catastrophes affecting the upper limb [3]. Diclofenac sodium is also a common over the counter drug being used for analgesia. It can lead to acute ischemia of the affected limb if administered intra-arterially because of its vasospastic action on the arterial wall. Common sites for error are the antecubital fossa, groin, and forearm due to the proximity of arteries and the veins at these sites [4].
The immediate reporting of the symptoms and accurate diagnosis are of central importance, as therapeutic strategies range from conservative methods to amputation of the affected limb. The medical sequel that is most commonly seen is paresthesia, severe pain, motor dysfunction, compartment syndrome, gangrene, and limb loss [5]. There can be acute and chronic manifestations of the accidental IA injection. Several patients complained of immediate discomfort within seconds. The pain may range from local irritation to intense pain distal to the site of injection. Soon thereafter, many patients also complained of tingling, burning and paresthesia. Altered motor functions such as involuntary muscle contractures and muscle weaknesses; and cutaneous manifestations such as flushing and mottling have been commonly reported.
In addition, there are patients that are at a higher risk of iatrogenic IA injection. Some examples including morbidly obese, dark pigmented patients, thoracic
outlet syndrome, patients with indwelling arterial catheters for blood pressure measurement, and preexisting vascular anomalies of the forearm [5].
A symptomatic classification was established by Rutherford in 1986, revised in 1987 [6]. Rutherford classified peripheral arterial disease in two parts, acute and chronic limb ischemia. The classification associated patient clinical symptoms with objective findings, including Doppler, arterial brachial index, and pulse volume recordings. It also emphasizes that each presentation requires different treatment algorithms (Table 1, Table 3).
The above classification was used to diagnose and treat a patient presenting with acute limb ischemia. It has helped the medical professionals to identify high-risk patients and treat accordingly.
Material and methods
A. Study design
This was a case control study conducted in the Vascular Surgery department of Shree Krishna Hospital from Jan 11th 2017 to Jan 07th 2018. A total of 5 patients with iatrogenic intra-arterial injection were studied. Accidental intra-arterial injection was defined as an intravenous injection administered in the upper limb for any illness, which was followed by sudden severe pain in the limb followed by bluish discoloration of any part of the limb.
Inclusion criteria
1. Patients presenting with signs and symptoms falling under the Rutherford Classification of Acute Limb Ischemia.
2. Patients having a recent history of intravenous drug administration, possibly leading to accidental intra-arterial injection.
3. Patients having positive Doppler findings indicating acute limb ischemia.
Exclusion criteria
1. Patients presenting with sensory and motor function loss but no recent history of intravenous drug administration.
Table 1. The Rutherford Classification for Acute Limb Ischemia
2. Patients showing no positive findings on Doppler patients' characteristics are summarized in Table 2.
B. Ethics
A verbal consent was taken from each patient to use his or her details for the study. The personal information of all the patients was kept confidential and in no manner manipulated. No harm was done to the patients. The patients' details were solely used for this study only and no other research studies.
Results
Among the 5 patients, 4 were males and 1 was a female (patients' characteristics are summarized in Table 2). The age of the patients ranged from 19-38 years. Three out of the 5 patients had presented with complains of pain in the right forearm and hand, numbness and tingling sensations, inability to move finger and wrist joint, and swelling of the arm. In addition, right upper limb ischemia with blackening of 2nd and 3rd digits and hypothermia of the arm was also present. The patients presented to Trauma and Emergency Care (TEC) within 1 hour of taking an intravenous line where Diclofenac sodium was administered. Upon general examination, the vitals of all the patients were within normal limits. The local examination of the arm showed that Brachial, Radial and Ulnar arteries were not palpable on the right side; Axillary artery was palpable. Palpation of all the arteries in the left upper limb was plausible.
The following treatment was employed immediately in the patients (treatment and investigation detailed are summarized in Table 4):
1. Injection Heparin 10,000 unit IV stat, followed by 1000 unit/ hour infusion. The target APTT being 75-85 seconds. Monitoring was done every 6 hourly for 5 days. This was done to prevent thrombosis.
2. Injection Hydrocortisone 200 mg IV TDS for 3 days, followed by 100 mg TDS for 2 days, and 100 mg OD for 2 days. It aided in enhancing tissue repair.
3. Injection Sulfamethoxazole-Trimethoprim 40 ml/ hour for 48 hours.
4. Sympathetic ganglion block of 0.1% Ropivo-caine 50 ml for 72 hours. Patients reported of pain relief with some movement of the digits. Also the local temperature of the digits began to increase.
Category Findings Doppler signal
Description/Prognosis Sensory loss Muscle weakness Arterial Venous
I. Viable Not immediately threatened None None Audible Audible
II. Threatened
a) Marginally Salvageable if promptly treated Minimal (toes) or none None Inaudible Audible
b) Immediately Salvageable with immediate revascularization More than toes, associated with rest pain Mild, Moderate Inaudible Audible
III. Irreversible Major tissue loss or permanent nerve damage inevitable Profound, anesthetic Profound, paralysis Inaudible Inaudible
Table 2. General details
Patient Age (Years) Sex History of IV line taken Drug Administered Time from when the first symptoms appeared -to when they presented to TEC
1 19 Male Yes Diclofenac Sodium 30 minutes
2 В5 Male Yes Diclofenac Sodium 45 minutes
В Вб Female Yes Diclofenac Sodium 60 minutes
4 Вб Male Yes Diclofenac Sodium After 12 hours
5 В8 Male Yes Diclofenac Sodium After 12 hours
5. Injection lidocaine (lignocaine) hydrochloride 2% IV infusion for 5 days. It helps in vasodilation and decreasing vasospasm.
6. Tablet Aspirin 75 mg once a day qPM.
7. Intravenous Analgesics.
8. Intravenous Antibiotics.
9. Upper Limb Fasciotomy under general anesthesia.
10. Limb elevation to favor limb drainage and prevent edema from occurring.
11. Physiotherapy.
12. Doppler ultrasonography was done every 24 hours.
A right upper limb arterial Doppler was performed in all the patients. It showed echogenic areas in the distal most part of right brachial artery, signs of thrombosis within, and lack of flow in the right radial and ulnar artery beyond. The patients were advised to undergo Right Upper Limb Fasciotomy under general anesthesia. Upon discharge all vitals of the patients were normal, and limb was successfully salvaged. The
patients were advised to keep the limb elevated and physiotherapy was prescribed.
The following drugs were prescribed:
1. Oral Antibiotics.
2. Oral Analgesics.
3. Tablet Aspirin 75 mg once a day qPM for 3 months.
4. Doppler USG was performed twice during the follow up to ensure proper functioning of brachial, radial and ulnar arteries.
5. The patients were asked to come for a follow up examination weekly for 2 weeks and biweekly afterwards. Upon completion of three months, the wound was completely healed and healthy. In addition, the patients reported of a well functioning limb. The remaining 2 patients had presented with complain of blackening of 1st, 2nd and 3rd digits. It was gradual in onset and progressive in nature. It was also associated with pain. They also reported a history of a previous injury when an IV line was taken to administer medications. No significant past history was
Table 3. Clinical features and Rutherford Classification
Patient Site of IV Line Clinical Features Rutherford Classification
l Right upper limb in the ante-cubital fossa 1. Pain in the right forearm and hand, numbness and tingling sensations, inability to move finger and wrist joint. 2. Brachial, Radial and Ulnar arteries were not palpable on the right side; Axillary artery was palpable. Palpation of all arteries on the left side was plausible Category IIb = Immediately, Threatened
2 Right Upper Limb in the ante-cubital fossa 1. Pain in the right forearm and hand, numbness and tingling sensations, inability to move finger and wrist joint, swelling over the forearm. 2. Brachial, Radial and Ulnar arteries were not palpable on the right side; Axillary artery was palpable. Palpation of all arteries on the left side was plausible Category IIb = Immediately, Threatened
3 Right Upper Limb in the ante-cubital fossa 1. Pain in the right forearm and hand, numbness and tingling sensations, inability to move finger and wrist joint, hypothermia present. 2. Brachial, Radial and Ulnar arteries were not palpable on the right side; Axillary artery was palpable. Palpation of all arteries on the left side was plausible Category IIb = Immediately, Threatened
4 Left Upper Limb in the ante-cubital fossa Blackening of left 1st, 2nd and 3rd digits Category III = Irreversible
5 Right Upper Limb in the ante-cubital fossa Blackening of right 1st, 2nd and 3rd digits Category III = Irreversible
Table 4. Investigations and Treatment
Patient Doppler usg study Treatment Outcome
1 Echogenic areas in the distal most part of right brachial artery, signs of thrombosis within, and lack of flow in the right radial and ulnar artery beyond 1. Right Upper Limb Fasciotomy. 2. Limb Elevation. 3. Physiotherapy 1. Healthy wound upon follow up. 2. Functions of the limb were restored. 3. Limb was salvaged
2 Echogenic areas in the distal most part of right brachial artery, signs of thrombosis within, and lack of flow in the right radial and ulnar artery beyond 1. Right Upper Limb Fasciotomy. 2. Limb Elevation. 3. Physiotherapy 1. Healthy wound upon follow up. 2. Functions of the limb were restored. 3. Limb was salvaged
3 Echogenic areas in the distal most part of right brachial artery, signs of thrombosis within, and lack of flow in the right radial and ulnar artery beyond 1. Right Upper Limb Fasciotomy. 2. Limb Elevation. 3. Physiotherapy 1. Healthy wound upon follow up. 2. Functions of the limb were restored. 3. Limb was salvaged
4 Amputation Done, Doppler Findings -Not applicable 1. Ray's Amputation of left 1st, 2 nd and 3rd digits. 2. Limb Elevation. 3. Physiotherapy 1. Amputation stump was healthy upon follow up. 2. 1st, 2nd, and 3rd digits not salvaged. 3. Left Upper Limb functioning well otherwise
5 Amputation Done, Doppler Findings -Not applicable 1. Ray's amputation of right 1st, 2nd and 3rd digits. 2. Limb Elevation. 3. Physiotherapy 1. Amputation stump was healthy upon follow up. 2. 1st, 2nd, and 3rd digits not salvaged. 3. Left Upper Limb functioning well otherwise
present. Upon general examination, all the vitals of the patients were normal. Local examination showed blackening of the 1st, 2nd and 3rd digits.
The following medications were administered immediately as the patients presented to Emergency Department:
1. Tablet Aspirin 75 mg once a day in qPM.
2. Intravenous Antibiotics.
3. Intravenous Analgesics.
4. Intravenous Fluids.
5. Ray's amputation was performed under sedation and block. Bone nibbled and metacarpophalan-geal joints and digits amputated. Sterile dressing was done with limb elevation.
6. Limb Elevation.
7. Physiotherapy.
Upon discharge the patients were advised a high protein and ketone diet. They were asked to come for a weekly follow up to ensure that the wound was healthy and healing well. No other complains were reported of.
The following recommendations were given upon discharge:
1. Oral Antibiotics.
2. Oral Analgesics.
3. Physiotherapy.
4. Limb Elevation.
Discussion
Complications occurring due to iatrogenic intra-arterial injection are a serious medical emergency, with incidence of complications between 1:3500 to 1:56000 as reported by several authors [7]. Some of the reported complications being acute limb isch-
emia, unbearable pain at site of injection, numbness, tingling sensations, inability to the move the limb, and lastly the onset of gangrene. Many drugs such as phenothiazines, diazepam, promazine, barbiturates and amphetamines are dangerous when administered intra-arterially. Recently, many cases of accidental intra-arterial injection of diclofenac sodium have been reported. It is a commonly used non-steroidal anti-inflammatory drug, usually administered intramuscularly and/or intravenously.
In a different article, Samantha and Samantha reported cases of accidental intra-arterial injection where the patient presented with necrosis of the finger for which amputation was performed [8]. Diclofenac sodium was injected in the radial artery, which was mistaken for a vein. The rate of amputation for accidental intra-arterial drug injection in such cases is 29% [9]. The most common site for intraarterial injection is the ante-cubital fossa where the branches of brachial and ulnar arteries are superficial and can be easily entered. Also, it has been previously proposed that the benzyl alcohol preservative used in the non- aqueous preparation of diclofenac could be the cause of the emergency vasospasm due to endothelial edema and capillary endothelial dysfunction. Vasospasm, intravascular thrombosis and chemical endoarteritis are the proposed pathophysiological mechanism [10]. An understanding of the mechanism can help with a treatment plan.
Arterial vasodilators, anticoagulant therapy, thrombolytic agents, inflammatory antagonists and prophylactic antibiotics can be administered to the patients presenting with the above complications. This study has helped to identify a standardized treatment plan that has worked in salvaging the limb.
The three patients that did not need amputation were all administered the same treatment that showed to have given good results. The other two patients presented with onset of gangrene, where amputation was a must. Although, the treatment plan can always be modified according to the patients' needs and their clinical features.
Conclusion
Clinically, it may not be easy to prevent intra-arterial injections, although we would like to suggest
that untrained staff or student nurses must not take intravenous line unsupervised, as they may not have had enough experience to differentiate between intravenous and intra-arterial route and may not be able to identify an incorrectly inserted needle. It is important that a medically trained physician supervise this task, in order to prevent such catastrophes from happening. Lastly, it is important to identify the signs early on, and administer appropriate treatment to reduce the possibility of amputation and prevent the patient from having a permanent disability.
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