Remember that Inadvertent Intra-Arterial Injection is Not Rare



Remember that Inadvertent Intra-Arterial Injection is Not Rare


Michael S. N. Hogan MB, BCh

Surjya Sen MD

Juraj Sprung MD, PhD



The estimated incidence of iatrogenic complication from accidental intra-arterial (IA) injection of drugs is between 1 in 3,440 and 1 in 56,000 anesthetics administered. The potential complications range from none to severe tissue ischemia and necrosis necessitating amputation. All anesthesia providers should be aware of risk factors, signs and symptoms, available therapeutic modalities, and preventive measures for IA drug injection during anesthesia. Commonly used anesthetic drugs and inadvertent IA injection effects are shown in Table 27.1.


RISK FACTORS FOR IA INJECTION



  • Patients who are unable to report pain on injection. Patients during general anesthesia, comatose patients, or patients with altered mental status, and very young pediatric patients.


  • Pre-existing vascular anomalies of the forearm. The most common arterial anomaly of the upper limb is a high-rising radial artery resulting in a superficial branch (prevalence, 1% to 14%). This anomaly results in the radial artery ending in a thin superficial palmar branch that can be mistakenly cannulated (Fig. 27.1, Left). Another common anomaly (1% prevalence) is the antebrachialis superficialis dorsalis artery (Fig. 27.1, Right). The radial artery bifurcates in the forearm, resulting in an anomalous superficial branch between the index finger and thumb. Often, this branch will cross underneath a terminal branch of the cephalic vein, just superficial to the radial styloid process—a common site for insertion of intravenous (IV) catheters (called the “intern vein”).


  • High-risk anatomic locations, where arteries and veins lie in close proximity.



    • Antecubital fossa: brachial artery may be cannulated rather than the median basilic vein.


    • Groin: femoral artery cannulation rather than femoral vein.


  • Multiple infusions through several IV lines with numerous ports (patients in the intensive care unit).


  • Miscellaneous factors. Morbid obesity, darkly pigmented skin, multiple attempts at line placement, placement of lines under nonideal situations (central line during operations and/or without ultrasonographic
    guidance), those with a pre-existing arterial or venous catheter who present for urgent resuscitation (trauma).








TABLE 27.1 EFFECTS OF IA INJECTION OF COMMONLY USED ANESTHETIC AGENTS




























































DRUG

EFFECT OF IA INJECTION


Midazolam

Initial discoloration but no long-term effect


Promethazine, chlorpromazine

Gangrene


Thiopental

Chemical endarteritis, immediate vasoconstriction, thrombosis, tissue necrosis, endothelial cell destruction


Etomidate

No reports of necrosis


Ketamine

Proximal skin necrosis


Propofol

Pain, cutaneous hyperemia


Lidocaine

Used therapeutically, no adverse effects


Penicillin

Gangrene


Cefazolin, ceftazidime

Arteriospasm and distal necrosis


Meperidine

Gangrene


Sodium bicarbonate

Edema, erythema, pain; tissue necrosis


Metoclopramide

Discoloration but no long-term effect


Phenytoin

Cyanosis, digital artery occlusion, gangrene


Atracurium

Marked ischemia but full recovery


Dextrose solution

Gangrene


Calcium chloride

No adverse effects reported Used therapeutically to localize insulinoma


Ephedrine, phenylephrine, epinephrine, succinylcholine, vecuronium, rocuronium, fentanyl, oxymorphone, hydromorphone, ketorolac, ondansetron, atropine, glycopyrrolate, neostigmine

No reports available


IA, intra-arterial.

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Jul 1, 2016 | Posted by in ANESTHESIA | Comments Off on Remember that Inadvertent Intra-Arterial Injection is Not Rare

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