Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 3  |  Page : 254-259

Evaluation and management of accidental intra-arterial injection in the antecubital fossa


Department of Vascular Surgery, Pramukhswami Medical College, Shree Krishna Hospital, Karamsad, Anand, Gujarat, India

Date of Submission12-Jan-2020
Date of Decision18-Feb-2020
Date of Acceptance04-Mar-2020
Date of Web Publication12-Sep-2020

Correspondence Address:
Pratiksha Shah
Department of Vascular Surgery, Pramukhswami Medical College, Shree Krishna Hospital, Karamsad, Anand, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_7_20

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  Abstract 


Introduction: Intra-arterial (IA) drug injection is a rare, but a potentially serious medical emergency. It is most commonly seen as an iatrogenic complication when administering an intravenous (IV) medication. Accidental IA injection was defined as an IV 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 affected limb. Aim: The aim of the study is to identify the risk factors early on for limb amputation following IA injection, to assess the efficacy of the various modalities of the treatments administered, and to establish a standardized treatment plan for IA injection to achieve limb salvaging. Materials and Methods: A total of 12 cases of accidental IA 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: Ten out of the twelve patients presented early, and limb salvation was achieved. Conservative treatment and upper limb fasciotomy proved to aid with the limb salvation. However, two out of the twelve patients presented after 12 h 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. Conclusion: Early evaluation and management of a case of accidental IA injection is of utmost importance due to its serious complications. Finally, all medical professionals must be regularly trained to prevent such mishaps from happening.

Keywords: Diclofenac sodium, fasciotomy, intra-arterial injection, Ray's amputation, sympathetic ganglion block


How to cite this article:
Patel J, Shah P, Gandhi F. Evaluation and management of accidental intra-arterial injection in the antecubital fossa. Indian J Vasc Endovasc Surg 2020;7:254-9

How to cite this URL:
Patel J, Shah P, Gandhi F. Evaluation and management of accidental intra-arterial injection in the antecubital fossa. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Oct 22];7:254-9. Available from: https://www.indjvascsurg.org/text.asp?2020/7/3/254/294910




  Introduction Top


Accidental intra-arterial (IA) 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 IA injections in an attempt of getting an intravenous (IV) access. Van der Post first reported the condition in 1942.[1] It is estimated that accidental IA 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 is a nonsteroidal anti-inflammatory drug that is commonly used to treat mild-to-moderate pain, hyperpyrexia, and inflammation. It is most commonly administered through oral, intramuscular, IV, transdermal, and rectal routes. 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 has been most commonly seen is paresthesia, severe pain, motor dysfunction, compartment syndrome, gangrene, and limb loss.[5] Acute and/or chronic manifestations can be seen due to accidental IA injection. Several patients complained of immediate discomfort within seconds to a few minutes. The pain may range from local irritation to intense pain, presenting distal to the site of injection. Soon thereafter, many patients also complained of tingling sensations, burning sensations, and paresthesia. Altered motor functions such as involuntary muscle contractures and muscle weaknesses and cutaneous manifestations such as flushing and mottling have also been commonly reported.

In addition, it has been proposed that there are patients that are at a higher risk of iatrogenic IA injection. Some examples include 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 studies, arterial brachial index, and pulse volume recordings. It also emphasized that each presentation requires different treatment algorithms [Table 1].
Table 1: Rutherford classification for acute limb ischemia

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The objective of the study is to identify the risk factors early on for limb amputation following IA injection, to assess the efficacy of the various modalities of the treatments administered, and to establish a standardized treatment plan for IA injection to achieve limb salvaging. Since IA 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.


  Materials and Methods Top


Study design

A case–control study was conducted in the Vascular Surgery Department of Shree Krishna Hospital from January 17, 2017, to December 30, 2018. A total of twelve patients with iatrogenic IA injection were studied. Accidental IA injection was defined as an IV 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. A thorough clinical history of all the patients was taken, enquiring about the various clinical features they may have experienced, for example, pain, weakness, numbness, swelling surrounding the area, and blackening of the affected region. Furthermore, the patients were examined for paresthesia, pallor, edema, local temperature of the affected region, muscle contractures, and signs of gangrene. Furthermore, the previous records were checked to determine the drug that had been accidentally administered intra-arterially. Simultaneously, all patients had been classified according to the Rutherford classification, in order to have a better understanding of the severity of the injury. The vitals were constantly monitored from the time of presentation. Following clinical examination, all patients underwent an arterial Doppler study to determine the extent of the injury. The treatment for each patients was determined according to their presenting clinical features, results from the Doppler study, and the Rutherford classification. Moreover, all the patients underwent a thorough clinical examination and arterial Doppler studies postoperatively.

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 IV drug administration, possibly indicating accidental IA 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 IV drug administration
  2. Patients showing no positive findings on Doppler examination.


Ethics

A verbal consent was taken from each patient to use his/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 Top


Among the twelve patients, eleven were males and one was a female. The age of the patients ranged from 19 to 55 years. Ten out of the 12 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, upper limb ischemia with blackening of second and third digits and hypothermia of the arm was also present. The patients presented to trauma and emergency care within 1 h of taking an IV 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 affected side; axillary artery was palpable. Palpation of all the arteries in the opposite upper limb was plausible. The patients were classified as Category IIb (immediately, threatened), according to the Rutherford classification.

The following treatment was employed immediately in the patients

  1. Injection heparin 10,000-unit IV stat, followed by 1000 unit/hour infusion. The target activated partial thromboplastin time was 75–85 s. Monitoring was done every 6 h for 5 days. This was done to prevent thrombosis. A significant improvement was noticed, due to which the use of thrombolytic therapy was not required
  2. Injection hydrocortisone 200 mg IV three times a day (TDS) for 3 days, followed by 100 mg TDS for 2 days, and 100 mg for 2 days. It aided in enhancing tissue repair
  3. Injection sulfamethoxazole–trimethoprim 40 ml/h for 48 h
  4. Sympathetic ganglion block of 0.1% ropivacaine 50 ml for 72 h. Patients reported pain relief with some movement of the digits. Also, the local temperature of the digits began to increase
  5. Injection lidocaine (lignocaine) hydrochloride 2% IV infusion for 5 days. It helped in vasodilation, hence decreasing vasospasm
  6. Tablet aspirin 75 mg once a day (every evening)
  7. IV analgesics
  8. IV 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 h.


An upper limb arterial Doppler was performed in all the patients. It showed echogenic areas in the distal most part of the affected brachial artery, signs of thrombosis within, and lack of flow in the radial and ulnar artery beyond. The patients were advised to undergo 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 upon discharge

  1. Oral antibiotics
  2. Oral analgesics
  3. Tablet aspirin 75 mg once a day qPM for 3 months
  4. Doppler ultrasound USG was performed twice during the follow-up to ensure proper functioning of brachial, radial, and ulnar arteries.


The patients were asked to come for a follow-up examination weekly for 2 weeks and biweekly afterward. Upon completion of 3 months, the wound was completely healed and healthy. In addition, the patients reported of a well-functioning limb.

The remaining two patients had presented with a complaint of blackening of first, second, and third 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 history was present. Upon general examination, all the vitals of the patients were normal. Local examination showed blackening of the first, second, and third digits. The patients were classified as Category III (Irreversible), under the Rutherford classification.

The following medications were administered immediately as they presented to the emergency department:

  1. Tablet aspirin 75 mg once a day in qPM
  2. IV Antibiotics
  3. IV Analgesics
  4. IV Fluids
  5. Ray's amputation was performed under sedation and block. Bone nibbled and metacarpophalangeal 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 drugs were prescribed upon discharge:

  1. Oral antibiotics
  2. Oral analgesics
  3. Physiotherapy
  4. Limb elevation [Table 2], [Table 3], [Table 4].
Table 2: General details of the patients selected for this study

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Table 3: Clinical features and Rutherford classification

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Table 4: Investigations and treatment

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  Discussion Top


IA injection is an infrequent event, leading to a serious medical emergency. It may be iatrogenic and/or in relation to drug abuse. The most common site for IA injection is the antecubital fossa where the branches of brachial and ulnar arteries are superficial and can be easily entered. Some of the proposed mechanisms that explain the emergency are vasospasm, intravascular thrombosis, and chemical endarteritis.[7] The following events lead to acute thrombosis of the affected artery, followed by a decrease in blood supply to the digits. This will eventually lead to the development of gangrene of the affected limb. Furthermore, it has been previously proposed that the benzyl alcohol preservative used in the nonaqueous preparation of diclofenac could be the cause of the emergency vasospasm due to endothelial edema and capillary endothelial dysfunction.

Conservative treatment comprised vasodilators, steroids, nerve blocks, analgesics, and prophylactic antibiotics. Lidocaine hydrochloride is a local anesthetic agent, which is a sterile, nonpyrogenic solution. It was one of the drugs administered to the patients who presented early and with no signs of gangrene, where it leads to vasodilatation of the artery. Low-molecular-weight heparin was administered to prevent further thrombosis from occurring. Monitoring of coagulation parameters was also performed to anticipate and prevent serious bleeding complications. Hydrocortisone is a steroid, which prevents the release of substances that lead to inflammation. When administered in patients, it aided in enhancing tissue repair. The utmost important modality, which proved to be of significance, was the sympathetic ganglion block. Patients reported of a decrease in pain and an increase in local temperature. The sympathetic nerve block targets the sympathetic nervous system, which contains a series of nerves that spread out from the spine to the body, helping to control several involuntary bodily functions. Furthermore, rest, physiotherapy, and elevation to the affected limb are of importance as it leads to a decrease in edema and speeds the recovery process.

Treatment for IA injection also comprises surgical modalities, which are employed in almost all the patients. Patients who presented early, with no clinical features of gangrene, can be easily operated upon to salvage the limb. Fasciotomy was the procedure performed, where the tissue surrounding the area was cut open to relieve pressure. It is a surgery to relieve swelling and pressure from any compartment of the body. This helps increase blood flow and to stop/slow down the rate of damage to the local tissue. Some complications that may appear are excessive bleeding, scarring, infection, and chronic pain. Moreover, patients who presented late and with clinical features of gangrene were immediately treated with Ray's amputation of the affected digits. The gangrene was halted at the very minimum severity as possible, hence preserving some function of the affected digits. In a different article, Samantha and Samantha reported cases of accidental IA 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 IA drug injection in such cases is 29%.[9] In addition, it is of utmost importance to follow-up with the patients to ensure proper functioning of the limb and to discover any occurrence of further complications.

Complications occurring due to iatrogenic IA injection have an incidence between 1:3500 and 1:56,000 as reported by several authors.[10] Some of the reported complications being acute limb ischemia, unbearable pain at the site of injection, numbness, tingling sensations, inability to move the limb, and finally the onset of gangrene. All the patients who were studied reported of two or more of the above-mentioned complications. This study has helped identify a standardized treatment plan that has worked in salvaging the limb. However, the treatment plan can always be modified according to the patients' needs and their clinical features.


  Conclusion Top


Clinically, it may not be easy to prevent cases of accidental IA injection from occurring; however, incidence can be lowered with supervision and proper training of the medical personnel. It is important that a medically trained physician supervises this task, in order to prevent such catastrophes from happening. Furthermore, 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. Finally, a clinician must not forget to educate and inform the patient of the possible outcome of his/her condition. The patients must be taken care of with the utmost care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
van der Post CW. A case of mistaken injection of pentothal sodium into an aberrant ulnar artery. S Afr Med J 1942;16:182-4.  Back to cited text no. 1
    
2.
Malik A, Ikramullah M, Khan MG, Ali Shah SM, Ilyas M. Accidental intra arterial injection and limb ischemia. Adv Pediatr 2017;29. Available from: http//www.ncbi.nlm.nih.gov/pubmed/28718237. [Last accessed on 2019 May 01].  Back to cited text no. 2
    
3.
Kumar M, Singh J, Sharma P, Khera A, Singh P. Accidental intra-arterial injection of diclofenac: Case report. Adv Pediatr 2015;9:PD16-PD17.  Back to cited text no. 3
    
4.
Lake C, Beecroft CL. Extravasation injuries and accidental intra-arterial Injection. Contin Educ Anaesth Crit Care Pain 2010;10:109-13. Available from: http//academic.oup.com/bjaed/article/10/4/109/381097. [Last accessed on 2019 Jun 23].  Back to cited text no. 4
    
5.
Sen S, Chini EN, Brown MJ. “Complications after unintentional intra-arterial injection of drugs: Risks, outcomes, and management strategies.” Mayo Clinic 2005;80:783-95. Available from: http//www.mayoclinicproceedings.org/article/S0025-6196(11)61533-4/fulltext. [Last accessed on 2019 Jun 23].  Back to cited text no. 5
    
6.
Cohen SM. “Accidental Intra-Arterial Injection of Drugs.” Adv Pediatr 1948;2:361. Available from: http//www.ncbi.nlm.nih.gov/pubmed/18881545. [Last accessed on 2019 Jun 25]  Back to cited text no. 6
    
7.
Ghouri AF, Mading W, Prabaker K. Accidental intraarterial drug injections via intravascular catheters placed on the dorsum of the hand. Anesth Analg 2002;95:487-91.  Back to cited text no. 7
    
8.
Samanta S, Samanta S. Accidental intra-arterial injection of diclofenac sodium and their consequences: Report of two cases. Anaesth Pain Intensive Care 2013;17:101-2.  Back to cited text no. 8
    
9.
Devulapalli C, Han KD, Bello RJ, LaPorte DM, Hepper CT, Katz RD. Inadvertent intra-arterial drug injections in the upper extremity: Systematic review. Adv Pediatr 2015;40:2262-2268.e5. Available from: http//www.ncbi.nlm.nih.gov/pubmed/26409581. [Last accessed on: 2019 Jul 01].  Back to cited text no. 9
    
10.
Stone HH, Donnelly CC. The accidental intraarterial injection of thiopental. Adv Pediatr 2006;22:995-1006. Available from: http//www.ncbi.nlm.nih.gov/pubmed/13917465. [Last accessed on: 2019 Jul 01].  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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