Accidental Injection Research Articles

Pulsed Radiofrequency Neuromodulation of the Sciatic Nerve in the Management of Posttraumatic Sciatic Neuritis

Abstract Accidental intraneural injection causing nerve injury is an iatrogenic catastrophe. Intramuscular injection (IM) is a common injury affecting the sciatic nerve. Sciatic nerve injury manifests as radicular pain with paraesthesia accompanied by an immediate onset of motor and sensory deficits. Treatment options include medical management with corticosteroids, neuropathic medications, and surgical exploration with or without anastomosis. We report a case of a young boy who presented with shooting pain with Numerical Rating Scale of 8/10 from the left buttock up to the left foot following accidental IM injection. The pain was associated with sensory loss over the left foot. Since he was unresponsive to medical management with corticosteroids and neuropathic medications, he was treated with pulsed radiofrequency neuromodulation of the left sciatic nerve. He responded well for the treatment and was discharged with good pain relief.

Cardiovascular and Vector-Cardiographic Effects of Articaine Anesthesia with Epinephrine.

The aim was to investigate the vector-cardiographic effects in patients submitted to dental extraction under local anesthesia. Twenty-one patients aged 36.6 ± 12.4 years with a clinical and radiographic indication of mandibular or maxillary tooth extraction were enrolled. The intervention was a local or mandibular nerve block anesthesia with 4% articaine hydrochloride containing epinephrine (1 : 100,000; 40 mg/ml + 10 μg/ml). Blood pressure (BP), heart rate (HR), pulse wave transit time, and vector-cardiography data were recorded throughout 3 min before and 5 min after injection. QRS- and T-wave area under the curve (QRS AUC/T AUC) were calculated from the X/Y/Z QRS-vector or T-vector. T-wave amplitude (T AM), T AUC values, and diastolic BP decreased, and HR significantly increased 4 min after injection. A transient moderate HR drop and a corresponding small increase in T AM and T AUC immediately after the injection procedure may be explained by a decreased sympathetic tone due to psychological relief. In dental anesthesia, the systemic epinephrine effects are represented by a decrease in T AUC. These effects are most pronounced in the X- and Y-leads. The 3D determination of vector planes or amplitudes is a simple method to register the sympathetic tone in local anesthesia independently of possible effects on T-wave characteristics in single leads. In conclusion, T-wave determination may help to detect even small increases in systemic adrenaline concentration in case of accidental intravascular injection. At the same time, full rhythm and spatial ischemia control is provided.

Poisoning with e-cigarette liquid (VPG Power Smoke Baze) - case report

Introduction and purpose: E-cigarettes have emerged as an alternative to traditional tobacco smoking. Toxicological studies have investigated the composition and potential toxicity of e-cigarette liquid components. While they are generally considered less harmful than combustible cigarettes, cases of poisoning associated with e-cigarette liquid ingestion or exposure have been reported.
 Brief description of the state of knowledge: Nicotine intoxication resulting from e-cigarette liquid ingestion can lead to a range of symptoms and complications, including cardiovascular effects, neurological symptoms, gastrointestinal disturbances, respiratory issues, and even death. This report presents a case of a 58-year-old woman hospitalized in the Toxicology and Cardiology Department due to poisoning with e-cigarette liquid.
 Conclusions: Accidental or intentional ingestion and/or injection of e-liquid is becoming a new emerging challenge for Emergency Medicine, mainly because of the easy accessibility of advertisements and the sales of e-cigarettes online, and the high nicotine concentration in e-liquids. It is important to report instances of e-liquid-related nicotine intoxication in order to improve the legal restrictions on the sale of e-liquid.

The Unique Management of Accidental Intra-Arterial Injection of Propofol in a Patient with Acute Subdural Hemorrhage: A Case Report

Propofol is a commonly used medication for sedation during surgery; however, it must be used with precaution in neurologic patients because of the subsequent adverse effects of cardiovascular and neurologic.
 An 83-year-old male patient with acute subdural hemorrhage was referred with a two-year history of falling and a recent occurrence of imbalance; the patient underwent urgent surgery under general anesthesia, using 100 µg fentanyl for premedication, 50 mg Propofol for induction, and Isoflurane gas and fentanyl drip for maintenance. During transmission of the patient for postsurgical computed tomography, two ccs Propofol 1% were mistakenly injected into the patient's radial artery and managed appropriately by the master. Following this management, the patient represented no alteration in his vital signs and was discharged in a favorable condition. Here, we report how this case could be managed successfully.
 Robust data regarding the complications of accidental administration of Propofol through an artery are lacking, and the presented results remain controversial. The authors have herby drawn attention to the unique management of an accidental intra-arterial injection of Propofol. Further studies are warranted to establish definite conclusions.

Management of Accidental Epinephrine Injection by an Expired Auto-Injector in Emergency Department Using Phentolamine: A Case Report

Management of Accidental Epinephrine Injection by an Expired Auto-Injector in Emergency Department Using Phentolamine: A Case Report

Inflammatory signal transduction pathways induced by prilocaine toxicity in cultured ARPE-19 cells.

Prilocaine (PRL) is a common local anesthetic. Despite the successful use of regional anesthesia for intraocular surgery, there are associated side effects that may affect the retina in case of accidental intravitreal injection. This study examined the signal transduction pathways activated by PRL toxicity and determined the protective role of nitric oxide synthase-2 (NOS2) inhibition in cultured human-derived retinal pigment epithelial cells (ARPE-19). Toxicity analysis was performed using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide assay to detect the toxic dose of PRL and protective effectiveness of asperglaucide (ASP), an NOS2 inhibitor. Nuclear factor kappa B p65 (NF-κB p65), phosphorylated NF-κB p65, phospho-protein kinase B (AKT), NOS2, nitrotyrosine, and cleaved caspase-3 protein levels were evaluated by immunofluorescence staining and/or western blot analysis. Interleukin-6 (IL-6) and nitrated protein levels were quantified using an immunoassay, whereas caspase-3 activity and nitrite/nitrate levels were measured using a fluorometric method. A significant increase in NF-κB p65, and phosphorylated NF-κB p65 and AKT levels due to PRL toxicity was observed. Similarly, IL-6, NOS2, nitrite/nitrate, and nitrotyrosine levels were significantly higher in PRL-treated cells than in control cells. Application of ASP to PRL-treated cells reduced NF-κB p65, and phosphorylated NF-κB p65 and AKT to basal levels. IL-6, NOS2, nitrite/nitrate, and nitrotyrosine levels also considerably decreased following ASP treatment in cells experiencing PRL-induced toxicity. Moreover, the caspase-3-dependent apoptotic pathway was not activated. Our results indicate that ASP could ameliorate PRL-induced activation of NF-κB p65 that led to inflammation in cultured ARPE-19 cells.

Accidental Injection of Sodium Hypochlorite into Buccal Mucosa Before Endodontic Treatment: Case Report

Accidental Injection of Sodium Hypochlorite into Buccal Mucosa Before Endodontic Treatment: Case Report

Modern possibilities of upper extremity regional anesthesia

Today, regional anesthesia is widely used during surgical interventions in orthopedic surgery. Blockades of individual nerves and plexuses are used. Objective. To introduce readers: surgeons, orthopedists-traumatologists with the possibilities of regional anesthesia like an adequate method of analgesia during upper limb interventions. Methods. Relevant literature from PubMed, Scopus, Google Scholar databases and own experience of regional anesthesia were analyzed. The results. The work describes the effect of regional anesthesia on the nervous, respiratory, cardiovascular and coagulation systems. Information about blocks of peripheral nerves of the upper extremities: interscalene, supraclavicular, subclavian, axillary. Their advantages and disadvantages were analyzed. Interscalene block is not recommended for patients with severe lung disease due to the risk of respiratory failure. Complications of this analgesia include: phrenic nerve block (up to 100 %), sympathetic chain block and Horner's syndrome. Also, possible accidental injection into the vertebral artery. Indications for the supraclavicular block are operations on the hand, forearm, elbow and shoulder. Complications — phrenic nerve block (17‒50 %), recurrent laryngeal blockade (22 %), pneumothorax (0.6‒6.1 %). When planning anesthesia, the accompanying pathology of the patient and his general condition should be taken into account. Particular care is required when the patient is taking anticoagulants. Risk of bleeding and thrombosis should be carefully assessed. Special attention should be paid to the toxicity of local anesthetics and ways to eliminate it. Conclusions. Regional anesthesia can be used in the pre-, intra- and postoperative periods. Sometimes it’s the only method that permit surgical intervention. It is necessary to understand all the advantages and limitations to ensure high quality of patient care.

Inadvertent Globe Penetration and Subretinal injection of Botulinum Toxin in an Oculocutaneous Albinism Patient.

To present a case of localized retinal detachment and mild vitreous hemorrhage in a patient with oculocutaneous albinism following accidental intraocular injection of botulinum toxin A. Botulinum toxin A injection were administered to a 5-year old oculocutaneous albinism patient with esotropia, and resulted in an ocular penetration. Dilated fundus examination indicated a nasal retinal tear causing a mild vitreous hemorrhage and a localized retinal detachment. No treatment was required for the retinal detachment and we observed the patient at regular intervals. On Day 1, the detachment resolved spontaneously without sequelae. On follow up, scarring at the lesion site was detected at one month after the incidence and the patient's vision was stable. In this instance, Observation was sufficient for our patient with complete resolution of retinal detachment and no long-term complication. Botulinum toxin A did not appear toxic to intraocular tissues. However, intramuscular botulinum toxin A injection should be administered carefully. Oculocutaneous albinism did not seem to affect the final outcome in our case.

Acute limb ischemia due to diclofenac sodium iatrogenic intra-arterial injection: a case report

We report the case of accidental intra-arterial injection of diclofenac sodium in the brachial artery leading to acute limb ischemia. Iatrogenic intra-arterial injection is rarely reported in the literature; however, it is toxic and can lead to limb amputation. Only two cases of intra-arterial injection of diclofenac have been reported in the literature. The proposed pathophysiological mechanism is vasospasm, intravascular thrombosis, and chemical endoarteritis. The most common anatomical location in accidental intra-arterial injection is the antecubital fossa, where branches of the ulnar and brachial arteries are more superficial. The injection of medication must be as careful as possible, since the intra-arterial injection can affect the functional prognosis of the organ.

Do Сovid-19 vaccines cause shoulder injuries: a survey among health care providers at Najran University hospital

Background: Shoulder injury related to vaccine administration (SIRVA) is a rare but serious side effect of the COVID-19 vaccine. The incidence of SIRVA among healthcare providers is not well understood. Aim: To investigate the incidence of SIRVA among healthcare providers working at a National University Hospital in Saudi Arabia and to assess their knowledge of SIRVA. Methodology: A cross-sectional online survey was distributed to all licensed healthcare providers currently employed by the National University Hospital. The survey collected information on personal, professional, and demographic characteristics, as well as symptoms and experiences related to SIRVA. Results: Of the 81 participants, 69.1% reported experiencing pain in their shoulder after receiving the COVID-19 vaccine, with 50% rating their pain as average (4-6 on a scale of 1-10) and 41.1% rating their pain as severe (7-10). Only 4.9% of participants reported visiting an orthopedic clinic for SIRVA and 76.5% did not receive treatment for their symptoms. A majority of participants (58%) believed that SIRVA occurs when the vaccine is injected too high up on the upper arm, with 34.6% believing it occurs in the middle of the upper arm and 7.4% believing it occurs too low down on the upper arm. It was also found that only 14.3% of participants were able to correctly identify the cause of SIRVA as accidental injection into the subdeltoid bursa. Additionally, a majority of participants believed that SIRVA is a rare condition (49.4%), and only a small percentage had received training about SIRVA (5.9%). Conclusions: These findings indicate a significant incidence of SIRVA among healthcare providers working at the National University Hospital and highlight the need for increased education and awareness about SIRVA among healthcare providers, as well as proper training in injection techniques to reduce the incidence of SIRVA.

Accidental intrathecal injection of tranexamic acid: a case report

BackgroundTranexamic acid is a well-known antifibrinolytic medication frequently prescribed to individuals with bleeding disorders. Following accidental intrathecal injection of tranexamic acid, major morbidities and fatalities have been documented. The aim of this case report is to present a novel method for management of intrathecal injection of tranexamic acid.Case presentationIn this case report, a 400 mg intrathecal injection of tranexamic acid resulted in significant back and gluteal pain, myoclonus of the lower limbs, agitation, and widespread convulsions in a 31-year-old Egyptian male with history of left arm and right leg fracture. Immediate intravenous sedation with midazolam (5 mg) and fentanyl (50 μg) was delivered with no response in seizure termination. A 1000 mg phenytoin intravenous infusion and subsequently, induction of general anesthesia was performed by thiopental sodium (250 mg) and atracurium (50 mg) infusion, and the trachea of the patient was intubated. Maintenance of anesthesia was achieved by isoflurane 1.2 minimum alveolar concentration and atracurium 10 mg every 20 minutes, and subsequent doses of thiopental sodium (100 mg) to control seizures. The patient developed focal seizures in the hand and leg, so cerebrospinal fluid lavage was done by inserting two spinal 22-gauge Quincke tip needles, one on level L2–L3 (drainage) and the other on L4–L5. Intrathecal normal saline infusion (150 ml) was done over an hour by passive flow. After cerebrospinal fluid lavage and the patient’s stabilization was obtained, he was transferred to the intensive care unit.ConclusionsEarly and continuous intrathecal lavage with normal saline, with the airway, breathing, and circulation protocol is highly recommended to decrease morbidity and mortality. The selection of the inhalational drug as a sedative and for brain protection in the intensive care unit provided possible benefits in management of this event with medication errors.

Intravitreal triamcinolone acetonide in Berger space: A rare complication

We report the case of a 50-year-old male who presented with a diminution of vision in his right eye for the past 6 months and was subsequently found to have central retinal vein occlusion with macular edema. The patient was given intravitreal triamcinolone in view of non-resolving macular edema despite repeated injections of anti-vascular endothelial growth factor. We report this rare occurrence of accidental injection of intravitreal triamcinolone acetonide in Berger space. A careful slit lamp examination before to look for the presence of prominent Berger space in patients planned for intravitreal injections, along with proper counseling of patients to avoid unwanted eye movements during an injection, can be potential ways to prevent such complications. In our case, the triamcinolone resolved after 6 weeks and the intraocular pressure (IOP) spike was managed using glaucoma medications. It is imperative to measure IOP at each visit in these patients and if spikes are noted, they should be managed accordingly.

Anaesthetic management of parturient posted for elective caesarean section with cerebral arteriovenous malformation

Sir, Cerebral arteriovenous malformation (AVM) has a prevalence of 0.01–0.05%.[1] We present a case of a 25-year-old primigravida at 37 weeks gestation, a known case of left frontoparietal AVM and epilepsy posted for elective cesarean section. Five years ago, she presented with weakness of the right upper and lower limbs. She was diagnosed with left frontoparietal AVM [Figures 1 and 2]. She had multiple seizure episodes and was started on T. levetiracetam 500 mg BD, T. lacosamide 200 mg BD, T. clobazam 10 mg BD, and T. phenytoin 100 mg OD.Figure 1: MR venogram showing large draining veins joining superior sagittal sinusFigure 2: MRI of the brain showing numerous flow voids along the left frontoparietal lobe and atrophy of neuroparenchyma in the left cerebral hemisphereA pre-anesthetic evaluation was done. She gave a history of seizure attacks 4 days back. She was premedicated with oral pantoprazole 40 mg and metoclopramide 10 mg 1 h before surgery and kept nil per oral for 6 h. All antiepileptic drugs were continued. In the operating room, the wedge was placed under her right hip. Standard pre-induction monitors were attached and intravenous (IV) access was secured. The cesarean section was done under general anesthesia. Rapid sequence induction was performed with IV thiopentone 5 mg/kg and rocuronium 1.2 mg/kg. The patient was intubated with a 7 mm internal diameter endotracheal tube after 1 min. Anesthesia was maintained with oxygen, air, and isoflurane. After delivery of a live female baby of 2.2 kg, IV fentanyl 2 mg/kg, midazolam 2 mg, ondansetron 4 mg, and oxytocin infusion were given. The patient was hemodynamically stable and the postoperative pain was managed with an ultrasound-guided bilateral transverses abdominis plane block. The parturient was extubated and shifted to the intensive care unit (ICU). She had an uneventful postoperative period. Cerebral AVM usually presents with intracranial hemorrhage, seizures, focal neurologic deficits, and headaches.[2] The symptoms of AVM may be mistaken with pregnancy-associated disorders such as eclampsia. computed tomography (CT) and magnetic resonance imaging (MRI) (with abdomen shielding) help to confirm the diagnosis. It is mandatory to document the neurological deficits, optimize antiepileptics, counsel regarding the potential complications, and the need for neurosurgery. The neurosurgeon and intervention radiologist were alerted regarding the patient’s delivery plan and the neurologist’s opinion was taken to optimize the antiepileptics. There are no conclusive data regarding the risk of AVM hemorrhage during pregnancy.[3,4] AVM hemorrhage during pregnancy is associated with 28% maternal and 14% neonatal mortality. Most centers prefer elective cesarean sections even though normal vaginal deliveries do not increase the risk of AVM hemorrhage. Uterine contractions during normal labor may increase the stress on the abnormal veins. Hence, if vaginal delivery is planned, epidural labor analgesia and assisted instrumental vaginal delivery are recommended. For cesarean section, general anesthesia is preferred over regional anesthesia to avoid neurological complications. cerebrospinal fluid (CSF) release with subarachnoid block causes a sudden change in the transmural pressure across the AVM predisposing it to rupture. An accidental intravascular injection of local anesthetic containing epinephrine test dose during the initiation of the test dose following epidural anesthesia could predispose to the rupture of AVM. The main aim of anesthetic management is to maintain the mean arterial and intracranial pressure within the normal range to reduce the risk of hemorrhage and cerebral hypoperfusion. Hypertensive responses to laryngoscopy and extubation should be obtunded. Thiopentone is the preferred induction agent.[5] Ketamine is avoided as it can increase blood pressure and intracranial pressure. Suxamethonium has to be avoided and a high dose of rocuronium 1.2 mg/kg is used for rapid sequence induction.[6] General anesthesia with controlled ventilation is used to keep PaCO2 at a low normal range to minimize cerebral vasodilatation and rise in intracranial pressure. Hypotension during surgery is avoided by optimal fluid resuscitation and vasopressors. Supine hypotension is avoided by the use of a wedge under the hip. Thus, multi-disciplinary care involving an obstetrician, intervention radiologist, neurologist, neurosurgeon, and obstetric anesthesiologist is required to ensure good pregnancy outcomes in these high-risk parturients. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

A case series of accidental xylazine intoxication in humans; Is there a role of naloxone as an antidote?

Xylazine is a type of sedative commonly used in veterinary medicine. It acts on the central alpha-2 receptor and suppresses norepinephrine release from the peripheral nerve terminal. It is also reported to have action on cholinergic, serotogenic, H2-histamine, dopaminergic, and opioid receptors. Once administered in animals, it causes hypotension, bradycardia, central nervous system depression, and respiratory depression. The effect will start within minutes after absorption and last up to 4 h depending on the dosage given. Till date, it is only exclusively used in animals as approved by the Food and Drug Administration. Human intoxication is uncommon, and no specific antidote is available. Naloxone, a competitive opioid receptor antagonist, was postulated to have an antidotal effect on xylazine. We report two cases of accidental human injection with xylazine. Naloxone was administered in one of the cases. Acute hypertension and mydriasis were observed; however, no apparent reversal of toxidrome was seen. This finding reveals the question regarding the efficacy and benefit of naloxone usage in xylazine intoxication. General management remains supportive of care focusing on ventilation and hemodynamics. Attending physicians should be aware of potential xylazine intoxication incidents in the area of livestock or veterinary activities.

Surgical removal of dexamethasone implant (Ozurdex) accidentally injected inside crystalline lens

AbstractPurpose: To present a rare case of accidental injection of dexamethasone implant (Ozurdex) into crystalline lens in a patient with diabetic macular edema, which was surgically removed by uneventful phacoemulsification.Methods: A 41‐year‐old male patient had been treated with multiple aflibercept intravitreal injections for diabetic macular edema in his right eye, but he showed suboptimal response. So, we decided to treat this patient with intravitreal injection of Ozurdex. The implant was inadvertently injected inside the lens. Subcapsular cataract was formed during the course of 3 weeks at the precise site of the insertion and there was an increase of intraocular pressure, which was addressed with topical anti‐glaucoma medication. Despite all that, the macular edema regressed.Results: We performed cataract surgery and simultaneous removal of the Ozurdex implant 3 months after the injection. Phacoemulsification was completed without any complications as the posterior capsule remained intact the entire surgical time and the one‐piece intraocular lens was successfully placed in the bag.Conclusions: The injection of intravitreal dexamethasone implant (Ozurdex) into the crystalline lens is a rare complication that can be effectively managed with the surgical extraction of the implant from the lens and implantation of a one‐piece intraocular lens in the posterior chamber in the bag without any complications.

EPINEPHRINE VIA NEEDLE-FREE DEVICE WOULD BE ADMINISTERED FASTER AFTER SYMPTOMS: RESULTS OF A PATIENT/CAREGIVER SURVEY

<h3>Introduction</h3> Intramuscular epinephrine is first-line treatment for severe allergic reactions. However, patients/caregivers often hesitate before using an epinephrine injectable device, endangering themselves or their child because progression of an allergic reaction can be quick and unpredictable. The time people wait before device use, what triggers use, and reasons for hesitation are not understood. Insight was sought regarding time to device use after symptom development and triggers for use. <h3>Methods</h3> A 20-minute double-blind survey of patients/caregivers who used an epinephrine injectable device within the preceding 12 months was conducted (exempt from IRB approval). Respondents were asked questions about their/their child's allergy, symptoms that triggered device use, and reasons for hesitation. <h3>Results</h3> A total of 200 individuals responded (caregivers and patients, n=100 each). Average time between symptom development and device use was 8.8 minutes, and the needle in the injectable device was the main reason for delay. When respondents were presented with a needle-free delivery device concept for administering epinephrine, estimated time to use was reduced to 4.9 minutes. A needle-free device was perceived as easier/less complicated and less painful to use; the lack of a needle would eliminate harm errors (e.g., striking bone or accidental intravenous injection). Respondents noted that they would be more likely to use a needle-free device at the onset of symptoms. <h3>Conclusion</h3> A needle-free option for administering epinephrine would be used more quickly after symptoms developed and would be easier to use versus an injectable device. This underscores the need to develop epinephrine modalities utilizing a non-needle-based delivery system.

Unintentional subarachnoid administration of tranexamic acid during spinal anesthesia

An accidental intrathecal tranexamic acid injection is a rare but extremely unpleasant case, which can lead to severe complications, including death. This review aimed to describe the clinical, pathophysiological changes and outcomes occurring in patients with unintentional tranexamic acid subarachnoid injection during spinal anesthesia. The review includes studies published in PubMed, The Cochrane Library, Google Scholar, and the Russian Science Citation Index databases. There were 31 reports (27 literature reports and 4 own observations) of unintended tranexamic acid administration during spinal anesthesia, including 12 cases in traumatology and orthopedics, 11 cases in cesarean section, and 8 cases in urology and general surgery. Typical signs and symptoms reported by the authors include severe pain in the lower back, buttocks, and lower extremities, seizure syndrome, marked tachycardia and arterial hypertension, and ventricular arrhythmias. Ten (32.1%) patients recovered without any consequences and six (19.4%) patients required long-term rehabilitation after hospital discharge due to severe neurological deficits or cognitive impairment. Of 11 females, 9 died during cesarean section and 4 of 12 patients died in traumatology and orthopedics. Overall, 15 (48.4%) patients had a fatal outcome. An unintentional subarachnoid tranexamic acid injection is a catastrophic event with extremely high patient risk and is accompanied by high mortality, especially in obstetric practice. Intensive care should include intravenous propofol or sevoflurane inhalation in the case of unintentional intrathecal tranexamic acid injection, and cerebrospinal fluid lavage is promising. Developing a formalized protocol for intrathecal administration of local anesthetic solutions is advisable to avoid errors associated with accidental drug administration not intended for spinal anesthesia.

Clinical Issues-October 2022.

Verifying patient identity before blood product administration Key words: patient identification, patient verification, blood transfusion, blood management, wristband. Surgical site infection risk with allogeneic blood administration Key words: patient blood management, restrictive transfusion triggers, allogeneic blood products, intraoperative blood salvage, surgical site infection. Information on topical thrombin Key words: hemostatic agents, licensed biological product, hemostasis, bovine thrombin, human thrombin. Safe use of topical thrombin Key words: severe adverse events, hemostatic agents, accidental injection, accidental intravascular uptake, product labeling.

A rare bifurcation of the external iliac artery into femoral and deep femoral arteries

The current cadaveric report describes a quite rare unilateral bifurcation of the external iliac artery (EIA) into two femoral arteries (FAs) of almost equal diameter and parallel course, at the level of the inguinal ligament (IL). The variant FAs were identified on a 75-year-old formalin-embalmed female cadaver, derived from a body donation program after a signed informed consent. The EIA bifurcated into a FA and a deep femoral artery (DFA). The DFA extremely high origin was identified at the IL level. Both lateral and medial circumflex femoral arteries originated from the DFA. The in-depth knowledge of the FA variant origin is of paramount importance to vascular surgeons and interventional radiologists during vessel catheterization and attempts to interpret the angiographic findings. In particular, the DFA's high origin from the EIA and the coexistence of two FAs in a parallel course may pose problems to clinicians during angiographic procedures leading to diagnostic errors. The DFA high origin may also complicate femoral arterial and venous puncture and femoral nerve blocks, due to the close neurovascular relationship. There is a possibility for the FA to be mistaken for a vein leading to accidental intra-arterial injection and consequently thrombosis. Thus, variable arterial pattern is important to be identified preoperatively using Doppler ultrasound imaging.