Inadvertent Intra-arterial Injection Research Articles

Good Clinical Outcome After Accidental Intra-arterial Injection of Flunitrazepam Tablets in 16 Drug Abusers with Critical Limb Ischaemia

Inadvertent intra-arterial injection of flunitrazepam tablets intended for intravenous use by drug abusers has devastating effects. We report here on the clinical outcome of 16 drug abusers developing critical limb ischaemia after flunitrazepam injection. Treatment combined immediate analgesia and anticoagulation, long-lasting local thrombolysis and vasodilatation, antibiotic prophylaxis, and physical mobilization. The immediate bolus injection of 5,000 IU heparin was followed by a continuous heparin infusion up to the target partial thromboplastin time. Under arteriographic control local intra-arterial infusion with alternating 4-h cycles of 5 mg recombinant tissue plasminogen activator followed by 5 μg prostaglandinE1 (PGE1) was performed for 24-48 hours. Subsequently, 60 μg PGE1 was applied once daily. Drug abusers, having been injected with 4-30 mg flunitrazepam, were treated 3-72 hours after the accident, with six of them not being treated until after 24 hours. All showed a high tissue ischaemia score. At the time of being discharged from hospital 13 patients had a normal extremity. In one patient, first receiving treatment 72 hours after injection, minor amputation of fingers was necessary. The life of the patient who injected 30 mg flunitrazepam in the leg was saved after hip disarticulation. One patient developed neurological dysfunction in the affected toes. Intensive treatment after inadvertent intra-arterial drug injection normalized the affected extremity in most drug abusers, even after the late onset of therapy.

Good Clinical Outcome After Accidental Intra-arterial Injection of Flunitrazepam Tablets in 16 Drug Abusers with Critical Limb Ischaemia

Inadvertent intra-arterial injection of flunitrazepam tablets intended for intravenous use by drug abusers has devastating effects. We report here on the clinical outcome of 16 drug abusers developing critical limb ischaemia after flunitrazepam injection. Treatment combined immediate analgesia and anticoagulation, long-lasting local thrombolysis and vasodilatation, antibiotic prophylaxis, and physical mobilization. The immediate bolus injection of 5,000IU heparin was followed by a continuous heparin infusion up to the target partial thromboplastin time. Under arteriographic control local intra-arterial infusion with alternating 4-h cycles of 5mg recombinant tissue plasminogen activator followed by 5μg prostaglandinE1 (PGE1) was performed for 24-48 hours. Subsequently, 60μg PGE1 was applied once daily. Drug abusers, having been injected with 4-30mg flunitrazepam, were treated 3-72 hours after the accident, with six of them not being treated until after 24 hours. All showed a high tissue ischaemia score. At the time of being discharged from hospital 13 patients had a normal extremity. In one patient, first receiving treatment 72 hours after injection, minor amputation of fingers was necessary. The life of the patient who injected 30mg flunitrazepam in the leg was saved after hip disarticulation. One patient developed neurological dysfunction in the affected toes. Intensive treatment after inadvertent intra-arterial drug injection normalized the affected extremity in most drug abusers, even after the late onset of therapy.

Intra-arterial injection, a rare but serious complication of sclerotherapy

Intra-arterial injections represent the most feared complication of sclerotherapy for varicose veins. We present a case of an inadvertent intra-arterial injection of polidocanol at the left medial calf in a 59-year-old woman with subsequent arterial occlusions of the posterior tibial artery and foot arteries. Despite several therapeutic interventions, lower-limb amputation could not be prevented. We conducted a PubMed search for articles reporting arterial complications related to sclerotherapy, in order to evaluate aetiology, clinical presentation, therapeutic management and outcome of sclerotherapy-associated intra-arterial injections during the past 50 years. Intra-arterial injection of a sclerosing solution was reported in 63 cases, mostly after injection near the ankle region or the distal medial calf. Clinical presentation was frequently characterized by immediate pain during injection and distal ischaemia with subsequent tissue loss. Despite several treatment approaches, amputation could not be prevented in 31 cases (52.5%). The pathophysiology of arterial complications related to intra-arterial injection and advisable therapeutic interventions are discussed. Inadvertent intra-arterial injection represents a limb-threatening complication of sclerotherapy. Target-oriented and prompt therapy seems inevitable in order to reduce the risk of permanent tissue loss and amputation.

Gastric ischemia after epinephrine injection in a patient with liver cirrhosis

Endoscopic epinephrine injection is relatively easy, quick and inexpensive. Furthermore, it has a low rate of complications, and it is widely used for the management of nonvariceal upper gastrointestinal bleeding. There have been several case reports of gastric ischemia after endoscopic injection therapy. Inadvertent intra-arterial injection may result in either spasm or thrombosis, leading to subsequent tissue ischemia or necrosis, although the stomach has a rich vascular supply and the vascular reserve of the intramural anastomosis. In addition to endoscopic injection therapy, smoking, hypertension and atherosclerosis are risk factors of gastric ischemia. We report a case of gastric ischemia after submucosal epinephrine injection in a 51-year-old woman with hypertension and liver cirrhosis.

Unilateral presenece of superficial ulner artery: A case report

The variations in the arterial pattern of upper extremities are not uncommon. During routine dissection of right upper extremity of 55 years old male cadaver we found brachial artery gave an unusual branch, a superficial ulnar artery (SUA), just before its termination into radial &ulnar arteries. It ran superficial to the bicipital aponeurosis & muscles of front of forearm. The knowledge of variation in arterial pattern of upper limb is of great importance since many surgical and invasive procedures are performed on it. Also the course of SUA makes it prone for inadvertent intra-arterial injections misinterpreting it as vein. So nurses, medical students & clinicians should be aware about this variation.

Cervical Myelomalacia in a Lamb (Ovis aries) and an Alpaca (Vicugna pacos) after Attempted Intramuscular Injection

Cervical Myelomalacia in a Lamb (<i><scp>O</scp>vis aries</i>) and an Alpaca (<i><scp>V</scp>icugna pacos</i>) after Attempted Intramuscular Injection

Inadvertent Intraarterial Injection of 18F-FDG: A Case Report and Literature Review of Hot Forearm and Hot Hand Signs

Unintentional intraarterial injection of radiotracers may cause artifacts leading to difficulties in accurately interpreting PET/CT images. We report a case of a 73-y-old man with a history of metastatic colon cancer who underwent a PET/CT scan for restaging. In the PET scan, there was intense and diffuse distribution of (18)F-FDG in his left forearm and hand. This is a classic sign of an accidental intraarterial injection of (18)F-FDG in the antecubital region. Similar phenomena after inadvertent intraarterial injection of other radiotracers are reviewed. The associated risk factors, preventive measures, and radiation dose to the arm are discussed.

Necrosis of the leg after intraarterial drug injection

Inadvertent intraarterial injections in the context of drug abuse can cause damage to the vascular system. The clinical picture depends on the drug properties and ranges from partial ischemia to necrosis of the affected extremity. There are no current evidence-based guidelines regarding the management of intraarterial drug injections. In many cases the concept of solving vasospasm after injection is based on the use of intraarterial application of prostaglandins. We report a case in which a mixture of drugs was injected into the left femoral artery. The patient arrived 24 hours later with ischemia of the left leg at our emergency department. Angiography showed that there was no blood flowing in the leg. Despite intraarterial application of vasodilatators, regional neurolysis and thrombolyis with urokinase major amputation was unavoidable. The outcome after inadvertent injection depends on certain drug properties and the delay between injection and the beginning of therapy.

Inadvertent Injection of a Cervical Radicular Artery Using an Atraumatic Pencil-Point Needle

Case report and review of the literature. To report the first case of inadvertent injection of a cervical radicular artery using an atraumatic pencil-point needle. Rare complications from cervical transforaminal epidural corticosteroid injection have resulted in infarction of the spinal cord and brain. The most often-hypothesized mechanism is inadvertent intra-arterial injection of particulate corticosteroids with a resulting embolus and infarction. Retrospective review of a patient's history and fluoroscopic imaging. A 30-year-old man with a diagnosed cervical radiculopathy underwent a right C6-C7 transforaminal epidural corticosteroid injection, using a 25-gauge 3.5-inch Whitacre spinal needle. Simultaneous epidural and radicular artery spread were observed under live fluoroscopy. The patient suffered no complications from the procedure. This case demonstrates that the use of pencil-point (Whitacre) needles does not eliminate the risk of inadvertent arterial injection during cervical transforaminal epidurals. Further investigation is required to determine whether the incidence of inadvertent vascular injection is reduced with pencil-point needles compared with sharp-beveled needles.

Regional Anesthesia and Eye Surgery

Regional Anesthesia and Eye Surgery

Branch Retinal Artery Occlusion After Septoplasty

Loss of vision after uncomplicated rhinosurgery is a rare and uncommon complication. The authors describe a case of branch retinal artery occlusion after septoplasty in a 40-year-old otherwise healthy man. The likely etiology was injection of local anesthetics into the nasal mucosa during surgery. Vision loss could potentially have been prevented through the application of topical vasoconstrictive agents prior to anesthetic injection. Furthermore, slow injection and aspiration prior to injection could also help prevent inadvertent intraarterial injection.

The clinical anatomy of the antecubital fossa

To the anatomist, the antecubital fossa is the space through which the principal vascular and nervous trunks pass into the forearm. To the surgeon it is also the site of possible injury to the brachial artery in fractures around the elbow, with the risk of Volkmann's ischaemic contracture constantly in mind. It is here where the surgeon is tempted to use the large superficial veins for venous access, but knows only too well the dangers of inadvertent intra-arterial or intraneural injection - something that may well be encountered in a 'main-line' drug addict. It is also a convenient site for arterial cannulation and for anaesthetic blocks of the nerves to the forearm.

6. Utility of the Anesthetic Test Dose to Avoid Catastrophic Injury During Cervical Transforaminal Epidural Injections

BACKGROUND CONTEXT: Inadvertent intra-arterial administration of corticosteroids during cervical transforaminal epidural injections has been associated with rare but serious complications including tetraplegia, stroke, and death. The utility of conventional techniques to prevent intravascular injection are known, including aspiration for blood and using live fluoroscopy to visualize vascular uptake of contrast. Unfortunately these measures have not always prevented major complications associated with inadvertent intra-arterial injection. Additional methods to reduce risk have been suggested but have not been formally analyzed. The anesthetic test dose is one such method, used with the following rational. If conventional methods fail to reveal injection into a vulnerable artery, the injection of anesthetic will result in transient symptoms related to vertebral artery or radiculomedullary artery injection. These symptoms allow the physician to avoid the vascular embolic event that would occur with subsequent injection of corticosteroids. No prior study has measured the incidence or utility of a positive anesthetic test dose.

Ultrasound-guided cervical transforaminal injection and selective nerve root block

Traditionally, cervical transforaminal injections have been performed under fluoroscopic guidance. Real-time fluoroscopy with contrast injection is necessary to minimize intra-arterial injections. But even with strict guidelines, multiple instances of inadvertent intra-arterial injections with resultant spinal cord injury have been reported. This has led some practitioners to question the use of this procedure and whether the benefits outweigh the risks. The use of ultrasound (US) imaging to facilitate nerve blocks has increased recently. US allows visualization of soft tissues, as well as nerves and vessels, and also permits visualization of the injectate around the nerve. Unlike fluoroscopy and computed tomography, US does not expose the patients or personnel to radiation, and the image can be performed continuously while the injectate can be visualized in real time, thereby increasing the precision of injection. US imaging can be used to obtain well-defined images of the cervical neural foramina with real-time visualization of the spinal nerves and vessels and may improve the safety of the technique. It may facilitate identifying anomalous critical vessels at unexpected locations relative to the intervertebral foramen and avoiding injury to such vessels, which is the leading cause of the reported complications from cervical nerve root injections.

A dusky hand—expect the unexpected

A 56-year-old Indian national woman with a history of hypertension presented to the emergency department with left forearm pain for 1 week with increasing pain for 2 days. Examination revealed a dusky left hand (Fig. 1) and cool skin distal to the distal half of the left arm. The left brachial and radial pulses were absent, confirmed by bedside Doppler scan. There was a pulsatile 3 × 4 cm mass in the left supraclavicular fossa (Fig. 2). The diagnosis of left subclavian artery aneurysm (SAA) with acute ischemia of the left upper limb was made. A bedside ultrasound scan (Fig. 3) demonstrated the aneurysm. Computed tomography angiography (Fig. 4) performed later showed the level of occlusion. She was discharged against medical advice for surgical treatment in India in view of costs involved locally. She received intravenous heparin overnight and was discharged on subcutaneous enoxaparin. Fig. 1 The left hand is noticeably dusky compared to the right Fig. 2 Fullness of the left supraclavicular fossa Fig. 3 Left subclavian artery dilatation of 1.2 cm suggestive of an aneurysm with intraluminal thrombus Fig. 4 Three-dimensional reconstruction showing occlusion of the left axillary artery at the level of the surgical neck of the humerus. No filling of the distal axillary artery The etiologies of SAA include atherosclerosis, trauma, thoracic outlet syndrome (e.g., cervical rib), and mycotic aneurysm from drug injection [1]. Locally, especially in the younger population, the inadvertent intra-arterial injection of illicit drugs such as pounded and diluted buprenorphine and midazolam should be suspected as a cause of the aneurysm. SAA may be present in association with other conditions such as coarctation of the aorta, Takayasu arteritis, and Ehlers-Danlos syndrome [2]. The most common complication is peripheral thromboembolism where patients may present with severe ischemic symptoms of the upper extremity, gangrene, and even hemiplegia. Hand ischemia is frequently misdiagnosed as vasospasm [3]. Other complications include rupture of the aneurysm and compression of the subclavian vein and brachial plexus.

Cervical Transforaminal Epidural Steroid Injections

Survey/case series. To survey pain physicians about neurologic infarctions following cervical transforaminal epidural steroid injections (TF-ESIs). Cervical TF-ESIs are commonly performed in patients with cervical radiculopathy, although there are no randomized controlled studies supporting their efficacy. Eight case reports of brain and spinal cord infarction have been published. In addition, one of the investigators (M.S.W.) has reviewed 4 cases of major cerebellum/brainstem infarction following cervical TF-ESIs with methylprednisolone. To better characterize these complications, anonymous surveys were sent to all U.S. physician members of the American Pain Society. Respondents were asked about awareness of complications, year of occurrence, practice setting and specialty of the treating physician, use of fluoroscopy/contrast/local anesthetic/corticosteroid, doses administered, and CT/MRI/autopsy findings. Overall response rate was 21.4% (287 of 1340). In all, 78 complications were reported, including 16 vertebrobasilar brain infarcts, 12 cervical spinal cord infarcts, and 2 combined brain/spinal cord infarcts. Brain infarcts invariably involved the cerebellum, brainstem, or posterior cerebral artery territory. Thirteen cases resulted in a fatal outcome: 5 with brain infarcts, 1 with combined brain/spinal cord infarcts, 1 following high spinal anesthesia, 1 associated with a seizure, and 5 with unspecified etiology. All 4 cases with corticosteroid alone involved methylprednisolone, resulting in 3 cerebellar infarcts and 1 posterior cerebral territory infarct. Of these, 3 had fatal outcomes and 2 autopsies revealed no vertebral artery trauma. This study demonstrates a significant risk of serious neurologic injury after cervical TF-ESIs. A growing body of evidence supports an embolic mechanism, whereby inadvertent intra-arterial injection of particulate corticosteroid causes a distal infarct. Embolism to the distal basilar artery region can cause midbrain, pons, cerebellum, thalamus, temporal and occipital lobe infarctions. Other potential mechanisms of infarction include vertebral artery perforation causing dissection/thrombosis and needle-induced vasospasm.

The clinical anatomy of the antecubital fossa

To the anatomist, the antecubital fossa is the space through which the principal vascular and nervous trunks pass into the forearm. To the surgeon it is also the site of possible injury to the brachial artery in fractures around the elbow, with the risk of Volkmann's ischaemic contracture constantly in mind. It is here where the surgeon is tempted to use the large superficial veins for venous access, but knows only too well the dangers of inadvertent intra-arterial or intraneural injection – something that may well be encountered in a ‘main-line’ drug addict. It is also a convenient site for arterial cannulation and for anaesthetic blocks of the nerves to the forearm.

Inadvertent intra-arterial drug injections: the role of angiographic and clinical findings

To evaluate the angiographic findings of patients who have inadvertently injected oral formulations of drugs into an upper extremity artery. The radiology files for the previous 4 years were analyzed retrospectively. Seven patients were referred from the Emergency Department for angiography and possible thrombolysis during that time period. The worst clinical results were found among the patients whose angiographic examinations showed absent flow. Two patients who were treated with local thrombolysis had no better results compared to the other five patients. Findings of delayed flow and absent flow in angiography should lead to intensified conservative treatment, especially among patients who have clinical findings of delayed capillary refilling or/and impaired muscular strength.

Fatal Case of Accidental Intra-arterial Phenytoin Injection

Introduction venae-comitantes. Small amounts of thrombus were removed proximally and distally. Attempts to enter An 83-year-old woman presented with status epithe ulna artery were unsuccessful. After the procedure the radial and brachial arteries were palpable and the lepticus. She had an intractable disorder and resided in a nursing home for epileptics. Treatment with rectal ulna artery was Doppler detectable, indicating that the thrombectomy was successful. During surgery intradiazepam and paraldehyde failed so an injection of 750 mg phenytoin in 50 ml of solution from a 50 ml arterial papaverine and heparin were given. Intravenous heparin and prostacycline were used postsyringe was given by hand over 30 min. This stopped the fitting. However, she went onto develop acute operatively. However, despite this treatment, gangrene of the limb ischaemia, which, despite aggressive therapy was not controlled and led to her death. ulna aspect of the hand and forearm developed within 6 h. The ischaemia progressed to involve the entire limb and chest wall. Right forequarter amputation was deemed inappropriate because of the extent of Report ischaemia and the patient’s declining clinical condition. She died of the complications of intra-arterial phenyTo control her fitting, a slow, manual injection of toin injection 4 days later. phenytoin solution was given. As venous access was difficult to achieve a 19G cannula was inserted into what was thought to be a vein in her right antecubital fossa and the solution injected. This controlled the Discussion fitting. Two hours later she developed pain in her right hand. The right arm was pale and paraesthetic from Inadvertent intra-arterial phenytoin injection is a rare the shoulder downwards. Pulses were impalpable and but serious cause of acute limb ischaemia. Accidental Doppler signals absent distal to the right subclavian. intra-arterial injection of drugs such as phenothiazines The antecubital fossa cannula had been removed. have been reported to cause limb ischaemia. The first An arteriogram confirmed occlusion at the level of reported case of accidental intra-arterial phenytoin the right subclavian artery with no distal flow. An injection was in 1992, when digital gangrene occurred embolectomy, under general anaesthesia, was pernecessitating amputation of the fingers following formed via a brachial approach. There was evidence phenytoin injection into the brachial artery. Intraof artery puncture, extravasation and thrombosis of the arterial phenytoin causes thrombosis in arterioles and capillaries that causes distal ischaemia. In our case the brachial artery injection led to progressive ischaemia, ∗ Please address all correspondence to: C. R. McLean, Research proximally and distally, despite aggressive treatment. Fellow, Department of Orthopaedic Surgery, Mayday University Hospital, London Road, Croydon CR7 7YE, U.K. Phenytoin solution is strongly alkaline with a pH of

Acute arterial spasm in an extremity caused by inadvertent intra-arterial injection successfully treated in the Emergency Department

We present a case of limb ischemia in a young man. For acute alcohol withdrawal, this patient was given chlordiazepoxide (Librium) through an angiocatheter inadvertently placed into a brachial arterial line. This caused severe spasm of the brachial artery and its branches. These findings were con- firmed by angiography. Successful treatment occurred with intra-arterial papaverin.