Inadvertent Intra-arterial Injection Research Articles

Superficial femoral artery mycotic aneurysm following appendicectomy

It was Sir William Osler in his 1885 Golstonian lecture who coined the term mycotic aneurysm associating abnormal heart valves and infection with microccoci. In recent times inadvertent intra-arterial injection of drugs by abusers is rapidly becoming a common cause of peripheral mycotic aneurysms. 1 Such aneurysms threaten not only the limb but also carry a high mortality from spontaneous rupture. Complex vascular complications of acute appendicitis are rare. Although sepsis of a pre-existing aortic aneurysm has been described, 2 the authors are unaware of any report of a mycotic aneurysm involving a previously normal artery from a bacteriaemia secondary to acute appendicitis.

Regional anesthesia for hand surgery

Several regional anesthetic techniques for hand and wrist surgery are mentioned. Of these techniques, the axillarybrachial plexus block offers several advantages, such as ease of administration, prolongation of analgesia, and very few potential complications. Three conditions must be met to provide effective regional anesthesia: (1) patient instruction, (2) a surgeon comfortable with the technique, and (3) a prepared anesthesiologist. The axillary brachial plexus block is performed aseptically in a manner that promotes proximal spread of local anesthetic, giving the opportunity to block the musculocutaneous nerve before its exit from the sheath. In our institution, we favor 1.5% mepivacaine versus 0.5 bupivacaine because of its inherent safety factor. However, all local anesthetics have the potential for systemic toxicity with either inadvertent intra-arterial injection or use of excessive amounts of drug. Toxic symptoms range from mild, such as as tinnitus, to more severe, such as convulsions, and further progression to cardiovascular collapse. This toxicity must be anticipated and treated appropriately. Our own institutional study showed an 89% success rate with axillary brachial plexus blocks used for hand and wrist procedures. However, the success rate dropped to 60% for surgery involving the elbow. These results were improved by the use of local anesthetic supplementation or intravenous sedation.

Digital ischemia in clandestine intravenous drug users

Five young adults were seen initially with digital ischemia without a history of trauma or underlying systemic illness. After careful evaluation and treatment, inadvertent intraarterial drug injection was found to be the cause of the ischemia. The diagnosis was initially overlooked because the patients did not offer a history of drug abuse and did not appear like the stereotypical drug user. These patients may be seen early or several months after their accidental intraarterial injection. With the increase in drug abuse today, all segments of society can be affected. This diagnosis should be considered in any patient with unexplained digital ischemia.

The Role of Intraarterial Vasodilators in the Treatment of Inadvertent Intraarterial Injection Injuries

Inadvertent arterial injections, both in cases of drug addiction and in iatrogenic situations, often result in significant loss of tissue and, eventually, loss of function distal to the injection site. Previous experimental studies regarding the effectiveness of agents to reverse vasospasm have been inconclusive. A recent clinical report, however, suggested that intraarterial injection of reserpine was affective in limiting tissue necrosis. This experiment was designed to study the affect of intraarterially injected reserpine and tolazoline hydrochloride in a rabbit ear model of necrosis following intraarterial injection of pentothal. Six groups of 5 rabbits each were studied. Animals in Group 1 received intraarterial saline injections. Animals in Group 2 received intraarterial pentothal. Animals in Group 3 received intraarterially injected pentothal plus intraarterial reserpine 30 minutes later. Animals in Group 4 received intraarterially injected pentothal plus intraarterial tolazoline 30 minutes later. Animals in Group 5 received intraarterially injected pentothal plus intraarterially injected reserpine and intraarterially injected tolazoline both administered immediately. Animals in Group 6 received intraarterially injected pentothal plus intraarterially injected reserpine and intraarterially injected tolazoline, both administered 30 minutes later. Results showed no significant difference in the amount of tissue necrosis between treated and untreated animals. We conclude that the use of intraarterial spasmolytic agents has no effect on the course of tissue necrosis after inadvertent intraarterial injections.

Visual Loss Following Intranasal Corticosteroid Injection

Visual loss from embolization of the ocular circulation is a rare but devastating complication of injections into the cutaneous and mucocutaneous tissues of the face, scalp, and nasopharynx.1,2The mechanism seems to be inadvertent intra-arterial injection into the branches of the ethmoidal arteries, with retrograde flow into the ophthalmic artery. Even though the visual symptoms are transient in most cases, permanent visual loss has been reported.3,4 A 37-year-old woman was treated with methylprednisolone acetate injections of the nasal turbinate for chronic allergic rhinitis. A few minutes after the injection, she became dizzy and described a sensation of seeing bright lights in the left eye, with blurring of vision. Examination revealed a best corrected visual acuity of 20/30 in the affected left eye, with 20/20 in the right eye. A paracentral scotoma was present on Amsler grid testing. Results of examination of the pupil and inspection of the anterior

Intravascular Injuries from Intramuscular Penicillin

Benzathine penicillin, procaine penicillin, and mixtures of both are opaque preparations for intramuscular injection. Visualization of aspirated blood, the fail-safe for avoiding intravascular injection, is predictably problematic. A spectrum of injuries, sometimes permanent, to the gluteal region, distal extremities, perineum, and spinal cord probably results from inadvertent intra-arterial injection, possibly due to vascular occlusion by large crystals of the penicillin salt(s). Since the arterial injurie disproportionately affect infants, use of these preparations in that age group should be minimized. The corresponding intravenous injection probably is Hoigne's syndrome, a procaine-induced central nervous system syndrome. Though usually brief and transient complications may be profound, including coma, convulsions, and death. Careful attention to details of anatomy and manufacturer's recommendations is critical.

The role of thromboxane in experimental inadvertent intra-arterial drug injections

Inadvertent intra-arterial injection of drugs produces a well-defined clinical syndrome whose pathophysiology remains unclear. This study was designed to determine the role of the inflammatory mediator, thromboxane, in intra-arterial drug injections. The rabbit ear model, as described by Kinmonth and Sheppard, was used. Five of the experimental groups were treated with specific or nonspecific thromboxane blocking agents and two groups served as controls. Immunohistochemical staining of the control ears showed elevated levels of thromboxane within the first 6 hours postinjury. The specific thromboxane blocking agents, methimazole and Aloe vera, showed almost complete blockade of thromboxane production. The percentage of ear survival was significantly greater in the group treated with topical Aloe vera (p less than 0.05) and even greater survival was achieved in the combined Aloe vera/methimazole group (p less than 0.01). On the basis of these results, we have begun treatment of such injuries with specific and nonspecific thromboxane blocking agents.

Unnoticed Change

To the Editor.— It has been brought to my attention that after the publication of my report, "Inadvertent Intra-arterial Injection of Penicillin: An Unseen Danger" (Pediatrics 1985;75:785-786), Wyeth made certain modifications to the Tubex syringe delivery system. Specifically, Wyeth bent back the needle so that aspirate could potentially be visualized at a certain point on the glass cartridge. This was commendable; however, almost no one knows about it. Furthermore, this spot is very hard to find even if one is looking for it.

Inadvertent Intra-arterial Injection of Penicillin: An Unseen Danger

The inadvertent intra-arterial injection of penicillin has been reported in the buttock1-3 and in the thigh.4,5 The resulting lesion in the small arterioles leads to thrombosis and ischemic damage to tissues supplied by them. Schanzer et al5 felt that accidental intra-arterial injections of penicillin were the result of a design flaw in the disposable, ready-to-use containers (Tubex) in which many of the penicillin preparations are supplied. This container consists of a glass tube with a 20-gauge, 3.2-cm needle at one end and a rubber disk (plunger head) with a threaded pin inserted in it at the other. The container is positioned in a metallic or plastic injector in which a plunger is screwed to the threaded pin permitting the contents to be ejected.

Inadvertent intra-arterial injection of phentaramine: A complication of drug abuse

A female drug abuser inadvertently injected an intravenous injection of an oral anorexiant, phentaramine (Preludin), into her own brachial artery. Severe hand pain, vasospasm, and ischemia occurred. Treatment with regional axillary block, intravenous dextran, intra-arterial priscoline, and salicylate anticoagulation may have influenced a favorable outcome. Intimal damage, vasospasm, and various additive effects after intra-arterial injection contribute to the potential for serious sequelae. Prompt diagnosis, vasodilatation, elevation and compression, pain relief and, in some cases, surgery appear to improve salvage of what is frequently a major extremity injury.

INADVERTENT INTRAARTERIAL INJECTION: A PROBLEM OF DRUG ABUSE

Peripheral ischaemia related to the inadvertent intra-arterial injection of crushed tablets in suspension, was seen in five drug addicts. Characteristic clinical, features were observed including pain, discolouration, oedema, immediate and delayed sensory and motor deficits, and pregangrenous and gangrenous changes distal to the site of injection. Definitive treatment remains to be established, but an approach to management, based upon probable pathophysiological mechanisms, is proposed.

Intra-arterial Administration of Oral Pentazocine

To the Editor.— While pentazocine is free of narcotic controls, many reports in the literature have described misuse of the drug, particularly in its parenterally administered form.1-6This example of inadvertent intra-arterial injection of a suspension of the orally administered form of pentazocine will undoubtedly be followed by others as pentazocine is more frequently used, and as abuse of all drugs continues to increase. Report of a Case.— A 23-year-old white male inhalation therapist, employed at another institution, was admitted through the emergency room at 6 AM Feb 20. 1970, with severe, radiating pain in the right arm 12 hours after injecting a 50-mg tablet of pentazocine dissolved in sterile water into the antecubital area. The patient had intended an intravenous injection but immediately after the injection noted pain radiating down the arm followed by blanching and tingling. He soaked the arm in warm water, but the arm and

Inadvertent intra-arterial injection.

To the Editor. — Doctors Morgan, Waugh, and Boback's recent article (212:476-478, 1970) prompted me to write this letter alerting physicians to the problem of inadvertent intraarterial injection which is not restricted to self-administration. Even in competent hands limb loss has resulted from medication intended to be given intravenously being given intra-arterially.1Hydroxyzine hydrochloride (Vistaril) has been known to produce necrosis of the upper extremities following intra-arterial injection.2 Presumably because of the following case and others like it, hydroxyzine has been withdrawn from the market as an intravenous medication. Report of a Case.— A 23-year-old, five months pregnant woman was admitted to the Mercer Hospital with a history of having received an injection in her left antecubital space three days before, administered by her physician. The medication injected was hydroxyzine and, for all intents and purposes, was administered intravenously. However, during the injection, the patient complained of

Accidental arterial injections

A case is presented of inadvertent intra-arterial injection of meperidine and promethazine. The initial sequence of events following injection was similar to that reported previously. Complete recovery ensued with the administration of intravenous heparin and corticosteroids. Consideration of the pathology seen with this accident suggests that the injury is a chemical endarteritis caused by a high concentration of drug delivered to the peripheral vessels. Immediate treatment should be instituted, including local sympathetic blocks, anticoagulation, and systemic corticosteroids. The basis of most inadvertent intra-arterial injections is the presence of an abnormal arterial branch adjacent to the intended vein. Prevention can best be accomplished by use of solutions containing low concentrations of the medication and by making sure that the needle is lying in the vein lumen for which it was intended.

Accidental Intra-Arterial Injection of Penicillin

INADVERTENT intra-arterial injection of materials intended for intramuscular use is unusual but serious in its untoward effects. The author has recently cared for an infant who received an injection of benzathine penicillin G and procaine penicilllin G mixture (Bicillin C-R 600) into the gluteal muscle. From the outcome it was postulated that the medication was introduced into a gluteal artery. The marked consequences of such a procedure are reported here to add additional warning to the hazard of buttock injections. Report of a Case This 2-month-old white female infant was in excellent health until Oct 31, 1964, when she developed an upper respiratory infection. On Nov 5, 1964, she was seen by her private physician. He injected 600,000 units of benzathine penicillin G and procaine penicillin G into the upper outer quadrant of the right buttock. Negative pressure was applied to the syringe and no blood was seen in the