Intra-arterial Injection Of Drugs Research Articles

Healthcare Associated Inadvertent Intra-Arterial Injection as a Cause of Acute Limb Ischemia

Background: The present study aimed to determine the outcome of healthcare related inadvertent intra-arterial injection as a cause of acute upper limb ischemia in terms of limb function and salvageability. Methods: A retrospective observational study was undertaken at the Department of Vascular and Endovascular Surgery, Shaheed Mohtarma Benazir Bhutto Institute Of Trauma, Karachi between 1st January 2020 to 31st December 2021. All patients who presented with ischemia secondary to inadvertent intra-arterial injection between the ages 18-70 years were included in the study. Files of the patients were reviewed and data was gathered to fill proformas. Follow up of the patients was reviewed for up to four months. Acute limb ischemia, limb salvageability, and limb function was assessed post-treatment. Results: In 14 (46.67%) no amputation occurred, 5 (16.67%) had minor amputation while 11 (36.67%) had major amputation. Seriousness of presenting symptoms was significantly associated with major amputation (p = 0.022). The majority of the patients who presented with pain, discoloration, sensory loss, motor loss, and gangrene had major amputations i.e. 4 (36.4%). memory loss was significantly associated with major amputation [8 (72.7%); p<0.0001]. Gangrene was also significantly associated with major amputation [8 (72.7%); p=0.002]. Conclusion: A number of mechanisms, including direct artery damage, arterial spasm, toxicity from the drug, embolism can result in ischemia following intra-arterial drug injection. In order to avoid such incidents and to make prompt diagnosis, healthcare providers should broaden their awareness of typical local injection practices, phases of injection drug use and the hazards connected with it. Keywords: Acute limb ischemia, gangrene, Injections, Intra-Arterial, Ischemia

Spinal osteomyelitis

Experience in diagnosis and treatment of 112 patients with spine osteomyelitis is presented. In 8 patients cervical spine, in 23 patients thoracic spine and in 81 patients lumbar spine was involved. Neurological deficit was observed in 45 (40.2%) patients. Forty seven (42%) patients underwent conservative and 65(58%) surgical treatment. Conservative treatment included intraarterial injection of antibacterial drugs. Surgical treatment consisted of radical resection of the osteomyelitis focus followed by stabilization of the spine with autografts. Long-term results were evaluated in terms from 1 to 20 years. In all patients the formation of bone block and regression of neurological symptoms was observed.

Status Quo and Trends of Intra-Arterial Therapy for Brain Tumors: A Bibliometric and Clinical Trials Analysis.

Intra-arterial drug delivery circumvents the first-pass effect and is believed to increase both efficacy and tolerability of primary and metastatic brain tumor therapy. The aim of this update is to report on pertinent articles and clinical trials to better understand the research landscape to date and future directions. Elsevier’s Scopus and ClinicalTrials.gov databases were reviewed in August 2021 for all possible articles and clinical trials of intra-arterial drug injection as a treatment strategy for brain tumors. Entries were screened against predefined selection criteria and various parameters were summarized. Twenty clinical trials and 271 articles satisfied all inclusion criteria. In terms of articles, 201 (74%) were primarily clinical and 70 (26%) were basic science, published in a total of 120 different journals. Median values were: publication year, 1986 (range, 1962–2021); citation count, 15 (range, 0–607); number of authors, 5 (range, 1–18). Pertaining to clinical trials, 9 (45%) were phase 1 trials, with median expected start and completion years in 2011 (range, 1998–2019) and 2022 (range, 2008–2025), respectively. Only one (5%) trial has reported results to date. Glioma was the most common tumor indication reported in both articles (68%) and trials (75%). There were 215 (79%) articles investigating chemotherapy, while 13 (65%) trials evaluated targeted therapy. Transient blood–brain barrier disruption was the commonest strategy for articles (27%) and trials (60%) to optimize intra-arterial therapy. Articles and trials predominately originated in the United States (50% and 90%, respectively). In this bibliometric and clinical trials analysis, we discuss the current state and trends of intra-arterial therapy for brain tumors. Most articles were clinical, and traditional anti-cancer agents and drug delivery strategies were commonly studied. This was reflected in clinical trials, of which only a single study had reported outcomes. We anticipate future efforts to involve novel therapeutic and procedural strategies based on recent advances in the field.

Intraarterial Injection of Drugs of Abuse into Femoral Artery: Case Report and Review of the Literature

Accidental intraarterial injection is a serious condition which can compromise the viability of the limb within hours. There are no evidence based guidelines suggesting the proper treatment protocol and there is no consensus about the ideal treatment for these events. We present a case where a mixture of benzodiazepine pills and street heroin was injected in right femoral artery. Patient arrived in hospital days after event. With intraarterial application of thrombolysis, vasodilators and heparin major amputation was avoided. It seems that in selected cases combined therapy with rtPA lysis and PGE1 intra-arterial infusion may prevent major limb amputation even in delayed presentation of acute leg ischaemia caused by inadvertent injection of drugs of abuse.

Evaluation & Management of Accidental Intra-Arterial Injection in the Ante-Cubital Fossa

Introduction: Intra-arterial drug injection is a rare, but a potentially serious medical emergency. It is most commonly seen as an iatrogenic complication when administering an intravenous medication. Accidental Intra-arterial injection was defined as an intravenous 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 intra-arterial injection. Also, to assess the efficacy of the various modalities of the treatments administered, and establish a standardized treatment plan for intra-arterial injection to achieve limb salvaging. Materials and methods: A total of twelve cases of accidental intra-arterial 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 hours 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 intra-arterial injection is of utmost importance due to its serious complications. Lastly, all medical professionals must be regularly trained in order to prevent such mishaps from happening.

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

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.

Continuous stellate ganglion block for the effective management of ischemic pain following compartment syndrome of upper limb due to accidental intra-arterial injection

In the present era of advanced medicine and patient safe practice, accidental intra-arterial injection of drugs is a rare occurrence. Compartment syndrome (CS) is one of its most detrimental complications, which leads to loss of circulation, ischemia, myonecrosis, nerve damage, and limb loss. Rapid recognition and emergent fasciotomy to relieve the compartment pressure are imperative to prevent irreversible damage. Sympathetic blockade is one of the most common interventions used in the management of early stages of CS, which interferes with the pain cycle and improves distal flow by vasodilatation. We report a complicated case of CS of the right upper limb following accidental intra-arterial injection. The patient suffered with persistent ischemic pain despite surgical decompression, which was successfully managed by continuous stellate ganglion block.

The Role of Anticoagulant Therapy with Heparine in Treatment of Acute Hand Ischemia

Hand ischaemia has multiple causes. The Methadone (C21H27NO) - opioid family of drugs and Alprazolam (C17H13Cl1N4) microcrystals, available under the trade name Xanax - benzodiazepine anxiolytic, when using in case of drugs abuser, are very powerful embolic agents which can cause thrombosis of small vessels. Microvascular embolization caused by microcrystals of the injectable powder has contributed to the process of ischaemia. This paper brings into discussions a case of acute ischaemia of the right hand due to intra-arterial injection of suspended tablets of Methadone and Alprazolam microcrystals into the right radial artery, in the distal 1/3 of the forearm.The therapeutic management consisted of restoring the arterial circulation at the ischaemic segment to prevent the propagation of thromboembolic complications by using of i.v. heparine and to preserve the function of the hand by preventing delayed ischaemia and compartment syndrome followed by necrosis. Heparin is a drug widely used in the treatment and prevention of arterial and venous thrombosis. The main effect of heparins lies in their anticoagulant activity. Heparins are involved in different pathways of the coagulation cascade with anticoagulant, antithrombotic, profibrinolytic, anti-aggregative, as well as anti-inflammatory effects.This paper aims to discuss a severe case of ischaemia which demonstrates that intra-arterial injection of oral drugs can lead to limb loss with currently accepted therapy.

Use of Continuous Brachial Plexus Blockade for Treatment of Accidental Intra-Arterial Injection

Introduction: Unintentional intra-arterial injection of drugs has serious problems and morbidity such as pain, ischemia, gangrene, and infection. Aberrant vascularization is a frequent cause of intra-arterial injection.Case Report: We describe a pediatric case of accidental cannulation of aberrant arterial vessel during venous insertion and our brachial plexus block treatment to obtain continuous vasodilatation to prevent ischemic effects.Conclusion: Sympatholysis with peripheral nerve blocks may decrease morbidity providing an additional benefit to pharmacological treatment by increasing blood flow to the tissue after the intra-arterial injection

An Anatomical Analysis of the Supratrochlear Artery: Considerations in Facial Filler Injections and Preventing Vision Loss.

Embolia cutis medicamentosa (ECM) is a rare phenomenon attributed to intra-arterial drug injection. Glabellar filler injections can result in potentially devastating visual loss from inadvertent retrograde arteriolar embolization due to the extensive vasculature within the upper face. The minimum amount of filler necessary to potentiate this complication has not yet been reported. We aim to determine the volume of filler necessary to occupy the supratrochlear artery from the glabella to the bifurcation of the ophthalmic and central retinal arteries. We specifically examine the volume of the supratrochlear artery from the glabella to orbital apex. The study was approved by Duke University Institutional Review Board and involved surgical dissection of six fresh tissue cadaver heads (12 hemifaces). The arterial system in each cadaver head was injected with latex for visualization. The supratrochlear arteries were isolated anteriorly from the glabella to the orbital apex posteriorly. Intra-orbital vessel radius and length were measured. The vessel volume was calculated by water displacement of the intra-arterial latex. The vessel volumes ranged from 0.04 to 0.12 mL. The average vessel volume was calculated as 0.085 mL, the average length as 51.75 mm, and the average radius as 0.72 mm. Vascular occlusion from filler injections can lead to devastating visual consequences due to inadvertent retrograde intra-arterial embolization. Our findings indicate that the average entire volume of the supratrochlear artery from the glabella to the orbital apex is 0.085 mL. Injectors should be aware that a bolus of this critical volume may lead to a significant adverse outcome.

Bilateral Radial Artery Aneurysm: Case Report and Review of Literature

While arterial aneurysm in the lower extremities is common, upper extremity aneurysms are relatively infrequent. Radial artery aneurysms are sometimes associated with trauma and connective tissue disorders. Very few cases of radial artery aneurysm have been reported in the literature. We have encountered a case of bilateral radial artery aneurysms in a 61 year old male. A review of the English language literature was performed using Pub Med database, resulting in 31 reported cases of radial artery aneurysms, with most cases being either traumatic or idiopathic in etiology. Of these reports, bilateral aneurysms had clear etiologies, including Marfan’s vasculopathy, granulomatous arteritis, arteriosclerotic disease and intra-arterial drug injection. To our knowledge, this is the first reported case of primary bilateral radial artery aneurysms.

Inadvertent Intra-Arterial Drug Injections in the Upper Extremity: Systematic Review

To review the literature pertaining to inadvertent intra-arterial drug injection in the upper extremity, explore the various treatment options and their outcomes, and identify risk factors for limb amputation following intra-arterial injection. A systematic review of Medline, EMBASE, and Cochrane databases (inception to March 2013) was completed for patients presenting with intra-arterial drug injection of the upper extremity. Details on intervention and outcome were extracted and subjected to pooled analysis with amputation as the primary outcome. A total of 25 articles (209 patients) were included for review. Mean patient age was 31 ± 8 years (male, 71%; female, 29%). Prescription opioids (33%) were the most commonly injected substance, and the brachial artery (39%) was the most common site. The overall weighted mean amputation incidence was 29%. Anticoagulants were the most common treatment used (77%). From pooled analysis, conditions requiring antibiotic use were significantly associated with a higher incidence of amputation; whereas use of steroids was associated with a lower incidence of amputation. Patients presenting 14 hours or more after injection and those injecting crushed pills rather than pure substances had significantly higher incidences of amputation. Intra-arterial drug injection of the upper extremity carries an amputation incidence of nearly 30%. Conditions requiring adjunctive antibiotic use and delay in receiving care were both significantly associated with higher incidences of amputation. No single treatment protocol to date has established superiority. Therapeutic IV.

Accidental Intra Arterial Injection of Ephedrine: What about the Treatment with Nitroglycerin?

Accidental intra-arterial (IA) injection of drugs in the perioperative setting is fortunately a rare event, but it can cause severe extremity ischaemia, which can result in significant morbidity due to tissue necrosis. There have been many articles reported about inadvertent intra-arterial injections of various drugs over the last decades. However, we found none about the unintentional IA injection of ephedrine, so we present the following case.

Accidental Intra-arterial Cannulation: an Unusual Case.

Dear editor, Mrs X, 21 years old G3P2 with premature rupture of membranes at 41 weeks gestation, had intravenous cannulation in cubital fossa for oxytocin augmentation. Oxytocin infusion was continued for 10 h. Thereafter, she was given intravenous injections of ampicillin and gentamicin. Immediately after injection, oedema of the forearm was noted which was thought to be due to extravasation of drug. Cannula was immediately removed, and magnesium sulphate ointment was applied locally. After 4 h, massive oedema and cyanosis were noticed in the forearm and hand distal to the cannula with absent radial pulsations, leading to a provisional diagnosis of brachial artery thrombosis. Urgent vascular surgeon consultation was obtained. By this time, cervix was fully dilated and patient delivered vaginally a 3-Kg baby, following which thromboembolectomy was done. Post thromboembolectomy, ultrasound Doppler revealed short segmental thrombus of the right brachial artery in distal one-third of arm; ulnar artery patent for only a segment of 3 cm from its origin and radial artery and veins patent throughout. Postoperative care included broad spectrum antibiotics, vasodilators, anticoagulants, limb elevation and dressings. Blisters were noticed over the dorsum of hand on postnatal day 2; diagnosis of compartment syndrome was made for which fasciotomy was done. Repeated ultrasound Doppler after 2 months revealed occlusion of short segment of right brachial artery in cubital fossa, occlusion of right ulnar artery in forearm with multiple collaterals in forearm. Patient had complete resolution of sequelae with complete functioning of hand in 3 months. Accidental intra-arterial anaesthetic drug injections have been reported previously [1]. It has been proposed that lipid soluble drugs are more problematic, and brachial artery is associated with more tissue damage than radial or ulnar [1]. The immediate clinical presentations include pain, pallor in hand and cyanosis of fingers followed by extensive oedema of hand and forearm within 5 h. Extensive injury includes nerve damage, compartment syndrome, thrombosis and gangrene leading to eventual amputation [2]. In this case, significant time elapsed before arterial catheterisation was discovered resulting in disastrous outcome. In summary, vigilance is the best therapy. An indwelling catheter not functioning properly should never simply be assumed to be positional. Alarming signs include marked increase in blood pressure on flushing the line, bright red appearance of blood, more intense pain than expected, distal signs of ischaemia, manual palpation of arterial pulse proximal to the catheter and retrograde pulsatile blood flow. Diagnosis is by pressure transducer or blood gas analysis. Treatment recommendations include continuous heparin infusion for 24 h which, if done immediately, leads to no sequelae; sympathetic blockage with brachial plexus block, stellate ganglion block and general anaesthesia for further sympatholysis, postoperative limb elevation and maintenance of warmth, intra-arterial vasodilators and surgical exploration to extract thrombus and fasciotomy [2]. To conclude, a high index of suspicion of intra-arterial cannulation can prevent disastrous consequences. It is recommended that if suspicion is high, intravenous catheterisation should be repeated unless situation is extremely dire and no other intravenous access is readily obtainable.

Massive Schmerzen und livide Verfärbung des linken Beins nach intravaskulärer Heroininjektion bei einem 32-jährigen Patienten

Acute leg ischemia after intra-arterial drug injection represents a critical vascular emergency scenario. Due to lack of evidence-based standards therapeutic strategies are oriented to the underlying pathomechanisms. For a sufficient therapy a close clinical monitoring and laboratory analyses as well as treatment with analgesics, anticoagulants, anti-inflammatory and spasmolytic agents are of utmost importance. This article reports on the diagnostic and therapeutic approaches in a 32-year-old patient with acute leg ischemia after intra-arterial administration of heroin and secondary infection with Peptostreptococcus and Peptoniphilus species.

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.

Near miss intra-arterial injection via a dual transducer pressure monitoring set

We write regarding a potential hazard of using a dual transducer pressure monitoring set for arterial and central venous catheters. A 20-G right radial arterial catheter (Becton, Dickinson and Company Critical Care Systems Pte Ltd., Franklin Lakes, NJ, USA) and a right internal jugular quad-lumen central venous catheter (Arrow-Howes, Uxbridge, UK) were connected to a dual transducer pressure monitoring set (Edwards Lifesciences Ltd., Irvine, CA, USA), attached to a common 500-ml flushing bag of 0.9% sodium chloride held at a pressure of 300 mmHg. We subsequently noted that a milky substance was being infused down the arterial limb of the transducer set and was approximately 30 cm from reaching the radial artery. Closer inspection revealed propofol and alfentanil infusion pumps were connected via a ‘Y’ connector to the integral three-way stopcock present on the venous limb of the pressure monitoring set, downstream to the flushing device. This three-way stopcock was open, with all three connections communicating. The propofol, presumably with the alfentanil, had flowed in a retrograde direction up the venous limb of the transducer set into the common flushing bag, from where they were flushed down the arterial limb towards the arterial catheter. Inspection of the transducer set revealed no fault and the flushing fluid was maintained at a pressure 300 mmHg. However, there had been intermittent problems flushing several of the central line lumens during the preceding 24 h. We postulate that at some point, the resistance of the central line lumen must have increased through blocking or kinking or perhaps the three-way stopcock may have been temporarily closed to the patient, allowing retrograde flow of the propofol and alfentanil up the venous limb of the transducer set. A PubMed search found a similar incident reported in the correspondence section of Anaesthesia involving an intra-arterial injection of intravenous contrast agent through a dual transducer pressure monitoring set [1]. We wonder if intra-arterial injection of drugs via dual transducer pressure monitoring sets may occur more frequently than is reported. We reviewed our local practice following this incident. We have decided to eliminate the risk by using separate single transducer monitoring sets for arterial and central venous catheters. The use of dual transducer pressure monitoring sets requires vigilance and care when using the injection port of the venous limb for drug delivery. No external funding and no competing interests declared.

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.

Gangrène des doigts après injection accidentelle en intra-artériel de floxacilline : à propos d’un cas

Accidental intra-arterial injection of drugs is rare in pediatric patients. It is a source of considerable morbidity. Vessel proximity, aberrant vasculature, difficult procedures, and clerical errors can contribute to accidental intra-arterial injection. We report a case of a 7-year-old girl who had an accidental intra-arterial injection of 500 mg of floxacillin in her right elbow for open wound of the index. Initial signs and symptoms consisted of intense forearm pain and cyanosis. Two to 3 hours later, discoloration and nail bed pallor became evident, with no radial pulse. Rapid development of signs of acute ischemia prompted urgent brachial artery embolectomy and exploration and forearm fasciotomy. Postoperative heparin was administered. Postoperatively gangrene of the five fingers of the right hand developed. We present a comprehensive review of literature, highlighting available information on symptoms, pathogenesis, sequelae and management strategies for accidental intra-arterial injection. We believe that all physicians and ancillary personnel who administer intravenous therapy should be aware of this serious risk.