Unintentional intra-arterial injection: Difference between revisions

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Background
==Background==
*A significant and potentially severe complication of medication administration 
*Must consider this scenario any time patient begins complaining of paresthesias or pain distal to IV site
*Self-inflicted cases are also being described in patients with IVDA


* Risk Factors
===Risk Factors<ref>Sen S, Chini E, Brown M. Complications After Unintentional Intra-arterial Injection of Drugs: Risks, Outcomes, and Management Strategies.  Mayo Clinic Proceedings 2005. 80(6):783-795</ref>===
  * Obesity
*Obesity
  * Hypotension
*Hypotension
*Procedurally difficult situations (ie. agitated patient, back of ambulance)
*Aberrant vascular anatomy


Management:
===Pathophysiology===
# Maintain catheter in place to deliver medications if indicated
Is often multifactorial and dependent upon type of medication administered. Theories include NE induced vasospasm, crystal formation, venous constriction, lipid solubility, direct cytoxicity, endothelial damage and high osmolality.  All pathways suggest the primary mediator of tissue injury is '''thrombosis'''<ref>Sen S, Chini E, Brown M. Complications After Unintentional Intra-arterial Injection of Drugs: Risks, Outcomes, and Management Strategies.  Mayo Clinic Proceedings 2005. 80(6):783-795</ref>
# Thoroughly evaluate medications administered through this catheter
 
# Evaluate severity of injury (soft compartments, neuro-vascular exam)
===Medications known to cause severe injury if administered IA:===
# Treat pain and symptoms
*Benzodiazepines
# Administer directed therapy
*Barbiturates
*Propofol
*Penicillins
*Amphetamines
*Phenothiazines
*Phenytoin
*Heroin
*Tubocurarine
*Atrcurium
*TPN
*NaHCO3
*Hypertonic Dextrose (D50)
 
==Clinical Features==
''Presentation is a spectrum of severity''
===Symptoms===
*Immediate:  pain on injection, numbness, weakness
*30 min-24 hours: decreased cap refill, pallor, skin mottling, cramping, paresthesias motor deficit
*24- 48 hours: swelling, edema, contractures, signs of compartment syndrome
*1-2 weeks:  clinical evidence of rhabdo, necrosis, gangrene, autoamputation<ref> Sen S, Chini E, Brown M. Complications After Unintentional Intra-arterial Injection of Drugs: Risks, Outcomes, and Management Strategies. Mayo Clinic Proceedings 2005. 80(6):783-795</ref>
 
===Tissue Severity Score===
''Assesses severity of symptoms''
*Skin color
*Capillary refill
*Distal sensation
*Distal extremity temperature
 
:Receives 1 point for every finding that is abnormal
:Score of >2 is associated with higher likelihood of requiring amputation despite early treatment and management.<ref>Treiman G, Yellin A, Weaver F, et al. An effective treatment protocol for intra-arterial drug injection. Journal of Vascular Surgery 1990; 12:456-466</ref>
 
==Differential Diagnosis==
*[[Skin and soft tissue infections]]
*[[DVT]]
*[[CT contrast media extravasation]]
*[[Allergic reaction]]
 
==Evaluation==
*Typically clinical
 
==Management==
''Treatment recommendations based off of case reports and animal models.  No good human clinical studies to guide therapy at this time.''
 
===Goals of Management:<ref> Sen S, Chini E, Brown M. Complications After Unintentional Intra-arterial Injection of Drugs: Risks, Outcomes, and Management Strategies. Mayo Clinic Proceedings 2005. 80(6):783-795</ref>===
*Symptom relief
*Evaluate and manage arterial spasm
*Reestablish distal perfusion
*Manage clinical sequelae of tissue injury
*Rehabilitation of limb
 
===Initial steps:<ref> Sen S, Chini E, Brown M. Complications After Unintentional Intra-arterial Injection of Drugs: Risks, Outcomes, and Management Strategies. Mayo Clinic Proceedings 2005. 80(6):783-795</ref>===
#If iatrogenic, maintain catheter in place:
#*Start slow infusion of isotonic solution to keep patent
#*to be used for arteriogram and administration of vasodilators
#Thoroughly evaluate medications administered through this catheter
#Evaluate severity of injury (soft compartments, neuro-vascular exam)
#Anticoagulation with IV [[heparin]] recommended
#Treat pain and symptoms
 
===Antibiotics===
*Some clinicians advocate initiation of coverage for [[gram positive]] and [[anaerobic]] organisms if patient is IV drug abuser
*Troer et al. withheld Antibiotics in this patient population if no sign of infection present.  No cellulitic changes or spreading infection noted in those managed with antibiotic.<ref>Treiman, GS, Yellin, AE, Weaver, FA, Barlow, WE, Treiman, RL, and Gaspar, MR. An effective treatment protocol for intraarterial drug injection. J Vasc Surg. 1990; 12: 456–465</ref>
 
===If Evidence of Vasospasm===
Consider initiation of the following:
#IA Papaverine 30MG followed by infusion of 180mg over 10 hours<ref>Arquilla, B, Gupta, R, Gernshiemer, J, and Fischer, M. Acute arterial spasm in an extremity caused by inadvertent intra-arterial injection successfully treated in the emergency department. J Emerg Med. 2000; 19: 139–143</ref>
#Extremity sympatholysis with plexus or nerve block<ref>Berger, JL, Nimier, M, and Desmonts, JM. Continuous axillary plexus block in the treatment of accidental intraarterial injection of cocaine [letter]. N Engl J Med. 1988; 318: 930</ref>
#IA CCB → Nicardipine IA infusion<ref>Boudaoud, S, Jacob, L, Lagneau, F, Payen, D, Servant, JM, and Eurin, B. Successful treatment of vasospastic acute ischaemia with intra-arterial nicardipine. Eur J Anaesthesiol. 1993; 10: 133–134</ref>
 
==Disposition==
*Much of management depends on extent of injury and timing.
*Admission for serial neurovascular exams and compartment checks is recommended with early elevation and aggressive pain management.
 
==See Also==
*[[CT contrast media extravasation]]
 
==External Links==
 
==References==
<references/>
 
[[Category:Toxicology]][[Category:Critical Care]][[Category:Pharmacology]]

Latest revision as of 03:38, 9 February 2017

Background

  • A significant and potentially severe complication of medication administration
  • Must consider this scenario any time patient begins complaining of paresthesias or pain distal to IV site
  • Self-inflicted cases are also being described in patients with IVDA

Risk Factors[1]

  • Obesity
  • Hypotension
  • Procedurally difficult situations (ie. agitated patient, back of ambulance)
  • Aberrant vascular anatomy

Pathophysiology

Is often multifactorial and dependent upon type of medication administered. Theories include NE induced vasospasm, crystal formation, venous constriction, lipid solubility, direct cytoxicity, endothelial damage and high osmolality. All pathways suggest the primary mediator of tissue injury is thrombosis[2]

Medications known to cause severe injury if administered IA:

  • Benzodiazepines
  • Barbiturates
  • Propofol
  • Penicillins
  • Amphetamines
  • Phenothiazines
  • Phenytoin
  • Heroin
  • Tubocurarine
  • Atrcurium
  • TPN
  • NaHCO3
  • Hypertonic Dextrose (D50)

Clinical Features

Presentation is a spectrum of severity

Symptoms

  • Immediate: pain on injection, numbness, weakness
  • 30 min-24 hours: decreased cap refill, pallor, skin mottling, cramping, paresthesias motor deficit
  • 24- 48 hours: swelling, edema, contractures, signs of compartment syndrome
  • 1-2 weeks: clinical evidence of rhabdo, necrosis, gangrene, autoamputation[3]

Tissue Severity Score

Assesses severity of symptoms

  • Skin color
  • Capillary refill
  • Distal sensation
  • Distal extremity temperature
Receives 1 point for every finding that is abnormal
Score of >2 is associated with higher likelihood of requiring amputation despite early treatment and management.[4]

Differential Diagnosis

Evaluation

  • Typically clinical

Management

Treatment recommendations based off of case reports and animal models. No good human clinical studies to guide therapy at this time.

Goals of Management:[5]

  • Symptom relief
  • Evaluate and manage arterial spasm
  • Reestablish distal perfusion
  • Manage clinical sequelae of tissue injury
  • Rehabilitation of limb

Initial steps:[6]

  1. If iatrogenic, maintain catheter in place:
    • Start slow infusion of isotonic solution to keep patent
    • to be used for arteriogram and administration of vasodilators
  2. Thoroughly evaluate medications administered through this catheter
  3. Evaluate severity of injury (soft compartments, neuro-vascular exam)
  4. Anticoagulation with IV heparin recommended
  5. Treat pain and symptoms

Antibiotics

  • Some clinicians advocate initiation of coverage for gram positive and anaerobic organisms if patient is IV drug abuser
  • Troer et al. withheld Antibiotics in this patient population if no sign of infection present. No cellulitic changes or spreading infection noted in those managed with antibiotic.[7]

If Evidence of Vasospasm

Consider initiation of the following:

  1. IA Papaverine 30MG followed by infusion of 180mg over 10 hours[8]
  2. Extremity sympatholysis with plexus or nerve block[9]
  3. IA CCB → Nicardipine IA infusion[10]

Disposition

  • Much of management depends on extent of injury and timing.
  • Admission for serial neurovascular exams and compartment checks is recommended with early elevation and aggressive pain management.

See Also

External Links

References

  1. ↑ Sen S, Chini E, Brown M. Complications After Unintentional Intra-arterial Injection of Drugs: Risks, Outcomes, and Management Strategies. Mayo Clinic Proceedings 2005. 80(6):783-795
  2. ↑ Sen S, Chini E, Brown M. Complications After Unintentional Intra-arterial Injection of Drugs: Risks, Outcomes, and Management Strategies. Mayo Clinic Proceedings 2005. 80(6):783-795
  3. ↑ Sen S, Chini E, Brown M. Complications After Unintentional Intra-arterial Injection of Drugs: Risks, Outcomes, and Management Strategies. Mayo Clinic Proceedings 2005. 80(6):783-795
  4. ↑ Treiman G, Yellin A, Weaver F, et al. An effective treatment protocol for intra-arterial drug injection. Journal of Vascular Surgery 1990; 12:456-466
  5. ↑ Sen S, Chini E, Brown M. Complications After Unintentional Intra-arterial Injection of Drugs: Risks, Outcomes, and Management Strategies. Mayo Clinic Proceedings 2005. 80(6):783-795
  6. ↑ Sen S, Chini E, Brown M. Complications After Unintentional Intra-arterial Injection of Drugs: Risks, Outcomes, and Management Strategies. Mayo Clinic Proceedings 2005. 80(6):783-795
  7. ↑ Treiman, GS, Yellin, AE, Weaver, FA, Barlow, WE, Treiman, RL, and Gaspar, MR. An effective treatment protocol for intraarterial drug injection. J Vasc Surg. 1990; 12: 456–465
  8. ↑ Arquilla, B, Gupta, R, Gernshiemer, J, and Fischer, M. Acute arterial spasm in an extremity caused by inadvertent intra-arterial injection successfully treated in the emergency department. J Emerg Med. 2000; 19: 139–143
  9. ↑ Berger, JL, Nimier, M, and Desmonts, JM. Continuous axillary plexus block in the treatment of accidental intraarterial injection of cocaine [letter]. N Engl J Med. 1988; 318: 930
  10. ↑ Boudaoud, S, Jacob, L, Lagneau, F, Payen, D, Servant, JM, and Eurin, B. Successful treatment of vasospastic acute ischaemia with intra-arterial nicardipine. Eur J Anaesthesiol. 1993; 10: 133–134
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