Be Careful with an IV Line

Abstract

A 57-year-old male with a past surgical history of a transhiatal oesophagectomy which was done for oesophageal carcinoma, presented with the complaint of dysphagia. Multiple bougie dilatations had already been done in the past, to relieve a stricture. A provisional diagnosis of a recurring stricture oesophagus was made. An upper gastrointestinal endoscopy was obtained and narrowing was observed at the anastomotic site; a diagnosis of a postoperative oesophageal stricture was confirmed and he underwent a bougie dilatation.Post-operative pain management was achieved by giving an IV injection of Fortwin (pentazocin). During its administration, he complained of a "hot flush sensation" as well as pain in the right hand at the IV line site. Two days later, redness and swelling was noted around the injection site. A right hand arterial Doppler was obtained and it showed radial artery thrombosis with complete occlusion, as well as a monophasic waveform in the proximal half of the ulnar artery, along with a trickle of flow in its distal half. A diagnosis of right arterial thrombosis which was secondary to an inadvertent IA injection was made. A CVTS consult advised that the patient be started on low molecular weight heparin. Despite this, blackish discolouration of the fingertips developed and gangrene ensued, compelling debridement under a brachial plexus block. A repeat Doppler was done, which showed a persistent thrombus in the right radial artery. LMWH was changed to oral Acitrom (nicoumalone), after which he was discharged and was told to return when the dry gangrene showed a clear line of demarcation.He returned two weeks later, and unfortunately the gangrene had progressed from his fingertips (which were now black and shriveled) to his entire palm, which was blackish and oedematous. Signs which were indicative of an extensive tissue injury were present: a right hand that was cold to touch, absence of sensation at the fingertips and decreased sensation over the palm, and absence of right radial and ulnar arterial pulsations. This quickly progressed to loss of all sensations over the right hand, and a clear line of demarcation was noted [Table/ Fig-1,2]. Wrist disarticulation was done eventually. Post-operatively, the amputation stump appeared healthy and he was advised regular follow-ups upon discharge. Surgery Section ABStRACtObtaining an intravenous (IV) access is a simple procedure which can be done in almost any hospital setting. One of the most dreaded complications of this procedure is an inadvertent intra-arterial cannulation. This can result in an accidental injection of medications intraarterially, which can potentially lead to life altering consequences. In the hope that these types of events can be prevented, we are presenting a case of a 57-year-old male who underwent bougie dilatation for an oesophageal stricture and was accidentally given medication for pain management intra-arterially through an improperly placed IV line, which resulted in ischaemia, gangrene and subsequent loss of the hand. Those wh...

'Intravenous' Cannulation: Always Assumed; Rarely Verified; Sometimes Dangerous - A Case Report

“…Perhaps if we exhibited similar vigilance with our cannulas, we may be able to identify such problems early on and prevent similar incidents. In short, be careful with an IV line [6], it may be a medical emergency.…”

Investigation of histopathological effects after intra-arterial sugammadex injection in an experimental animal model

“…Accidental intra-arterial injections have very destructive effects on patients' lives (1,2). Case reports about iatrogenic intraarterial injection of medications are available since the 1940s.…”