The incidence, significance, and management of accidental intra-arterial injection: a narrative review

Rare but relevant: The injection of tablet preparations and pulmonary hypertension

Intravascular injection of dissolved medicinal preparations such as crushed tablets is associated with a risk of injecting particulate material into the vasculature. This particulate material will naturally pass to the lungs where it will be largely filtered out in the pulmonary vascular bed, and in turn, it can result in a range of pathological processes in the lungs including pulmonary arterial hypertension, granulomatous lung disease, and pulmonary fibrosis. On rare occasions, a rapid increase in pulmonary vascular resistance can result in sudden death of the injecting drug user.

Inadvertent Intra-Arterial Administration of Rocuronium During Anesthetic Care in a Sixteen-Year-Old Patient

The inadvertent intra-arterial (IA) injection of medications can result in significant clinical sequelae, including paresthesia, pain, loss of motor function, compartment syndrome, gangrene, and loss of digits or limb. We present the inadvertent IA administration of rocuronium during intraoperative anesthetic care of a 16-year-old patient. Following the inhalation of incremental concentrations of sevoflurane in nitrous oxide and oxygen, an intravenous (IV) cannula was placed in the left antecubital fossa. Rocuronium was administered through an IV cannula to facilitate endotracheal intubation. The forearm and hand became mottled and it was determined that the cannula was in the brachial artery. During the ensuring 2 h, there was a gradual return of the extremity to its baseline appearance. The patient was discharged home and no further sequelae were noted. Previous reports of the IA injection of neuromuscular blocking agents are reviewed, techniques to prevent such problems discussed, and a pathway for treatment outlined.

Unforeseen Impact of the IV Fluid Shortage on Patient Safety: A Case of Inadvertent Intra-arterial Injection During General Anesthesia

Accidental intra-arterial injection of medications is rare but can have devastating results. There have been many case reports written over the years illustrating this issue and the various sequelae, ranging from minimal impact on the patient to permanent tissue damage and even limb amputation. We report on a surgical case that was performed from start to finish through an unrecognized intra-arterial catheter. This case is unique as it was performed in November 2024 in the United States, which was in the midst of a severe intravenous fluid shortage due to Hurricane Helene. As a result, this case and thousands of others were done without a running IV. Instead, this case was performed by pushing medications through an IV and then flushing in the medications with a small amount of fluid from a syringe in an effort to conserve IV fluids for urgent or emergent use. We postulate that due to not having a running IV, this accidental intra-arterial catheter went unrecognized in a 90-minute surgical case. In all likelihood, with a running IV connected to an intra-arterial catheter, the IV would not have functioned normally and in troubleshooting the IV, the error would have been recognized much sooner. Consequently, the patient would not have been exposed to the dangers of receiving medications through an intra-arterial catheter. This case highlights the critical role of continuous IV fluids in detecting misplaced catheters and underscores the importance of reinstating this practice as soon as supply constraints allow.

Accidental intra-arterial injection of enoxaparin sodium leading to abdominal wall expanding subcutaneous hematoma and abdominal wound: case report-vascular

Introduction

Enoxaparin sodium (Lovenox®) is a commonly used anticoagulant medication that is self-administered via subcutaneous injection to prevent the formation of pathologic blood clots. It is used as a bridge to long-term anticoagulation with warfarin in patients at high risk for thromboembolic events. It is generally well-tolerated and has a favorable safety profile. The most common injection site reactions caused by enoxaparin sodium are urticaria, ecchymosis, and skin and fat necrosis.

Case Report

A 56 year-old female with extensive thromboembolic history was completing an enoxaparin sodium bridge to warfarin when she accidentally self-injected enoxaparin sodium into the left superficial epigastric artery, resulting in the formation of a large expanding hematoma and the development of hemorrhagic shock. Controlling the bleeding required reversal of anticoagulation, transfusion, and coil embolization of the affected arteries. Surgical evacuation of the hematoma was performed, and the resultant wound was managed postoperatively with negative pressure wound therapy (NPWT) for one month. After discontinuation of NPWT, the wound was allowed to heal by secondary intention using dressing changes.

Conclusions

The findings of this case report suggest that NPWT followed by conventional dressings can be used to close and heal the wound created by surgical hematoma evacuation.

Guidelines for management of actual or suspected inadvertent intra-arterial injection of sclerosants

BACKGROUND

Inadvertent intra-arterial injection of sclerosants is an uncommon adverse event of both ultrasound-guided and direct vision sclerotherapy. This complication can result in significant tissue or limb loss and significant long-term morbidity.

OBJECTIVES

To provide recommendations for diagnosis and immediate management of an unintentional intra-arterial injection of sclerosing agents.

METHODS

An international and multidisciplinary expert panel representing the endorsing societies and relevant specialities reviewed the published biomedical, scientific and legal literature and developed the consensus-based recommendations.

RESULTS

Actual and suspected cases of an intra-arterial sclerosant injection should be immediately transferred to a facility with a vascular/interventional unit. Digital Subtraction Angiography (DSA) is the key investigation to confirm the diagnosis and help select the appropriate intra-arterial therapy for tissue ischaemia. Emergency endovascular intervention will be required to manage the risk of major limb ischaemia. This includes intra-arterial administration of vasodilators to reduce vasospasm, and anticoagulants and thrombolytic agents to mitigate thrombosis. Mechanical thrombectomy, other endovascular interventions and even open surgery may be required. Lumbar sympathetic block may be considered but has a high risk of bleeding. Systemic anti-inflammatory agents, anticoagulants, and platelet inhibitors and modifiers would complement the intra-arterial endovascular procedures. For risk of minor ischaemia, systemic oral anti-inflammatory agents, anticoagulants, vasodilators and antiplatelet treatments are recommended.

CONCLUSION

Inadvertent intra-arterial injection is an adverse event of both ultrasound-guided and direct vision sclerotherapy. Medical practitioners performing sclerotherapy must ensure completion of a course of formal training (specialty or subspecialty training, or equivalent recognition) in the management of venous and lymphatic disorders (phlebology), and be personally proficient in the use of duplex ultrasound in vascular (both arterial and venous) applications, to diagnose and provide image guidance to venous procedure. Expertise in diagnosis and immediate management of an intra-arterial injection is essential for all practitioners performing sclerotherapy.

Sonographic diagnosis and evaluation in patients with superficial radial arteries

BACKGROUND

The superficial radial artery (SRA) is a rare congenital anomaly in the forearm. However, it can be detected incidentally via trauma, intraoperative findings, angiography, or ultrasonography. In addition, intra-arterial infusion of intravenous medications and difficulties in radial artery catheterization may occur in cases of the SRA.

METHODS

Between December 2016 and July 2020, anomalous branches of radial arteries were found incidentally in nine patients at the preoperative visit and identified during ultrasound-guided radial artery puncture in 21 patients when radial artery catheterization using the palpation method proved difficult. Ultrasound examinations were performed for diagnosis and evaluation of these 30 patients.

RESULTS

All anomalous branches of the radial artery were SRAs; 11 (37%), 13 (43%), 6 (20%) were present on the right side, on the left side, and bilaterally, respectively. All SRAs ran close to the cephalic vein. The vascular diameters of the radial arteries were the smallest in the radial artery distal to the SRA bifurcation (followed by in the SRA) and the largest in the radial artery proximal to the bifurcation (p < .001). In two cases, color Doppler study revealed that both the blood flow and color Doppler signal of the SRA disappeared with compression of the radial artery proximal to the SRA bifurcation.

CONCLUSIONS

Because the SRA runs very close to the cephalic vein, a tourniquet applied to the arm may easily lead to intravenous catheter misplacement into the SRA. In addition, the small radial artery distal to the SRA bifurcation causes difficulty in radial artery catheterization. Furthermore, SRA cases may have falsely normal Allen's test results. Therefore, the authors recommend that the SRA must be identified before vascular puncture for safe vascular catheterization in the forearm.

Causes, risk factors, and complications of accidental intra-arterial administration of medications in a children's hospital: a case series

BACKGROUND

Accidental intra-arterial administration of a medication can lead to serious iatrogenic harm. Most studies have discussed single cases of accidental intra-arterial administration of a medication, but only a few have described multiple cases occurring in a single, pediatric hospital setting.

METHODS

The subjects were pediatric patients with an accidental intra-arterial administration of a medication. After obtaining approval from the institutional review board, the relevant cases were extracted from incident reports submitted to the patient safety office of the study center between November 2016 and April 2023.

RESULTS

A review of 18,204 incident reports yielded 10 cases (patient age: 27 days to 13 years) of accidental intra-arterial administration of a medication. The most common site of the cannulation was the dorsum of the foot followed by the dorsum of the hand. The medications administered were narcotics, sedatives, muscle relaxants, antibiotics, and crystalloids. No serious adverse events occurred after injection. In some cases, the accidental arterial cannulation was not discovered immediately (53 min to 26 days). Seven patients had difficult intravenous access; in two of these, ultrasound-guided peripheral venous cannulation was used.

CONCLUSIONS

We experienced 10 cases of accidental intra-arterial administration of a medication. The dorsalis pedis artery and the radial artery around the anatomical tobacco socket were common sites of unintentional arterial cannulation. Difficult intravenous (IV) access may be associated with unintentional arterial cannulation. If IV access is difficult or the free IV drip is sluggish, strict vigilance and repeated confirmation are needed to prevent unintentional arterial cannulation.

Inadvertent administration of intravenous anaesthesia induction agents via the intracerebroventricular, neuraxial or peripheral nerve route - A narrative review

Intravenous (IV) medication administration error remains a major concern during the perioperative period. This review examines inadvertent IV anaesthesia induction agent administration via high-risk routes. Using Medline and Google Scholar, the author searched published reports of inadvertent administration via neuraxial (intrathecal, epidural), peripheral nerve or plexus or intracerebroventricular (ICV) route. The author applied the Human Factors Analysis and Classification System (HFACS) framework to identify systemic and human factors. Among 14 patients involved, thiopentone was administered via the epidural route in six patients. Four errors involved the routes of ICV (propofol and etomidate one each) or lumbar intrathecal (propofol infusion and etomidate bolus). Intrathecal thiopentone was associated with cauda equina syndrome in one patient. HFACS identified suboptimal handling of external ventricular and lumbar drains and deficiencies in the transition of care. Organisational policy to improve the handling of neuraxial devices, use of technological tools and improvements in identified deficiencies in preconditions before drug preparation and administration may minimise future risks of inadvertent IV induction agent administration.

Can Currently Available Non-invasive Continuous Blood Pressure Monitors Replace Invasive Measurement With an Arterial Catheter?

Deviations from normal blood pressure (BP) during general anesthesia have been clearly linked to several adverse outcomes. Measuring BP accurately is therefore critically important for producing excellent outcomes in health care. Normal BP does not necessarily guarantee adequate organ perfusion however and adverse events have occurred even when BP seemed adequate. Invasive blood pressure monitoring has recently evolved beyond merely measuring BP. Arterial line-derived pulse contour analysis is used now to assess both cardiac output and stroke volume variation as indices of adequate intravascular volume. Confirmation of acceptable cardiac output with data derived from invasive intra-arterial catheters has become very important when managing high-risk patients. Newer devices that measure BP continuously and non-invasively in the digital arteries via a finger cuff have also become available. Many clinicians contemplate now if these new devices are ready to replace invasive monitoring with an arterial catheter. Unlike non-invasive devices, intra-arterial catheters allow frequent blood sampling. This makes it possible to assess vital parameters like pH, hemoglobin concentration, ionized calcium, potassium, glucose, and arterial partial pressure of oxygen and carbon dioxide frequently. Non-invasive continuous BP measurement has been found to be unreliable in critically ill patients, the elderly, and patients with calcified arteries. Pulse contour-derived estimates of cardiac output and stroke volume variation have been validated better with data derived from arterial lines than that from the newer finger cuff monitors. Significant advances have been recently made with non-invasive continuous BP monitors. Invasive monitoring with an arterial line however remains the gold standard for measuring BP and assessing pulse contour analysis-derived hemodynamic variables in critically ill patients. In the future, non-invasive continuous BP monitors will likely replace intermittent oscillometers in the operating room and the postoperative period. They will however not eliminate the need for arterial catheterization in critically ill patients.

When the course deviates from expected: Misplacement of an epicutaneo-caval catheter in a neonate

Central venous access, a common and essential component of the care of the critically ill neonate, is associated with complications such as infection, thrombosis, and bleeding. Unintentional arterial cannulation of a venous catheter is a rare but potentially dangerous complication. In the report, we describe the accidental cannulation of an artery with an epicutaneo-caval catheter in an extremely low birth weight infant. We discuss the physical and radiological findings that raise the suspicion of an arterial placement of a catheter, the diagnostic tools to confirm the misplacement, the potential complications, and strategies to prevent it.