Accidental intra-arterial injection of propofol

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

This narrative review discusses the incidence, risk factors, mechanisms of injury, complications, and treatment regimens for accidental intra-arterial injection of medications. Despite awareness of the issue and the establishment of safety recommendations by national agencies, accidental iatrogenic intra-arterial injection of medications continues to occur. Most of these injuries are caused by accidental injection into an established arterial cannula or the inadvertent and unrecognized cannulation of an artery instead of a vein. Although many medications have been injected into arteries without significant consequence, a number of drugs are consistently associated with severe morbidity, including the need for amputation, making early incident recognition and treatment vital. Accidental intra-arterial injection of medications has also been increasingly reported in those who use illicit drugs, as these intravenous injection attempts can be misdirected into an artery. These reports have improved understanding of these injuries and possible treatment modalities. While the characteristics of injuries from illicit injections are diverse and the optimal treatment modalities are still uncertain, a regimen that includes anticoagulation and intra-arterial injection of thrombolytics and prostaglandins may improve outcomes. Steroids, vasodilators, and sympathetic blocks do not appear to influence amputation rates. Owing to the small and sporadic number of cases, no definitive clinical trial evidence exists, but the treatment modalities found to be useful in the illicit intra-arterial injection group may benefit treatment of similar iatrogenic injuries.

Missed Carotid Artery Cannulation: A Line Crossed and Lessons Learnt

We report a case of an infusion of intra-aortic propofol after the missed inadvertent placement of a centra venous catheter into the right common carotid artery. Radiological imaging revealed bilateral ischaemic infarct in the posterior fossa and right cerebral artery territories consistent with an embolic source. The potential cause of the neurological injuries sustained in this case are explored. Discussion focuses on the sequelae, managemen and prevention of an iatrogenic carotid artery injury from a central venous catheter insertion. Finally, we propose an algorithm for management of iatrogenic carotid artery cannulation.

Extravasation of propofol is associated with tissue necrosis in small children

Propofol is widely used for induction of anesthesia and many reports document extravasation and even intra-arterial injections without clinical sequelae. We report a case of tissue necrosis after subcutaneous injection of propofol in a 31-day-old infant.

Complications after unintentional intra-arterial injection of drugs: risks, outcomes, and management strategies

Unintentional intra-arterial injection of medication, either iatrogenic or self-administered, is a source of considerable morbidity. Normal vascular anatomical proximity, aberrant vasculature, procedurally difficult situations, and medical personnel error all contribute to unintentional cannulation of arteries in an attempt to achieve intravenous access. Delivery of certain medications via arterial access has led to clinically important sequelae, including paresthesias, severe pain, motor dysfunction, compartment syndrome, gangrene, and limb loss. We comprehensively review the current literature, highlighting available information on risk factors, symptoms, pathogenesis, sequelae, and management strategies for unintentional intra-arterial injection. We believe that all physicians and ancillary personnel who administer Intravenous therapies should be aware of this serious problem.

Accidental intraarterial drug injections via intravascular catheters placed on the dorsum of the hand

IMPLICATIONS

Two cases of placement of a catheter in the dorsum of a hand into an artery mistaken to be a vein are described. Diagnosis and treatment of such mishaps are discussed.

[Pain associated with the injection of Diprivan]

Pain at the site of propofol injection is a real problem which requires particular attention in children. In adults, undergoing planned surgery, premedication or opioid administration prior to propofol seem to sufficiently reduce the frequency and severity of the pain induced by the injection of the agent into a distal arm vein. Adding lidocaine to propofol just before the injection is debatable in day-case procedures, especially if the injection is carried out on the dorsum of the hand. In children, intravenous administration of lidocaine seems to be more routinely performed, whatever the type of surgery.

Multicentre study of propofol in day case surgery

An open multicentre study that involved 879 patients was set up after the launch of propofol to examine its use outside of the clinical trial programme and within the context of a routine clinical setting. Propofol was assessed as the main anaesthetic agent for a range of day case surgery that included gynaecological, urogenital, body surface, orthopaedic and dental procedures. For the purposes of the study, supplementary agents were restricted to fentanyl, alfentanil or nitrous oxide; no volatile anaesthetics were allowed. Induction of anaesthesia was smooth; 91.6% of patients experienced no excitatory or other adverse effect. The mean duration of anaesthesia was 12 minutes 12 seconds and the mean dosage of propofol was 10.6 mg/kg/hour. Maintenance was uneventful in the large majority of patients. Pain on injection affected approximately 25% of patients and the incidence was reduced when large veins were used for injection. Recovery was rapid with a short interval of approximately 1 minute between awakening and orientation (time to giving correct date of birth). There was a low incidence of postoperative nausea and vomiting.