alexa Accidental Intra Arterial Injection of Ephedrine: What about the Treatment with Nitroglycerin? | Open Access Journals
ISSN: 2155-6148
Journal of Anesthesia & Clinical Research
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Accidental Intra Arterial Injection of Ephedrine: What about the Treatment with Nitroglycerin?

Sergeja Kozar1* and Goran Kurnik2

1Department of Anaesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia

2Department of Anaesthesiology and Intensive Therapy, General Hospital Novo mesto, Novo mesto, Slovenia

*Corresponding Author:
Sergeja Kozar
Department of Anaesthesiology and Intensive Therapy
General Hospital Slovenj Gradec Slovenj Gradec, Slovenia
Tel: +38640800090
E-mail: [email protected]

Received date: February 09, 2015, Accepted date: February 24, 2015, Published date: February 28, 2015

Citation: Kozar S and Kurnik G (2015) Accidental Intra Arterial Injection of Ephedrine: What about the Treatment with Nitroglycerin?. J Anesth Clin Res 6:510. doi: 10.4172/2155-6148.1000510

Copyright: © 2015 Kozar S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

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.

Keywords

Ephedrine; Intra-arterial injection; Treatment; Nitroglycerin

Introduction

Ephedrine is a sympathomimetic that has both, a direct (α, β1 and β2 receptor agonists) and an indirect (release of norepinephrine from presynaptic nerve terminals and monoamine oxidase inhibition) mechanisms of action. It is a safe and widely used drug in the daily anesthesia practice to prevent or treat hypotension resulting from sympathetic blockade during regional anesthesia or from the effects of general anaesthesia. Ephedrine sulphate injection is manufactured for subcutaneous, intramuscular and intravenous administration [1].

Case report

A 66-year old right handed female, with medical history of arterial hypertension and allergy to nimodipine, was scheduled for embolisation with micro-coils due to cold aneurysm of anterior communicant artery.

She had no history of smoking, hyperlipidemia or problems in terms of peripheral vascular disease.

Initially, patient received two intravenous cannulas (G18) preoperatively. Following Allen's test (as according to local protocol), an 20 G arterial cannula (BD Arterial Cannula, Becton Dickinson Critical Care Systems Pte Ltd) was easily inserted in the left radial artery for continuous blood pressure monitoring. The catheter was flushed with standard normal saline solution with heparin (1 IU/ml) and connected to a pressure transducer, showing normal arterial waveform on the monitor. Induction of general anaesthesia was performed using propofol, remifentanyl and rocuronium.

Total intravenous anaesthesia (propofol, remifentanyl) with intermittent boluses of rocuronium was chosen for the maintenance.

Few minutes after induction, drop in arterial pressure was detected. Colloids were used for primary treatment, however the hypotension persisted. A decission to treat it with 10 mg of ephedrine (2 ml) was made. A member of the anaesthesia team accidentally injected the solution into the artery line. The left hand became colder and slightly paler as compared to the right one. Pulse oximeter, placed on the left index finger, showed low quality pulse signal and still adequate oxygen saturation. This mistake was immediately noticed, arterial line was disconnected and catheter flushed with normal saline with heparin. After reconnection of the line, there was no regular arterial wave on the monitor. The intra-arterial catheter was left in place and an infusion of 0.9% saline solution (75 ml/h) via catheter was started to maintain patency. An initial loading dose of heparin 5000 IU was given intravenously and the hand was elevated. Meanwhile, the right radial artery was cannulated for blood pressure monitoring, showing normal waveform.

The scheduled procedure was then initiated and approximately half an hour after IA injection of ephedrine, contrast angiography of the left upper limb was made, indicating multiple narrowings of radial artery due to vasospasms with absence of flow distally at the palmar region, which was maintained through a collateral flow from ulnar artery (Figure 1).

anesthesia-clinical-research-Digital-subtraction

Figure 1: Digital subtraction angiography of the left forearm (intrarterial anterograde contrast injection with angiographic catheter paced in a left axillary artery) immediately after the ephedrine application. Multiple narrowings of radial artery due to vasospasms with absence of flow distally at the palmar region is seen (arrows). Perfusion of palmar region is maintained through a collateral flow from ulnar artery (deep palmar arch).

The operation lasted for around 3 hours without any surgical complications, meantime acetylsalicylic acid 500 mg intravenously was administered and heparin 1000 IU was repeated every hour as according to local protocol.

Throughout the procedure, the left hand was carefully observed. It was warm and of normal color, pulse oximeter placed on the left index finger showed quality pulse signal and normal oxygen saturation.

After the procedure, angiography of left arm was done again, showing persistent vasospasms of left radial artery with absence of distal blood flow (Figure 2).

anesthesia-clinical-research-Vasospasms-radial

Figure 2: Digital subtraction angiography of the left forearm (with angiographic catheter placed at the same site as on Figure 1.) at the time of termination of operative procedure (approximately after 3 hours). Vasospasms of radial artery with absence of flow distally are still seen (arrows).

An injection of 300 µg nitroglycerin as a bolus (10 ml of 30 µg/ml solution) via arterial catheter in the left radial artery was done, followed by contrast through the same catheter after 3 minutes. Angiography was repeated, showing complete restoration of left radial artery flow (Figure 3).

anesthesia-clinical-research-retrograde-contrast

Figure 3: Digital subtraction angiography of the left forearm (intraarterial retrograde contrast injection through the arterial line) after intraarterial nitroglycerin application. Immediate restoration of normal patency of entire radial artery is obvious (arrow).

After that, the patient was extubated and transferred to high dependency unit.

The recovery was uneventful; the left hand was of appropriate color, painless and warm. Capillary refill, sensation and motoric properties of the hand were normal (Figure 4).

anesthesia-clinical-research-Sensation-motoric

Figure 4: Sensation and motoric properties of the hand.

Arterial catheter with normal saline infusion was removed in the morning on the first day after surgery.

The patient was explained about the IA injection during the procedure and possible late complications. She has also received written instructions on her discharge home.

Discussion

First reports of unintentional IA injections were published more than 60 years ago [2,3].

The estimated incidence of that event is between 1:56 000 to 1:3440 [4].

IA injections can have devastating consequences for the patients, such as limb ischemia, necrosis, gangrene or amputations, so it is very important to be aware of the symptoms, signs and immediate treatment options of such an unpleasant event. The only problem is that no definite guidelines are available so far and that all the recommendations for management of inadvertent IA injections are more or less anecdotal and based on individual case reports. Treatment of these patients is therefore directed toward symptomatic relief, cessation or reversal of arterial spasm, reestablishment of blood flow, treatment of any sequelae and long-term rehabilitation [4].

When it comes to suspected IA injection, catheter should be left in place for administration of various medication for vasodilatation and spasm relief. Some also suggest continuous infusion of isotonic solution to maintain catheter patency [4], and we have done this in our case.

We have also performed angiography of the affected limb as soon as possible, showing us the extent of blood flow impairment and helping us with treatment decisions [5].

It is known, that complications after accidental IA injections are closely related to the drugs injected, highlightening the pH and osmolarity as the most important factors determining the sequelae [4]. So, according to various investigators, high pH or high osmolarity of injected medication can result in more severe complications; occuring also later in the peri- and postoperative period [4,6]. But that was not the case with ephedrine, which has acidic pH and low tonicity ( pH 5.8; osmolarity 310 mOsm/L).

There are also many other different pathophysiological mechanisms described in the literature, causing reflex vasospasm after IA injection, but it seems that thrombosis is the common end point for all IA injections [4]. Thereafter we flushed the catheter with heparinized saline solution and administered 5000 IU of heparin intravenously.

The next objective in management of spasm caused by IA injection is to promote local vasodilatation and relief of arterial constriction. This can be achieved either with extremity sympatholysis (nerve blocks) or applications of various medicines. Local anesthetics, direct arterial vasodilatators, tromboxane inhibitors, iloprost, papaverine, thrombolytics and corticosteroids have all been already proposed or used for vasospasm after IA injection [4]. Since emergency IA injections of local anaesthetics have often been succesfully performed for spasm relief [7-9], we wanted to use 0.5% lidocaine IA, but because Ghouri et al. [10] warned about possible risks that can worsen already affected blood flow to the limb, we decided to wait and observe the hand. Nicardipine was also effectively used in one case [11], but our patient had known allergy to it.

If the patient had pain and low limb perfusion after the procedure, we would also treat her with an axillary plexus block.

Nitroglycerin is a potent vasodilator, that has effects on arteriolar and venous smooth muscle. This is caused by activation of guanylate cyclase, leading to a local increase in cyclic-guanosine monophosphate. Nitroglycerine is most commonly used for the treatment of angina pectoris, myocardial infarction, acute heart failure, hypertensive crisis and for the maintenance of the desired blood pressure [1]. Many articles also outline its effective intra arterial use [12-14], so based on this data, we decided to treat persisiting vasospasm after procedure with the intra-arterial bolus of nitroglycerin, which proved to be very effective.

Conclusion

As according to our knowledge, this is the first case of accidental IA injection of ephedrine. Likewise, despite many therapeutic options already advised, we found no article describing nitroglycerin as a potential medicine for the treatment of arterial spasm following inadvertent IA injection. We think that IA administration of nitroglycerin is very interesting approach in the management of arterial spasm, but more similar cases or studies should be done to approve its use and determine the appropriate dosing.

References

  1. Calvey N, Williams N (2008) Principles and Practice of Pharmacology for Anaesthetists. Oxford: Blackwell Publishing.
  2. Macintosh RR, Heyworth PA (1943) Intra-arterial injection of pentothal. Lancet 2: 571.
  3. Cohen SM (1948) Accidental intra-arterial injection of drugs.  Lancet 2: 409-417.
  4. Sen S, Chini EN, Brown MJ (2005). Complications after unintentional intra-arterial injection of drugs: risks, outcomes, and management strategies. Mayo ClinProc 80: 783-795.
  5. Rautio R, Keski-Nisula L (2006) Inadvertent intra-arterial drug injections: the role of angiographic and clinical findings.  ActaRadiol 47: 554-558.
  6. Evans JM, Latto IP, Ng WS (1974) Accidental intra-arterial injection of drugs: a hazard of arterial cannulation. 3 Case reports.  Br J Anaesth 46: 463-466.
  7. Samanta S, Samanta S (2013) Accidental intra arterial injection of diclofenac sodium and their consequences: report of two cases. Anaesth Pain & Intensive Care 17: 101-102.
  8. HannyJohner AR, Cartier Faessler V, Walder B (2012) Accidental Intra- Arterial Injection of Alcoholic Chlorhexidine-Complications and their Management. J Clinic Toxicol2: 140.
  9. Shukla AN, Ghaffar ZBA, Joshi SC (2009) Inadvertent intra arterial injection of Rocuronium: A case report. The Internet Journal of Anesthesiology.
  10. Ghouri AF, Mading W, Prabaker K (2002) Accidental intraarterial drug injections via intravascular catheters placed on the dorsum of the hand.  AnesthAnalg 95: 487-491, table of contents.
  11. Boudaoud S , Jacob L , Lagneau F , Payen D , Servant JM , et al. (1993) Successful treatment of vasospastic acute ischaemia with intra-arterial nicardipine. Eur J Anaesthesiol 10:133-134.
  12. Stoeckelhuber BM, Suttmann I, Stoeckelhuber M, Kueffer G (2003) Comparison of the vasodilating effect of nitroglycerin, verapamil, and tolazoline in hand angiography.  J VascIntervRadiol 14: 749-754.
  13. Dharma S, Shah S, Radadiya R, Vyas C, Pancholy S, et al. (2012) Nitroglycerin Plus Diltiazem Versus Nitroglycerin Alone for Spasm Prophylaxis with Transradial Approach. J Invasive Cardiol 24: 122-125.
  14. El-Zammar ZM, Latorre JG, Wang D, Satyan S, Elnour E, et al. (2012)Intra-arterial vasodilator use during endovascular therapy for acute ischemic stroke might improve reperfusion rate. Ann N Y Acad Sci 1268:134-140.
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