Intra-Arterial Injections
A Case Report with a Comprehensive Review of the Literature
Timothy J. Cahill, MD and Steven Robicsek, MD,
PhD
Department of Anesthesiology, University of Florida, Gainesville, Florida
ABSTRACT
Introduction: Inadvertent intra-arterial injections of medications are a
known complication of arterial line placement with potentially devastating
consequences. An intra-arterial injection may result in serious limb
impairment and even loss of the extremity. Many pharmacologic agents have
been implicated in causing serious complications from an intra-arterial
injection, including barbiturates, penicillin derivatives, promethazine,
phenytoin and propofol. Although the mechanism of injury may be
multifactorial, the leading hypotheses include: alkaline pH, precipitation,
additives such as microcrystalline cellulose and endothelial irritation
causing vascular spasm and/or vasculitis. All of these lead to
intra-arterial thrombosis and ischemia.
Design: A case report followed by a comprehensive review of the literature
concerning intra-arterial injections is presented. All available case
reports, review articles and animal studies dating back to 1955 were
reviewed. MEDLINE search terms included intra-arterial, accidental,
gangrene, sodium thiopental, penicillin, promethazine, phenytoin, propofol,
treatment. Relevant sources from previous articles were also investigated
and cited.
Patients/Subjects: Our case report was a male who developed digital ischemia
and eventual gangrene requiring amputation following an inadvertent
intra-arterial injection of promethazine.
Goals/Objectives: A comprehensive review of the literature regarding
offending agents, patient age, location of injection and treatment
modalities has not been reported.
Conclusions: Our review consists of 45 in-hospital intra-arterial injections
and 23 cases involving IV drug abusers. Of the cases reviewed, the most
common offending agents include propofol (7 cases), barbiturates (31 cases),
phenytoin (2 cases), penicillin derivatives (11 cases) and promethazine (6
cases). We have found that the most important factors in determining
morbidity and mortality include agent injected, age of the patient,
treatment vs. non-treatment, and in-hospital vs. drug abuse.
