4.3 Intra-Arterial Injection Flashcards
a) What factors predispose to inadvertent intra-arterial (IA) drug injection that could lead to severe
extremity injury? (35%)
Patient factors:
> > Unconscious so unable to indicate pain
on cannulation/injection.
> > Hypotension or hypoxia,
causing failure to recognise cannula as arterial.
> > Anatomically anomalous artery
accidentally cannulated,
thoracic outlet syndrome with loss of radial pulse
on abduction or rotation of arm.
Staff factors:
» Poor training resulting in
failure to differentiate between artery and vein.
> > Failure to check which line is being accessed.
> > Failure to label line as arteria
Drug factors:
> > Some drugs have greater potential for harm
than others, e.g. vasoactive
drugs, hyperosmolar drugs.
b) Outline the possible intravascular mechanisms of injury. (15%)
> > Arterial spasm resulting in distal ischaemia: secondary to the drug itself
or due to mediators released in response to drug.
> > Chemical arteritis:
direct tissue damage causing
endothelial damage.
> > Initiation of release of
harmful endogenous substances,
e.g.
thromboxane, which cause endothelial damage and activation of platelets resulting in thrombosis.
> > Drug precipitation and crystal
formation in distal microcirculation
causing ischaemia and thrombosis.
c) What are the acute clinical features
of inadvertent IA injection? (20%)
> > Failure of drug to have intended effect.
> > Pain at and distal to the injection site.
> > Pallor, cyanosis and coolness of limb,
or redness and warmth.
> > Paraesthesia.
d) What is the early management of an acute IA injection injury? (30%)
> > Stop injection.
ABC assessment of patient,
to include intravenous access and
administration of drug by intended route if urgent.
> > Keep cannula in situ for consideration
of IA sympatholysis
(with, for example, iloprost or local anaesthetic)
but ensure no other use.
> > Elevation of extremity to improve
venous and lymphatic drainage.
> > Pain control.
> > Consideration of anticoagulation with heparin.
> > Documentation.
> > Explanation and apology to
patient/patient’s family, followed up in writing.
> > Incident report.
> > Plastics referral.
> > Consideration of stellate ganglion/
lower limb sympathetic blocks.
