Abstract
We describe the successful management of extravasation injury to the left hand by contrast medium with stellate ganglion block and intra-arterial nitroglycerin in a patient which befell during contrast-enhanced imaging. The incidence of contrast-medium extravasation injury is increasing because of the convenience and availability of contrast-enhanced imaging and ease of injection access. Extravasation of contrast medium may results in severe pain, erythema, cyanosis, and edema or even skin necrosis, which is largely related to the ionization, osmolarity, and volume of the contrast medium. The conservative treatment is often adequate in small amount extravasation, but if the extravasation is overwhelming further energetic management is mandatory. A 29-year-old man was brought to our emergency because of diffuse abdominal pain and he was arranged to receive intravenous contrast media enhanced abdominal computed tomography for diagnosis. Ruptured appendicitis with abscess formation was suspected; then the patient underwent emergent appendectomy and drainage of the abscess. However, severe swelling and cyanotic change that radiated from the intravenous catheter insertion site in every direction over the entire dorsum of the left hand were noted after the surgery. Contrast-medium extravasation injury was highly contemplated and a left stellate ganglion block was performed immediately for relief of symptoms. The consulting surgeon ruled out compartment syndrome, but advised emergent left upper limb arteriography, which revealed signs of vasospasm with high intravascular pressure of the left distal ulnar and radial arteries; thus nitroglycerin was injected into left distal ulnar and radial arteries for relief of vasospasm. The clinical symptoms were improved after the above managements and the patient was discharged 7 days later without any sequela.
Keywords
Contrast media; Extravasation of diagnostic and therapeutic materials; NitroglycerinSpasm: vascular; Stellate ganglion;
1. Introduction
Extravasation is an unintentionally inadvertent injection or leakage of parenteral intravenous fluid to the perivascular or subcutaneous space. Extravasation of contrast medium is mostly a complication of contrast-enhanced imaging. There is a wide spectrum of clinical presentations of extravasations of contrast media with injuries, ranging from localized erythema, edema and, skin necrosis. Large-volume extravasation (>50 mL) of high-osmolar is fortunately rare, but may result in serious skin cyanosis, necrosis, swelling, and ulceration. Here we report a case of extravasation injury to the dorsum of left hand from exsuding of large-volume ionic contrast medium and describe the successful management made possible by stellate ganglion block (SGB) and intra-arterial administration of 100 μg nitroglycerin (NTG).
2. Case report
A 29-year-old man was brought to our emergency department because of diffuse abdominal pain. Peritoneal signs and diffuse rebounding pain were noted, suggestive of acute abdomen; contrast-medium enhanced abdominal computed tomography (CT) was carried out to confirm the diagnosis. Approximately 100 mL of ionic radiographic iodinated contrast medium (meglumine and sodium ioxitalamate) was delivered by means of a rapid infusion pump (Optivantage DH; Liebel-Flarsheim Company, Cincinnati, OH, USA) to the 20 gauge intravenous catheter (Surflo; Terumo, Tokyo, Japan) set up on the dorsum of his left hand. The CT examination failed to reveal visible contrast-medium enhanced images in the abdomen and rupture appendicitis with abscess formation over right lower quadrant was suspected; then the patient was brought to the operation room for emergent appendectomy and drainage of abscess. The intravenous line over the left dorsum was checked before anesthesia induction. It was found that the infusion fluid could be still running through it but maximum entry at full-run speed was denied; so we set another intravenous line on the elbow of the same hand for perioperative use. Following premedicated with atropine 0.6 mg, fentanyl 150 μg, propofol 200 mg, and rocuronium 70 mg were given by means of the new intravenous line for anesthesia induction; no evident delay of apnea was observed and no cry of pain was uttered on injection of the drugs. Following tracheal intubation anesthesia was maintained with desflurane in O2. Standard physiological monitors were applied throughout the anesthetic course and the operative procedure, which lasted for 3 hours uneventfully. Because the surgeon in charge adopted laparoscopic approach for convenience the patient’s both hands were wrapped in aseptic sheets and laid aside the edges of the table, and thus we could not check the condition of the hands during the entire procedure. 1700 mL intravenous fluid was given intraoperatively.
The patient regained consciousness soon after termination of anesthesia and was extubated and sent to the recovery room for close observation. However, the dorsum of his left hand was found to be severely swollen with cyanosis. The patient also complained of sensation of cold and pain of his left hand (Fig. 1). The patient even could not move the left fingers, and felt the left hand extremely painful while he tried to make hand movements. While inquiring again, the patient uttered that he experienced swelling and severe painful sensation of the left hand while receiving the CT examination, but did not notify the X-ray professional of the fact on the spot. Contrast-medium extravasation injury was highly contemplated and left side SGB was performed immediately for relief of symptoms. We inserted a needle to the anterior tubercle of C6 and injected 10 mL of 0.5% bupivacaine there. The patient felt relief from pain and warm sensation (due to vasodilatation) of his left hand at once. A plastic surgeon was also consulted who measured the intracompartmental pressure of the dorsum of left hand, which was revealed around 9 mmHg and thus he excluded the possibility of the compartment syndrome and thus fasciotomy was not suggested. Emergent left upper limb arteriography was arranged, which revealed patency of left subclavian artery, left brachial artery, left ulnar artery, and left radial artery, but high intravascular pressure was found in the left distal ulnar and radial arteries, suggestive of vasospasm (Fig. 2). Diluted NTG 100 μg was injected into left distal ulnar and radial arteries for relief of vasospasm. Timely follow-up imaging revealed improved distal blood flow (Fig. 2). Severe pain, swelling, cold sensation, and cyanosis were much improved after the above managements. The patient was discharged 7 days later without any sequela.
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3. Discussion
Extravasation of contrast medium is a well-recognized complication of contrast-enhanced imaging. The introduction of automated power injection has increased the incidence because power injection may result in large-volume extravasation in a short period of time,1, 2 leading to severe tissue damage. Infants, young children, and unconscious and debilitated patients are particularly at risk of extravasation during contrast-medium injection. It is not possible to predict the degree of final tissue injury at initial examination after the incident. Large volume (>50 mL) of high-osmolar contrast medium is known to induce severe skin cyanosis, necrosis, swelling, and ulceration.2, 3, 4, 5, 6 The severity of extravasation injury may be affected by a combination of factors, including solution cytotoxicity, osmolarity, vasoconstrictor properties, inflammation, infusion pressure, regional anatomical peculiarities, and patient intrinic. According to the European Society of Urogenital Radiology (ESUR) 2002 guideline, conservative management including limb elevation, applying ice packs, and careful monitoring is often adequate in most cases. Corticosteroids, vasodilators, and a variety of other agents have been proposed for treating extravasation. If a serious injury is suspected, seeking the advice of a surgeon is recommended.
SGB is a type of sympathetic blockade technique frequently used for a variety of therapeutic, diagnostic, and prognostic purposes, including vascular insufficiency and pain syndromes of the face, neck, and upper extremities. Efficacy of SGB in treatment of vasospasm remains controversial. Its efficacy as reported is based on anecdotal experience rather than large studies with good experimental design7; however theoretically, block of the stellate ganglion could successfully denervate the sympathetic component resulting in vasodilatation of the upper extremities, leading to increase of blood flow to the injury area besides offering pain relief.8, 9
NTG is used for decades to treat angina pectoris and, more recently, myocardial infarction in the acute and chronic phases and congestive heart failure. NTG has effects on arteriolar and venous smooth muscle relaxation, which decreases afterload and preload.10 Wong et al11 reported that the peripheral tissue ischemia caused by radial artery catheterization or dopamine extravasation could be treated with 2% topical NTG ointment in neonates. Transdermal NTG was also useful to reduce the incidence of intravenous line failure caused from phlebitis and extravasation.12 The radial artery has increased in popularity as a conduit for use in coronary artery bypass surgery. However, concerns remain regarding the risk of radial artery spasm. NTG has also been demonstrated to be an effective vasodilator to relieve vasospasm after coronary artery bypass.13, 14 When NTG is given for 24 hours postoperatively, it is better tolerated and more effective in preventing infarction than diltiazem,15, 16 owing to its anti-vasospasm effect.
Here, we report a successful management of contrast-medium extravasation injury with SGB and intra-arterial NTG. In this instance, we adopted the strategy step by step pursuant to the European Society of Urogenital Radiology guidelines. Since the patient’s condition, as we contemplated, could not be relieved with conservative management, we decided to consult surgeon immediately for advice but SGB was expediently performed to treat his severe pain and cold sensation. After the exclusion of compartment syndrome by the consulting surgeon, emergent arteriography was arranged for the revealation of the extent of vascular injury and confirmation of the final diagnosis. Vasospasm caused from the extravasation of contrast medium was established by angiography; then intra-arterial NTG was given immediately by the radiologist on duty in an attempt to improve the distal radial and ulnar arterial blood flow. A possible severe complication in consequence of vasospasm or inpatency of vascularity had thus been avoided.
It is important that extravasation injury by contrast medium could be successfully managed through a multidiscipline cooperative strategy. It is also necessary to remind all clinical anesthesiologists and radiologists that they should closely watch the examinee’s responses while they are injecting the contrast medium. From this rare case, we suggest that when circumstances are suspicious of extravasation of contrast medium detailed physical examination should be performed, for it could detect the condition earlier so as to prevent graver complication. We also found that the SGB and intra-arterial NTG could be the suitable options for the management of extravasation injury.
In conclusion, we report here our successful management of a young man who saw contrast-medium extravasation injury. We suggest that as anesthesiologists, we should keep vigilance while the patients are receiving contrast medium for examination. High suspicion of contrast-medium extravasation injury with which the circumstantial evidence suits should call for action in its wake, and detailed physical examination could detect the advertence earlier and lighten its side effects; a multidiscipline strategy should also adopted immediately if it occurs.
† All authors have contributed to the paper and have never submitted the manuscript, in whole or in part, to other medical journals.