Department of Anesthesiology; firstname.lastname@example.org (Fikkers)
Department of Clinical Pharmacy (Wuis)
Department of Pediatric Surgery (Wijnen)
Department of Anesthesiology; Radboud University Nijmegen Medical Centre; Nijmegen, The Netherlands; email@example.com (Scheffer)
To the Editor:
Anesthesiologists are occasionally confronted with difficult or even impossible IV access, particularly in children (1). In such cases, knowledge of alternative possibilities may be useful. We report a case in which an arterial cannula was the only available intravascular access for a minor procedure in an infant.
A 14-mo, 9.2-kg boy was scheduled for left inguinal hernia repair. An uneventful inhaled anesthetic induction was performed using sevoflurane in oxygen. Peripheral venous access was attempted but, because no veins were visible on any site of his body, this was unsuccessful. Finally, during an attempt to cannulate the right femoral vein, a 22-gauge line was accidentally introduced in the femoral artery. It was decided to leave the line in place, using it for parenteral fluids only and atropine, if required. A laryngeal mask airway was placed and the anesthesia was supplemented with an ilioinguinal block. The surgical procedure was uneventful. In the recovery room the arterial line was removed as soon as the patient was awake and stable.
When venous cannulation is impossible, alternatives should be considered (2). In case only drugs are needed, IM, intralingual, endobronchial, buccal, or rectal administration are possibilities. For drugs and fluids, intraosseous infusion is the recommended route of access in an emergency situation (3). However, elective use of intraosseous infusion in children in the operating room is debatable (4). Intraarterial infusion is also a possibility, provided pump pressures are kept high. This was common practice during the Korean War, but it was abandoned by 1965, when it was obvious that the intraarterial route did not have any advantage and had far more complications compared with IV access (2). Since then, clinicians have avoided intraarterial administration of drugs. We are aware of only one case report in the last 25 yr deliberately discussing the intraarterial route as an alternative for IV access (5). In that case, an arterial line was already in place.
Inadvertent intraarterial injection of drugs may be accompanied by serious complications. Management strategies were discussed in a recent review (6) and also in this Journal (7). Several anesthetic drugs have been injected intraarterially by accident (Table 1). Thiopental was one of the first drugs in which this complication was described, being able to cause extensive edema, gangrene, limb loss, and even death (8).
In general, intraarterial injection should be discouraged. However, when IV cannulation is impossible and intraosseous access is deemed too invasive, intraarterial cannulation may be an option. Isotonic fluid administration is safe and drug administration should be limited as much as possible. Among the anesthetic drugs that have been injected intraarterially without adverse effects are fentanyl, midazolam, succinylcholine, pancuronium, and atropine (Table 1). Intraarterial injection of drugs not dissolved in water (such as diazepam, propofol, and etomidate) or with an alkaline pH (like thiopental, phenytoin) should be avoided at all cost.
Bernard G. Fikkers, MD, PhD
Department of Anesthesiology
Eveline W. Wuis, PharmD, PhD
Department of Clinical Pharmacy
Marc H. Wijnen, MD, PhD
Department of Pediatric Surgery
Gert Jan Scheffer, MD, PhD
Department of Anesthesiology
Radboud University Nijmegen Medical Centre
Nijmegen, The Netherlands
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