We are grateful to Dr de Armendi and Dr Butt1 for their critical review of our recently published case reports on the accidental intra-arterial injection of paracetamol and diclofenac.2,3
There are many reported cases available in the literature of accidental intra-arterial drug administration with adverse consequences as well as cases where drugs were intentionally given through the intra-arterial route for medical reasons. During the last few years, we have encountered five or six such cases of accidental intra-arterial injection of different drugs by inadequately trained nursing staff or new residents during the perioperative or postoperative period, sometimes resulting in catastrophic events, and in some cases without any untoward consequences. We retrospectively analysed these cases. Our interest grew when we realised that two different preparations of the same drug produced different results on administration through the intra-arterial route creating the same kind of complications in both the cases of paracetamol and diclofenac.
We commonly attach a 10 cm extension line to the arterial line with a high-pressure monitoring line attached between the arterial transducer and the extension line. Usually, the high-pressure monitoring line is removed postoperatively, keeping the 10 cm extension in place for subsequent sampling of arterial blood gas analyses. We always strictly label the 10 cm extension line, such as ‘prohibited for drug administration’. Still, accidents do sometimes happen as described in our cases.2,3
We appreciate that de Armendi and Butt1 have summarised the different management modalities of accidental intra-arterial drug injection. We used morphine for pain relief, and other supportive therapy such as limb elevation, massage, oxygen supplementation and intravenous steroids. We did not mention those supportive therapies due to word limitations. Also, we did not proceed with more invasive modalities, such as temporary sympathectomy via stellate ganglion block or axillary nerve block due to the inability to obtain informed patient consent in both cases. There are ethical limitations for a controlled study comparing different treatment options after accidental intra-articular drug administration. Most of the treatments are based on observations from case reports and uncontrolled case series. Finally, we apologise for the inappropriate labelling of Fig. 1.
Acknowledgements relating to this article
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1. de Armendi AJ, Butt AL. Intra-arterial injection; timely and proper treatment can make all the difference. Eur J Anaesthesiol
2. Samanta S, Chakraborty N, Samanta S. Accidental intra-arterial injection of paracetamol: different preparations, different results. Eur J Anaesthesiol
3. Samanta S, Samanta. S. Accidental intra arterial injection of diclofenac sodium and their consequences: report of two cases [Internet]. Anaesth Pain Intensive Care 2013; 17:101–102.