Intra-arterial nitroglycerin for intra-operative arterial vasospasm during pediatric renal transplantation.

Intra-operative arterial vasospasm during pediatric renal transplantation is an urgent clinical situation resulting in end-organ ischemia, associated changes in parenchymal turgor and color, diminished flow on ultrasound, and if left untreated, allograft loss. We hypothesized that intra-operative intra-arterial injection of nitroglycerin would reverse vasospasm and improve renal perfusion. A three-yr-old girl with end-stage renal disease due to autosomal recessive polycystic kidney disease on peritoneal dialysis underwent deceased donor renal transplantation. After optimal immediate reperfusion and hemodynamic parameters, the kidney lost turgor and became mottled in appearance despite adequate hilar arterial and venous Doppler waveforms. Two aliquots of 40 µg (0.4 mL of a 100 µg/mL) nitroglycerin solution were injected directly into the renal artery 10 min apart. Nitroglycerin resulted in dramatic change in the consistency and appearance of the allograft. An improvement in renal blood flow was demonstrated by ultrasound after the second intra-arterial nitroglycerin injection with only a transient decrease in systemic arterial blood pressure. The child experienced normal allograft perfusion on serial postoperative ultrasounds, with a prompt decrease in serum creatinine and excellent diuresis. Intra-arterial nitroglycerin is a promising option for intra-operative arterial vasospasm during pediatric renal transplantation with objective improvement in blood flow and perfusion.

Inadvertent Intra-Arterial Drug Injections in the Upper Extremity: Systematic Review.

PURPOSE: To review the literature pertaining to inadvertent intra-arterial drug injection in the upper extremity, explore the various treatment options and their outcomes, and identify risk factors for limb amputation following intra-arterial injection. METHODS: A systematic review of Medline, EMBASE, and Cochrane databases (inception to March 2013) was completed for patients presenting with intra-arterial drug injection of the upper extremity. Details on intervention and outcome were extracted and subjected to pooled analysis with amputation as the primary outcome. RESULTS: A total of 25 articles (209 patients) were included for review. Mean patient age was 31 ± 8 years (male, 71%; female, 29%). Prescription opioids (33%) were the most commonly injected substance, and the brachial artery (39%) was the most common site. The overall weighted mean amputation incidence was 29%. Anticoagulants were the most common treatment used (77%). From pooled analysis, conditions requiring antibiotic use were significantly associated with a higher incidence of amputation; whereas use of steroids was associated with a lower incidence of amputation. Patients presenting 14 hours or more after injection and those injecting crushed pills rather than pure substances had significantly higher incidences of amputation. CONCLUSIONS: Intra-arterial drug injection of the upper extremity carries an amputation incidence of nearly 30%. Conditions requiring adjunctive antibiotic use and delay in receiving care were both significantly associated with higher incidences of amputation. No single treatment protocol to date has established superiority. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Relationship between Injection Rate and Contrast Enhancement on Three-dimensional Digital Subtraction Angiography of the Cerebral Arteries.

OBJECTIVE: Three-dimensional (3D) digital subtraction angiography (DSA) is becoming a common technique for the assessment of the cerebral arteries. Nevertheless, the injection parameters for each artery are not standardized among institutions. The objective of this study was to analyze the relationship between injection rate and contrast enhancement on 3D DSA of the common carotid artery. MATERIALS AND METHODS: Twenty-four patients who underwent 3D DSA of the common carotid artery from June 2013 to March 2015 were included in this retrospective study. Contrast enhancement of each patient was analyzed for four cerebral arteries segments (A1, A2, M1 and M2) by measuring the average pixel value on the source rotational two-dimensional DSA images. Linear regression analysis was used to investigate the correlation between injection rate and contrast enhancement. RESULTS: All four regression lines showed that a higher injection rate led to higher contrast enhancement. There was a significant relationship for the A1, A2 and M1 segments (P = 0.008, 0.03 and < 0.001) but not for the M2 segment (P = 0.13). The goodness-of-fit of the regression lines was high for the M1 segment (R2 = 0.63). However, as the size of the vascular lumen became narrower, the value for the A1 (R2 = 0.28) and A2 (R2 = 0.19) segments became lower. CONCLUSION: In 3D DSA of the common carotid artery, contrast enhancement of a relatively wide lumen could be optimized by adjusting the injection rate. However, it is difficult to optimize the contrast enhancement of a relatively narrow lumen only by adjusting the injection rate.

Intra-arterial injection of sclerosants: Report of three cases treated with systemic steroids.

Intra-arterial injection of sclerosants is a significant but uncommon complication of sclerotherapy that may result in extensive tissue necrosis and in rare cases digit or limb amputation. We have managed three cases in the past 10 years. One patient was referred for immediate treatment following intra-arterial injection of liquid polidocanol. The other two had undergone foam sclerotherapy with polidocanol and sodium tetradecyl sulphate, respectively. All patients were treated with a combination of oral steroids (prednisone 0.5-1 mg/kg) and systemic anticoagulants (enoxaparin 1.5 mg/kg daily subcutaneous injection). One case progressed to skin ulceration where prednisone was started five days after the adverse event and prematurely stopped after four weeks. The other cases did not progress to necrosis or other long-term sequelae. In these patients, prednisone was commenced immediately and slowly reduced over the following 12 weeks. The inflammation that follows ischemia plays a significant role in tissue necrosis and the immediate management of this adverse event may benefit from anti-inflammatory measures and in particular systemic steroid therapy unless contraindicated.

Accidental intra-arterial injection of diclofenac -case report.

Diclofenac sodium is a very common drug used in medical practice for analgesia and is freely available over the counter without any medical prescription. The drug is also the most commonly used or misused by quacks working all over India. Many case reports have been published on upper limb catastrophe of unintentional intra-arterial injection of barbiturates, thiopental sodium, narcotics, and tranquilizers but only two cases of inadvertent intra-arterial injection of diclofenac have been reported till date. Potential serious complication of inadvertent intra-arterial injection of diclofenac sodium leading to gangrene has been recently reported in medical literature. It is a medical emergency and literature has shown that timely diagnosis with early intervention can salvage the limb. We hereby report a case of accidental intra-arterial injection of diclofenac sodium in the ulnar artery by a quack for pain abdomen leading to gangrene of the distal part of affected little, ring and part of middle finger of right hand.