Letters to Editor
Accidental cannulation of aberrant radial artery The Editor, Incidence of superficial aberrant radial artery has been reported to be 0.8‑1%.[1,2] Its unawareness may lead to accidental intra‑arterial injection of therapeutic drugs, complications and litigation. We report a case of aberrant radial artery cannulation, which was recognized early and managed. A 20‑year‑old male was scheduled for double valve replacement. After attaching standard monitors, an intravenous access was secured by an anesthesia technician on the radial aspect of the right wrist joint with an 18 G cannula after applying tourniquet [Figure 1]. An unusual backflow was noted after the removal of the tourniquet and the color of the blood was bright red. With the suspicion of the aberrant radial artery cannulation a fluid bag was connected, which showed pulsatile backflow into the tubing. This was further confirmed by attaching a transducer, which showed arterial waveform [Figure 2] and by blood gas sampling, which showed findings corresponding to arterial blood gas. It was decided to continue with this line for arterial pressure monitoring for induction. Arterial pulse on the usual site of the right radial artery was feeble, but showed definitive flow on Doppler. The radial artery course was normal on the left side. An intravenous line was secured on the dorsum of the left hand with an 18 G cannula. After induction of anesthesia femoral artery was cannulated for further arterial pressure monitoring which was continued post‑operatively. The cannula placed in the aberrant radial artery was removed in the immediate post‑operative period. The reported incidence of accidental arterial cannulation and injection is 1 in 56,000 to as common as 1 in 3440. [3] Common sites for accidental arterial cannulation are radial aspect of the wrist where the aberrant radial artery is confused with the cephalic vein. Other common sites for accidental arterial cannulation are antecubital area where brachial artery is superficial and accidentally cannulated mistaking with antecubital vein and groin region where femoral artery is accidentally cannulated mistaking with the femoral vein especially in patients with hypotension and low saturation. Accidental 76
Figure 1: Aberrant radial artery accidentally cannulated with 18 G cannula
Figure 2: Arterial waveform after transducing
intra‑arterial injection of drugs causes severe pain and paresthesia followed by vascular insufficiency. Accidental arterial cannulation is detected by the presence of pulsation in the vessel proximal to the site of cannulation; and by the presence of pulsatile backflow of bright red blood in the cannula; the accidental cannulation of aberrant artery can be further confirmed by transducing the pressure in the cannulated vessel and by blood gas analysis of the sample collected from the cannulated vessel.[4] Treatment of inadvertent intra‑arterial injection includes keeping the cannula in situ, local infusion of heparin saline and systemic anticoagulation with heparin. Other measure includes local anesthetics injection, calcium channel blockers, intra‑arterial papaverine, stellate ganglion block and axillary plexus block.
Sathish N., Prasad S. R., Nagesh K. S., Jagadeesh A. M. Department of Cardiac Anaesthesia, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, Karnataka, India Address for correspondence: Dr. S. R. Prasad, Department of Cardiac Anaesthesia, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bannerghatta Road, Bangalore ‑ 560 069, Karnataka, India. E‑mail: [email protected]
Annals of Cardiac Anaesthesia Vol. 17:1 Jan-Mar-2014
Letters to Editor
REFERENCES
CURRENT PRACTICE AT MOST HOSPITALS
1. Rodríguez‑Niedenführ M, Vázquez T, Nearn L, Ferreira B, Parkin I, Sañudo JR. Variations of the arterial pattern in the upper limb revisited: A morphological and statistical study, with a review of the literature. J Anat 2001;199:547‑66. 2. Wood SJ, Abrahams PH, Sañudo JR, Ferreira BJ. Bilateral superficial radial artery at the wrist associated with a radial origin of a unilateral median artery. J Anat 1996;189:691‑3. 3. Sen S, Chini EN, Brown MJ. Complications after unintentional intra‑arterial injection of drugs: Risks, outcomes, and management strategies. Mayo Clin Proc 2005;80:783‑95. 4. Ghouri AF, Mading W, Prabaker K. Accidental intraarterial drug injections via intravascular catheters placed on the dorsum of the hand. Anesth Analg 2002;95:487‑91.
Cardiologist refers the patient for surgery to the cardiac surgeon who in turn accepts and schedules the patient for surgery. Cardiac anesthesiologist interacts with the patient only a day prior to surgery and mostly after admission in hospital. A lot of precious time is available in this intervening period (from referral to cardiac surgeon until the time patient is admitted for proposed surgery), which we utilize for preanesthetic assessment.
Access this article online
Author’s hospital is a tertiary care center performing about 700‑800 cardiac surgeries annually. At our hospital, patients are accepted by the cardiac surgeon for surgery and thereafter begin the process of preanesthetic assessment, risk stratification and scheduling the patient for surgery as follows:
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Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.124165
Preanesthesia assessment clinic for cardiac surgery by cardiac anesthesiologist: A practice statement The Editor, Preanesthesia assessment clinics (PAC’s) have been in existence for quite a long time in general surgical practice and have contributed a lot in terms of reducing patient anxiety and fear, improving the quality of pre operative care and cutting pre operative costs.[1] However, PAC’s have not yet taken shape in cardiac surgical practice in most of the teaching hospitals as well as private hospitals. Even though the major cause of cancellation on the day of surgery has been found to be inadequate medical checkup,[2‑4] there has not been much stress on setting up PAC’s for cardiac surgical patients. Annals of Cardiac Anaesthesia Vol. 17:1 Jan-Mar-2014
PRACTICE AT THE AUTHOR’S HOSPITAL
Step I First patient visit: Cardiac surgeon refers the patient to cardiac anesthesiologist who reviews the medical history, general examination notes, available investigations and examines the patient; thereafter, directs the supporting staff to schedule the patient for surgery according to waiting list. Step II Second patient visit: 10 days prior to provisional date of surgery; patient is asked to undergo pre‑operative investigations as per the hospital’s protocol. Step III Seven days prior to surgery: Investigation results are reviewed by the anesthesiologist and any consultations (nephrology, neurology etc.) if required are informed telephonically to the patient. If the patient is declared fit for anesthesia and surgery, risk stratification is done according to European system for cardiac operative risk evaluation 2 (EuroSCORE 2) and Society of Thoracic Surgeons (STS) risk scoring system and patient is informed about the risk telephonically. At the same time, a final and confirmed date for surgery is given to patient. Patient is also advised about drug treatment and stoppage of certain drugs like clopidogrel, warfarin as per the hospital’s protocol. Step IV Third visit (Optional) for patients who require consultations: A review of such patients’ records is made after every 2 days and the patient is informed about the progress. If the patient insists on a visit, the 77
Copyright of Annals of Cardiac Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Accidental cannulation of aberrant radial artery The Editor, Incidence of superficial aberrant radial artery has been reported to be 0.8‑1%.[1,2] Its unawareness may lead to accidental intra‑arterial injection of therapeutic drugs, complications and litigation. We report a case of aberrant radial artery cannulation, which was recognized early and managed. A 20‑year‑old male was scheduled for double valve replacement. After attaching standard monitors, an intravenous access was secured by an anesthesia technician on the radial aspect of the right wrist joint with an 18 G cannula after applying tourniquet [Figure 1]. An unusual backflow was noted after the removal of the tourniquet and the color of the blood was bright red. With the suspicion of the aberrant radial artery cannulation a fluid bag was connected, which showed pulsatile backflow into the tubing. This was further confirmed by attaching a transducer, which showed arterial waveform [Figure 2] and by blood gas sampling, which showed findings corresponding to arterial blood gas. It was decided to continue with this line for arterial pressure monitoring for induction. Arterial pulse on the usual site of the right radial artery was feeble, but showed definitive flow on Doppler. The radial artery course was normal on the left side. An intravenous line was secured on the dorsum of the left hand with an 18 G cannula. After induction of anesthesia femoral artery was cannulated for further arterial pressure monitoring which was continued post‑operatively. The cannula placed in the aberrant radial artery was removed in the immediate post‑operative period. The reported incidence of accidental arterial cannulation and injection is 1 in 56,000 to as common as 1 in 3440. [3] Common sites for accidental arterial cannulation are radial aspect of the wrist where the aberrant radial artery is confused with the cephalic vein. Other common sites for accidental arterial cannulation are antecubital area where brachial artery is superficial and accidentally cannulated mistaking with antecubital vein and groin region where femoral artery is accidentally cannulated mistaking with the femoral vein especially in patients with hypotension and low saturation. Accidental 76
Figure 1: Aberrant radial artery accidentally cannulated with 18 G cannula
Figure 2: Arterial waveform after transducing
intra‑arterial injection of drugs causes severe pain and paresthesia followed by vascular insufficiency. Accidental arterial cannulation is detected by the presence of pulsation in the vessel proximal to the site of cannulation; and by the presence of pulsatile backflow of bright red blood in the cannula; the accidental cannulation of aberrant artery can be further confirmed by transducing the pressure in the cannulated vessel and by blood gas analysis of the sample collected from the cannulated vessel.[4] Treatment of inadvertent intra‑arterial injection includes keeping the cannula in situ, local infusion of heparin saline and systemic anticoagulation with heparin. Other measure includes local anesthetics injection, calcium channel blockers, intra‑arterial papaverine, stellate ganglion block and axillary plexus block.
Sathish N., Prasad S. R., Nagesh K. S., Jagadeesh A. M. Department of Cardiac Anaesthesia, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, Karnataka, India Address for correspondence: Dr. S. R. Prasad, Department of Cardiac Anaesthesia, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bannerghatta Road, Bangalore ‑ 560 069, Karnataka, India. E‑mail: [email protected]
Annals of Cardiac Anaesthesia Vol. 17:1 Jan-Mar-2014
Letters to Editor
REFERENCES
CURRENT PRACTICE AT MOST HOSPITALS
1. Rodríguez‑Niedenführ M, Vázquez T, Nearn L, Ferreira B, Parkin I, Sañudo JR. Variations of the arterial pattern in the upper limb revisited: A morphological and statistical study, with a review of the literature. J Anat 2001;199:547‑66. 2. Wood SJ, Abrahams PH, Sañudo JR, Ferreira BJ. Bilateral superficial radial artery at the wrist associated with a radial origin of a unilateral median artery. J Anat 1996;189:691‑3. 3. Sen S, Chini EN, Brown MJ. Complications after unintentional intra‑arterial injection of drugs: Risks, outcomes, and management strategies. Mayo Clin Proc 2005;80:783‑95. 4. Ghouri AF, Mading W, Prabaker K. Accidental intraarterial drug injections via intravascular catheters placed on the dorsum of the hand. Anesth Analg 2002;95:487‑91.
Cardiologist refers the patient for surgery to the cardiac surgeon who in turn accepts and schedules the patient for surgery. Cardiac anesthesiologist interacts with the patient only a day prior to surgery and mostly after admission in hospital. A lot of precious time is available in this intervening period (from referral to cardiac surgeon until the time patient is admitted for proposed surgery), which we utilize for preanesthetic assessment.
Access this article online
Author’s hospital is a tertiary care center performing about 700‑800 cardiac surgeries annually. At our hospital, patients are accepted by the cardiac surgeon for surgery and thereafter begin the process of preanesthetic assessment, risk stratification and scheduling the patient for surgery as follows:
Quick Response Code:
Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.124165
Preanesthesia assessment clinic for cardiac surgery by cardiac anesthesiologist: A practice statement The Editor, Preanesthesia assessment clinics (PAC’s) have been in existence for quite a long time in general surgical practice and have contributed a lot in terms of reducing patient anxiety and fear, improving the quality of pre operative care and cutting pre operative costs.[1] However, PAC’s have not yet taken shape in cardiac surgical practice in most of the teaching hospitals as well as private hospitals. Even though the major cause of cancellation on the day of surgery has been found to be inadequate medical checkup,[2‑4] there has not been much stress on setting up PAC’s for cardiac surgical patients. Annals of Cardiac Anaesthesia Vol. 17:1 Jan-Mar-2014
PRACTICE AT THE AUTHOR’S HOSPITAL
Step I First patient visit: Cardiac surgeon refers the patient to cardiac anesthesiologist who reviews the medical history, general examination notes, available investigations and examines the patient; thereafter, directs the supporting staff to schedule the patient for surgery according to waiting list. Step II Second patient visit: 10 days prior to provisional date of surgery; patient is asked to undergo pre‑operative investigations as per the hospital’s protocol. Step III Seven days prior to surgery: Investigation results are reviewed by the anesthesiologist and any consultations (nephrology, neurology etc.) if required are informed telephonically to the patient. If the patient is declared fit for anesthesia and surgery, risk stratification is done according to European system for cardiac operative risk evaluation 2 (EuroSCORE 2) and Society of Thoracic Surgeons (STS) risk scoring system and patient is informed about the risk telephonically. At the same time, a final and confirmed date for surgery is given to patient. Patient is also advised about drug treatment and stoppage of certain drugs like clopidogrel, warfarin as per the hospital’s protocol. Step IV Third visit (Optional) for patients who require consultations: A review of such patients’ records is made after every 2 days and the patient is informed about the progress. If the patient insists on a visit, the 77
Copyright of Annals of Cardiac Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
