Extremity Necrosis Caused by Indwelling Arterial Catheters Frank E. Johnson, MD,’ Seattle, Washington David S. Sumner, MD,f Seattle, Washington D. E. Strandness, Jr, MD, Seattle, Washington
Insertion of a plastic catheter into a small peripheral artery frequently facilitates the care of critically ill patients. This technically simple procedure allows highly accurate monitoring of arterial blood pressure and pulse rate [l-3]. It also permits repeated sampling of blood for arterial blood gas determination and for routine laboratory studies. Arterial cannulation eliminates the need for frequent venipunctures, arterial punctures, and standard pulse and blood pressure determinations. These advantages account for the widespread and growing acceptance of this technic. Catheterization may be done by cutdown as well as percutaneously. The radial artery is most frequently used for this purpose, since it is accessible and easy to cannulate. The ulnar, temporal, and dorsalis pedis arteries [4] are also occasionally used. Various complications of this procedure have been reported, including pain, hematoma formation, thrombosis, and antegrade or retrograde embolization of thrombus [1,2,5-91. Apparently, frank tissue necrosis rarely occurs. However, Bartlett and Munster [2] reported one patient with necrosis of fingers in a series of more than 500 radial artery cannulations; Samaan [IO] also reported several cases involving ischemia and necrosis of the hand. $Ve have observed tissue necrosis in four such patients recently. It seems likely that this complication is more common than previously suspected and has received insufficient mention in the surgical literature. A summary of the clinical course of these patients, as well as a description of measures useful in the prevention, early detection, and
From the Department of Surgery, University of Washington School of Medicine, Seattle, Washington 98195. Reprint requests should be addressed to D. E. Strandness, Jr, MD, Dapartment of Surgery, University of Washington School of Medicine, Seattle, Washington 99915. * Resent address: Department of Surgery, University of Colorado School of Medicine, Denver, Colorado 90220. t Present address: Department of Surgery, Southern Illinois School of Medicine, Springfield, Illinois.
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treatment of ischemic basis of this report.
complications,
forms the
Case Reports Case I. A 1,100 gm Caucasian female (gestational age 26 to 28 weeks) was admitted to the Newborn Intensive Care Unit on July 27, 1972. She had idiopathic respiratory distress syndrome and remained in the Newborn Intensive Care Unit for ten weeks, requiring respirator therapy and intravenous feeding. She was discharged home with radiographic evidence of chronic lung disease. On December 29, 1972, at age five months she was readmitted for bronchiolitis and deteriorated rapidly. To facilitate monitoring, an Angiocatha catheter (Deseret Pharmaceutical Company, Sandy, Utah 84070) was inserted by cutdown into her right radial artery on December 30, 1972. The catheter was irrigated with a continuous infusion of 5 per cent dextrose solution plus heparin. The next day, an endotracheal tube was inserted and respiratory therapy was begun. On January 1, 1973, the arterial line was noted to be working improperly for a period of 12 hours but functioned normally again later that day. Twenty-six hours after insertion of the arterial cannula, a “dark area” appeared on the patient’s right arm. Although the catheter was implicated as a possible cause, it was not removed since an ulnar pulse was still palpable. Later that same day, the entire arm became discolored, but the arterial catheter still functioned properly and was allowed to remain in place. It was finally removed on January 3, 1973, after it had been in place approximately 84 hours (and 46 hours after the first observation of cutaneous color change). At this time, the hand was white and a 1 by 2 cm area of “skin slough” was noted overlying the catheter tip. (Figure 1.) Evaluation with the ultrasonic velocity detector revealed radial, ulnar, and distal brachial artery occlusion. By January 4, 1973, the right upper arm and lateral chest had become mottled and demarcation had begun over the right arm below the elbow. (Figures 1 and 2.) Repeat examination the next day with the velocity detector revealed that occlusion had extended to the proximal brachial artery. Since this was presumed to be secondary to propagation of the intra-arterial thrombus, the patient was heparinized. The arm became gangrenous and was amputated 2 cm below the elbow on January 16,1973.
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Figure 1. Case I. Photograph taken one day affer removal of arterial catf#er. Note mottling of chest wail and upper arm, as well as below-elbow demarcation. Arrow points to area of skin discoloration overlying catheter tip. Stitches in antecubitai fossa are for intravenous catheter.
Figure 2. Case I. View of dorsal aspect of arm and posterior chest wail. Mottling and below-elbow demarcation are again evident. Comment: During this illness, the patient did not exhibit a PO* lower than 57 torr and hypotension was never a significant problem, thus ruling out these factors as probable causes of this complication. It seems likely that the catheter itself was responsible for the thrombosis. If the first sign of cutaneous color change had led to catheter removal, this patient’s extremity might have remained viable. Case II. A sixty-four year old Caucasian female was admitted to the Intensive Care Unit on May 28, 1973. She had sustained a 60 to 70 per cent full thickness flame burn over her head, oropharynx, most of her trunk and upper extremities, and parts of her lower extremities. Her urine was grossly red due to myoglobinuria. Inspiratory and expiratory rhonchi were present. On admission to the Intensive Care Unit, her vital signs were: blood pressure, 110/60; respiratory rate, 18 per minute;
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temperature, 94.6OF. To facilitate her management, an Angiocath catheter was placed by cutdown in her right dorsalis pedis artery at 9:30 AM on the day of admission. Five per cent dextrose solution containing 2,000 units of heparin per liter was infused through the catheter. The arterial cannula was removed on June 1, 1973, because it was not functioning properly. An Intrafusofl catheter (Sorenson Research Company, 2505 South West Temple, Salt Lake City, Utah 84115) was inserted through the same arterial puncture site for a distance of 10 cm and normal function was restored. By June 2, 1973, her blood pressure dropped to 90/50; we believed this to be due to klebsiella pneumonia and bacteremia. Levarterenol and gentamicin were begun. During the next two days, her clinical course worsened. She became oliguric, areflexic, and unresponsive. On June 4, 1973, approximately 160 hours after placement, the arterial cannula was removed when an area of “pallor and discoloration” of the anterior leg overlying the catheter were noted. Her condition continued to worsen and she died on June 6, 1973. At that time, an area over her anterior foot extending 20 cm proximally had become necrotic. Comment: At autopsy, the causes of death were: burns of 75 per cent of the body surface area and bronchopneumonia. Postmortem biopsy revealed complete occlusion and necrotizing arteritis of the anterior tibia1 artery and skin and muscle necrosis. (Figures 3 and 4.) Gram-negative rods were seen in the thrombus within the anterior tibia1 artery. Her arterial blood gases were maintained within acceptable limits, although her POz once transiently decreased to 38 torr. Sputum culture grew klebsiella and Escherichia coli. Postmortem culture of the infarcted tissue of the patient’s leg grew enterococcus, klebsiella, and Candida albicans. Blood cultures grew klehsiella. All klebsiella organisms isolated had the same antibiotic sensitivities. In this patient, hypotension and sepsis were important factors predisposing to thrombosis around the arterial catheter. Septic thrombosis, however, was not observed in other medium sized arteries and the presence of the catheter itself undoubtedly played a major role in the development of this complication.
Case III. A sixty-six year old Caucasian male was brought into the hospital on February 7, 1973, unresponsive and cyanotic. His blood pressure was unrecordable, temperature was 98.4’F, and heart rate was 100 beats per minute. No history could be obtained, but he was known to be alcoholic and to have chronic obstructive pulmonary disease. Arterial blood gases were: pH, 7.08; POz, 68 torr; PCOz, 30 torr; bicarbonate, 8 mEq/L. He was given dexamethasone, NaHCOs, and penicillin, and an endotracheal tube was inserted. Chest x-ray film revealed bilateral basilar infiltrates compatible with aspiration pneumonitis. At 4:30 PM on the day of admission, an arterial cannula was placed in his left radial artery through which a 5 per cent dextrose solu-
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Figure 3. Case Il. Section taken through anterior tibiai artery in the vicinity of the catheter tip, demonstrating thrombosis and necrotizing arteritis. (Original magnifkat/on X 15.)
Figure 4. Case ii. A section through anterior tibiai artery midway between catheter hub and catheter tip. Note organizing fibrin sheath, whkh presumably formed around arterial catheter. and thrombus in the remainder of vessel. (Original magnifkation X 15.)
tion containing 2,000 units of heparin per liter was infused. Although his left hand was noted to be blue on February 8,1973, the arterial catheter was not removed until 7:30 AM on February 9, 1973, 39 hours after insertion. Evaluation at that time with the ultrasonic velocity detector revealed occlusion of the left radial artery and patent ulnar and brachial arteries. Later that day, a left axillary block with 0.5 per cent lidocaine and 0.2 per cent tetracaine was performed. Venous dilatation was noted, but no change in skin temperature or color were observed. By February 11, 1973, digits two through five had become necrotic with demarcation at about the proximal interphalangeal joint level. The patient continued a worsening course with development of cavitary pseudomonas pneumonia, tension pneumothorax, and empyema. He was given levarterenol for maintenance of blood pressure but died at 9:00 AM on February 20, 1973.
Case IV. A fifty-four year old Caucasian male was admitted to the hospital on November 25,1973. He was in shock, with a blood pressure of 70/50. He had a rigid abdomen and evidence of free intraperitoneal air. He was immediately taken to the operating room, where an arterial catheter was placed percutaneously in his right radial artery. The patient was noted to have cool extremities and palpable radial pulses prior to placement, but no other evaluation of the hand circulation was carried out at that time. At operation, a perforation in the sigmoid colon was found; it was repaired and a diverting colostomy was created. Postoperatively, he had adult respiratory distress syndrome and was maintained on a respirator in the Intensive Care Unit. During this time, his arterial line was flushed frequently with a 5 per cent dextrose solution containing 2,000 units of heparin per liter. By November 27, 1973, his right thumb was cold and cyanotic, and demarcation at the distal interphalangeal joint was beginning. Evaluation with the ultrasonic velocity detector at that time revealed no radial arterial signal and an obstructed palmar arch signal. However, the ulnar arterial signal was normal. By the next day, the entire right hand and wrist had begun to demarcate and no signal was present at the wrist or below, except for an ulnar arterial signal, which was consistent with incomplete obstruction. At this time, approximately 72 hours after insertion and 36 hours after the first obser-
Comment: This patient’s arterial blood gas values were acceptable after intubation, with PO:! dipping only transiently to 51 torr on one occasion. It was felt that he had aspirated vomitus before admission, hypotension had developed on that basis,. and his subsequent course was due to this. His autopsy showed pneumonia and sepsis with hypotension as the cause of death. The radial artery was not studied post mortem.
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vation of ischemia, the catheter was removed. On November 29,1973, although the flowmeter evaluation was unchanged, the entire forearm was cold and cyanotic. The patient continued a course of sepsis, hypotension, and acute respiratory failure and died at 3:30 AM on November 30,1973. Comment: At autopsy, the right radial artery and all ita branches were thrombosed. The right ulnar artery was thrombosed distally but not proximally. The left ulnar artery was patent, but the left radial artery was thrombosed. A central fibrin cylinder was present with-
in the thrombosed left radial artery, similar to that illustrated in Figure 4. Again, the presence of a foreign body within the arterial lumen and the associated changes in local hemodynamics were important in the genesis of this complication. However, systemic hypotension and sepsis may also have been significant factors. Prompt catheter removal at the first sign of &hernia might have prevented this complication. Comments
In this report, four cases of extremity necrosis attributable to indwelling catheters in small peripheral arteries are documented. Many factors appear to play a part in the development of this complication. All four patients were critically ill and three died. Sepsis, hypotension, and hypoxemia may have been contributory factors. In case I, ominous physical findings were present for several days before the arterial catheter was removed. To a lesser extent, this was also true of cases three and four. In none of the cases was there any preplacement evaluation of the collateral circulation to the extremity. In one of our patients (case II), septic thrombosis and necrotizing arteritis were associated with an arterial cannula. Although septic complications due to plastic intravenous catheters have been well demonstrated [II], we are aware of no previous reports in the literature of this complication in association with arterial catheters. Since it is logical to assume that arterial catheters likewise predispose to septic complications, there will probably be a growing recognition of this problem. Other investigators have documented a high incidence of occlusion of the radial artery after cannulation. Hasse et al [6] demonstrated angiographic evidence of occlusion in 60 per cent of twentyeight cases. Dalton and Laver [5] have presented evidence that, at least in some cases, arterial insufficiency may be due to arterial spasm. Ryan et al 121, using digital plethysmography, found evidence of thrombosis in twelve of thirteen catheterized radial arteries that they studied. Using serial
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physiologic measurements with the ultrasonic velocity detector, Bedford and Wollman [1] studied 100 patients undergoing percutaneous radial artery cannulation and found that 38 per cent of cannulations resulted in thrombosis of the vessel. They also noted that all radial arteries that became obstructed eventually regained patency, if observed long enough. This observation is important. It indicates that even if an extremity becomes ischemic due to an arterial catheter complication, the limb may ultimately become asymptomatic, provided that necrosis can be prevented during this time. Some complications may be due to technical factors, although our data on this subject are incomplete. It is not clear at present whether any significant difference in complication rate may be ascribed to the solution infused through an arterial line, although certain drugs, such as barbiturates, have been inadvertently injected intra-arterially with disastrous results. Whether one variety of plastic catheter is preferable to another has been studied by Downs et al [13]. They concluded that higher rates of thrombosis occurred when catheters of larger external diameter were used. The arterial circulation of the hand has been well studied by Coleman and Anson [14]. The superficial and deep volar arches may assume a large number of patterns. In Coleman and Anson’s study, approximately 22 per cent of superficial arches were incomplete, as were 3 per cent of deep arches. In addition to these anastomoses, the arterial rete about the wrist forms a measure of potential protection for the hand if one of the major arteries to the hand becomes obstructed. To avoid ischemic complications after arterial catheterization, certain simple measures appear to be useful. Prevention of complications rest largely on patient selection, and this is not usually difficult. Simple palpation of the artery proposed for cannulation, as well as potential collateral vessels, provides much information. If the major arterial supply to an extremity is delivered via a single artery, and if that artery occludes due to cannulation, there is considerable risk of devitalization of distal tissues. Manual occlusion of these arteries is also useful, particularly Allen’s test [1,15]. The demonstration of reactive hyperemia following release of manual compression of an artery indicates that cannulation, of that artery would be hazardous. The ultrasonic velocity detector may be used to gain further information about the arterial supply of the extremity [1,16]. This instrument, when
lhe American Journal of Surgery
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available, allows one to reliably map out the arterial tree and also the direction of arterial flow when used in conjunction with maneuvers such as exercise, compression, and reactive hyperemia. Once cannulation has been done, it is important to keep the arterial entry site as sterile as possible in order to prevent septic thrombosis, which occurred in one of our cases. Antibiotic ointment should be applied over the wound site and the dressings over it changed frequently. Constricting dressing, vasoconstrictor drugs, hypothermia, and arterial hypotension, all of which may predispose to thrombosis or ischemia, should be avoided. Mortenson [7] and Samaan [IO] discuss other factors that increase the risk of extremity artery cannulation, such as old age, hypertension, aortic insufficiency, and Raynaud’s phenomenon. Frequent clinical evaluation of the patient’s extremity is an important but often neglected aspect of the management of patients who require indwelling catheters. This is particularly true in critically ill patients with multiple medical problems. The develqpment of a reddened or discolored area overlying the tip of the catheter (Figure 1) appears to be an important clue to impending arterial thrombosis. Two of our patients (cases I and II) exhibited this sign prior to the development of clinical extremity infarction. Other authors [1,2] have mentioned this sign as well. We advocate immediate removal. of the catheter if this phenomenon occurs. Similarly, loss of ultrasonic flowmeter signals in areas where signals were previously heard indicates occlusion of underlying vessels and usually dictates removal of the catheter, although the patient of Dalton and Laver [5] was successfully treated for arterial spasm with intra-arterial lidocaine. Clinical signs of suppuration along the course of a cannulated artery is also an indication for immediate catheter removal. Evidence of ischemia distal to a catheter site is an absolute indication for immediate catheter removal and institution of sunnortive measures to maintain viabilitv of the ext;e’mity. Finally, Mozersky et al [I 7] cite a case where successful artery thrombectomy was carried out.
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Summary
Four patients sustained tissue loss due to indwelling catheters, three of which were in radial arteries and one of which was in the dorsalis pedis artery. In one of the patients, septic thrombosis was demonstrated. The risk of such complications can be minimized by precannulation evaluation of the arterial circulation of the extremity, by proper care of the catheter when in place, and by careful observation for clinical evidence of infection, ischemia, and other treatable problems. References 1. Bedford RF, Wollman Ii: Complications of percutaneous radial-artery cannulation. Anesthesiology 38: 228, 1973. 2. Bartlett RH, Munster AM: An improved technic for prolonged arterial cannulation. N Eng/ J Med 279: 92. 1968. 3. Barr PO: Percutaneous puncture of the radial artery with a multipurpose teflon catheter for indwelling use. Acta PhysiolScand51: 343, 1961. 4. Gurman EB, Hairabet JK, Roman DG: The use of indwelling radial artery needles in paediatric anaesthesia. 8r J Anaesth 44: 531. 1972. 5. Dalton l3, Laver MB: Vasospasm with an indwelling radial artery cannula. Anesthesiology 34: 194, 197 1. 6. Hasse J, Pus&la C, Cloeven S, et al: Angiographische Untersuchungen nach Dauer-kanijlierung der Arteria radialis. Schweiz Med Wochenschr 101: 1057, 1971. 7. Mortensen JD: Clinical sequelae from arterial needle puncture, cannulation, and incision. Circulation 35: 1118, 1967. 8. Lowenstein E. Little JW Ill. Lo HH: Prevention of cerebral embolization from flushing radial-artery cannulas. N Engl JMed285: 1414, 1971. 9. Mathieu A. Dalton B. Fischer JE, Kumar A: Expanding aneurysm of the radial artery after frequent puncture. Anesthesiology 38: 401, 1973. 10. Samaan HA: The hazards of radial artery pressure monitoring. J Cardiovasc Surg (Torino) 12: 342, 197 1. 11. Bernard -RW, Stahl WM, Chase RM: Subclavian vein catheterizations. Ann Surg 173: 191, 1971. 12. Ryan JF, Raimes J, Dalton BC, et al: Arterial dynamics of radial artery cannulation. Anesth Analg 52: 1017. 1973. 13. Downs JB, Rackstein AD, Klein EF Jr, et al: Hazards of radial-artery catheterization. Anesthesiology 38: 283, 1973. 14. Coleman SS, Anson BJ: Arterial patterns in the hand based upon a study of 650 specimens. Surg Gynecol Obstet 113: 409, 1961. 15. Allen EV: Thromboangiitis obliterans: methods of dia nosis of chronic occlusive arterial lesions distal to thP wrist withillustrative cases. Am J MedSci 178: 237, 1929. 16. Strandness DE Jr: Peripheral Arterial Disease. Boston, Little, Brown, 1969. 17. Morersky DJ, Buckley CJ, Hagood CO Jr, et al: Ultrasonic evaluation of the palmar circulation. Am J Surg 126: 810, 1973.
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Insertion of a plastic catheter into a small peripheral artery frequently facilitates the care of critically ill patients. This technically simple procedure allows highly accurate monitoring of arterial blood pressure and pulse rate [l-3]. It also permits repeated sampling of blood for arterial blood gas determination and for routine laboratory studies. Arterial cannulation eliminates the need for frequent venipunctures, arterial punctures, and standard pulse and blood pressure determinations. These advantages account for the widespread and growing acceptance of this technic. Catheterization may be done by cutdown as well as percutaneously. The radial artery is most frequently used for this purpose, since it is accessible and easy to cannulate. The ulnar, temporal, and dorsalis pedis arteries [4] are also occasionally used. Various complications of this procedure have been reported, including pain, hematoma formation, thrombosis, and antegrade or retrograde embolization of thrombus [1,2,5-91. Apparently, frank tissue necrosis rarely occurs. However, Bartlett and Munster [2] reported one patient with necrosis of fingers in a series of more than 500 radial artery cannulations; Samaan [IO] also reported several cases involving ischemia and necrosis of the hand. $Ve have observed tissue necrosis in four such patients recently. It seems likely that this complication is more common than previously suspected and has received insufficient mention in the surgical literature. A summary of the clinical course of these patients, as well as a description of measures useful in the prevention, early detection, and
From the Department of Surgery, University of Washington School of Medicine, Seattle, Washington 98195. Reprint requests should be addressed to D. E. Strandness, Jr, MD, Dapartment of Surgery, University of Washington School of Medicine, Seattle, Washington 99915. * Resent address: Department of Surgery, University of Colorado School of Medicine, Denver, Colorado 90220. t Present address: Department of Surgery, Southern Illinois School of Medicine, Springfield, Illinois.
volum8 181, wmdl1@76
treatment of ischemic basis of this report.
complications,
forms the
Case Reports Case I. A 1,100 gm Caucasian female (gestational age 26 to 28 weeks) was admitted to the Newborn Intensive Care Unit on July 27, 1972. She had idiopathic respiratory distress syndrome and remained in the Newborn Intensive Care Unit for ten weeks, requiring respirator therapy and intravenous feeding. She was discharged home with radiographic evidence of chronic lung disease. On December 29, 1972, at age five months she was readmitted for bronchiolitis and deteriorated rapidly. To facilitate monitoring, an Angiocatha catheter (Deseret Pharmaceutical Company, Sandy, Utah 84070) was inserted by cutdown into her right radial artery on December 30, 1972. The catheter was irrigated with a continuous infusion of 5 per cent dextrose solution plus heparin. The next day, an endotracheal tube was inserted and respiratory therapy was begun. On January 1, 1973, the arterial line was noted to be working improperly for a period of 12 hours but functioned normally again later that day. Twenty-six hours after insertion of the arterial cannula, a “dark area” appeared on the patient’s right arm. Although the catheter was implicated as a possible cause, it was not removed since an ulnar pulse was still palpable. Later that same day, the entire arm became discolored, but the arterial catheter still functioned properly and was allowed to remain in place. It was finally removed on January 3, 1973, after it had been in place approximately 84 hours (and 46 hours after the first observation of cutaneous color change). At this time, the hand was white and a 1 by 2 cm area of “skin slough” was noted overlying the catheter tip. (Figure 1.) Evaluation with the ultrasonic velocity detector revealed radial, ulnar, and distal brachial artery occlusion. By January 4, 1973, the right upper arm and lateral chest had become mottled and demarcation had begun over the right arm below the elbow. (Figures 1 and 2.) Repeat examination the next day with the velocity detector revealed that occlusion had extended to the proximal brachial artery. Since this was presumed to be secondary to propagation of the intra-arterial thrombus, the patient was heparinized. The arm became gangrenous and was amputated 2 cm below the elbow on January 16,1973.
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Figure 1. Case I. Photograph taken one day affer removal of arterial catf#er. Note mottling of chest wail and upper arm, as well as below-elbow demarcation. Arrow points to area of skin discoloration overlying catheter tip. Stitches in antecubitai fossa are for intravenous catheter.
Figure 2. Case I. View of dorsal aspect of arm and posterior chest wail. Mottling and below-elbow demarcation are again evident. Comment: During this illness, the patient did not exhibit a PO* lower than 57 torr and hypotension was never a significant problem, thus ruling out these factors as probable causes of this complication. It seems likely that the catheter itself was responsible for the thrombosis. If the first sign of cutaneous color change had led to catheter removal, this patient’s extremity might have remained viable. Case II. A sixty-four year old Caucasian female was admitted to the Intensive Care Unit on May 28, 1973. She had sustained a 60 to 70 per cent full thickness flame burn over her head, oropharynx, most of her trunk and upper extremities, and parts of her lower extremities. Her urine was grossly red due to myoglobinuria. Inspiratory and expiratory rhonchi were present. On admission to the Intensive Care Unit, her vital signs were: blood pressure, 110/60; respiratory rate, 18 per minute;
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temperature, 94.6OF. To facilitate her management, an Angiocath catheter was placed by cutdown in her right dorsalis pedis artery at 9:30 AM on the day of admission. Five per cent dextrose solution containing 2,000 units of heparin per liter was infused through the catheter. The arterial cannula was removed on June 1, 1973, because it was not functioning properly. An Intrafusofl catheter (Sorenson Research Company, 2505 South West Temple, Salt Lake City, Utah 84115) was inserted through the same arterial puncture site for a distance of 10 cm and normal function was restored. By June 2, 1973, her blood pressure dropped to 90/50; we believed this to be due to klebsiella pneumonia and bacteremia. Levarterenol and gentamicin were begun. During the next two days, her clinical course worsened. She became oliguric, areflexic, and unresponsive. On June 4, 1973, approximately 160 hours after placement, the arterial cannula was removed when an area of “pallor and discoloration” of the anterior leg overlying the catheter were noted. Her condition continued to worsen and she died on June 6, 1973. At that time, an area over her anterior foot extending 20 cm proximally had become necrotic. Comment: At autopsy, the causes of death were: burns of 75 per cent of the body surface area and bronchopneumonia. Postmortem biopsy revealed complete occlusion and necrotizing arteritis of the anterior tibia1 artery and skin and muscle necrosis. (Figures 3 and 4.) Gram-negative rods were seen in the thrombus within the anterior tibia1 artery. Her arterial blood gases were maintained within acceptable limits, although her POz once transiently decreased to 38 torr. Sputum culture grew klebsiella and Escherichia coli. Postmortem culture of the infarcted tissue of the patient’s leg grew enterococcus, klebsiella, and Candida albicans. Blood cultures grew klehsiella. All klebsiella organisms isolated had the same antibiotic sensitivities. In this patient, hypotension and sepsis were important factors predisposing to thrombosis around the arterial catheter. Septic thrombosis, however, was not observed in other medium sized arteries and the presence of the catheter itself undoubtedly played a major role in the development of this complication.
Case III. A sixty-six year old Caucasian male was brought into the hospital on February 7, 1973, unresponsive and cyanotic. His blood pressure was unrecordable, temperature was 98.4’F, and heart rate was 100 beats per minute. No history could be obtained, but he was known to be alcoholic and to have chronic obstructive pulmonary disease. Arterial blood gases were: pH, 7.08; POz, 68 torr; PCOz, 30 torr; bicarbonate, 8 mEq/L. He was given dexamethasone, NaHCOs, and penicillin, and an endotracheal tube was inserted. Chest x-ray film revealed bilateral basilar infiltrates compatible with aspiration pneumonitis. At 4:30 PM on the day of admission, an arterial cannula was placed in his left radial artery through which a 5 per cent dextrose solu-
The Amedcan Journal of Surgwy
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Figure 3. Case Il. Section taken through anterior tibiai artery in the vicinity of the catheter tip, demonstrating thrombosis and necrotizing arteritis. (Original magnifkat/on X 15.)
Figure 4. Case ii. A section through anterior tibiai artery midway between catheter hub and catheter tip. Note organizing fibrin sheath, whkh presumably formed around arterial catheter. and thrombus in the remainder of vessel. (Original magnifkation X 15.)
tion containing 2,000 units of heparin per liter was infused. Although his left hand was noted to be blue on February 8,1973, the arterial catheter was not removed until 7:30 AM on February 9, 1973, 39 hours after insertion. Evaluation at that time with the ultrasonic velocity detector revealed occlusion of the left radial artery and patent ulnar and brachial arteries. Later that day, a left axillary block with 0.5 per cent lidocaine and 0.2 per cent tetracaine was performed. Venous dilatation was noted, but no change in skin temperature or color were observed. By February 11, 1973, digits two through five had become necrotic with demarcation at about the proximal interphalangeal joint level. The patient continued a worsening course with development of cavitary pseudomonas pneumonia, tension pneumothorax, and empyema. He was given levarterenol for maintenance of blood pressure but died at 9:00 AM on February 20, 1973.
Case IV. A fifty-four year old Caucasian male was admitted to the hospital on November 25,1973. He was in shock, with a blood pressure of 70/50. He had a rigid abdomen and evidence of free intraperitoneal air. He was immediately taken to the operating room, where an arterial catheter was placed percutaneously in his right radial artery. The patient was noted to have cool extremities and palpable radial pulses prior to placement, but no other evaluation of the hand circulation was carried out at that time. At operation, a perforation in the sigmoid colon was found; it was repaired and a diverting colostomy was created. Postoperatively, he had adult respiratory distress syndrome and was maintained on a respirator in the Intensive Care Unit. During this time, his arterial line was flushed frequently with a 5 per cent dextrose solution containing 2,000 units of heparin per liter. By November 27, 1973, his right thumb was cold and cyanotic, and demarcation at the distal interphalangeal joint was beginning. Evaluation with the ultrasonic velocity detector at that time revealed no radial arterial signal and an obstructed palmar arch signal. However, the ulnar arterial signal was normal. By the next day, the entire right hand and wrist had begun to demarcate and no signal was present at the wrist or below, except for an ulnar arterial signal, which was consistent with incomplete obstruction. At this time, approximately 72 hours after insertion and 36 hours after the first obser-
Comment: This patient’s arterial blood gas values were acceptable after intubation, with PO:! dipping only transiently to 51 torr on one occasion. It was felt that he had aspirated vomitus before admission, hypotension had developed on that basis,. and his subsequent course was due to this. His autopsy showed pneumonia and sepsis with hypotension as the cause of death. The radial artery was not studied post mortem.
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vation of ischemia, the catheter was removed. On November 29,1973, although the flowmeter evaluation was unchanged, the entire forearm was cold and cyanotic. The patient continued a course of sepsis, hypotension, and acute respiratory failure and died at 3:30 AM on November 30,1973. Comment: At autopsy, the right radial artery and all ita branches were thrombosed. The right ulnar artery was thrombosed distally but not proximally. The left ulnar artery was patent, but the left radial artery was thrombosed. A central fibrin cylinder was present with-
in the thrombosed left radial artery, similar to that illustrated in Figure 4. Again, the presence of a foreign body within the arterial lumen and the associated changes in local hemodynamics were important in the genesis of this complication. However, systemic hypotension and sepsis may also have been significant factors. Prompt catheter removal at the first sign of &hernia might have prevented this complication. Comments
In this report, four cases of extremity necrosis attributable to indwelling catheters in small peripheral arteries are documented. Many factors appear to play a part in the development of this complication. All four patients were critically ill and three died. Sepsis, hypotension, and hypoxemia may have been contributory factors. In case I, ominous physical findings were present for several days before the arterial catheter was removed. To a lesser extent, this was also true of cases three and four. In none of the cases was there any preplacement evaluation of the collateral circulation to the extremity. In one of our patients (case II), septic thrombosis and necrotizing arteritis were associated with an arterial cannula. Although septic complications due to plastic intravenous catheters have been well demonstrated [II], we are aware of no previous reports in the literature of this complication in association with arterial catheters. Since it is logical to assume that arterial catheters likewise predispose to septic complications, there will probably be a growing recognition of this problem. Other investigators have documented a high incidence of occlusion of the radial artery after cannulation. Hasse et al [6] demonstrated angiographic evidence of occlusion in 60 per cent of twentyeight cases. Dalton and Laver [5] have presented evidence that, at least in some cases, arterial insufficiency may be due to arterial spasm. Ryan et al 121, using digital plethysmography, found evidence of thrombosis in twelve of thirteen catheterized radial arteries that they studied. Using serial
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physiologic measurements with the ultrasonic velocity detector, Bedford and Wollman [1] studied 100 patients undergoing percutaneous radial artery cannulation and found that 38 per cent of cannulations resulted in thrombosis of the vessel. They also noted that all radial arteries that became obstructed eventually regained patency, if observed long enough. This observation is important. It indicates that even if an extremity becomes ischemic due to an arterial catheter complication, the limb may ultimately become asymptomatic, provided that necrosis can be prevented during this time. Some complications may be due to technical factors, although our data on this subject are incomplete. It is not clear at present whether any significant difference in complication rate may be ascribed to the solution infused through an arterial line, although certain drugs, such as barbiturates, have been inadvertently injected intra-arterially with disastrous results. Whether one variety of plastic catheter is preferable to another has been studied by Downs et al [13]. They concluded that higher rates of thrombosis occurred when catheters of larger external diameter were used. The arterial circulation of the hand has been well studied by Coleman and Anson [14]. The superficial and deep volar arches may assume a large number of patterns. In Coleman and Anson’s study, approximately 22 per cent of superficial arches were incomplete, as were 3 per cent of deep arches. In addition to these anastomoses, the arterial rete about the wrist forms a measure of potential protection for the hand if one of the major arteries to the hand becomes obstructed. To avoid ischemic complications after arterial catheterization, certain simple measures appear to be useful. Prevention of complications rest largely on patient selection, and this is not usually difficult. Simple palpation of the artery proposed for cannulation, as well as potential collateral vessels, provides much information. If the major arterial supply to an extremity is delivered via a single artery, and if that artery occludes due to cannulation, there is considerable risk of devitalization of distal tissues. Manual occlusion of these arteries is also useful, particularly Allen’s test [1,15]. The demonstration of reactive hyperemia following release of manual compression of an artery indicates that cannulation, of that artery would be hazardous. The ultrasonic velocity detector may be used to gain further information about the arterial supply of the extremity [1,16]. This instrument, when
lhe American Journal of Surgery
Extremity Necrosis
available, allows one to reliably map out the arterial tree and also the direction of arterial flow when used in conjunction with maneuvers such as exercise, compression, and reactive hyperemia. Once cannulation has been done, it is important to keep the arterial entry site as sterile as possible in order to prevent septic thrombosis, which occurred in one of our cases. Antibiotic ointment should be applied over the wound site and the dressings over it changed frequently. Constricting dressing, vasoconstrictor drugs, hypothermia, and arterial hypotension, all of which may predispose to thrombosis or ischemia, should be avoided. Mortenson [7] and Samaan [IO] discuss other factors that increase the risk of extremity artery cannulation, such as old age, hypertension, aortic insufficiency, and Raynaud’s phenomenon. Frequent clinical evaluation of the patient’s extremity is an important but often neglected aspect of the management of patients who require indwelling catheters. This is particularly true in critically ill patients with multiple medical problems. The develqpment of a reddened or discolored area overlying the tip of the catheter (Figure 1) appears to be an important clue to impending arterial thrombosis. Two of our patients (cases I and II) exhibited this sign prior to the development of clinical extremity infarction. Other authors [1,2] have mentioned this sign as well. We advocate immediate removal. of the catheter if this phenomenon occurs. Similarly, loss of ultrasonic flowmeter signals in areas where signals were previously heard indicates occlusion of underlying vessels and usually dictates removal of the catheter, although the patient of Dalton and Laver [5] was successfully treated for arterial spasm with intra-arterial lidocaine. Clinical signs of suppuration along the course of a cannulated artery is also an indication for immediate catheter removal. Evidence of ischemia distal to a catheter site is an absolute indication for immediate catheter removal and institution of sunnortive measures to maintain viabilitv of the ext;e’mity. Finally, Mozersky et al [I 7] cite a case where successful artery thrombectomy was carried out.
votumo 181, march 1976
Summary
Four patients sustained tissue loss due to indwelling catheters, three of which were in radial arteries and one of which was in the dorsalis pedis artery. In one of the patients, septic thrombosis was demonstrated. The risk of such complications can be minimized by precannulation evaluation of the arterial circulation of the extremity, by proper care of the catheter when in place, and by careful observation for clinical evidence of infection, ischemia, and other treatable problems. References 1. Bedford RF, Wollman Ii: Complications of percutaneous radial-artery cannulation. Anesthesiology 38: 228, 1973. 2. Bartlett RH, Munster AM: An improved technic for prolonged arterial cannulation. N Eng/ J Med 279: 92. 1968. 3. Barr PO: Percutaneous puncture of the radial artery with a multipurpose teflon catheter for indwelling use. Acta PhysiolScand51: 343, 1961. 4. Gurman EB, Hairabet JK, Roman DG: The use of indwelling radial artery needles in paediatric anaesthesia. 8r J Anaesth 44: 531. 1972. 5. Dalton l3, Laver MB: Vasospasm with an indwelling radial artery cannula. Anesthesiology 34: 194, 197 1. 6. Hasse J, Pus&la C, Cloeven S, et al: Angiographische Untersuchungen nach Dauer-kanijlierung der Arteria radialis. Schweiz Med Wochenschr 101: 1057, 1971. 7. Mortensen JD: Clinical sequelae from arterial needle puncture, cannulation, and incision. Circulation 35: 1118, 1967. 8. Lowenstein E. Little JW Ill. Lo HH: Prevention of cerebral embolization from flushing radial-artery cannulas. N Engl JMed285: 1414, 1971. 9. Mathieu A. Dalton B. Fischer JE, Kumar A: Expanding aneurysm of the radial artery after frequent puncture. Anesthesiology 38: 401, 1973. 10. Samaan HA: The hazards of radial artery pressure monitoring. J Cardiovasc Surg (Torino) 12: 342, 197 1. 11. Bernard -RW, Stahl WM, Chase RM: Subclavian vein catheterizations. Ann Surg 173: 191, 1971. 12. Ryan JF, Raimes J, Dalton BC, et al: Arterial dynamics of radial artery cannulation. Anesth Analg 52: 1017. 1973. 13. Downs JB, Rackstein AD, Klein EF Jr, et al: Hazards of radial-artery catheterization. Anesthesiology 38: 283, 1973. 14. Coleman SS, Anson BJ: Arterial patterns in the hand based upon a study of 650 specimens. Surg Gynecol Obstet 113: 409, 1961. 15. Allen EV: Thromboangiitis obliterans: methods of dia nosis of chronic occlusive arterial lesions distal to thP wrist withillustrative cases. Am J MedSci 178: 237, 1929. 16. Strandness DE Jr: Peripheral Arterial Disease. Boston, Little, Brown, 1969. 17. Morersky DJ, Buckley CJ, Hagood CO Jr, et al: Ultrasonic evaluation of the palmar circulation. Am J Surg 126: 810, 1973.
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