Reminder of important clinical lesson
CASE REPORT
Hand ischaemia after radial artery cannulation Ozkan Onal,1 Ebru Salman,2 Fahri Yetisir,3 Mehmet Kilic3 1
Department of Anesthesiology and Intensive Care, Selcuk University Medical Faculty, Konya, Turkey 2 Department of Anesthesiology and Intensive Care, Ataturk Educational and Training Hospital, Ankara, Turkey 3 Department of General Surgery, Ataturk Educational and Training Hospital, Ankara, Turkey Correspondence to Professor Ozkan Onal, [email protected] Accepted 21 July 2015
SUMMARY Arterial cannulation for haemodynamic monitoring has become a routine procedure in the clinical management of critically ill adults. Thrombosis is the most common complication of this procedure. We report the case of a patient with multiple traumatic injuries in which radial artery cannulation was associated with compartment syndrome of the forearm and hand.
OUTCOME AND FOLLOW-UP
BACKGROUND The primary aim of arterial cannulation is to provide uninterrupted display of pulse contour and continuous beat-to-beat haemodynamic measurement.1 Complications associated with radial artery cannulation, such as thrombosis or infection, can be seen rarely. Thrombosis is the most common complication of this procedure.2 The radial artery is the most frequently cannulated site for haemodynamic monitoring.3 Although radial artery thrombosis has a high rate of occurrence (25–33%), clinical hand ischaemia secondary to cannulation is uncommon (≤1/500).4 5 We report the case of a patient with multiple traumatic injuries in which radial artery cannulation was associated with compartment syndrome of the forearm and hand. This case points to the potential morbidity of arterial cannulation.
CASE PRESENTATION
To cite: Onal O, Salman E, Yetisir F, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2015211145
hand, the wrist and the dorsal aspect of the forearm (figure 1). Also, sepsis developed, of which the source was unclear. The brachial artery to the ulnar artery wrist level and the radial artery to the middle portion were patent. On consultation with the orthopaedics department, amputation was carried out at the wrist. The patient died due to septic shock on day 3 following amputation.
A 67-year-old man with a history of Alzheimer’s disease and cerebrovascular event went into arrest in the service where he was being treated for pneumonia. After responding to cardiopulmonary resuscitation, the patient was transferred to the anaesthesia intensive care unit for further treatment. An arterial cannula (BD Angiocath20G (1.1 mm, 48 mm); Becton Dickinson, Sandy, Utah, USA) was placed in his right radial artery on first trial after performing the Allen’s test. Because his blood pressure was low, inotropic and vasopressor support treatment was administered. Blood clotting tests were higher than the normal range (PT:18.2 s, APTT: 36.4 s, INR:1.87). On day 4 of cannulation, coldness and bruising developed in the fingers of the right hand; subsequently, the arterial cannula was removed and pressure was applied. After consultation with cardiovascular surgery, arterial Doppler ultrasonography was carried out; 60 mg enoxaparin (Clexane, Sanofi Aventis, Turkey) 2 times a day for 2 days was initiated, and elevation and heat were applied. Surgical intervention was not considered. However, the patient did not respond to anticoagulant treatment and heating. Total necrosis developed in the thumb of the right hand, with necrosis in the distal phalanxes of the second and third fingers and the dorsal of the right
The Allen’s test is a poor predictor, a fact that should be kept in mind in the clinical setting. The benefits of monitoring with arterial cannulation must be balanced against the associated risks, and the benefits must outweigh the potential harm.
DISCUSSION Radial artery ischaemia has been associated with various risk factors. These include female gender, low body mass index, advanced age, history of hypertension or prolonged hypotension, vascular disease (Raynaud), catheter size and composition (eg, long and large), cannulas left in place longer than 48–72 h, low cardiac output, use of vasopressors,6 excessive trauma from multiple attempts at the same site, hyperlipoproteinaemia, thrombosis and haematoma formation at the site,7 disseminated intravascular coagulation, and wrist
Figure 1 Total necrotic right hand after radial arterial cannulation.
Onal O, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-211145
1
Reminder of important clinical lesson circumference
CASE REPORT
Hand ischaemia after radial artery cannulation Ozkan Onal,1 Ebru Salman,2 Fahri Yetisir,3 Mehmet Kilic3 1
Department of Anesthesiology and Intensive Care, Selcuk University Medical Faculty, Konya, Turkey 2 Department of Anesthesiology and Intensive Care, Ataturk Educational and Training Hospital, Ankara, Turkey 3 Department of General Surgery, Ataturk Educational and Training Hospital, Ankara, Turkey Correspondence to Professor Ozkan Onal, [email protected] Accepted 21 July 2015
SUMMARY Arterial cannulation for haemodynamic monitoring has become a routine procedure in the clinical management of critically ill adults. Thrombosis is the most common complication of this procedure. We report the case of a patient with multiple traumatic injuries in which radial artery cannulation was associated with compartment syndrome of the forearm and hand.
OUTCOME AND FOLLOW-UP
BACKGROUND The primary aim of arterial cannulation is to provide uninterrupted display of pulse contour and continuous beat-to-beat haemodynamic measurement.1 Complications associated with radial artery cannulation, such as thrombosis or infection, can be seen rarely. Thrombosis is the most common complication of this procedure.2 The radial artery is the most frequently cannulated site for haemodynamic monitoring.3 Although radial artery thrombosis has a high rate of occurrence (25–33%), clinical hand ischaemia secondary to cannulation is uncommon (≤1/500).4 5 We report the case of a patient with multiple traumatic injuries in which radial artery cannulation was associated with compartment syndrome of the forearm and hand. This case points to the potential morbidity of arterial cannulation.
CASE PRESENTATION
To cite: Onal O, Salman E, Yetisir F, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2015211145
hand, the wrist and the dorsal aspect of the forearm (figure 1). Also, sepsis developed, of which the source was unclear. The brachial artery to the ulnar artery wrist level and the radial artery to the middle portion were patent. On consultation with the orthopaedics department, amputation was carried out at the wrist. The patient died due to septic shock on day 3 following amputation.
A 67-year-old man with a history of Alzheimer’s disease and cerebrovascular event went into arrest in the service where he was being treated for pneumonia. After responding to cardiopulmonary resuscitation, the patient was transferred to the anaesthesia intensive care unit for further treatment. An arterial cannula (BD Angiocath20G (1.1 mm, 48 mm); Becton Dickinson, Sandy, Utah, USA) was placed in his right radial artery on first trial after performing the Allen’s test. Because his blood pressure was low, inotropic and vasopressor support treatment was administered. Blood clotting tests were higher than the normal range (PT:18.2 s, APTT: 36.4 s, INR:1.87). On day 4 of cannulation, coldness and bruising developed in the fingers of the right hand; subsequently, the arterial cannula was removed and pressure was applied. After consultation with cardiovascular surgery, arterial Doppler ultrasonography was carried out; 60 mg enoxaparin (Clexane, Sanofi Aventis, Turkey) 2 times a day for 2 days was initiated, and elevation and heat were applied. Surgical intervention was not considered. However, the patient did not respond to anticoagulant treatment and heating. Total necrosis developed in the thumb of the right hand, with necrosis in the distal phalanxes of the second and third fingers and the dorsal of the right
The Allen’s test is a poor predictor, a fact that should be kept in mind in the clinical setting. The benefits of monitoring with arterial cannulation must be balanced against the associated risks, and the benefits must outweigh the potential harm.
DISCUSSION Radial artery ischaemia has been associated with various risk factors. These include female gender, low body mass index, advanced age, history of hypertension or prolonged hypotension, vascular disease (Raynaud), catheter size and composition (eg, long and large), cannulas left in place longer than 48–72 h, low cardiac output, use of vasopressors,6 excessive trauma from multiple attempts at the same site, hyperlipoproteinaemia, thrombosis and haematoma formation at the site,7 disseminated intravascular coagulation, and wrist
Figure 1 Total necrotic right hand after radial arterial cannulation.
Onal O, et al. BMJ Case Rep 2015. doi:10.1136/bcr-2015-211145
1
Reminder of important clinical lesson circumference
