Letters to Editor
between these drugs. In this situation, in case of severe hypotension, it is recommended to use vasopressors with direct action.[6] Anesthesia in patients using amphetamines requires a careful administration of drugs that interfere in the synthesis, release and reuptake of catecholamines, as unpredictable and severe interactions may occur. Adriano Bechara de Souza Hobaika, Andre Valentim Diniz Muita1, Barbara Silva Neves2 1
Master of Science in Medicine, Mater Dei Hospital, Vila da Serra Hospital, Santa Casa BH, 2Master of Science in Medicine, Santa Casa BH, Belo Horizonte, Brazil Address for correspondence: Dr. Adriano Bechara de Souza Hobaika, Rua Gonçalves Dias, 2700 (Bloco I) CEP 30.140-093, Brazil. E-mail: [email protected]
REFERENCES 1.
Samuels SI, Maze A, Albright G. Cardiac arrest during cesarean section in a chronic amphetamine abuser. Anesth Analg 1979;58:528-30.
2. 3.
4. 5. 6.
Perruchoud C, Chollet-Rivier M. Cardiac arrest during induction of anesthesia in a child on long-term amphetamine therapy. Br J Anaesth 2008;100:421-2. Fischer SP, Schmiesing CA, Guta CG, Brock-Utne JG. General anesthesia and chronic amphetamine use: Should the drug be stopped preoperatively? Anesth Analg 2006;103:203-6. Fischer SP, Healzer JM, Brook MW, Brock-Utne JG. General anesthesia in a patient on long-term amphetamine therapy: Is there cause for concern? Anesth Analg 2000;91:758-9. Allan D, Baird JR, Ellis KE. Interaction between (plus or minus)-amphetamine and atropine on the rat cardiovascular system. Br J Pharmacol 1969;37:367-70. Johnston RR, Way WL, Miller RD. Alteration of anesthetic requirement by amphetamine. Anesthesiology 1972;36:357-63.
Access this article online Quick Response Code:
Website: www.saudija.org
DOI: 10.4103/1658-354X.130763
Tissue necrosis of hand caused by phenytoin extravasation: An unusual occurrence Sir, Phenytoin has been implicated as a serious cause of tissue necrosis on extravasation.[1,2] It is a unique complication for the anesthetist and not much is quoted in anesthesia literature. We cite here an incident, where a 3-year-old child weighing 12 kg was shifted to neurosurgery ICU from emergency around midnight with head injury. On examination, swelling was seen around dorsum [Figure 1] of her left hand associated with slight skin discoloration and a 22 G IV cannula inserted very near to wrist joint seemed to be the cause. The cannula was removed immediately and hand was elevated. By evening the situation worsened with blister formation on dorsum of hand and purple discoloration. The radial artery was barely palpable. Diagnosed as compartment syndrome due to tissue necrosis, decision was made in favor of prophylactic fasciotomy [Figures 1 and 2]. On enquiry about the cause, a consensus was made that phenytoin might be the only agent as nothing other than normal saline and phenytoin 150 mg were injected via the cannula in emergency room Saudi Journal of Anesthesia
prior to her admission in ICU. At one time it appeared that the hand was beyond salvage but after a few days of dressing the normal texture of the tissue appeared and the injury was managed. Phenytoin extravasation has an incidence in between 3 and 7% and causes chemical cellulitis, which may even progress to necrosis requiring amputation. [1-4] Many prudent measures are advised while infusing phenytoin such as avoidance of cannula less then 20G size for infusion and in sites such as over joints where mechanical obstruction is common, minimizing infusion rate below 25 mg/min and substitute the use of fosphenytoin.[2,3] If extravasation occurs, limb elevation and dry heat should be applied and in severe cases fasciotomy should be opted for.[1,4] For an anesthetist the experience of this type of complication due to phenytoin is rare, and moreover we use phenyotoin in neurological and neurosurgical cases in OT and ICU more often to load the patient, which requires the high infusion rate. We hope that this experience of ours will aware others to be vigilant in using phenytoin. Vol. 8, Issue 2, April-June 2014
Page | 309
Letters to Editor Page | 310
Figure 1: Dorsum of the hand after fasciotomy and dressing
Neha Hasija, Amar Jyoti Hazarika, Navdeep Sokhal, Shailendera Kumar Department of NeuroAnesthesia, All India Institute of Medical Sciences, New Delhi, India Address for Correspondence: Dr. Neha Hasija, Department of Neuro Anesthesia, All Institute of Medical Sciences, New Delhi, India. E-mail: [email protected]
Figure 2: Palmar aspect of the same hand
3. 4.
in patients receiving intravenous phenytoin. Neurology 1998;51:1034-9. Kilarski DJ, Buchanan C, Von Behren L. Soft-tissue damage associated with intravenous phenytoin. N Engl J Med 1984; 311:1186-7. Spengler RF, Arrowsmith JB, Kilarski DJ, Buchanan C, Von Behren L, Graham DR. Severe soft-tissue injury following intravenous infusion of phenytoin: Patient and drug administration risk factors. Arch Intern Med 1988;148:1329-33. Access this article online Quick Response Code:
REFERENCES 1. 2.
Helfaer MA, Ware C. Case report: Purple glove syndrome. J Neurosurg Anesthesiol 1994;6:48-9. O’Brien TJ, Cascino GD, So EL, Hanna DR. Incidence and clinical consequence of the purple glove syndrome
Website: www.saudija.org
DOI: 10.4103/1658-354X.130766
Abnormal arterial waveform with 4 peaks Sir, A 48-years-male patient presented with acute anterior wall myocardial infarction with cardiogenic shock. Transthoracic echocardiography revealed large post MI ventricular septal rupture. Intra-aortic balloon pump (IABP) was inserted and patient was scheduled for emergency coronary artery bypass grafting surgery and ventricular septal repair under cardiopulmonary bypass (CPB). During weaning from bypass, IABP was restarted to decrease the afterload and increase cardiac output. Arterial waveform showed four peaks [Figure 1]. Normal arterial wave is having only one peak. In patient with IABP, four peaks (systolic Vol. 8, Issue 2, April-June 2014
and augmented diastolic peak) are observed. Post bypass peripheral vasoconstriction may be responsible for early backward progression of reflected wave creating four peaks in waveform. Such abnormal waveform implies increased afterload on heart which is not favorable in weaning patient from CPB. Pulmonary artery catheter was inserted. Hemodynamic variables obtained also showed raised systemic vascular resistance. Milrinone intravenous infusion was started to reduce afterload. Arterial waveform gradually returned back to normal two peak waveform of IABP. Saudi Journal of Anesthesia
Copyright of Saudi Journal of 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.
between these drugs. In this situation, in case of severe hypotension, it is recommended to use vasopressors with direct action.[6] Anesthesia in patients using amphetamines requires a careful administration of drugs that interfere in the synthesis, release and reuptake of catecholamines, as unpredictable and severe interactions may occur. Adriano Bechara de Souza Hobaika, Andre Valentim Diniz Muita1, Barbara Silva Neves2 1
Master of Science in Medicine, Mater Dei Hospital, Vila da Serra Hospital, Santa Casa BH, 2Master of Science in Medicine, Santa Casa BH, Belo Horizonte, Brazil Address for correspondence: Dr. Adriano Bechara de Souza Hobaika, Rua Gonçalves Dias, 2700 (Bloco I) CEP 30.140-093, Brazil. E-mail: [email protected]
REFERENCES 1.
Samuels SI, Maze A, Albright G. Cardiac arrest during cesarean section in a chronic amphetamine abuser. Anesth Analg 1979;58:528-30.
2. 3.
4. 5. 6.
Perruchoud C, Chollet-Rivier M. Cardiac arrest during induction of anesthesia in a child on long-term amphetamine therapy. Br J Anaesth 2008;100:421-2. Fischer SP, Schmiesing CA, Guta CG, Brock-Utne JG. General anesthesia and chronic amphetamine use: Should the drug be stopped preoperatively? Anesth Analg 2006;103:203-6. Fischer SP, Healzer JM, Brook MW, Brock-Utne JG. General anesthesia in a patient on long-term amphetamine therapy: Is there cause for concern? Anesth Analg 2000;91:758-9. Allan D, Baird JR, Ellis KE. Interaction between (plus or minus)-amphetamine and atropine on the rat cardiovascular system. Br J Pharmacol 1969;37:367-70. Johnston RR, Way WL, Miller RD. Alteration of anesthetic requirement by amphetamine. Anesthesiology 1972;36:357-63.
Access this article online Quick Response Code:
Website: www.saudija.org
DOI: 10.4103/1658-354X.130763
Tissue necrosis of hand caused by phenytoin extravasation: An unusual occurrence Sir, Phenytoin has been implicated as a serious cause of tissue necrosis on extravasation.[1,2] It is a unique complication for the anesthetist and not much is quoted in anesthesia literature. We cite here an incident, where a 3-year-old child weighing 12 kg was shifted to neurosurgery ICU from emergency around midnight with head injury. On examination, swelling was seen around dorsum [Figure 1] of her left hand associated with slight skin discoloration and a 22 G IV cannula inserted very near to wrist joint seemed to be the cause. The cannula was removed immediately and hand was elevated. By evening the situation worsened with blister formation on dorsum of hand and purple discoloration. The radial artery was barely palpable. Diagnosed as compartment syndrome due to tissue necrosis, decision was made in favor of prophylactic fasciotomy [Figures 1 and 2]. On enquiry about the cause, a consensus was made that phenytoin might be the only agent as nothing other than normal saline and phenytoin 150 mg were injected via the cannula in emergency room Saudi Journal of Anesthesia
prior to her admission in ICU. At one time it appeared that the hand was beyond salvage but after a few days of dressing the normal texture of the tissue appeared and the injury was managed. Phenytoin extravasation has an incidence in between 3 and 7% and causes chemical cellulitis, which may even progress to necrosis requiring amputation. [1-4] Many prudent measures are advised while infusing phenytoin such as avoidance of cannula less then 20G size for infusion and in sites such as over joints where mechanical obstruction is common, minimizing infusion rate below 25 mg/min and substitute the use of fosphenytoin.[2,3] If extravasation occurs, limb elevation and dry heat should be applied and in severe cases fasciotomy should be opted for.[1,4] For an anesthetist the experience of this type of complication due to phenytoin is rare, and moreover we use phenyotoin in neurological and neurosurgical cases in OT and ICU more often to load the patient, which requires the high infusion rate. We hope that this experience of ours will aware others to be vigilant in using phenytoin. Vol. 8, Issue 2, April-June 2014
Page | 309
Letters to Editor Page | 310
Figure 1: Dorsum of the hand after fasciotomy and dressing
Neha Hasija, Amar Jyoti Hazarika, Navdeep Sokhal, Shailendera Kumar Department of NeuroAnesthesia, All India Institute of Medical Sciences, New Delhi, India Address for Correspondence: Dr. Neha Hasija, Department of Neuro Anesthesia, All Institute of Medical Sciences, New Delhi, India. E-mail: [email protected]
Figure 2: Palmar aspect of the same hand
3. 4.
in patients receiving intravenous phenytoin. Neurology 1998;51:1034-9. Kilarski DJ, Buchanan C, Von Behren L. Soft-tissue damage associated with intravenous phenytoin. N Engl J Med 1984; 311:1186-7. Spengler RF, Arrowsmith JB, Kilarski DJ, Buchanan C, Von Behren L, Graham DR. Severe soft-tissue injury following intravenous infusion of phenytoin: Patient and drug administration risk factors. Arch Intern Med 1988;148:1329-33. Access this article online Quick Response Code:
REFERENCES 1. 2.
Helfaer MA, Ware C. Case report: Purple glove syndrome. J Neurosurg Anesthesiol 1994;6:48-9. O’Brien TJ, Cascino GD, So EL, Hanna DR. Incidence and clinical consequence of the purple glove syndrome
Website: www.saudija.org
DOI: 10.4103/1658-354X.130766
Abnormal arterial waveform with 4 peaks Sir, A 48-years-male patient presented with acute anterior wall myocardial infarction with cardiogenic shock. Transthoracic echocardiography revealed large post MI ventricular septal rupture. Intra-aortic balloon pump (IABP) was inserted and patient was scheduled for emergency coronary artery bypass grafting surgery and ventricular septal repair under cardiopulmonary bypass (CPB). During weaning from bypass, IABP was restarted to decrease the afterload and increase cardiac output. Arterial waveform showed four peaks [Figure 1]. Normal arterial wave is having only one peak. In patient with IABP, four peaks (systolic Vol. 8, Issue 2, April-June 2014
and augmented diastolic peak) are observed. Post bypass peripheral vasoconstriction may be responsible for early backward progression of reflected wave creating four peaks in waveform. Such abnormal waveform implies increased afterload on heart which is not favorable in weaning patient from CPB. Pulmonary artery catheter was inserted. Hemodynamic variables obtained also showed raised systemic vascular resistance. Milrinone intravenous infusion was started to reduce afterload. Arterial waveform gradually returned back to normal two peak waveform of IABP. Saudi Journal of Anesthesia
Copyright of Saudi Journal of 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.
