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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 3  |  Page : 290-291

Acute hand ischemia after radial artery catheterization in a young patient


1 Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Orthopaedics, Command Hospital, Chandigarh, India
3 Department of Ophthalmology, Command Hospital (SC), Armed Forces Medical College, Pune, Maharashtra, India

Date of Submission25-Jan-2020
Date of Decision20-Apr-2020
Date of Acceptance30-Apr-2020
Date of Web Publication28-Jul-2020

Correspondence Address:
Dr. Shalendra Singh
Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_8_20

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  Abstract 


Cannulation of the radial artery is frequently required for the continuous beat-to-beat monitoring of blood pressure and frequent aspiration of blood samples for performing arterial gas analysis. Acute hand ischemia after radial artery cannulation is an uncommon complication encountered in the young population. An unusual occurrence of this relatively uncommon ischemia is described herewith in a young male.

Keywords: Arterial gas analysis, hand ischemia, vasospasm


How to cite this article:
Singh S, Venigalla SK, Sood M, Taank P, Dwivedi D. Acute hand ischemia after radial artery catheterization in a young patient. Int J Health Allied Sci 2020;9:290-1

How to cite this URL:
Singh S, Venigalla SK, Sood M, Taank P, Dwivedi D. Acute hand ischemia after radial artery catheterization in a young patient. Int J Health Allied Sci [serial online] 2020 [cited 2020 Sep 30];9:290-1. Available from: http://www.ijhas.in/text.asp?2020/9/3/290/290721




  Introduction Top


Frequent cannulation of the radial artery is done for the continuous beat-to-beat monitoring of blood pressure and frequent aspiration of blood samples for performing arterial gas analysis due to its easy accessibility and the presence of collateral circulation in hand.[1] Common complications encountered with radial artery cannulation are hemorrhage, hematoma, temporary radial artery occlusion, bacteremia, infection, acute carpal tunnel syndrome, compartment syndrome, pseudoaneurysm, thrombosis, and permanent ischemic damage.[2],[3] Common risk factors for above-mentioned complications are elderly patients, females, cannula size ≥20 G, a high number of puncture attempts, increased duration of catheter placement, vasospasm, hypotension, use of vasopressors, systemic diseases, hypercoagulable states, disseminated intravascular coagulation, heparin-induced thrombocytopenia, thrombotic thrombocytopenic purpura, and previous upper extremity surgery or arterial injury.[4]


  Case Report Top


We report a case of acute hand ischemia after the radial artery cannulation in a 29-year-old male, 66 kg (body mass index –22.8 kg/m 2) patient of chronic alcoholism with necrotizing pancreatitis who underwent open pancreatic necrosectomy under general anesthesia. Preoperative investigations were within the normal limits. Written informed consent nil per oral status was ensured, and the patency of the central line (right internal jugular vein), which was placed preoperatively in the intensive care unit (ICU) was confirmed. An arterial cannula under local anesthesia was placed in the right radial artery on the first attempt after performing Allen's negative test. Standard monitoring ensued, and general anesthesia was administered with injection fentanyl 100 μg, propofol 100 mg, and atracurium 25 mg intravenous (IV). Intraoperatively, patient's blood pressure dropped from a baseline of 150/86 mmHg to 80/50 mmHg, and the heart rate increased from 94 to 130/min. Injection noradrenaline infusion 4–6 mcg/min was titrated to maintain the mean blood pressure of 65 mmHg. The rest of the intraoperative period was uneventful (total intraoperative period of 5 h), and blood loss of 600 ml, which was replaced with 2L of crystalloids. The patient was shifted to ICU for postoperative mechanical ventilation. In ICU, after 24 h, the patient's right hand was observed to be pale and cold with the formation of blisters [Figure 1]. Arterial waveform and radial pulse were both absent with a capillary refilling time of ≥3 s. Color Doppler ultrasonography confirmed the absence of a radial pulse with the presence of an ulnar pulse. Immediately, radial artery cannula was removed, and warm compression was applied to the affected part of the hand to improve the collateral circulation with immediate improvement in the color. A new arterial line in the right femoral artery was secured, as an infusion of noradrenaline 4–6 mcg/min was going on due to persistent hypotension. The patient was observed over the next few days with complete restoration of blood flow in the right radial artery. The patient was discharged on day 10 with complete resolution of the hand ischemia.
Figure 1: Discoloration and formation of blisters overhand

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  Discussion Top


Complications related to radial artery cannulations are around 0.1%–20%.[5] Widely available peripheral IV cannula is a common alternative for arterial cannulation at many institutes.[6] The cause of transient ischemia in our case could be transient vasospasm or an embolus, as we ruled out other causes. Vasospasm could be either due to the vasoconstriction caused by noradrenaline or due to the injury to the intima of the radial artery because of cannulation or both. Sepsis could have led to a procoagulant state, which could be the response for an embolus.

To conclude, radial artery cannulation should be conducted carefully after checking the collateral flow and continuous monitoring of the distal flow. Rapid assessment of complications and prompt intervention with proper treatment helps in reducing morbidity and mortality.

Declaration of patient consent

The patient's course was not fatal, and his identity not identified. The approval for publication of the manuscript came from the Department of Anesthesiology and Critical Care at the Armed Forces Medical College, Pune. Patient's names and initials are not published and due efforts are made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
English LA, Maye JP, Dalton-Link MT. Hand ischemia associated with profound hypotension and radial artery catheterization in a pediatric patient: A case report. AANA J 2003;71:41-3.  Back to cited text no. 1
    
2.
Harvey JA, Kim S, Ireson ME, Gulati R, Bell MR, Moran SL. Acute upper-limb complications following radial artery catheterization for coronary angiography. J Hand Surg Am 2020. pii: S0363-5023 (19) 31507-2.  Back to cited text no. 2
    
3.
Wallach SG. Cannulation injury of the radial artery: Diagnosis and treatment algorithm. Am J Crit Care 2004;13:315-9.  Back to cited text no. 3
    
4.
Valentine RJ, Modrall JG, Clagett GP. Hand ischemia after radial artery cannulation. J Am Coll Surg 2005;201:18-22.  Back to cited text no. 4
    
5.
Scheer B, Perel A, Pfeiffer UJ. Clinical review: Complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine. Crit Care 2002;6:199-204.  Back to cited text no. 5
    
6.
Kaushal A, Bindra A, Singh S, Saeed Z. Modification of intravenous cannula for arterial line insertion: Simple yet effective technique. Indian J Anaesth 2018;62:397-9.  Back to cited text no. 6
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