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 Table of Contents  
LETTER TO EDITOR
Year : 2021  |  Volume : 10  |  Issue : 2  |  Page : 178-180

Acral limb ischemia postarterial cannulation in a critically ill COVID-19 patient


1 Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Pulmonary, Critical Care and Sleep Medicine, AICTS, Pune, Maharashtra, India

Date of Submission22-Nov-2020
Date of Decision02-Apr-2021
Date of Acceptance02-Apr-2021
Date of Web Publication18-May-2021

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_268_20

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How to cite this article:
Singh S, Reddy S, Gupta N, Marwah V. Acral limb ischemia postarterial cannulation in a critically ill COVID-19 patient. Int J Health Allied Sci 2021;10:178-80

How to cite this URL:
Singh S, Reddy S, Gupta N, Marwah V. Acral limb ischemia postarterial cannulation in a critically ill COVID-19 patient. Int J Health Allied Sci [serial online] 2021 [cited 2021 Jun 22];10:178-80. Available from: https://www.ijhas.in/text.asp?2021/10/2/178/316291



Sir,

In a critical care setting, invasive blood pressure (BP) monitoring using the radial artery (RA) is a standard method for BP monitoring, due to clinically significant discrepancies between invasive and noninvasive systolic BP measurements during hypotension.[1] Acral limb ischemia is a known rare complication of RA cannulation risk factors for which include elderly patients, female sex, cannula size ≥20 G, a high number of puncture attempts, increased duration of catheter placement, use of vasopressors, systemic diseases, and coagulopathies.[1],[2] Severe coronavirus disease (COVID)-19 patients with coagulopathy may present with vascular thromboembolic complications, leading to limb ischemia.[3],[4] However, there is limited evidence whether the occurrence of limb ischemia associated with arterial cannulation has a higher incidence in severe COVID-19 patients as compared to non-COVID-19 critically ill patients. We report a case of acral limb ischemia in a critically ill elderly COVID-19 patient after radial arterial cannulation for a better understanding of the association between severe COIVD-19 disease and arterial catheter-associated thromboembolic complications.

An 80-year-old female with no known medical comorbidities presented with a history of fever, chills, and worsening dyspnea for 3 days. She was admitted and on investigation tested COVID-19 real-time reverse transcription-polymerase chain reaction positive. She had clinical features suggestive of respiratory distress with normal sensorium, oxygen saturation of 85% on room air, and initial chest X-ray demonstrating bilateral patchy opacities. The patient had to be intubated and put on mechanical ventilation on the 4th day owing to continued respiratory distress. The patient was started on 5000 U intravenous heparin 12 hourly. Considering the critical condition of the patient, invasive monitoring was planned, and the right RA was cannulated in a single attempt after performing Allen's test which was suggestive of functioning collaterals. Five days after the cannulation of the right RA, the patient developed gradually worsening the duskiness of thumb and index finger tips of the right hand [Figure 1]. After that, indwelling catheter was removed following which the left RA was cannulated for monitoring purposes. Intravenous heparin was continued along with limb warming. The patient was watched over the next few days with complete restoration of blood flow in the right RA. The clinical condition of the patient deteriorated over the course of intensive care unit (ICU) stay and the patient succumbed to illness on the 16th day of ICU admission.
Figure 1: Acral limb ischemia of the right hand

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Easy accessibility and rich collateral circulation make the RA an attractive site for arterial cannulation in critically ill patients, despite the high risk of limb ischemia and gangrene in a setting of hypercoagulability. We hypothesize that, in our patient, coagulopathy and endothelial injury owing to COIVD-19 infection and stasis because of persistent hypotension despite vasopressor use played a pivotal role in fulfilling the Virchow's triad and manifested as limb ischemia.

We believe that it is appropriate to use an alternative large vessel such as the femoral artery, especially in severe COVID-19 patients. However, there is no evidence to suggest that this alternative is risk free and cannulation at this site comes with its own set of risks. A high index of suspicion and constant vigilance is essential after arterial cannulation, especially in COVID-19 patients with ongoing coagulopathy and requiring very high doses of vasopressors as early detection of ischemia and prompt removal of the cannula may save the limb from gangrene.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be 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.
Lehman LW, Saeed M, Talmor D, Mark R, Malhotra A. Methods of blood pressure measurement in the ICU. Crit Care Med 2013;41:34-40.  Back to cited text no. 1
    
2.
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.  Back to cited text no. 2
  [Full text]  
3.
Levolger S, Bokkers RP, Wille J, Kropman RH, de Vries JP. Arterial thrombotic complications in COVID-19 patients. J Vasc Surg Cases Innov Tech 2020;6:454-9.  Back to cited text no. 3
    
4.
Helms J, Tacquard C, Severac F, Leonard-Lorant I, Ohana M, Delabranche X, et al. High risk of thrombosis in patients with severe SARS-CoV-2 infection: A multicenter prospective cohort study. Intensive Care Med 2020;46:1089-98.  Back to cited text no. 4
    


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