Catastrophic Intravascular Injections - A Complete Guide

Introduction

An intravascular injection delivers injectable drugs directly into the bloodstream through veins or arteries. An intravascular injection is the fastest and most efficient route to administer drugs and replace body fluids. This route is used to administer drugs that range from antibiotics, antifungals, anti-cancer agents, and electrolytes.

An intravascular injection is the route of choice during emergency drug administration and when the patient cannot take drugs through the oral route. However, when infused paradoxically into the unwanted vascular compartment, these intravascular drugs result in catastrophic effects that cause dangerous complications.

What Are the Types of Intravascular Injections?

Drugs can be delivered directly into the bloodstream through two vascular compartments. They are:

• Intravenous - Drugs administered into the vein.

• Intra-arterial- Drugs administered into the artery.

What Are the Complications of Intravascular Injections?

Inadvertent use of intravenous injection technique results in:

• The deposition of drugs into adjacent vital structures.

• Irritation to internal structures of the vein.

• Puncture injury to the vein.

Such accidental damages are caused to the veins either due to improper administration technique or due to the presence of various chemical components in the intravenously infused drugs. Based on the above causes, the complications of intravenous injection can be broadly divided into:

• Drug-induced complications.

• Technique-induced complications.

Drug-Induced Complications:

Sudden Adverse Drug Reaction: When the drugs are administered through the intravenous route, the medication immediately gets delivered into the circulation, and the pharmacological effects of drugs occur immediately. This immediate action of drugs sometimes results in conditions like:

• Hypotension.

• Syncope.

• Convulsion.

Accidental intravenous administration of local anesthesia causes cardiac arrhythmias and seizures. Rapid intravenous administration of hypnotic drugs results in respiratory depression.

Phlebitis: When the pH of the drugs falls below 5.0, it irritates the internal walls of the vein and results in phlebitis. Phlebitis presents as an erythematous area with pain and diffuse injection site swelling.

Technique-induced Complications:

• Infiltration of Drugs: During intravenous drug administration, if the needle is placed outside the lumen of the vein, drugs are deposited into the adjacent structures, thus resulting in the infiltration of drugs into them. This infiltration leads to side or toxic effects based on the infiltration site.

• Thrombophlebitis: Thrombophlebitis is the inflammation and swelling of the vein caused by thrombus formation due to the puncturing of the vein by improper injection procedures. This leads to swelling, pain, and redness under the skin surrounding the injection site.

• Hematoma: Hematoma is a tumor-like swelling caused by vein rupture and the extravasation of blood from the vein into the muscles and subcutaneous structures. As a result, the injection site shows swelling with redness and pain.

Air Embolism: Accidental injection of air bubbles through the needle into the vein causes air embolism. The infused air bubble enters the circulation and may lodge itself into vital structures like the heart and lungs. The air embolism causes signs like:

• Difficulty in breathing.

• Stroke.

• Cyanosis.

• Joint pain.

What Are the Complications of Intra-Arterial Injections?

Catastrophic events follow intra-arterial injection due to:

• Drug deposition into the intravascular compartment accidentally during attempted injection into the intravenous channel or intramuscular region.

• Inadvertent injection and damage of the intra-arterial structure.

• Chemical components of the injected drug.

Complications Due to Chemical Composition of the Drug:

Drugs that contain chemical components can affect the structure of arteries, or the component may overreact to cause adverse effects. They often occur iatrogenically and cause complications like necrosis, paresthesia, motor dysfunction, and compartment syndrome (increased pressure of the body’s compartments resulting in swelling, pain, and numbness).

• Paresthesia: Paresthesia or altered sensation at the affected area is caused by unintentional or accidental injection of anesthetic drugs into the arterial vessels. This may result in altered sensations like pinprick sensation, numbness, and shock-like effects.

• Thromboangitis: The pH of a drug that may fall within a highly acidic or alkaline nature may lead to inflammation of the internal structure of the artery and result in thromboangitis.

• Ischemic Pain: Intra-arterial injection of drugs that contain vasoconstrictors like Lignocaine and Phentolamine in clinical practice may lead to profound vasoconstriction of the vessel and cause ischemic pain.

• Gangrene: Vasoconstrictor drugs with long-standing effects lead to infarction and gangrene or necrosis of the parts supplied by that artery.

Complications Due to Improper Technique

During intra-arterial injection, improper needle placement may lead to the deposition of drugs to adjacent structures like veins or muscles or damage to the arterial wall. This type of improper injection technique leads to the following complications.

• Hematoma: Hematoma (swelling) occurs due to an improperly placed needle that may damage the arterial wall and result in the seepage of blood into the submucosal or intramuscular region. The hematoma, thus formed, results in tumor-like swelling and pain.

• Extravasation of Drugs: Inappropriate techniques can lead to the extravasation of drugs into adjacent structures.

How to Prevent Catastrophic Events?

• Accidental intra-arterial or intravenous administration of medications often occurs in clinical or hospital settings. Iatrogenic intravenous injection complications can be reduced by carefully placing an intravenous cannula and avoiding injection sites close to an adjacent artery.

• It is also essential to select drugs that contain components that do not cause damage to the internal structure of the veins.

• Drugs that cause immediate effects on the cardiovascular and central nervous system should be administered with proper titration to minimize rapid action and adverse effects.

• In the case of intra-arterial injection, care should be practiced while administering block injection, and a needle with the proper gauge should be selected to avoid injuring the arterial vessel.

How to Manage Catastrophic Intravascular Injections?

Management of catastrophic events following intravascular injections depends on their etiology. However, emergencies should always be addressed immediately to avoid further complications. Prompt, effective management leads to a good prognosis and prevents catastrophic consequences.

Conclusion

Overall, severe complications like embolism, necrosis (tissue death), and even death can occur after intravascular administration. Thus, intravascular injections should be administered under the guidance of an experienced medical professional to avoid any catastrophic events. Rapid recognition, immediate cessation, and medical intervention are necessary to prevent mortality. Seek a doctor's help at once in case of any consequences.