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Inadvertent Intra-Arterial Drug Injections in the Upper Extremity: A Review of Literature
Kevin D. Han, MD1; Chaitan Devulapalli, MD2; Ryan D. Katz, MD1
1Curtis National Hand Center, Union Memorial Hospital, Baltimore, MD; 2Department of Surgery, Georgetown University Hospital, Washington, DC

Introduction: Accidental intra-arterial drug injection (IADI) in the upper extremity by drug abusers is common and can result in devastating vascular complications even leading to limb loss. Due to a paucity of literature, hand surgeons treating this problem lack clear guidelines for appropriate treatment. We reviewed the available literature to examine previously reported treatment options and outcomes.

Materials & Methods: A systematic review of MEDLINE and Cochrane databases from 1970 to April 2013 was completed to include intra-arterial injections, upper extremity vascular injuries, and intravenous drug abuse. Non-English language, iatrogenic injections, and commentaries were excluded. The primary outcome measured was amputation.

Results: From a total of 9,977 intra-arterial injection citations, only 25 citations including 17 case reports, 6 retrospective reviews, and 2 prospective studies met inclusion criteria (Figure 1). There were 217 patients (143 males (66%), 74 females (34%)). The mean age of the study population was 32 (r, 1-57). The most commonly injected artery was the brachial artery (26%). This was followed by the radial artery (21%). Non-heroin opioids represented the injected agent in 18% of the reported cases. Amphetamines, barbiturates, and benzodiazepines were encountered in 14% of cases. Heroin and cocaine reflected 5% and 2% of cases respectively. The most common presenting complaints were severe pain (95 patients, 43%), edema (85 pts, 39%), and gangrene (35 pts, 16%). Early angiography (within 24 hours of presentation) was performed in 36 patients (16%). 153 patients (71%) were anticoagulated with unfractionated heparin (75%). Broad spectrum antibiotics were started on 67 patients (30%). During their hospital stay, 33 patients (15%) required at least one fasciotomy to relieve compartment syndrome. Average length of initial hospital stay was 15 days. By the end of their hospitalization, 66 patients (30%) required amputations, 49 patients (23%) at the digital level, 8 patients (3.6%) at the metacarpal level, and 9 patients (4%) required forearm amputations.

Conclusion: Based on the limited available reports of upper extremity IADI, opioids were the most commonly abused substance. A large percentage of patients received early angiography, systematic anticoagulation, and antibiotics. The amputation rate for IADI is alarmingly high at 30% regardless of the treatment pursued. There exist no evidence based treatment algorithms for this challenging problem.

Figure 1: Study attrition characteristics.

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