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Accidental Intra-Arterial Injection of Diclofenac –Case Report

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Mohinder Malhotra at Maharishi Markandeshwar University, Mullana
Mohinder Malhotra
Jasdeep Singh
Jasdeep Singh
Jasdeep Singh
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Pratibha Sharma
Pratibha Sharma
Pratibha Sharma
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Aadhar Khera
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Abstract

Diclofenac sodium is a very common drug used in medical practice for analgesia and is freely available over the counter without any medical prescription. The drug is also the most commonly used or misused by quacks working all over India. Many case reports have been published on upper limb catastrophe of unintentional intra-arterial injection of barbiturates, thiopental sodium, narcotics, and tranquilizers but only two cases of inadvertent intra-arterial injection of diclofenac have been reported till date. Potential serious complication of inadvertent intra-arterial injection of diclofenac sodium leading to gangrene has been recently reported in medical literature. It is a medical emergency and literature has shown that timely diagnosis with early intervention can salvage the limb. We hereby report a case of accidental intra-arterial injection of diclofenac sodium in the ulnar artery by a quack for pain abdomen leading to gangrene of the distal part of affected little, ring and part of middle finger of right hand.
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Journal of Clinical and Diagnostic Research. 2015 Jan, Vol-9(1): PD16-PD17
1616
DOI: 10.7860/JCDR/2015/11205.5430
Case Report
CASE REPORT
A 62-year-old male patient presented with dry gangrene of the
distal part of his little, ring and part of middle finger of right hand
with ecchymosis on ulnar aspect below right elbow [Table/Fig-1].
Patient gave history of injection of Voveran (diclofenac sodium) by a
quack for pain abdomen about one month back. Patient developed
severe excruciating pain at the site of injection with involvement of
limb distal to the site of injection. Patient noticed swelling and bluish
discoloration of three fingers of right hand when he woke up next
morning. Patient was not given any treatment for the complication
for the next 48 h. Patient was advised elevation of limb with oral
pentoxyfylline (Trental 400 mg).
Patient received oral pentoxyfylline, 400mg three times daily for four
weeks before he presented to us in OPD. Oedema of the hand
subsided and blackening got restricted to the distal phalanx of little,
ring, and middle finger of right hand. Doppler examination of right
upper limb confirmed the site of injection in medial aspect of elbow
near cubital fossa with course of ulnar artery. Patient has been
advised to undergo amputation of distal part of affected fingers
as there were no sensations in the area of dry gangrene. Patient
underwent amputation of distal parts of affected fingers and post-
operative recovery was uneventful.
DISCUSSION
It is difficult to establish the incidence of complication of intra-arterial
injections as many cases go unreported. Estimates by certain
authors place incidence of this complication between 1:3500 to
1:56000 [1,2]. Many commonly used drugs like phenothiazines,
meperidine diazepam, promazine, barbiturates, tubocuraine,
amphetamines and strophanthin have been found injurious
when given intra arterially [3]. Recently toxic effect of intra-arterial
injections of diclofenac sodium, a commonly used analgesic have
been reported by Samantha S and Samantha S and similar case
of diclofenac toxicity is being reported by us [3]. Any drug given
intra-arterially should be considered toxic. Many case reports have
been published on upper limb catastrophe following unintentional
arterial injection [1,2,4-7]. Accidental intra-arterial injection occurs
most commonly in the ante-cubital fossa where branches of the
ulnar and brachial arteries are more superficial and easily entered.
Anomalies of these vessels are common [5]. Therefore, we should be
careful while injecting drugs in ante-cubital fossa region. According
to Samantha S & Samantha S, benzyl alcohol preservative used
in non aqueous preparation of diclofenac may be the cause of
Keywords: Diclofenac sodium, Gangrene, Intra-arterial injections, Medical emergencies
vasospasm due to endothelial oedema and capillary endothelial
dysfunction [3]. Vasospasm, intravascular thrombosis, chemical
endoarteritis are the proposed pathophysiological mechanism [7].
Complications of intra-arterial injection of non aqueous agents
(phenytoin, propofol) and highly alkaline drugs (thiopentone) are well
documented [2,8]. Though lipid soluble drugs are known to cause
more complications if given intra arterially however anaesthetic
drugs like atropine, fentanyl, vecuronium have been used without
any deleterious effects [8]. Many hypothesis has been proposed
for the arterial hypo perfusion or spasm which is final event leading
to limb ischemia. Chances of complications are much common in
postoperative period when patient is recovering from anaesthesia.
In children especially in emergency situations, when intravenous
access was difficult intentional induction using intra arterial route
has been reported in literature [3,9]. Though guidelines are not
available, case reports and review reported that water soluble drugs
and drugs with pH closer to arterial blood pH may be used through
intra-arterial route. The limb can be salvaged by immediate heparin
and lignocaine administration in arterial line as done in second
case described by Samantha S & Samantha S where diclofenac
Surgery Section
Accidental Intra-Arterial Injection of
Diclofenac –Case Report
MOHINDER KUMAR1, JASDEEP SINGH2, PRATIBHA SHARMA3, AADHAR KHERA4, PUNEET SINGH5
ABSTRACT
Diclofenac sodium is a very common drug used in medical practice for analgesia and is freely available over the counter without any
medical prescription. The drug is also the most commonly used or misused by quacks working all over India. Many case reports
have been published on upper limb catastrophe of unintentional intra-arterial injection of barbiturates, thiopental sodium, narcotics,
and tranquilizers but only two cases of inadvertent intra-arterial injection of diclofenac have been reported till date. Potential serious
complication of inadvertent intra-arterial injection of diclofenac sodium leading to gangrene has been recently reported in medical
literature. It is a medical emergency and literature has shown that timely diagnosis with early intervention can salvage the limb. We
hereby report a case of accidental intra-arterial injection of diclofenac sodium in the ulnar artery by a quack for pain abdomen leading to
gangrene of the distal part of affected little, ring and part of middle finger of right hand.
[Table/Fig-1]: Showing site of injection and gangrene of fingers
www.jcdr.net Mohinder Kumar et al., Accidental Intra-Arterial Injection of Diclofenac –“A Medical Emergency”
Journal of Clinical and Diagnostic Research. 2015 Jan, Vol-9(1): PD16-PD17 1717
Keywords: Diclofenac sodium, Gangrene, Intra-arterial injections, Medical emergencies
PARTICULARS OF CONTRIBUTORS:
1. Associate Professor, Department of Surgery, MMISR, Mullana, Ambala, Haryana, India.
2. Senior Resident, Department of Surgery, MMISR, Mullana, Ambala, Haryana, India.
3. Post Graduate Resident, Department of Surgery, MMISR, Mullana, Ambala, Haryana, India.
4. Post Graduate Resident, Department of Surgery, MMISR, Mullana, Ambala, Haryana, India.
5. Post Graduate Resident, Department of Surgery, MMISR, Mullana, Ambala, Haryana, India.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Mohinder Kumar,
Associate Professor, Department of Surgery, MMISR, Mullana, Ambala, Haryana-133207, India.
E-mail : malhotramsfrcs@yahoo.co.in
FINANCIAL OR OTHER COMPETING INTERESTS: None.
Date of Submission: Sep 10, 2014
Date of Peer Review: Oct 25, 2014
Date of Acceptance: Nov 01, 2014
Date of Publishing: Jan 01, 2015
was accidently administered. Radial arteries Doppler shown normal
arterial pulse waves and affected limb remain uncomplicated even
after seven days follow up with Doppler study [3].
CONCLUSION
We would like to remind our medical colleagues who may have to
work with less trained staff for many reasons, at times beyond their
control, that they should not depend too much on them. Injections
are at times given by student nurses or ward boys in hospitals and
by untrained staff in smaller nursing homes. These trainees may
not realize the importance and difference in intravenous or intra-
arterial route or may not be able to differentiate a wrong inserted
line. Clinicians’ incharge of the patient is vicariously liable for their
act. It is true that there are less chances of occurrence of this type
of catastrophe if medically trained physicians directly supervise the
action of junior staff. How many clinicians are practically able to
supervise the event? It requires Clinicians forced to work in such
situations to introspect and take some time out to educate and train
the staff.
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Samanta S and Samanta S. Accidental intra arterial injection of diclofenac [3]
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... Intra-arterial cannulation can occur in any age group but IA cannulation with penicillin [5] [7] [8] is common in babies. Nowadays, it is increasingly seen in IV drug abusers [3] [9]. It occurs more commonly in antecubital fossa [1] [6] where branches of radial and brachial artery are more superficial or there may be anomalies of these vessels [1] [6] [10]. ...
... It is a medical emergency. With timely diagnosis and early intervention, limb perfusion can be restored [3] [10] and severity of morbidity can be reduced to minimum by Initiating anticoagulation, instituting symptomatic relief and specific rehabilitation [1]- [3] [6]. The paramedical staff who are involved in the administration of injections should be well trained and be well aware of complications resulting from accidental intra-arterial cannulation. ...
... It is a medical emergency. With timely diagnosis and early intervention, limb perfusion can be restored [3] [10] and severity of morbidity can be reduced to minimum by Initiating anticoagulation, instituting symptomatic relief and specific rehabilitation [1]- [3] [6]. The paramedical staff who are involved in the administration of injections should be well trained and be well aware of complications resulting from accidental intra-arterial cannulation. ...
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