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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 34  |  Issue : 1  |  Page : 50-52

Continuous stellate ganglion block for the effective management of ischemic pain following compartment syndrome of upper limb due to accidental intra-arterial injection


Department of Anaesthesiology, Pain and Palliative Care Unit, JSS Medical College, JSS Academy of Higher Education and Research, Mysore, Karnataka, India

Date of Submission30-Aug-2019
Date of Acceptance03-Oct-2019
Date of Web Publication16-Apr-2020

Correspondence Address:
Dr. M S Poorna
Department of Anaesthesiology, Pain and Palliative Care Unit, JSS Medical College, JSS Academy of Higher Education and Research, Mysore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_64_19

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  Abstract 

In the present era of advanced medicine and patient safe practice, accidental intra-arterial injection of drugs is a rare occurrence. Compartment syndrome (CS) is one of its most detrimental complications, which leads to loss of circulation, ischemia, myonecrosis, nerve damage, and limb loss. Rapid recognition and emergent fasciotomy to relieve the compartment pressure are imperative to prevent irreversible damage. Sympathetic blockade is one of the most common interventions used in the management of early stages of CS, which interferes with the pain cycle and improves distal flow by vasodilatation. We report a complicated case of CS of the right upper limb following accidental intra-arterial injection. The patient suffered with persistent ischemic pain despite surgical decompression, which was successfully managed by continuous stellate ganglion block.

Keywords: Accidental intra-arterial injection, compartment syndrome, ischemic pain, stellate ganglion block, sympathetic block


How to cite this article:
Matche P, Poorna M S. Continuous stellate ganglion block for the effective management of ischemic pain following compartment syndrome of upper limb due to accidental intra-arterial injection. Indian J Pain 2020;34:50-2

How to cite this URL:
Matche P, Poorna M S. Continuous stellate ganglion block for the effective management of ischemic pain following compartment syndrome of upper limb due to accidental intra-arterial injection. Indian J Pain [serial online] 2020 [cited 2020 May 29];34:50-2. Available from: http://www.indianjpain.org/text.asp?2020/34/1/50/282553


  Introduction Top


Accidental intra-arterial drug injection is a rare emergency, with the brachial artery being the most common site.[1],[2] One of the most dreadful complications is the development of compartment syndrome (CS), which if untreated will lead to ischemia and gangrene of the distal limb parts with grievous consequences. Prompt recognition and early treatment with a multidisciplinary approach are necessary. Sympathetic block is the preferred therapeutic approach during the initial stages of CS and to treat sympathetically mediated pain in various conditions.[3],[4] We report our experience of treating ischemic pain with continuous stellate ganglion block (CSGB) in an uncommon case of accidental intra-arterial injection with CS to achieve a desirable outcome.


  Case Report Top


A 23-year-old adult male with a history of accidental intra-arterial injection of an unknown drug in the right antecubital region was brought to our hospital after over 6 h following the injection. He gave a history of intense pain immediately during injection, followed by discoloration of the right forearm and hand after 1 h of the incident. The patient was hospitalized and the first line of treatment was started with limb elevation; intravenous (IV) infusion of heparin 1000 IU/h, IV linezolid 600 mg twice a day, IV tramadol 50 mg thrice a day, and IV paracetamol 1 g thrice a day were advised. After 12 h of conservative management, signs of CS were noted in the extensor compartment of the right upper limb, for which emergency fasciotomy was performed under brachial plexus block. Although there was some improvement, the patient continued to have severe burning type of pain in spite of receiving the routine analgesics. The patient was then referred to the pain clinic 24 h after the surgery for pain management. He presented with severe pain, paresthesia, and burning sensation of the right upper limb with numerical rating scale (NRS) score of 9/10. He also complained of limitation of limb movements due to swelling and stiffness of the right hand. Pain aggravated at night and disturbed his sleep. On examination, the forearm was bandaged from elbow to wrist following fasciotomy. The right hand was swollen and tense. The surface of the hand was cold with blackish discoloration of the right thumb, index, and middle fingers [Figure 1]- Above]. Along with tenderness, there was a significant reduction in the range of movement of fingers and wrist. As the patient showed signs and symptoms of ischemic pain, IV fentanyl infusion at 25 mcg/h was started and SGB was planned. IV heparin was stopped for 6 h before the procedure. Right-sided CSGB with catheter placement was performed under fluoroscopy and contrast dye guidance by anterior paratracheal approach at C7 level along with the placement of 20 G perineural catheter, fixed by tunneling [Figure 2], [Figure 3], [Figure 4]. Six milliliters 2% lignocaine and 4 mg dexamethasone were given as loading dose following which NRS score reduced from 9/10 to 3/10 and the temperature of affected extremity was increased by 1.5°C. No complications were noted.
Figure 1: Above - Ischemic changes in right hand before SGB. Below - Improvement in colour and decreased swelling after SGB

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Figure 2: Fluoroscopy guided SGB

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Figure 3: Placement of catheter after tunneling

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Figure 4: Patient with CSGB catheter

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The patient was shifted to the ward and continuous infusion of bupivacaine 0.125% + clonidine 2 mcg/ml with a volume of 5 ml/h was started. Infusion was continued for 10 days along with physiotherapy and oral paracetamol 1 g 3 times a day. Patient's hemodynamics was regularly monitored along with NRS score. Range of movements and color change in fingers were also noted each day. Hemodynamics remained stable throughout with gradual improvement in the other parameters. At the end of 10 days, NRS score was decreased to 0/10. The swelling of hand was reduced with improvement in the color of the fingers and hand [Figure 1] -Below]. Significant recovery in the range of movement was seen. He was able to sleep well with a notable change in the quality of life [Figure 4].


  Discussion Top


The accidental injection of therapeutic or illicit drugs into a peripheral artery is a devastating rare emergency, resulting in severe ischemia leading to varying degrees of tissue damage. Early symptoms include acute discomfort and severe pain distal to the site of injection followed by pallor, paresthesia, and cyanosis of the affected limb. Severe cases may progress to profound edema and gangrene.[5] One of the detrimental complications is acute CS. It occurs when the pressure within a fibro-osseous space increases to a level that results in a decreased perfusion gradient across tissue capillary beds. It includes 5Ps – pain, pallor, paresthesia, pulselessness, and paralysis.[3] Most common findings include a swollen compartment with or without neurological symptoms and pain elicited by passive movement of the muscles in that compartment. Other signs include cyanosis and functional limitation. Our patient exhibited similar clinical picture and underwent emergency fasciotomy. In spite of this, the patient continued to experience a severe burning type of pain and persistent discoloration of the digits.

A multidisciplinary coordinated approach including interventional pain management techniques is an integral part of management of CS. The most commonly performed intervention for early CS is a sympathetic block. Somatic nerve blockade with local anesthetic (LA) can also be performed, but sympathetic block provides pain relief by preferential blockade of only pain afferent fibers and sympathetic efferents without any motor blockade.[6] In addition, it denervates the sympathetic component resulting in vasodilatation improving perfusion. Hence, CSGB was considered as the intervention of choice. A study conducted by Toshniwal et al. has concluded that CSGB is feasible and safe and has a better outcome compared with repeated intermittent SGB in sympathetically mediated pain.[6]

Clonidine is an alpha-2 agonist originally used in the treatment of hypertension which has gained popularity in the treatment of perioperative and chronic pain. It is approved by the Food and Drug Administration for neuropathic pain.[7] The addition of clonidine to prolong peripheral nerve blockade has been demonstrated in several clinical trials.[8] Few studies have concluded that adding clonidine to LA in repeated sympathetic blocks prolongs analgesia and improves edema and tolerability to physical therapy.[7] Our patient also exhibited similar beneficial effects.

There are data available on the use of SGB in the management of early phases of CS. However, there is no literature available regarding the same in management of persistent ischemic pain after the surgical treatment of CS.


  Conclusion Top


The management of ischemic pain in CS poses a challenge to the pain physician. This case emphasizes the role of continuous sympathetic block in treating sympathetically mediated pain. CSGB can be used as a safe and effective treatment option in the comprehensive management of persistent ischemic pain in spite of surgical decompression in upper limb CS.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms containing consent for clinical information to be reported in the journal. The patients understand that their names and initials 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.
Rai KM, Rao KS, Maudar KK. Accidental intra-arterial drug injection: A case report. Med J Armed Forces India 1997;53:137-9.  Back to cited text no. 1
    
2.
Berguer R, Benietz P. Surgical emergencies from intravascular injection of drugs. In: Bergan JJ, Yao JS, editors. Vascular Surgical Emergencies. Orlando, USA: Grune and Stratton; 1987. p. 309-18.  Back to cited text no. 2
    
3.
Díaz RC, Escobar LF, Ramírez SM, Hoyos VC. Compartment syndrome of the upper limbs after bee sting: Case report. Colomb J Anesthesiol 2014;42:65-9.  Back to cited text no. 3
    
4.
Lee CC, Chuang CC, Liou JY, Hsieh YC, Tsou MY, Chen KH. Successful management of contrast medium extravasation injury through stellate ganglion block and intra-arterial nitroglycerin. Acta Anaesthesiol Taiwan 2011;49:116-8.  Back to cited text no. 4
    
5.
Lake C, Beecroft CL. Extravasation injuries and accidental intra-arterial injection. Contin Educ Anaesth Crit Care Pain 2010;10:109-13.  Back to cited text no. 5
    
6.
Toshniwal G, Sunder R, Thomas R, Dureja GP. Management of complex regional pain syndrome type I in upper extremity-evaluation of continuous stellate ganglion block and continuous infraclavicular brachial plexus block: A pilot study. Pain Med 2012;13:96-106.  Back to cited text no. 6
    
7.
Hakim KY, Abd El Fatah AM. Clonidine in lumbar sympathetic block for lower limb complex regional pain syndrome. Ain Shams J Anaesthesiol 2014;7:320-6.  Back to cited text no. 7
    
8.
Tryba M, Gehling M. Clonidine-a potent analgesic adjuvant. Curr Opin Anaesthesiol 2002;15:511-7.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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