Compartment Syndrome of the Hand Induced by Peripherally Extravasated Phenylephrine

Abstract

Background: Compartment syndrome of the hand is a rare and devastating complication of peripheral intravenous extravasation. With changes in critical care research, vasoactive medications are now more frequently administered through peripheral lines in the acute setting. Methods: We present the case of a patient diagnosed with compartment syndrome of the hand secondary to phenylephrine extravasation in the setting of hypovolemic shock. Results: The use of fasciotomy compartment release and intraoperative phentolamine resulted in significant improvement in tissue perfusion postoperatively. Conclusion: With incraesed incidence of peripherally administered vasoactive medications, the hand surgeon should be aware of potential complications and treatment of compartment syndrome with urgent fasciotomy and phentolamine administration.

Introduction

Peripherally inserted intravenous (IV) catheters are routinely used in a wide variety of medical procedures and patient care. Complications typically considered with the use of a peripheral IV catheter include pain, phlebitis, infection, nerve injury, and infiltration. A rare and serious complication of IV infiltration is compartment syndrome. In a recent review, from 1975 to 2000, only 43 cases of compartment syndrome were reported as result of IV complications, 20 of which occurred in the hand.¹ Compartment syndrome is defined as intracompartmental pressure exceeding capillary filling pressure and decreasing tissue perfusion, resulting in progressive ischemic death of compartment contents.² Compartment syndrome of the hand can result from trauma and drug overdose leading to direct compression, crotalid envenomation, insect bites, and possibly extravasation of IV fluids.³

Vasoactive medications such as dopamine, norepinephrine, and phenylephrine are typically administered through central lines. These drugs are not typically administered through peripheral access lines due to the concern that extravasation of these medications may result in local tissue injury by means of vasoconstriction through their alpha-adrenergic effects.⁴ Recent literature has supported peripheral administration of these vasoactive medications for critically ill patients in an emergency setting while waiting for central access. Reported rates of peripherally administered vasoactive extravasation range from 2% to 9%.^4-6 Certain factors increasing the risk of extravasation have been outlined, including duration of infusion, concentration of the infusate, infusion rate, and the size and location of the peripheral line.⁵

Phentolamine is a selective alpha-blocking agent that has been well described as an agent to reverse tissue ischemia in the face of alpha-adrenergic drug extravasation.^7,8 First described in 1950, 5 to 10 mg of phentolamine is used as a local infiltrate to prevent tissue ischemia and skin sloughing up to 18 hours after extravasation of vasoactive compounds.⁹

To the authors’ knowledge, there has only been 1 report of vasoactive medication–induced compartment syndrome of the hand, secondary to dopamine extravasation.¹⁰ However, there have been no reports of phenylephrine-induced compartment syndrome in the hand. Here, we present a case of peripherally administered phenylephrine resulting in compartment syndrome of the hand.

Case Report

CC is a right-handed 33-year-old woman who presented at an outside hospital emergency department in labor at 41 weeks’ gestation. After failure to progress, she underwent cesarean section without complication. Postoperatively, the patient developed hypovolemic shock. She was initially resuscitated with 9 L of crystalloid, 3 units of packed red blood cells (PRBCs), and later started on phenylephrine through an 18-gauge peripheral IV catheter in her left hand to maintain adequate blood pressure acutely. A computed tomographic scan demonstrated a large intra-abdominal hematoma, and she was taken to the operating room for an emergent hysterectomy to control bleeding. Hemostasis was achieved. She received an additional 2 units of PRBCs, 2 units of fresh frozen plasma, and 1 unit of platelets intraoperatively. Postoperatively she was intubated, sedated, and transferred to the intensive care unit. Her blood pressure was stable off of phenylephrine; however, her left hand became cold to touch and appeared purplish-blue and mottled. She exhibited withdrawal to palpation of the affected hand. Of note, her radial pulse was palpable and audible via Doppler. The patient was then transferred to our medical center for management of her ischemic hand.

Upon arrival at our tertiary care center approximately 12 hours after the onset of hand symptoms, she had significant purple discoloration of her fingers, worse on the radial side of the hand (Figure 1a). Radial, ulnar, and palmar arch arterial signals were audible via Doppler. She was taken to the operating room for left hand fasciotomies, carpal tunnel release, and a distal forearm fasciotomy (Figures 1b and 1c). Intraoperatively the muscles of the hand were tense and edematous, consistent with compartment syndrome. There was also significant fluid in the subcutaneous tissues and extensive venous thrombosis. Five milligrams of phentolamine diluted in 10 mL of 0.9% sodium chloride was injected into the tissues of the dorsal and volar hand subcutaneously. The carpal tunnel and the proximal portion of the forearm fasciotomy incision were closed. A negative pressure dressing was applied to the distal forearm fasciotomy incision and she was placed in a volar splint. On postoperative day (POD) 0, the patient’s left hand had improved perfusion and color. She was taken back to the operating room on POD 5 for delayed primary closure of the left dorsal hand and left hypothenar fasciotomy incisions. Her left forearm and thenar eminence was covered with a split-thickness skin graft due to persistent edema and inability to close primarily. She was discharged from the hospital on POD 9 and was seen in follow-up on POD 12. She has since made clinical improvements in function, with return of strength to her intrinsic hand muscles and increased hand function, but reports decreased sensation in the median and ulnar nerve distributions at POD 40 (Figure 1d).

Figure 1.

(a) Preoperative appearance of the left hand. (b) Intraoperative dorsal hand fasciotomies. (c) Volar fasciotomies and closed carpal tunnel release and proximal forearm fasciotomy. (d) As seen in clinic on postoperative day 40.

Discussion

Peripheral administration of vasoactive medications has well-described benefits in the acute setting, including reducing the numbers of central lines placed, reducing the complications associated with central line placement, and decreasing time from shock to vasopressor administration.^4-6 As peripheral infusion of vasopressors becomes more common, due to emerging research supporting their safety in the acute setting, it is imperative that nurses, anesthesiologists, and critical care physicians carefully observe for signs of hand ischemia and compartment syndrome. Cardenas-Garcia et al⁴ described a protocol for frequent monitoring of peripheral IV sites infusing vasoactive medications, as well as urgent phentolamine injection at bedside once extravasation is suspected. Hand surgeons need to also be aware of this complication and be prepared for urgent decompression if compartment syndrome develops.

Phentolamine administration in the setting of vasoactive extravasation is well described in a paper by Reynolds et al. Their group advises it should be injected as a local infiltrate using 5 to 10 mg (diluted in 10 mL of 0.9% sodium chloride) as soon as possible, with efficacy dropping off precipitously after 13 hours. The paper recommends using a hypodermic needle to inject the subcutaneous tissue in multiple sites or is used as a digital blockade in the setting of digital ischemia.⁸

Increased use of peripherally administered vasoactive medications comes with the risk of extravasation and tissue damage. Our group does not condone its use at any time other than as an emergent, life-saving measure. We hope in sharing this report—it highlights the danger of delay in management of extravasation events and brings awareness to those involved in the care of the critically ill.