Anesth Analg 2007; 105:1130-1131
© 2007 International Anesthesia Research Society
doi: 10.1213/01.ane.0000278625.00308.dc
GENERAL ARTICLES
Detecting an Infiltrated Intravenous Catheter Using Indigo Carmine: A Novel Method
Mingda Chen, MD,
Ashraf S. Habib, MB FRCA,
Moeen K. Panni, MD, PhD, and
John R. Schultz, MD
From the Department of Anesthesiology, Duke University, Duke University Medical Center, Durham, North Carolina.
Address correspondence and reprint requests to Moeen K. Panni, MD, PhD, Department of Anesthesiology, University of Texas, Houston Medical School, 6431 Fannin, Suite 5.020, Houston, TX 77030. Address e-mail to moeen.k.panni{at}uth.tmc.edu.
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Abstract
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An extravasated IV catheter may have serious clinical consequences. These include the inability to circulate emergency medications, cause pain on injection, infection at the site, and tissue damage. Clinical signs such as swelling, redness, and pain with injection are valuable, but may not be helpful in the presence of obesity, edema, or in a tracheally intubated and sedated patient. Here we describe a case illustrating a novel approach in which we used an IV dye injection (indigo carmine) to detect a correctly placed and then an extravasated IV. The ability to see visible flow of IV dye intravascularly helped confirm the correct placement. The technique we describe is quick, safe, and inexpensive.
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Introduction
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An extravasated IV catheter may have serious clinical consequences. These include the inability to circulate emergency medications, cause pain on injection, infection at the site, and tissue damage. These may potentially lead to tissue necrosis (1) and compartment syndrome (2). Although it is often easy to determine whether an IV is correctly placed, there are situations where this may not be straightforward. In these situations, it is important to have reliable methods by which to determine whether the IV is placed intravascularly. Clinical signs such as swelling, redness, and pain with injection are valuable, but may not be helpful in the presence of obesity, edema, or in a tracheally intubated and sedated patient. Here we describe a case illustrating a novel approach in which we used an IV dye injection to detect a correctly placed and then an extravasated IV.
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CASE REPORT
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A 44-yr-old woman with a history of pulmonary fibrosis secondary to mixed connective tissue disease and morbid obesity (body mass index = 44), presented with uncontrollable uterine bleeding and subsequently developed respiratory distress and hypotension requiring endotracheal intubation, vasopressor therapy, and medical intensive care unit (ICU) admission. In the ICU, multiple attempts at placing a central line were unsuccessful, and vasopressors were given via a peripherally inserted central catheter. After several days of stabilization in the ICU, she was weaned off epinephrine and vasopressin and was scheduled for exploratory laparotomy. On arrival to the operating room, the patient had a running 20-gauge IV, a double-lumen peripherally inserted central catheter, and an arterial catheter. A decision was made either to place another peripheral IV or to attempt central line placement under ultrasound guidance. The body habitus of the patient and additional anasarca made identifying veins in the extremities difficult. However, a superficial vein was seen on the anterior chest/shoulder and an 18-gauge cannula was inserted. There was brisk return of blood and free flowing of IV fluids under gravity when attached to the cannula. However, due to the unusual area of IV cannulation and potential undetectable swelling of the general area, it was not certain that the cannula was placed IV. Administering a test dose epinephrine was considered, but given the patient’s baseline tachycardia in the 110 s, it was deemed unwise to further stress the heart. Instead, 1 mL of indigo carmine dye was injected via the IV, and signs of extravasation were observed. A venous pattern of flow of the dye was seen along the surrounding veins, with a caput-medusa-like outward spread. The dye coloration lasted 1–2 s and then disappeared promptly, with no blue dye seen in the surrounding tissues. The IV was then secured. After approximately 30 min, it was noted that localized swelling developed and the IV stopped dripping. Indigo carmine dye was applied again to the IV, and this time, the entire area became blue instantly and did not fade away. It was determined that the IV had infiltrated.
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DISCUSSION
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There are no reports of dye being used to confirm correct placement of IV catheters. One study by Goodie and Phillip (3) described counting the number of drips of IV fluid over time as an indicator of resistance of flow in IV versus subcutaneous tissue. Their study found that there was a significant difference in flow rate between IV versus extravasated cannulas. Similar studies by Harris and von Maltzahn (4) were performed on infusion pumps that allow automatic detection of IV infiltration or obstruction based on the principle of pressure/volume response or electric conductance. Their study was limited by the use of infusion pumps, which also adds time, space, and cost to the operation. Stevenson et al. (5) described opening the IV tubing to air and using gravity to drain blood from the IV as an indication of patency. Such a test is practical, but does expose the patient to possible air bubble administration and exposes the clinician to unnecessary blood contamination. Dean (6) recommended palpating a thrill of IV or listening for bruits above the IV site as fluids are injected under pressure.
In our case, because of the uncommon location of the IV, we used indigo carmine injected through the IV. The ability to see visible flow of IV dye intravascularly helped confirm the correct placement. Similarly, other dyes such as methylene blue could also be used. The technique we describe is quick, safe, and inexpensive. The potential problems of using this method include the following: 1) blue dye may not be as apparent in dark skinned individuals; 2) the vein may have to be superficial to see superficial extravasations; 3) dye may cause temporary discoloration of the tissues, lymph nodes, and urine, making it undesirable in certain types of surgeries; 4) some patients may have sensitivity/allergy to the dye; 5) there may be other side effects of injecting indigo carmine, such as transient decrease in the recorded oxygen saturation (7) and potential hypertension due to vasoconstriction (8). Considering these limitations, we describe a novel and safe method to confirm IV placement.
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Footnotes
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Accepted for publication June 7, 2007.
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REFERENCES
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Abstract
Introduction
