title: Inadvertent Intra-Arterial Drug Injections in the Upper Extremity: Systematic Review.
abstract: OBJECTIVE
  To review the literature pertaining to inadvertent intra-arterial drug injection in the upper extremity, explore the various treatment options and their outcomes, and identify risk factors for limb amputation following intra-arterial injection.
  
  
  METHODS
  A systematic review of Medline, EMBASE, and Cochrane databases (inception to March 2013) was completed for patients presenting with intra-arterial drug injection of the upper extremity. Details on intervention and outcome were extracted and subjected to pooled analysis with amputation as the primary outcome.
  
  
  RESULTS
  A total of 25 articles (209 patients) were included for review. Mean patient age was 31 ± 8 years (male, 71%; female, 29%). Prescription opioids (33%) were the most commonly injected substance, and the brachial artery (39%) was the most common site. The overall weighted mean amputation incidence was 29%. Anticoagulants were the most common treatment used (77%). From pooled analysis, conditions requiring antibiotic use were significantly associated with a higher incidence of amputation; whereas use of steroids was associated with a lower incidence of amputation. Patients presenting 14 hours or more after injection and those injecting crushed pills rather than pure substances had significantly higher incidences of amputation.
  
  
  CONCLUSIONS
  Intra-arterial drug injection of the upper extremity carries an amputation incidence of nearly 30%. Conditions requiring adjunctive antibiotic use and delay in receiving care were both significantly associated with higher incidences of amputation. No single treatment protocol to date has established superiority.
  
  
  METHODS
  Therapeutic IV.
authors.affiliation: Department of Surgery, MedStar Georgetown University Hospital, Washington, DC.
authors.forename: Chris
authors.initials: C
authors.lastname: Devulapalli
authors.affiliation: Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD.
authors.forename: Kevin D
authors.initials: KD
authors.lastname: Han
authors.affiliation: Universidad Central de Venezuela, Caracas, Venezuela.
authors.forename: Ricardo J
authors.initials: RJ
authors.lastname: Bello
authors.affiliation: Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD.
authors.forename: Dawn M
authors.initials: DM
authors.lastname: LaPorte
authors.affiliation: Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD.
authors.forename: C Tate
authors.initials: CT
authors.lastname: Hepper
authors.affiliation: Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD. Electronic address: anne.mattson@medstar.net.
authors.forename: Ryan D
authors.initials: RD
authors.lastname: Katz
mesh_terms: D000671:Amputation, Surgical; D006801:Humans; D007269:Injections, Intra-Arterial / Q000009:adverse effects*; D023821:Limb Salvage; D019300:Medical Errors; D012307:Risk Factors; D015819:Substance Abuse, Intravenous / Q000150:complications*; D034941:Upper Extremity
keywords: IVDU; drug abuse; hand ischemia; intra-arterial injections