Extensive skin color change caused by extravasation of indigo carmine

Corresponding author: Jeong Jin Lee, M.D., Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, Ilwon-dong, Gangnam-gu, Seoul 135-710, Korea. Tel: 82-2-3410-2467, Fax: 82-2-3410-0362, E-mail: jjeong. [email protected] This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. CC Indigo carmine has been widely used in the clinic and its safety has been proven, but adverse reactions have been continuously reported [1-3]. We encountered a case of accidental extravasation of indigo carmine into a patient’s forearm during general anesthesia. A 72-year-old, 56 kg, American Society of Anesthesiologists physical status II man was scheduled for robot-assisted laparoscopic radical prostatectomy for prostate cancer. His medical history was significant for chronic obstructive pulmonary disease and he had no known allergies. He arrived in the operating room with an 18-gauge peripheral intravenous (IV) line in his left forearm. Noninvasive blood pressure cuff, electrocardiography and pulse oximetry were applied. The pulse oximetry was applied on his right index finger. Anesthesia was induced with thiopental (275 mg) and rocuronium (50 mg), and endotracheal intubation was performed. Then, a 16-gauge peripheral IV line was placed in the right forearm and a radial arterial catheter was placed in the left radial artery. IV lines were working well and there were no swellings surrounding the IV insertion site. The patient position was lithotomy with Trendelenburg (30) and both arms were placed beside the patient’s body. Both arms were wrapped with a cotton roll to prevent hypothermia during surgery and were firmly attached to the bed using plaster. Anesthesia was maintained with isoflurane and continuous infusion of remifentanil. Remifentanil was infused through the left IV line. Hartmann’s solution was administered through the same line at a rate of 200 ml/hour and normal saline was infused in the right IV line at a rate of 100 ml/hour. Two hours after induction, 5 ml of 0.8% indigo carmine (40 mg) was administered to the right side IV line according to the surgeon’s request. However, 30 minutes after the injection of dye, the effect was not seen in the operating field, so the surgeon requested a repeated dose of indigo carmine injection. When we tried to inject the second time, we noticed that fluid administration via the right side IV line was slow. We tried to confirm the patency of the IV line by injecting a bolus of 10 ml of normal saline but the speed of fluid administration did not increase. Suspecting a block in the IV line, no more fluid was administered. The patient’s arm was covered and underneath the operation field, and therefore approach to it was difficult. There were no change in the wave of the pulse oximetry and total fluid administered through that IV was 200 ml so we deduced that compartment syndrome did not occur. The indigo carmine was administered via the left side IV line and 5 minutes later the dye was confirmed at the surgical field. The surgery ended approximately 3.5 hour after the first dye injection. During the operation the patient’s blood pressure, heart rate and peripheral oxygen saturation were within normal range. Also, the arterial blood gas analysis implemented after the second dye injection were within normal range. The patient was awakened and trachea extubation was done. After the surgical drapes were removed, we noticed that the entire right forearm was blue and swollen. The range of discoloration was from the elbow to the dorsal part of the hand and the discoloration was distinct around the venous line (Fig. 1A).