Forearm extravasation injury during robot-assisted low anterior resection

provided the original work is properly cited. CC A 47-year-old female with an American Society of Anesthesiologists physical status of I was scheduled for robot-assisted low anterior resection and right hepatectomy. Her routine preoperative examination results were unremarkable. Standard monitoring devices were applied in the operating room, including a noninvasive blood pressure monitoring system, electrocardiogram, and pulse oximeter. A warm blanket was placed under the patient to maintain her body temperature. General anesthesia was induced with propofol 120 mg, continuous remifentanil infusion 0.25 μg/kg/min, and rocuronium 0.6 mg/kg via a pre-existing 20-gauge intravenous catheter in the right ventral forearm without apparent resistance. Anesthesia was maintained with desflurane (5–7 vol%) and remifentanil (0.05–0.20 μg/kg/min). The right radial artery and right subclavian vein were catheterized. The patient was placed into the lithotomy and Trendelenburg position with both arms tucked using a fabric arm-straining device placed immediately proximal to the peripheral cannulation. All cannulations were confirmed to be functional. All fluids and medication were administered through the central cannulation with the exception of the anesthetic induction agents, 1.5 L of crystalloid solution (Plasmalyte A; Baxter, Deerfield, IL, USA), and 250 ml of 5% albumin, the latter two of which are isotonic and iso-oncotic, respectively, with human plasma. Four hours later, both the arterial pressure waveform and the ipsilateral pulse oximeter reading were dampened. The monitoring devices and peripheral line flow were checked, and the peripheral line was not flowing smoothly. Because the intravenous line worked well initially and only malfunctioned later, we assumed that frequent changes in positioning might have affected the alignment or tightness of the catheter and arm-restraining device, potentially kinking or dislodging the catheter. Considering that the operation was almost completed, we immediately stopped using the peripheral intravenous line to prevent extravasation injury. A new pulse oximeter probe was applied to the patient’s right ear. Because the dampening of the arterial cannulation appeared to worsen, noninvasive blood pressure was measured on the opposite arm. At the end of the procedure, the right forearm was undraped. The ventral surface of the arm was mildly swollen with bullae, redness, and skin abrasions, especially under the site of the arm-restraining device (Fig. 1). In contrast, the dorsal surface showed no abnormalities. Physical examination revealed palpable radial arterial capillary filling pressure with no sensory or motor defects. Following consulta-