What happens when an intravenous (IV) line is inadvertently placed in an artery?

Inadvertent Arterial Cannulation with IV Line

When an intravenous line is inadvertently placed in an artery, the catheter should be left in place and a vascular surgeon, general surgeon, or interventional radiologist must be immediately consulted before any decision to remove it. 1

Immediate Recognition and Management

Recognition of Arterial Placement

• Bright red, pulsatile blood return is the classic sign of arterial cannulation during attempted IV access 1
• Pressure waveform measurement or manometry can confirm arterial placement after catheterization 1
• Ultrasound can identify the catheter or guidewire position within an artery 1

Critical Management Decision: DO NOT REMOVE

The most important principle is that large-bore catheters or dilators inadvertently placed in arteries must NOT be immediately removed. 1

• Case reports demonstrate that immediate catheter removal from arteries results in severe complications including cerebral infarction, arteriovenous fistula, and hemothorax 1
• In contrast, no such complications were reported when catheters were left in place pending surgical consultation and repair 1
• This applies specifically to large-bore catheters and vessel dilators, not small-gauge needles 1

Potential Complications

If Medications Are Injected Intra-arterially

Accidental intra-arterial injection of medications can cause devastating limb-threatening complications. 2, 3

• Severe sequelae include: paresthesias, severe pain, motor dysfunction, compartment syndrome, gangrene, and limb loss 2
• The severity depends on the specific medication injected, with certain drugs consistently associated with severe morbidity including amputation 3
• Early recognition and treatment are vital to prevent permanent injury 3

Vascular Injury Complications

• Arterial trauma from the cannulation itself can lead to bleeding, hematoma formation, or pseudoaneurysm 1
• Distal ischemia may occur from arterial spasm, thrombosis, or embolization 2, 3
• Nerve injury is possible due to proximity of nerves to major arteries 1

Treatment Approach for Intra-arterial Drug Injection

Immediate Interventions

If medication has already been injected intra-arterially, a multi-modal treatment regimen should be initiated immediately. 3

• Anticoagulation should be started to prevent thrombosis 3
• Intra-arterial thrombolytics and prostaglandins may improve outcomes and should be considered 3
• Vasodilators and sympathetic blocks do not appear to influence amputation rates and are not recommended as primary therapy 3
• Steroids similarly do not reduce amputation risk 3

Surgical Consultation

• Vascular surgery or interventional radiology consultation is mandatory for all cases of inadvertent arterial cannulation with large-bore catheters 1
• The specialist will determine whether surgical repair, endovascular intervention, or careful catheter removal with manual compression is appropriate 1
• For stable arterial injuries, primary arterial repair is preferred when feasible 4

Prevention Strategies

Technical Considerations

• Use ultrasound guidance for all non-emergent vascular access to visualize vessel anatomy and avoid arterial puncture 1, 5
• Recognize anatomical risk factors: aberrant vasculature, difficult procedural situations, and normal proximity of arteries to veins increase risk 2
• Confirm venous placement before advancing large-bore catheters or dilators using pressure waveform, manometry, or ultrasound visualization 1

High-Risk Situations

• Patients with hypotension or shock may have less obvious differences between arterial and venous pressure 2
• Multiple cannulation attempts increase the risk of inadvertent arterial puncture 1
• Medical personnel error and procedural inexperience contribute significantly to these events 2

Common Pitfalls to Avoid

• Never immediately remove a large-bore catheter from a suspected arterial placement - this is the single most important error to avoid 1
• Do not assume that manual pressure alone will be adequate for hemostasis after removal of arterial catheters 1
• Do not delay surgical consultation while attempting conservative management 1
• Avoid injecting any medications through a line with pulsatile, bright red blood return until arterial placement is definitively ruled out 2, 3