Brief history:
Patient was admitted to the hospital for abdominal pain, where she was found to have a bowel stricture and colonic perforation. While there, she was also diagnosed with bilateral upper extremity DVTs. She was discharged with Eliquis. Patient is well known to be a “hard stick” for IVs due to her Factor V Leiden. Records show her IV sites need to be changed often and there have been many failed attempts at placement.
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The patient returned to the hospital approximately a month later with worsening abdominal pain. Her condition worsened and they determined she needed a colostomy on 1/20, which was successful.
Due to the colostomy, she was started on PPN. She was receiving PPN through a 20g IV placed in her left hand on 1/23 at 0648. On 1/23, the patient also had a VL UE Venous Duplex Left study for the DVTs previously mentioned. There were no signs of a DVT on her left side.
The next day, on 1/24 at 0052, an order was created with the following request:
• Order Details: 1/24 12:52:00 AM EST, Peripheral IV Insertion, mid line infiltrated. need new line for PPN
A progress note at 0547 states:
• Patient a/ox4. VSS. Patient complaint of pain in her left hand and ask for PPN to stop. Pt left arm swollen to her fingers. RN removed midline and PIV. RN apply heat pack and elevated pt left arm. Rn inserted new 20G PIV in RT arm and started PPN. Dr notified during am assessment.
At 0558 the IV was removed and the note states, “Swelling, cool, pain/discomfort at or above site”.
At 0731, an MD evaluated the patient. The notes state:
• Musculoskeletal: L forearm and hand swollen, mottled, cool to palpation. Decreased ROM 2/2 pain. Sensation intact. Radial pulse present to palpation and by doppler. Capillary refill < 2s.
• Impression:
1. LUE DVT
Assessment: edema, pallor, pain and cold to palpation L forearm and hand with decreased ROM but palpable radial pulse suggests venous thrombus
Plan:
- CTA neck and L arm + IV contrast
- will adjust anticoagulation per results of CTA
- On home therapeutic Apixaban 5mg BID
A CTA UE with contrast was ordered at 0748.
At 1026, a nursing note states:
• pt complaint of increased pain and swelling in left upper extremity; nurse noted increased swelling, pain 10/10 to touch with tightness of skin, and more dusky color; this nurse notified Dr. who reported to bedside to assess new findings; see chart for orders.
Two minutes later, the referenced MD ordered a CTA Neck with contrast.
An anesthesiologist evaluated the patient at 1045 and stated the following:
• Upper Extremity Motor Strength Exam: LUE swollen, hand bluish purple with positive capillary refill primary team aware.
- Multimodal analgesia
- Continue Gabapentin 300 mg q8hrs
- Agree with scheduled Tylenol
- Continue methadone 30 mg tid
- EKG from 1/20 reviewed; QTc 450
- ordered ekg
- Discontinue IR morphine 20 mg q4hrs prn pain
- start po dilaudid 6-8mg q4 prn
- Added lidocaine patches to surgical site
- Rest of care per primary team
The patient had an EKG completed at 1301 and her CTAs were completed at 1512.
• EKG Results: Qtc 451
• Results of CTA Neck: No large vessel occlusion or significant stenosis in the neck.
• Results of CTA UE:
o 1. The distal proximal segment of the left ulnar artery is not visualized approximately 5cm distal to the elbow joint, however limited exam secondary to suboptimal contrast bolus timing and venous artifact contamination. The lateral aspect of the arm is not included in this field-of-view. Catheter angiography may be recommended for more detailed evaluation of the segment, if clinically appropriate.
o 2. Moderate narrowing within the mid right upper extremity brachial artery with severe soft tissue edema and adjacent scattered air. Correlate for soft tissue infection and/or prior instrumentation
At 1809, a nurse noted:
• pt complaint of excruciating pain 10/10 in LUE; pt states "it feels like my bones are being twisted"; pt medicated with prn 0.5mg Dilaudid IV push and scheduled Tylenol; Dr. notified and making rounds at this time
There is no indication the referenced MD saw the patient at this time.
At 1844, the patient had an Ortho consult:
• HPI: Patient is a 34 year old female with PMHx of Factor V Leiden, methadone use (for chronic back pain), prior history of Bilateral upper extremity DVTs on home Eliquis, sigmoid stricture s/p sigmoid resection with general surgery. Hand consulted as over the past 24 hours the pt has noted increased pain, edema, swelling in L hand. Per report, she had a midline and IV in her left arm and was receiving TPN through it. She noted increased pain overnight and significant swelling. Per discussion with nursing, there was not any concern for TPN extravasation or IV infiltration, but both were subsequently removed. Endorses significant pain with palpation about wrist/forearm. Endorses numbness/tingling throughout hand in nonspecific distribution. No trauma reported. Primary team has tried ice/elevation without relief. CTA was not significant for any obvious occlusion, and the primary team reported triphasic signals in radial/palmar arch with some signal in ulnar artery.
• Hand examination:
o M/R/U sensation diminished in nonfocal pattern
o Motor intact to median, radial and ulnar nerves but significantly weak secondary to pain, AIN/PIN weak
o Hand is cool to touch
o Laceration: No lacerations or abrasions
o Doppler: intact radial/ulnar digital arteries to all fingers/wrist with normal cap refill in all 5 digits, pulsox with mixed saturation in digits 2-4 (ranging from 60-95 in each digit).
o No obvious bony deformity, no crepitus
o Significant swelling throughout the hand/forearm
o Moderate to severe pain with passive stretch
o No palpable crepitus
• Assessment/Plan
Patient is a 34 year old female with left hand/forearm swelling, concern for compartment syndrome of Left hand.
- NWB LUE
- Ice/elevate extremity above level of heart
- Pain control regimen
- Please complete XRs of L forearm and hand now
Three sets of x-rays were ordered at 2047.
• XR Hand 3+ Views Left completed at 2149
o Impression: Diffuse soft tissue swelling of the dorsal wrist and hand.
• XR Forearm 2 Views completed at 2150
o IMPRESSION: Mild diffuse soft tissue swelling of the forearm and wrist
• XR Humerus 2+ Views completed at 2150
o IMPRESSION: 1. Diffuse upper extremity soft tissue swelling. 2. Mild enthesopathy at the common flexor tendon origin about the elbow.
At 2237, Ortho evaluated the patient again and determined she needed emergency surgery for fasciotomy of the left hand and possible forearm.
At 2345, the patient was transferred to the OR. See Op Report for Hand Surgery document attached.
The patient’s hand did not improve after the surgery. There were no other surgical interventions after this as they were waiting for complete demarcation.
On 1/27, the patient had a Hematology consult to establish whether her Factor V Leiden was a contributing factor.
• Her underlying Factor V Leiden does not appear to be a major contributing factor to the left hand compartment syndrome. There was not a new thrombotic event. Doubt vasculitis but if concerned please consult Rheumatology. Recommend switching UFH to therapeutic LMWH (1mg/kg SC q12 hrs). Transition back to home apixaban 5 mg bid when able to take adequate po. She needs to be on therapeutic anticoagulation for 3 months from 12/8 which is the date of her previous DVT diagnosis.
On 1/28, she had a consult with Rheumatology.
• Tragic and confusing case of 34 yo woman with critical ischemia of left hand in context of confusing sequence of events. Known to be heterozygous for factor V Leiden and, just today, report of strongly positive functional and antibody tests for lupus anticoagulant syndrome. No strong evidence of connective tissue disease/vasculitis but substantial evidence of hypercoagulability from at least two causes. This will not effect current therapy but may effect discharge medications. Will send serologic w/u for SLE though doubt it will be positive.
A progress note on 1/30 states:
• Teaching Surgeon Attestation: Hand remains grossly ischemic, improved proximally, but with acral darkening, potentially consistent with superficial necrosis, particularly beneath the nail beds.
MSK: L arm wrapped and elevated on pillows. Changed dressing. Hand with edema, cyanotic L digits (black finger tips), open fasciotomy incisions without sign of infection. Limited ROM. TTP throughout hand. Sensation decreased but grossly intact.
Vascular: multiphasic radial, ulnar and palmar arch signals in LUE
She eventually had 4 fingers, some of her palm, and much of her thumb amputated 2 months later.
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Do you believe there might have been medical error?
This is a complex case of a patient with known upper extremity venous thrombosis and a severe abdominal medical condition requiring colostomy and administration of parenteral nutrition. One of the known and reported complications of parenteral nutrition administration is extravasation, which can cause compartment syndrome and local tissue damage. Partial amputation of a hand is not outside of the realm of possibility when this occurs. The complication of extravasation was noted when it occurred and the appropriate consultation was ordered, hand surgery, who then performed an appropriate workup and management with emergent fasciotomy. However, the time it took for the CTA to be completed and then the time from CTA complete to orthopedic consultation must be fully elucidated. When was the orthopedic Hand consultation ordered? If there was an unnecessary delay in ordering the consultation, that could be a locus of medical error. Additionally, while the urgency of the fasciotomy surgery was noted, the time from consultation to surgery in the OR was approximately 5 hours. That is a long time for the hand to remain ischemic. Finally, the operative note must be clarified. There is a discrepancy between the beginning and the text of the note. The preamble states that they did forearm and not hand fasciotomies. However the actual note itself describes hand fasciotomies. This is concerning as well.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Ischemic injury and reperfusion injury are the two most likely phenomena leading to this patient's amputation. It is possible that even with swift treatment she may have ended up with an amputation. However, it is also possible that those critical 5-8 hours of relative delay caused the amputation. Exact timelines would have to be fleshed out and examined and there may not be a way to completely ever establish with certainty the causation - however within a reasonable degree of certainty it is likely that the delay caused the injury.
What makes you a good expert for this case?
I am a fellowship-trained hand and upper extremity surgeon with years of experience covering level one trauma centers and performing and evaluating patients for extravasation, compartment syndrome, and amputations.
How often do you encounter cases similar to this one in your practice?
These are not common cases. I see extravasation cases about once per month, compartment syndrome from extravasation about once per quarter, and amputation from compartment syndrome cases about once annually.
Do you believe there might have been medical error?
A terrible outcome, but hematoma at the site of an IV with someone with history of thrombotic disease now on anticoagulation is not uncommon, nor is it an error. You needed an IV. The bleed was probably not avoidable. The condition (hematoma leading to compartment syndrome) was evaluated appropriately. Unless you can prove that there was an unacceptable delay in management, which is doubtful given the unclear clinical picture and appropriate level of clinical concern, the treatment was appropriate. Just a bad, bad outcome.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Again, this patient had a longstanding history of difficult IV sticks with multiple failed IV's. She's a vasculopath. Another IV getting blown is an eventuality more than a possibility.
What makes you a good expert for this case?
I am a hand surgeon who sees compartment syndrome often.
How often do you encounter cases similar to this one in your practice?
Leading to amputation? Rarely. Compartment syndrome and rule-out compartment syndrome - every few months.
Do you believe there might have been medical error?
pt has multiple medical and anatomic issues that present challenges to obtaining/maintaining IV access, at the same time require access for necessary treatment. Infiltration is a known possibility with IV access & treatment. The timeline for recognition, evaluation and mitigating action in this case seems reasonable.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
pt has multiple medical and anatomic issues that present challenges to obtaining/maintaining IV access, at the same time require access for necessary treatment. Infiltration is a known possibility with IV access & treatment. The timeline for recognition, evaluation and mitigating action in this case seems reasonable.
What makes you a good expert for this case?
I am a fellowship trained orthopedic surgeon with 19 years experience.
How often do you encounter cases similar to this one in your practice?
Consulted at least several times a year to evaluate infiltration events, and separately to evaluate for compartment syndrome.
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