Volkman’s Contracture, Persistent Limb Ischaemia, and Amputation: A Complication of Brachial Artery Catheterisation for Haemodynamic Monitoring Using PiCCO

We report a case of a 64-year-old woman who was admitted to intensive care unit with multiorgan failure secondary to Plasmodium falciparum malaria. Haemodynamic monitoring using the transpulmonary thermodilution with pulse contour analysis system (PiCCO) was achieved via the left brachial artery. Two days later, a flexion deformity of the left hand was noted, and examination revealed left lower arm ischaemia. Removal of the catheter resulted in an immediate improvement of the contracture. However, distal pulses were still absent, and the arm remained ischaemic resulting in a below elbow amputation. This is the first documented case of a persistent limb ischaemia following the insertion of an arterial catheter for haemodynamic monitoring with PiCCO. We therefore highlight the need for regular assessment of limb perfusion after arterial catheterisation for haemodynamic monitoring with PiCCO. In addition, the brachial artery should be avoided, and femoral artery catheterisation is recommended. 1. Introduction Advanced haemodynamic monitoring is used extensively in intensive care to help assist with cardiovascular management of critically ill patients. Traditionally, advanced haemodynamic management involved the use of pulmonary artery catheters (PAC); however, this method is becoming less popular as the benefits of using this technique remain controversial [1, 2]. In addition, its use has been associated with complications such as arrhythmias, infection, thrombotic complications [3], and, rarely, rupture of the pulmonary artery [4, 5]. Transpulmonary thermodilution monitoring using the PiCCO system (PULSION Medical System, Munich, Germany) is being used as a popular alternative to PAC. It’s claimed benefits include minimal side effects, less invasiveness and is well validated against PAC. Data on the complications associated with this monitoring technique is limited; however, a recent prospective study which included over 500 patients in 14 different European intensive care units has shown that haemodynamic monitoring with PiCCO is safe, and serious complications are rare [6]. 2. Case Report A 64-year-old lady with recent history of traveling to Uganda was admitted to the hospital with Plasmodium falciparum malaria. Her comorbidities included hypertension and morbid obesity. The initial parasite count was 14%. Soon after her admission, her clinical condition deteriorated, and she developed multiple organ failure requiring ventilatory, renal supports, and advanced haemodynamic management. To help assist with cardiovascular and circulatory management,