Case 13 A stiff hand

A male infant, Rory, was born at 39 weeks gestation, weighing 3.92 kg. His mother developed chickenpox 3 days prior to his birth.

What are the implications for the baby?

Rory was in good condition at birth, but in view of the maternal history, he was treated with intramuscular varicella-zoster immune globulin (ZIG), and a decision was made to treat him with prophylactic iv aciclovir, 10 mg/kg 8 hourly for 7 days. An iv cannula was sited in the dorsum of the left hand with some difficulty, and aciclovir was commenced by iv infusion.

Shortly after commencement of the second dose of aciclovir, the nurse thought that Rory seemed unsettled, stopped the infusion, and called the neonatal ST3 to review him. The doctor examined the infant and thought he appeared well, the iv line flushed easily when tested with a bolus of 0.9% sodium chloride, and no abnormal signs were noted. The infusion was continued.

Half way through the third dose of aciclovir, Rory appeared to be in pain, and the infusion was stopped. The ST3 reviewed Rory, and found his left hand to be swollen and tense, with a white area 2 × 1.5 cm in diameter over the dorsum of the hand.

What would you do next? What physical signs are important?

The ST3 removed the cannula and called his registrar for help. On review, 30 minutes later, the fingers had normal perfusion, the radial and ulnar pulses were normal, but the dorsum of the hand and wrist were very swollen and tense, with a white mottled area on the dorsum of the hand as described previously.

After referring to the hospital’s extravasation policy, the subcutaneous tissue of the dorsum of the hand was thoroughly irrigated with 0.9% sodium chloride, wide bore needle holes were made in the skin peripheral to the pale area, and saline solution injected into the pale area. The perfusion of the dorsum of the hand appeared to improve. The hand was dressed and elevated. Aciclovir was continued via a new cannula in a larger and more proximal vein.

What follow-up is needed?

By 24 hours, an ulcer had developed at the site of the cannula, measuring 4 × 6 mm. The ulcer healed slowly by epithelialization from the periphery of the ulcer, and left a scar on the dorsum of the hand measuring 4 mm in diameter.

Rory did not develop chickenpox, and was discharged home at the age of 10 days.

At six months of age, Rory’s parents complained that their son had difficulty extending his left middle and ring fingers. A plastic surgeon was consulted, who found scarring and tethering of the extensor tendons of the left middle and ring fingers. Rory’s parents made a complaint stating that the iv aciclovir infusion had been inadequately monitored and that this had led to all the subsequent problems.

Expert opinion

Maternal chickenpox at the end of pregnancy carries a risk of transmission of the virus to the fetus, which may result in severe haemorrhagic neonatal chickenpox. Rory’s mother is infectious to the fetus when she is viraemic, and thus can infect her baby whilst incubating her infection, even if her symptoms develop postnatally. As she has not had time to mount an immune response to the virus, if maternal symptoms occur from seven days before delivery to seven days postnatally, the baby will have no passive immunity to chickenpox, and should receive passive immunization with ZIG. Intravenous aciclovir should also be considered for infants whose mothers develop chickenpox four days before to two days after delivery as they are at the highest risk of a fatal outcome despite ZIG prophylaxis.

Aciclovir is an irritant drug when made up as an iv infusion, with an alkaline pH of 11. It is wise to give such infusions into large veins or to use a central line, so that the infusion is rapidly diluted by the blood within the vein flowing past the cannula tip. It is particularly important that the iv line is closely observed, that the infusion site is monitored, and that action is taken immediately if there is a suspicion that the line is not working. Very young children are at increased risk of extravasation, because their tissues are more delicate, and they are less able to communicate.

In this case, line insertion was difficult (possibly traumatizing the lining of the vein), and a relatively small vein was used. The nurse noticed irritability (possibly indicating pain), and it would have been prudent to re-site the cannula even though the initial insertion had been difficult.

The appearance of the iv site after the extravasation suggests that a significant volume of the infusate had entered the soft tissues, raising questions about the vigilance of monitoring of the infusion site.

Once the extravasation had been identified, the infusion should have been stopped, but the cannula should not have been removed until an attempt had been made to aspirate as much of the drug as possible through the cannula.

Flushing of the soft tissues with 0.9% saline was a reasonable emergency response to this injury, but an early consultation with a plastic surgeon would have been wise, particularly once evidence of ulceration had been seen.

Careful follow-up of the hand and physiotherapy to maintain a physiological range of movement of the wrist and fingers might have reduced the subsequent disability.

Legal comment

The parents have complained to the hospital about the treatment that their child has received. Although it was wise to administer aciclovir to Rory, a number of mistakes were made in the administration of the aciclovir and then in the aftercare, as detailed in the Expert Opinion, and the hospital should apologize immediately. It will be easy for the parents to prove that the treatment was negligent and if they pursue a claim it will be successful. But Rory is only a baby and it will be some time before it becomes clear how the tethering of the tendons has affected him and a lawyer instructed by the family would probably wish to wait a few years to see how the condition develops, before pressing for compensation. After all, Rory will have until he is 21 to bring a claim. The affected hand is the left hand and it may not be the dominant hand, but the disability may prevent him from taking a job that requires manual dexterity. The value of the claim will probably be low: between £5000 and £20,000. However, if the injury is found to limit his earning capacity, then the damages will be increased accordingly.