Upper-Limb Compartment Syndrome Following Rapid Infusion Catheter Extravasation During Orthotopic Liver Transplantation: A Case Report.

Rapid infusion catheters (RICs) provide high-flow peripheral venous access for major haemorrhage but can cause severe tissue injury if pressurised infusion becomes extravascular. We report upper-limb acute compartment syndrome during orthotopic liver transplantation following transfusion through an 8.5 Fr Arrow RIC (Teleflex Incorporated, Morrisville, NC, USA). A female in her late 60s with decompensated cryptogenic cirrhosis underwent urgent transplantation. Four hours before surgery, an attempt to place an 8.5 Fr RIC in the left antecubital fossa was abandoned because of guidewire resistance. Immediately before incision, a second 8.5 Fr RIC was inserted at the same site under real-time ultrasound guidance; intraluminal position was confirmed and a 20 mL saline flush produced no resistance or swelling. Approximately 4.5 L of blood products and resuscitation fluid were subsequently delivered through the circuit over two hours, although the proportion that extravasated could not be determined. During the dissection phase, potassium increased to 6.1 mmol/L and lactate to 5.2 mmol/L. Examination beneath the drapes revealed a cool, dusky hand with an absent radial pulse, a tense anterior compartment of the upper arm, and ecchymosis, epidermolysis, and haemorrhagic bullae extending from the antecubital fossa into the proximal forearm. Infusion was stopped immediately, and surgical decompression of the anterior compartment of the upper arm was performed in parallel with the transplant. The radial pulse returned immediately after fascial release, and full motor and sensory function was present at discharge and at six-week follow-up. This case demonstrates that successful ultrasound confirmation and an unremarkable test flush at insertion do not ensure continued intravascular function during positioning, draping, and pressurised infusion. Persistent or unexplained guidewire resistance warrants reassessment, and a potentially traumatised vein should not be reused for high-pressure infusion when safer alternative access is available. High-flow peripheral access sites should remain visible whenever feasible or undergo a defined programme of reinspection throughout use.