Accidental intra-arterial injection of medications is rare but can have devastating results. There have been many case reports written over the years illustrating this issue and the various sequelae, ranging from minimal impact on the patient to permanent tissue damage and even limb amputation. We report on a surgical case that was performed from start to finish through an unrecognized intra-arterial catheter. This case is unique as it was performed in November 2024 in the United States, which was in the midst of a severe intravenous fluid shortage due to Hurricane Helene. As a result, this case and thousands of others were done without a running IV. Instead, this case was performed by pushing medications through an IV and then flushing in the medications with a small amount of fluid from a syringe in an effort to conserve IV fluids for urgent or emergent use. We postulate that due to not having a running IV, this accidental intra-arterial catheter went unrecognized in a 90-minute surgical case. In all likelihood, with a running IV connected to an intra-arterial catheter, the IV would not have functioned normally and in troubleshooting the IV, the error would have been recognized much sooner. Consequently, the patient would not have been exposed to the dangers of receiving medications through an intra-arterial catheter. This case highlights the critical role of continuous IV fluids in detecting misplaced catheters and underscores the importance of reinstating this practice as soon as supply constraints allow.

Johnson LM, Evans C, Bratton J, Johnson MH. Unforeseen Impact of the IV Fluid Shortage on Patient Safety: A Case of Inadvertent Intra-arterial Injection During General Anesthesia. Cureus. 2025 Mar 17;17(3):e80722. doi: 10.7759/cureus.80722. PMID: 40242685; PMCID: PMC12002558.