Guidelines for management of actual or suspected inadvertent intra-arterial injection of sclerosants.

BACKGROUND: Inadvertent intra-arterial injection of sclerosants is an uncommon adverse event of both ultrasound-guided and direct vision sclerotherapy. This complication can result in significant tissue or limb loss and significant long-term morbidity. OBJECTIVES: To provide recommendations for diagnosis and immediate management of an unintentional intra-arterial injection of sclerosing agents. METHODS: An international and multidisciplinary expert panel representing the endorsing societies and relevant specialities reviewed the published biomedical, scientific and legal literature and developed the consensus-based recommendations. RESULTS: Actual and suspected cases of an intra-arterial sclerosant injection should be immediately transferred to a facility with a vascular/interventional unit. Digital Subtraction Angiography (DSA) is the key investigation to confirm the diagnosis and help select the appropriate intra-arterial therapy for tissue ischaemia. Emergency endovascular intervention will be required to manage the risk of major limb ischaemia. This includes intra-arterial administration of vasodilators to reduce vasospasm, and anticoagulants and thrombolytic agents to mitigate thrombosis. Mechanical thrombectomy, other endovascular interventions and even open surgery may be required. Lumbar sympathetic block may be considered but has a high risk of bleeding. Systemic anti-inflammatory agents, anticoagulants, and platelet inhibitors and modifiers would complement the intra-arterial endovascular procedures. For risk of minor ischaemia, systemic oral anti-inflammatory agents, anticoagulants, vasodilators and antiplatelet treatments are recommended. CONCLUSION: Inadvertent intra-arterial injection is an adverse event of both ultrasound-guided and direct vision sclerotherapy. Medical practitioners performing sclerotherapy must ensure completion of a course of formal training (specialty or subspecialty training, or equivalent recognition) in the management of venous and lymphatic disorders (phlebology), and be personally proficient in the use of duplex ultrasound in vascular (both arterial and venous) applications, to diagnose and provide image guidance to venous procedure. Expertise in diagnosis and immediate management of an intra-arterial injection is essential for all practitioners performing sclerotherapy.

Analysis of Part 1 of the latest Austroads Guidelines, June 2022.

The Austroads Fitness to Drive Guidelines were updated in 2022. Most of the focus to date has been on Part 2 of the Guidelines, which provide guidance as to specific medical conditions. Less attention has been paid to Part 1 of the Guidelines, which cover a medical practitioner's ethical and legal obligations. This paper addresses the imbalance by considering and amplifying the obligations discussed in Part 1 of the Guidelines.

Fitness to drive and seizures - Recent medicolegal considerations to tell or not to tell? - THAT IS THE QUESTION!

This paper reviews a Coroner's inquest into the deaths of two people. The deaths were caused when a driver had a seizure, and lost control of his car, which then plowed into a café. The Coroner reviews the roles and responsibilities of primary and tertiary caregivers, with special focus on the question of who has the responsibility to inform the Drivers' Licensing Authority of a patient's unfitness to drive - the patient or the practitioner? The Coroner recommends the establishment of a multi-agency committee to advance work in this area. The paper notes a separate but parallel development - a review of AUSTROADS Assessing Fitness to Drive Guidelines, which may achieve the outcomes sought by the Coroner.

Medical certificates attesting fitness to drive.

Few if any sanctions have been imposed on doctors for inappropriate certification of fitness to drive. This paper reviews a recent Tribunal decision on inappropriate certification of fitness to drive. This paper reviews the facts of the case of Medical Board of Australia v Andrew and discusses the legal implications for doctors who certify patients as fit to drive. The paper offers a necessary and timely warning that the Medical Board sought harsh sanctions, more severe than were imposed by the Tribunal, but that the Tribunal also felt compelled to impose 'general deterrence' to prevent inappropriate certification. The paper emphasises the need for scrupulous attention to detail and an absolute need for circumspection when assessing patients who claim to be seizure free, or who minimise impairment from a range of other conditions, insisting on clearance to be able to drive.

Usefulness of Austroads' fitness-to-drive guidelines: lessons from the Gillett case.

Regina v Gillett deals with a man who did not disclose his epilepsy when seeking a drivers licence. Subsequently, he had a seizure while driving, causing an accident in which three people died. He was found guilty but appealed. During the trial to decide whether Gillett was guilty of dangerous driving occasioning death, the judge decided that the Austroads fitness-to-drive guidelines were extraneous to legal consideration of the acceptable risk to be attached to chronic medical conditions. Although the appeal was unsuccessful with respect to guilt and sentencing, it did reinstate the relevance of the Austroads guidelines when evaluating suitable risk with respect to potentially dangerous drivers. We suggest that even greater protection can be afforded to the community if a clearly enunciated warning, outlining a driver's responsibilities, were to appear on each drivers license.