intravenous ( iv ) administration of phenytoin can result in soft tissue injury at the site of injection leading to oedema and purplish - black discolouration of the hand . it may occur during 1.75.9% of all phenytoin administrations depending on the recognition as well as adverse drug event reporting . the anaesthetic management of such a case can be very challenging as no ideal technique has been advocated . a 65-year - old woman weighing 43 kg presented with an alleged history of generalised tonic - clonic seizures . the physician administered 600 mg of injection phenytoin sodium dissolved in 100 ml of normal saline through a 22 g cannula sited into a vein on the dorsum of her left hand to flow over 20 min . , maintenance dose of iv phenytoin was allowed to flow ( 100 mg in 500 ml of normal saline over 8 h ) . four hours later , the patient complained of pain at the site of injection , which progressively became severe . the fingers , hand and forearm were swollen and within an hour had a purplish - black discolouration [ figure 1 ] . the iv cannula was removed and the arm was kept elevated to reduce the oedema . the ultrasound doppler study of the arm showed normal flow through the subclavian to digital arteries but the veins appeared collapsed . initially , conservative management was initiated with iv non - steroidal anti - inflammatory drugs for pain relief . however , there was no respite in pain and the condition rapidly deteriorated with gangrenous changes appearing over the left hand up to the mid arm [ figure 2 ] . surgical consultation was obtained and the diagnosis of pgs was suggested with the need for emergency amputation . emergency amputation below the elbow was performed under general anaesthesia under spontaneous ventilation , and proseal lma size 3 was used for airway management . amputation was performed , and the procedure was uneventful . at the end of surgery , anaesthesia was reversed and with the return of protective airway reflexes , the proseal lma was removed . swollen fingers and hand of the left upper extremity with bluish discoloration after phenytoin injection gangrenous changes of the left hand extending up to mid arm phenytoin , a broad spectrum anticonvulsant , has been widely administered parenterally for the treatment of seizures for more than 40 years . iv phenytoin is employed in emergency departments and neurological units for patients with active seizure disorders or who are unable to tolerate oral medication . adverse reactions to phenytoin are not uncommon , due to phenytoin 's narrow therapeutic index and pharmacokinetics ; however , the adverse drug reaction known as pgs is a less heard of clinical entity with a prevalence of 1.75.9% . pgs gets its name from the characteristic bluish discoloration of the skin , accompanied by pain and oedema distal to the site of iv administration of phenytoin . , a pale blue or dark purple discoloration appears around the iv insertion site , 212 h after the administration of the drug . during the next 1216 h ( second stage ) , progression occurs as oedema and discolouration spread around all sides of the fingers , hand and forearm , hence the term  purple glove. healing is the last stage as the discoloration recedes , starting from the periphery and moving toward the original site of injury . the majority of reported cases resolve without complication , but a few cases resulting in necrosis have been reported . it has been suggested that the alkaline drug precipitates upon contact with blood and leaks out of the vein , from around the cannula and into the interstitial tissue . this is likely to happen in a slow flowing stream or if the cannula is kinked , leading to stasis . another possible mechanism could be that the highly alkaline solution induces vasoconstriction of the vein resulting in disruption of the endothelial - intercellular junctions and seepage of the drug into the interstitial space . extravasation of the highly albumin - bound ( 7090% ) phenytoin increases the interstitial oncotic pressure leading to oedema . other factors associated with increased risk include peripheral vascular disease and diseases that weaken the vascular and dermal integrity , use of iv catheters smaller than 20-gauge and infusion of phenytoin at more than 25 mg / ml . there were multiple risk factors in our patient like elderly age group , female gender , use of 22 g cannula for administering phenytoin as well as the rate of infusion . therefore , administration of phenytoin should be into a free - flowing infusion line , through a large bore iv catheter sited into a large vein of the forearm , in a concentration of 10 mg / ml , and at a rate not exceeding 50 mg / min . it should be diluted in 0.9% normal saline solution , and dextrose solutions and lactated ringers solutions can not be used with iv phenytoin due to the potential for precipitation . any evidence of venous irritation such as pain , oedema and erythema warrants immediate discontinuation of the infusion and removal of the iv catheter . the diagnosis of pgs is based on the characteristic clinical findings and a high index of suspicion when it occurs after the administration of phenytoin . the management is mainly conservative ( limb elevation , physiotherapy , control of pain , reassurance to the patient ) and should be directed at minimising the degree of soft tissue damage . the role of the anaesthesiologist in this situation can be either for pain relief or a definitive surgical intervention like fasciotomy or amputation . a low concentration of local anaesthetic would relieve the pain by preferentially blocking the a and b fibres . the addition of fentanyl potentiates local anaesthetic action via central opioid receptor mediated analgesia by peripheral uptake of fentanyl to the systemic circulation . the sympathetic blockade , by blocking the  receptors , improves blood flow in vasospastic disorders . stellate ganglion blockade has the advantage of blocking the sympathetic innervation of the upper limb , thus improving the perfusion and relieving the ischaemic pain associated with vasospasm . brachial plexus blockade has been used for this condition , and the use of general anaesthesia in pgs has not been described before . iv administration of phenytoin can lead to pgs when small peripheral lines are used for drug administration . ensuring a slow flow rate through larger lines can prevent such a complication .
purple glove syndrome ( pgs ) is a devastating complication of intravenous ( iv ) phenytoin administration . 
 anaesthetic management during the amputation of the limb for such patients is very challenging due to limited clinical experience . a 65-year - old woman developed pgs of left upper extremity after iv administration of phenytoin following generalised tonic - clonic seizures . the condition progressed rapidly leading to gangrene of left hand extending to the mid arm . 
 amputation was carried out under general anaesthesia with a supraglottic airway device . 
 we discuss the prevention and alternate managements in pgs , which is a rare clinical entity with limited data in the literature .