**4. Clinical vignette**

A 49-year-old female with type 2 diabetes mellitus and morbid obesity underwent an abdominoplasty due to recurrent lower abdominal cellulitis. Following a series of failed PIV placement attempts in the left forearm, venous access was established on the dorsum of left hand with an 18G cannula. This PIV was then used during the induction of anesthesia, without any apparent problems. The complex operation took approximately 5 h to complete. During this time, fluid replacements were given intravenously. During the procedure, there was no evidence of left upper extremity swelling, color, or temperature change. The point of insertion of the PIV cannula appeared unremarkable when the patient arrived in the postanesthesia care unit (PACU).

Within 4 h, however, the patient reported severe pain in her left hand. This pain persisted despite escalating doses of analgesics. There was a mild but visible swelling in the left hand as compared to the right side, along with decreased capillary refill and distal paresthesia. When the patient's surgeon came to examine the patient, he exposed the entire left upper extremity and discovered an intravenous tourniquet still in place, hiding behind the hospital gown sleeve. The tourniquet was immediately removed, but it was too late to reverse the resultant extremity compartment syndrome. The PIV was also discontinued, and a new catheter is placed in the contralateral hand. An emergency fasciotomy was performed, allowing salvage of the left hand and forearm, at the cost of a large left forearm scar. This substantially increased the length of stay and associated costs and reduced the patient's hospital experience. Fortunately, there were no signs of ischemic injury or permanent nerve damage, and the patient had good functional recovery.
