Effect of warm and cold applications on the resolution of i.v. infiltrations

Intravenous contrast medium extravasation: systematic review and updated ESUR Contrast Media Safety Committee Guidelines

NEED FOR A REVIEW

Guidelines for management and prevention of contrast media extravasation have not been updated recently. In view of emerging research and changing working practices, this review aims to inform update on the current guidelines.

AREAS COVERED

In this paper, we review the literature pertaining to the pathophysiology, diagnosis, risk factors and treatments of contrast media extravasation. A suggested protocol and guidelines are recommended based upon the available literature.

KEY POINTS

• Risk of extravasation is dependent on scanning technique and patient risk factors. • Diagnosis is mostly clinical, and outcomes are mostly favourable. • Referral to surgery should be based on clinical severity rather than extravasated volume.

Detection of Excess Presence of 99m Tc-MDP Near Injection Site-A Case Report

Nuclear medicine extravasations and prolonged venous stasis may cause poor quality and quantification errors that can affect image interpretation and patient management. Radiopharmaceutical remaining near the administration site means that some portion of the radioactivity is not circulating as required for the prescribed uptake period. This case describes how detection of excess presence of ^99mTc-MDP near the injection site enabled the technologist to apply mitigation tactics early in the uptake process. It also suggests that detecting an extravasation or stasis early in the injection process can be important for image interpretation and minimizing radiation dose to tissue.

Recommendations for Management of Noncytotoxic Vesicant Extravasations

To prepare clinicians to treat extravasation of noncytotoxic vesicants with antidotes and thermal compresses, a literature review was performed to identify noncytotoxic vesicants and to create evidence and consensus-based recommendations. The stage of injury and vesicant's mechanism of tissue injury dictate treatment. For a vasopressor extravasation, warm compresses and administration of a vasodilator are recommended. For osmolarity, pH, absorption refractory, and cytotoxic concentration-dependent vesicants, warm compresses and administration of hyaluronidase are recommended. Compared with potentially catastrophic costs of undertreatment, the cost of overtreatment is minimal.

Large-volume iodinated contrast medium extravasation: low frequency and good outcome after conservative management in a single-centre cohort of more than 67,000 patients

OBJECTIVES

Our aim was to retrospectively investigate the frequency and outcome of large-volume iodinated contrast medium (CM) extravasation in our institution and to compare our management protocol to current practice.

METHODS

Institutional review board approval was obtained, and informed consent was waived because the study was retrospective. From January 2008 to September 2016, radiological examinations with intravenous non-ionic iodinated CM administration were performed in 67,129 patients. Contrast medium extravasation events on CT scans and intravenous pyelograms but not on angiograms were included. All data were collected prospectively and stratified according to age, injection method (manual vs auto-injection), prevention of extravasation by various means (including intercom alarm), management of extravasation (routine application of silver sulfadiazine ointment, clobetasol propionate cream, and damp gauze at room temperature), etc. RESULTS: The incidence of large-volume CM extravasation was very low (0.04% [27/67,129] overall; 0.03% related to manual injection [age range, 59-92 years; mean, 75.4 years], and 0.045% related to auto-injection [age range, 36-86 years; mean, 65.8 years]). The CM extravasation volume in majority of patients was 20-40 ml in 5 of 9 patients (55.6%) in the manual injection group and 14 of 18 (77.8%) in the auto-injection group. Swelling and pain were the most common symptoms. No patient developed severe signs or needed surgical intervention.

CONCLUSIONS

Results show a very low incidence of large-volume CM extravasation without severe complications or sequelae. The casual effect between our protocols and good outcome cannot be scrutinised thoroughly because the study lacks a control group and is retrospective.

KEY POINTS

• The incidence of large-volume contrast medium extravasation (≥20 ml) was 0.04%. • No patient needed surgical intervention, and most recovered within 7 days. • Each element of our management protocol contributed to good outcome.

Extravasation of Noncytotoxic Drugs: A Review of the Literature

OBJECTIVE

Extravasation is a potential complication associated with intravenous therapy administration. Inadvertent leakage of medications with vesicant properties can cause severe tissue necrosis, which can lead to devastating long-term consequences. Recognizing potential agents is an essential step in mitigating the risk of extravasation.

DATA SOURCE

A literature search was carried out using PubMed with the following key words: extravasation, soft tissue injury, phlebitis, and infiltration, from January 1961 through January 2014.

STUDY SELECTION AND DATA EXTRACTION

The publications were screened manually and reviewed to identify reports for medications that included synonyms of the International Nonproprietary Name, while excluding antineoplastic agents, radiographic contrast material, investigational or nonmarketed drugs, and animal data, to yield 70 articles. Furthermore, reference citations from publications were also reviewed for relevance and yielded 4 articles.

DATA SYNTHESIS

We discovered 232 cases of extravasation involving 37 agents (in order of frequency): phenytoin, parenteral nutrition, calcium gluconate, potassium chloride, calcium chloride, dopamine, dextrose solutions, epinephrine, sodium bicarbonate, nafcillin, propofol, norepinephrine, mannitol, arginine, promethazine, vancomycin, tetracycline, dobutamine, vasopressin, sodium thiopental, acyclovir, amphotericin, ampicillin, cloxacillin, gentamicin, metronidazole, oxacillin, penicillin, amiodarone, albumin, furosemide, lipids, lorazepam, immunoglobulin, morphine, and sodium valproate. Potential properties contributing to extravasation include the following: pH, osmolarity, diluent, vasoactive properties, and inactive ingredients. Antidotes and supportive care agents used in the management of these cases of extravasation include hyaluronidase, phentolamine, terbutaline, topical anesthetics (such as lidocaine and prilocaine cream), topical antimicrobials (such as silver sulfadiazine and chlorhexidine), topical debridement agents (collagenase ointment), topical steroids, and topical vasodilators (nitroglycerin).

CONCLUSION

Data on the management of noncytotoxic extravasations is sparse, consisting primarily of case reports and anecdotal evidence. Fortunately, this adverse outcome is preventable and identification of vesicant agents plays a pivotal role. The intent of this review is to provide a reference identifying noncytotoxic vesicants and the management of extravasations associated with specific agents.

Infiltration and extravasation: update on prevention and management

Infiltration and extravasation are risks of intravenous administration therapy involving unintended leakage of solution into the surrounding tissue. Consequences range from local irritation to amputation. While immediate action using appropriate measures (ie, dilution, extraction, antidotes, and supportive treatments) can decrease the need for surgical intervention, many injuries may be prevented by following established policy and procedures. However, timely surgical intervention, when necessary, can prevent more serious adverse outcomes. Clinicians should be prepared to act promptly when an event occurs. Thorough incident documentation helps determine whether infusion care meets the standard of practice and is a keystone to medicolegal defense.

Infiltration and extravasation

The Infusion Nurses Society's national standards of practice require that a nurse who administers IV medication or fluid know its adverse effects and appropriate interventions to take before starting the infusion. A serious complication is the inadvertent administration of a solution or medication into the tissue surrounding the IV catheter--when it is a nonvesicant solution or medication, it is called infiltration; when it is a vesicant medication, it is called extravasation. Both infiltration and extravasation can have serious consequences: the patient may need surgical intervention resulting in large scars, experience limitation of function, or even require amputation. Another long-term effect is complex regional pain syndrome, a neurologic syndrome that requires long-term pain management. These outcomes can be prevented by using appropriate nursing interventions during IV catheter insertion and early recognition and intervention upon the first signs and symptoms of infiltration and extravasation. Nursing interventions include early recognition, prevention, and treatment (including the controversial use of antidotes, and heat and cold therapy). Steps to manage infiltration and extravasation are presented.

Functional magnetic resonance imaging in nursing research

Functional magnetic resonance imaging (fMRI) is a powerful noninvasive neuroimaging technique nurse scientists can use to investigate the structure and cognitive capacities of the brain. A strong magnetic field and intermittent high-frequency pulses cause protons in body tissues to release energy, which can be recorded and processed into images that are sensitive to specific tissue characteristics. Although temporal and spatial resolution constraints define an upper limit to the precision of magnetic resonance (MR) scanners, the primary index of neuronal activity, hemodynamic response, can be efficiently estimated. Characteristics of the experimental environment, the hypothesis of interest, and the physiology of the cognitive process under investigation provide guidance for the design and limit available options. The processing of functional data to remove unwanted variability is briefly described as are the techniques used to estimate statistical effects and control for the rate of false positives in the results. A detailed applied example of nursing research is included to demonstrate the practical application of the theory, methods, and techniques being discussed. A glossary of key terms is also provided.

Transdermal nitroglycerin for the prevention of intravenous infusion failure due to phlebitis and extravasation

OBJECTIVE

To evaluate the clinical use of transdermal nitroglycerin for the prevention of intravenous infusion failures due to phlebitis or extravasation.

DATA SOURCES

Clinical literature was accessed through a MEDLINE search (1966-May 2000). Key search terms included nitroglycerin, transdermal, phlebitis, extravasation, intravenous, and infusion.

DATA SYNTHESIS

Common and serious consequences of intravenous therapy include the occurrence of postinfusion phlebitis and failure to maintain intravenous therapy due to intravenous fluid extravasation. Transdermal application of nitroglycerin has been evaluated as a treatment and preventive method for intravenous infusion failures related to phlebitis or extravasation. An evaluation of studies focusing on transdermal nitroglycerin in the prevention of infusion failures due to phlebitis or extravasation was conducted.

CONCLUSIONS

Use of transdermal nitroglycerin as a prophylactic measure for intravenous infusion failures is a therapeutic option for patients requiring long-term intravenous therapy (i.e., > 50 h).

Negative outcomes of intravascular therapy in infants and children

Intravascular therapy is essential in the care of acutely ill infants and children, but it is not without risks. The purpose of this article is to discuss potential intravascular, extravascular, and systemic complications related to peripheral and central intravascular therapy in infants and children. The formation of thrombi, infiltration, and sepsis are the most common complications. Less common complications are phlebitis, arterial spasm, catheter retention, catheter embolus, air emboli, dysrhythmias, and hemorrhage. Financial implications of long-term negative outcomes and nursing liability are discussed, and a proposed standard of preventative nursing care for intravascular therapy is presented.