Childhood extravasation injuries: Improved outcome following the introduction of hospital-wide guidelines

Risk Factors for Contrast Media Extravasation in Intravenous Contrast-Enhanced Computed Tomography: An Observational Cohort Study

RATIONALE AND OBJECTIVES

To identify the risk factors for contrast media (CM) extravasation and provide effective guidance for reducing its incidence.

MATERIALS AND METHODS

We observed adult inpatients (n = 38 281) who underwent intravenous contrast-enhanced computed tomography between January 1, 2018, and December 31, 2022. Risk factors for CM extravasation were evaluated using univariate and multivariate logistic regression.

RESULTS

Among the 38 281 inpatients who underwent enhanced computed tomography angiography, 3885 received peripherally inserted central venous catheters (PICCs) and 34 396 received peripheral short catheters. In 3885 cases of PICCs, no CM extravasation occurred, but in five cases, ordinary PICCs that are unable to withstand high pressure were mistakenly used; three of those patients experienced catheter rupture, and eventually, all five patients underwent unplanned extubation. Among 34 396 cases of peripheral short catheters, 224 (0.65%) had CM extravasation. Female sex (odds ratio [OR]=1.541, 95% confidence interval [CI]: 1.111-2.137), diabetes (OR=2.265, 95% CI: 1.549-3.314), venous thrombosis (OR=2.157, 95% CI: 1.039-4.478), multi-site angiography (OR=9.757, CI: 6.803-13.994), and injection rate ≥ 3 mL/s (OR=6.073, 95% CI: 4.349-8.481) were independent risk factors for CM extravasation. Due to peripheral vascular protection measures in patients with malignant tumor, there was a low incidence of CM extravasation (OR=0.394, 95% CI: 0.272-0.570).

CONCLUSION

Main risk factors for CM extravasation are female, diabetes, venous thrombosis, multi-site angiography, and injection rate ≥ 3 mL/s. However, patients with malignant tumor have a low incidence of CM extravasation.

CLINICAL IMPACT

Analysis of these risk factors can help reduce the incidence of CM extravasation.

Contrast media extravasation injury: a prospective observational cohort study

OBJECTIVE

To identify the risk factors for moderate and severe contrast media extravasation and provide effective guidance to reduce the degree of extravasation injuries.

METHODS

We observed 224 adult patients who underwent contrast media extravasation at Xiangya Hospital of Central South University, Hunan Provincial Maternal and Child Healthcare Hospital, and Xiangya Changde Hospital, Hunan Province between January 1, 2018 and December 31, 2022. Risk factors for moderate extravasation injuries were evaluated using univariate and multivariate logistic regression.

RESULTS

Among 224 patients, 0 (0%) had severe, 18 (8.0%) had moderate, and 206 (92.0%) had mild contrast media extravasation injury. Multivariate logistic regression analysis revealed malignant tumors (odds ratio [OR] = 6.992, 95% confidence interval [CI]: 1.674-29.208), Iohexol (OR = 9.343, 95% CI 1.280-68.214), large-volume (> 50 mL) extravasation (OR = 5.773, 95% CI 1.350‒24.695), and injection site (back of the hand) (OR = 13.491, 95% CI 3.056-59.560) as independent risk factors for moderate injury.

CONCLUSION

Risk factors for moderate contrast media extravasation injury are malignant tumors, iohexol, large-volume (> 50 mL) extravasation, and back-of-the-hand injection. Analysis of these risk factors can help reduce the degree of injury after extravasation.

CLINICAL RELEVANCE STATEMENT

High-risk patients with extravasation support should choose the appropriate contrast media type, avoiding back-of-the-hand injections. We recommend that patients with cancer be implanted with a high-pressure resistant central venous catheter and receive effective measures to timely detect and reduce extravasation.

Extravasation injury management for neonates and children: A systematic review and aggregated case series

BACKGROUND

Pediatric extravasation injuries are significant healthcare-associated injuries, with sometimes significant sequelae. Evidence-based guidance on management is necessary to prevent permanent injury.

PURPOSE

A systematic review of the literature, including aggregated case series, investigating extravasation injury management of hospitalized pediatric patients.

DATA SOURCES

PubMed, Cummulative Index to Nursing and Allied Health Literature (CINAHL), and Excerpta Medica database (EMBASE) were searched on December 13, 2021.

STUDY SELECTION

Primary research investigating extravasation injury management of hospitalized pediatric patients (to 18 years), published from 2010 onwards and in English, independently screened by two authors, with arbitration from a third author.

DATA EXTRACTION

Data regarding the study, patient (age, primary diagnosis), extravasation (site, presentation, outcome), and treatment (first aid, wound management) were extracted by two authors, with arbitration from a third author.

DATA SYNTHESIS

From an initial 1769 articles, 27 studies were included with extractable case data reported in 18 studies, resulting in 33 cases. No clinical trials were identified, instead, studies were primarily case studies (52%) of neonates (67%), with varied extravasation symptoms. Studies had good selection and ascertainment, but few met the causality and reporting requirements for quality assessments. Signs and symptoms varied, with scarring (45%) and necrosis (30%) commonly described. Diverse treatments were categorized into first aid, medical, surgical, and dressings.

CONCLUSIONS

Despite infiltration and extravasation injuries being common within pediatric healthcare, management interventions are under-researched, with low-quality studies and no consensus on treatments or outcomes.

A new approach to skin extravasation injury management during the neonatal period

Background

To identify a standard protocol for managing extravasation injuries in neonates.

Methods

We recruited all the neonates with extravasation wounds from the neonatal intensive care unit of Shariati hospital, Tehran, Iran, between October 2018 and October 2020. Sixteen patients with grade 3–4 extravasation were evaluated in this retrospective study. All grade 3 and 4 extravasation wounds were injected with hyaluronidase at 5 points of the wound circle; the procedure was repeated every 5 min at different points in a smaller circle to the core. The wound was then covered with a warm compress for 24 h. Twenty-four hours after injection, the cover was changed twice a day with normal saline irrigation. Fibrinolysin ointment was applied on top of the wound. The ulcer was then dressed with phenytoin ointment until healing.

Results

Out of 16 neonates who were followed up, 10 of them were male, with the average birth weight being 1.37 (range 1.05–3.75) kg. The mean (± SD) wound healing duration was 13.12 (± 6) (range: 7–29) days. Factors including the cannulation duration before the appearance of the lesion (R:0.2, P = 0.2), birth weight (R = -.37, P = 015), and extravasated substances (p = 0.2) were not associated with the duration of hospital stay. The only exception to this trend is the wound size factor of 7.31(± 7.45) (R = .83, P < 0.001). Continuous and categorical variables were summarized as mean (SD) and proportions, respectively, and the Kruskal–Wallis test and Spearman correlation coefficients were used.

Conclusions

Limited evidence exists on the effects of different protocols on extravasation management in neonates in the NICU. We recommend our method as a standard protocol in NICU for high-stage extravasated lesions because of the shorter duration of healing, non-invasive nature of this procedure, and lack of side effects or surgical involvement.

Extravasation of Concentrated Potassium Chloride: A Case Report

Background

The extravasation of potassium chloride will cause serious harm, especially if it is not diagnosed or treated promptly. Objective:to report the clinical course of a patient who was suffering a potassium extravasation and to discuss steps that can be done to decrease the chances of this event from occurring in other patients.

Methods

After discontinuation of infusion device and withdrawal of intravenous catheter, wet packing with magnesium sulfate and local injection of papaverine and lidocaine were applied.

Results

After 11 days, the extravasation injury had recovered.

Conclusions

To avoid a repeat of such an adverse event, proper sites for administering, accurate dilution of potassium chloride solutions, close observation, and increased awareness of trained personnel of extravasation dangers are vital. Once extravasation occurs, timely wet application with magnesium sulfate and local injection of papaverine and lidocaine may have been useful in producing a favorable recovery.

Extravasation Injuries of the Limbs in Neonates and Children-Development of a Treatment Algorithm

BACKGROUND

Hospitalized children and neonates very often receive intravenous treatment. There has not yet been any systematic study of the incidence of extravasation injuries in this age group. In a few studies of neonates in intensive care receiving intravenous treatment, incidence figures in the range of 18-46% have been reported; 2.4-4% sustain serious complications, such as necrosis and ulceration, that can lead over the long term to contractures, deformities, and impaired limb function due to unfavorable scarring. No guidelines currently exist for the care of pediatric extravasation injuries.

METHODS

This review is based on pertinent publications (from 1979 to June 2020) retrieved by a selective search in PubMed, as well as on experience from the authors' own institution.

RESULTS

In the absence of randomized controlled trials on the care of pediatric extravasation injuries, the available evidence is limited to small-scale comparative studies and case series. Conservative, medical, or surgical treatment can be used, depending on the volume of the extravasate, the nature of the substrate, and individual patient-related factors. It should first be determined whether the extravasated substance has no primary toxic properties or is a tissue irritant or a necrosis-inducing substance (vesicant). The skin and subcutaneous tissue should be examined for injury, coloration, swelling, capillary refill time, and pulses distal to the injury. Depending on the volume of the extravasate, the substrate, and the degree of tissue damage, the injury can be treated conservatively; medically, with the administration of an antidote, hyaluronidase, or a vasodilator such as phentolamine; or surgically, with multiple puncture procedures, washouts, or liposuction.

CONCLUSION

As there is no clear evidence that one form of treatment is superior to any other, the treatment of pediatric extravasation injuries remains an individual decision, with the known attendant risks of off-label treatment.

[Guidelines for neonatal skin management in the neonatal intensive care unit (2021)]

Neonates are easily suffering from local or systematic infections due to their vulnerable skin barrier function, which leads to the increasing risk of death. Therefore, it is important to protect neonatal skin integrity and prevent neonatal skin injury in the neonatal intensive care unit (NICU). Based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) and current evidence, the guidelines for neonatal skin management in the NICU were developed to provide recommendations on routine skin care and prevention and treatment of iatrogenic skin injury of neonates for health care providers.

Elaboration and validation of an algorithm for treating peripheral intravenous infiltration and extravasation in children

OBJECTIVE

to elaborate and validate the content and appearance of an algorithm for treating infiltration and extravasation of non-chemotherapy drugs and solutions administered to children.

METHOD

a methodological study of the technology formulation and validation type. To elaborate the algorithm, a bibliographic review was carried out to list the scientific evidence on the treatment of infiltration and extravasation. Content and appearance validation was in charge of 14 specialists in pediatric nursing, using the Delphi technique, adopting a value equal to or greater than 0.80 as Content Validation Index.

RESULTS

the algorithm was validated in the third evaluation by the judges, reaching a Global Content Validation Index of 0.99, being composed by the perception of the occurrence of the complication; discontinuation of intravenous therapy infusion; verification of signs and symptoms; measurement of edema; application of an infiltration and extravasation assessment scale and conduits to be used according to the characteristics of the fluid administered and the type of complication.

CONCLUSION

the algorithm was validated and can be used in a practical and objective way by health professionals, in order to promote safety in the care of hospitalized children, with regard to reducing harms caused by infiltration and extravasation.

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.

Extravasation Injuries: A Trivial Injury Often Overlooked with Disastrous Consequences

With the advent of parenteral, intravenous infusion for various purposes like chemotherapy, parenteral nutrition, radiocontrast intravenous injection for imaging studies, extravasation injuries are emerging as a serious problem with often disastrous complications, if not recognized early. Fortunately, if treated early, the affected extremities can be salvaged and hence the role of plastic surgeons cannot be over-emphasized, especially when it comes to the reconstruction of necrotic and ischemic wounds as a result of these injuries. Proper monitoring and immediate intervention will go a long way in minimizing the morbidity associated with these injuries. However, if there is a delay in recognition and treatment, it can lead to complications like skin necrosis, gangrene, extensive soft tissue defects and contractures. Treatment in these circumstances needs an individualized approach and entails wound debridement followed by skin grafts and flap cover. Documentation and prompt intervention can avoid medicolegal issues for the physician and the hospital.

Surgical intervention for paediatric infusion-related extravasation injury: a systematic review

OBJECTIVES

This systematic review aims to assess the quality of literature supporting surgical interventions for paediatric extravasation injury and to determine whether there is sufficient evidence to support invasive techniques in children.

METHODS

We performed a systematic review by searching Ovid MEDLINE and EMBASE as well as AMED, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and clinicaltrials.gov from inception to February 2019. Studies other than case reports were eligible for inclusion if the population was younger than 18 years old, if there was a surgical intervention aimed at treating extravasation injury and if they reported on outcomes. Study quality was graded according to the National Institutes of Health study quality assessment tools.

RESULTS

26 studies involving 728 children were included-one before-and-after study and 25 case series. Extravasation injuries were mainly confined to skin and subcutaneous tissues but severe complications were also encountered, including amputation (one toe and one below elbow). Of the surgical treatments described, the technique of multiple puncture wounds and instillation of saline and/or hyaluronidase was the most commonly used. However, there were no studies in which its effectiveness was tested against another treatment or a control and details of functional and aesthetic outcomes were generally lacking.

CONCLUSION

Surgical management is commonly reported in the literature in cases where there is significant soft tissue injury but as there are no comparative studies, it is unclear whether this is optimal. Further observational and experimental research evaluating extravasation injuries, including a centralised extravasation register using a universal grading scheme and core outcome set with adequate follow-up, are required to provide evidence to guide clinician decision-making.

Upper limb extravasation of cytotoxic drugs: results of the saline washout technique in children

PURPOSE

Extravasation of cytotoxic vesicant drugs is a surgical emergency (within six hours) since this incident can lead to severe skin and soft-tissue damage. Outcomes after the saline washout procedure have been extensively described in adults, but rarely in children. The aim of this study was to evaluate the outcome of early saline washout procedure for upper limb cytotoxic drug extravasation in children.

METHODS

All consecutive children with vesicant drug extravasation were retrospectively reviewed. The saline washout procedure was performed. Cosmetic aspect, residual pain and range of movement were analyzed as well as time to surgery and chemotherapy resumption at last follow-up.

RESULTS

Between 2014 and 2018, 13 cytotoxic vesicant drug extravasations occurred (mean age 8 years (sem 5)), including 11 treated by the saline washout procedure. At mean follow-up of 11 months (sem 7), the patients had no or low pain and ranges of movement were fully conserved. Two patients (one within the six hours' delay) had soft-tissue necrosis leading to extensive reconstructive surgery.

CONCLUSION

The saline washout procedure is safe and easy and significantly reduces the incidence of extensive skin damage. Early referral to a specialized department is essential. However, the key parameter remains prevention by educating medical staff and nurses about these injuries and by training them for early and urgent management.

LEVEL OF EVIDENCE

IV.

Management of Intravenous Infiltration Injuries

BACKGROUND

Intravenous (IV) lines are ubiquitous in hospital settings. These lines can malfunction, leaking noxious contents into subcutaneous tissue. Existing literature describes invasive intervention and complex treatment protocols. These persist despite significant changes in the composition and administration of IV agents. The purpose of this study is to examine the consequences of IV infiltrations at a tertiary medical center to update protocols and treatment algorithms.

MATERIALS AND METHODS

This study is an observational, retrospective chart review performed at a tertiary care medical center. All inpatient plastic surgery consultations for IV infiltration were reviewed from 2011 to 2017. Patients were included if IV infiltration was suspected or documented. Data were collected for each injury regarding patient demographics, substance, and intervention.

RESULTS

The plastic surgery service evaluated 381 IV infiltration injuries from 2011 to 2017, with 363 meeting the criteria. Injuries per year progressively increased, with 32 consultations in 2011 and 102 consultations in 2017. The vast majority of injuries identified (91%) were treated with only elevation and observation. The minority consisted of wound care (7%) performed by nursing or any form of incision, aspiration, or antidote injection (2%) performed by the physician. Of the 363 injuries, the most common infiltrates were noncytotoxic (35%), radiographic contrast (27%), and known vesicants (18%). Interestingly, a large portion of consultations were requested by other surgical services (32%).

CONCLUSIONS

Although there is an increase in expert involvement for cases of IV infiltration injuries, the vast majority of these injuries are managed with minimal intervention. This is most likely owing to recent changes that have decreased the potential for harmful infiltration. Contrary to existing literature, invasive intervention is almost never indicated.

Treatment of extravasation injuries in infants and young children: a scoping review and survey

BACKGROUND

Extravasation injuries are caused by unintended leakages of fluids or medicines from intravenous lines, but there is no consensus on the best treatment approaches.

OBJECTIVES

To identify which treatments may be best for treating extravasation injuries in infants and young children.

DESIGN

Scoping review and survey of practice.

POPULATION

Children aged < 18 years with extravasation injuries and NHS staff who treat children with extravasation injuries.

INTERVENTIONS

Any treatment for extravasation injury.

MAIN OUTCOME MEASURES

Wound healing time, infection, pain, scarring, functional impairment, requirement for surgery.

DATA SOURCES

Twelve database searches were carried out in February 2017 without date restrictions, including MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature) Plus and EMBASE (Excerpta Medica dataBASE).

METHODS

Scoping review - studies were screened in duplicate. Data were extracted by one researcher and checked by another. Studies were grouped by design, and then by intervention, with details summarised narratively and in tables. The survey questionnaire was distributed to NHS staff at neonatal units, paediatric intensive care units and principal oncology/haematology units. Summary results were presented narratively and in tables and figures.

RESULTS

The evidence identified in the scoping review mostly comprised small, retrospective, uncontrolled group studies or case reports. The studies covered a wide range of interventions including conservative management approaches, saline flush-out techniques (with or without prior hyaluronidase), hyaluronidase (without flush-out), artificial skin treatments, debridement and plastic surgery. Few studies graded injury severity and the results sections and outcomes reported in most studies were limited. There was heterogeneity across study populations in age, types of infusate, injury severity, location of injury and the time gaps between injury identification and subsequent treatment. Some of the better evidence related to studies of flush-out techniques. The NHS survey yielded 63 responses from hospital units across the UK. Results indicated that, although most units had a written protocol or guideline for treating extravasation injuries, only one-third of documents included a staging system for grading injury severity. In neonatal units, parenteral nutrition caused most extravasation injuries. In principal oncology/haematology units, most injuries were due to vesicant chemotherapies. The most frequently used interventions were elevation of the affected area and analgesics. Warm or cold compresses were rarely used. Saline flush-out treatments, either with or without hyaluronidase, were regularly used in about half of all neonatal units. Most responders thought a randomised controlled trial might be a viable future research design, though opinions varied greatly by setting.

LIMITATIONS

Paucity of good-quality studies.

CONCLUSIONS

There is uncertainty about which treatments are most promising, particularly with respect to treating earlier-stage injuries. Saline flush-out techniques and conservative management approaches are commonly used and may be suitable for evaluation in trials.

FUTURE WORK

Conventional randomised trials may be difficult to perform, although a randomised registry trial may be an appropriate alternative.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

A New Model for Non-Lipid Compounded Neonatal Parenteral Nutrition Solution Osmolality

BACKGROUND

Osmotic stress is a physical risk factor for adverse events related to peripheral parenteral nutrition (PN) administration, such as infiltration. We sought to improve prediction of compounded PN osmolality utilizing basic nutrient solutions available to North American neonatal intensive care units. This study tested the hypothesis that calculated osmolarity underestimates osmolality in compounded PN.

METHODS

Osmolarity (mOsm/L) was calculated utilizing commercial software. Osmolality (mOsm/kg) was determined by a freezing-point depression micro-osmometer. The relationship between calculated osmolarity and measured osmolality was modeled from linear or polynomial regression analysis using the least squares method. Regression models were based upon calculated osmolarity and included various combinations of PN components.

RESULTS

Calculated osmolarity significantly underestimated measured osmolality in all PN samples (n = 363). Based upon the osmolality of PN and the basic nutrient solutions, we determined a polynomial regression that effectively corrects for the osmolal gap (measured osmolality-calculated osmolarity) in the validation set (R² = 0.99367). The unbiased analysis corrected for the osmolal gap based on individual solute behaviors, as well as the solute-solute interactions in compounded solutions.

CONCLUSIONS

Calculated osmolarity (mOsm/L) significantly underestimates the osmolality (mOsm/kg) in compounded PN. We developed a new algorithm to more accurately predict PN osmolality based upon calculated osmolarity from commercial software and composition of neonatal basic nutrient solutions used in North America. We propose that use of this PN algorithm will facilitate future studies to determine whether a causal association exists between PN osmolality and adverse events, and to establish safe thresholds for PN concentration in neonates.

Younger age and in situ duration of peripheral intravenous catheters were risk factors for extravasation in a retrospective paediatric study

AIM

Epidemiological data on the incidence and risk factors of extravasation of peripheral intravenous catheters (PIVC) in neonates and children are scarce and that is what this study explored.

METHODS

This was a one-year retrospective study of all neonates and paediatric intensive care patients with at least one recorded PIVC at the Geneva University Hospitals, Switzerland, in 2013. The extravasation rate was determined for all patients, including neonates below 28 days, and for all PIVCs. Multivariate analysis of the associated risk factors was performed.

RESULTS

We analysed 1300 PIVC in 695 paediatric patients with a median age of 1.5 years. The overall extravasation incidence was 17.6% for all patients and 11.7% for PIVC. The overall incidence rate of PIVC extravasation was 4.5 per 100 catheters days, and the risk was highest in the 201 neonates, at 28.4%. The incidence rate four days after insertion of the PIVC was around three times higher than on day one. Neonates and the in situ duration of PIVCs were associated risk factors (p < 0.001).

CONCLUSION

Extravasation was frequent and neonates were particularly at risk. Younger age and longer in situ PIVC duration were independent risk factors for extravasation.

Infiltration and extravasation in pediatric patients: A prevalence study in a children’s hospital

Purpose:

The aim of this study is to determine the prevalence of infiltration and extravasation among children staying in a children’s hospital and the interventions carried out when infiltration or extravasation occurred.

Methods:

A prospective and descriptive research design was used in the study, conducted between September 2015 and February 2016, and determined the prevalence of infiltration and extravasation and their characteristics. The study sample consisted of 297 peripheral catheters in 173 pediatric patients.

Results:

Of 297 peripheral catheters, 50.8% were located on the right and 30.6% were inserted in the dorsal metacarpal vein. Infiltration and extravasation occurred in 2.9% and 2.3% of the patients, respectively. The prevalence of infiltration and extravasation was 5.5 and 4.4 per 1000 patient-days, respectively. The applied interventions after infiltration or extravasation included covering with a gauze dressing or alcohol-soaked cotton, cold application, irrigation with physiological saline, and elevation.

Conclusion:

The infiltration and extravasation prevalence were found to be high, but the interventions to address them were inadequate. Training and implementation strategies should be planned for pediatric nurses to prevent infiltration and extravasation.

[Emergency management of extravasation in children]

The subcutaneous diffusion of intravenous drips, or extravasation, is a frequent iatrogenic complication in children, mainly in the neonatal period. This potentially severe pathology can lead to local ischemia that sometimes mimics compartment syndrome. It can also evolve towards vast soft-tissue necrosis. Nursing staff often underestimate the risk of functional, aesthetic, and psychological consequences. The speed and quality of the initial medical and surgical management can greatly decrease morbidity associated with extravasation. Prevention is fundamental, such as raising awareness in and training medical and paramedical staffs and creating efficient protocols. Surgical management involving aspiration and washing the site as early as possible improves the prognosis. Aspiration and washing can be done on a larger area if one criteria of severity is met, particularly in cases of extravasation using a vesicant or hyperosmolar agent. If necrotic lesions appear, it is wise to wait until they become delimited. Debridement and coverage can be performed using classical methods.

Computed tomography contrast media extravasation: treatment algorithm and immediate treatment by squeezing with multiple slit incisions

In our hospital, an adverse event reporting system was initiated that alerts the plastic surgery department immediately after suspecting contrast media extravasation injury. This system is particularly important for a large volume of extravasation during power injector use. Between March 2011 and May 2015, a retrospective chart review was performed on all patients experiencing contrast media extravasation while being treated at our hospital. Immediate treatment by squeezing with multiple slit incisions was conducted for a portion of these patients. Eighty cases of extravasation were reported from approximately 218 000 computed tomography scans. The expected extravasation volume was larger than 50 ml, or severe pressure was felt on the affected limb in 23 patients. They were treated with multiple slit incisions followed by squeezing. Oedema of the affected limb disappeared after 1-2 hours after treatment, and the skin incisions healed within a week. We propose a set of guidelines for the initial management of contrast media extravasation injuries for a timely intervention. For large-volume extravasation cases, immediate management with multiple slit incisions is safe and effective in reducing the swelling quickly, preventing patient discomfort and decreasing skin and soft tissue problems.