Prehospital Dextrose Extravasation Causing Forearm Compartment Syndrome: A Case Report

A case report of furosemide extravasation in the hand: a rare cause of compartment syndrome

In emergency departments, many drugs, fluids, and materials for medical examinations and treatment are typically administered to patients intravenously. One of the most common complications of the intravenous bolus or infusion of drugs is extravasation injuries. These injuries may cause certain morbidities for the patient, increase the cost of treatment, and prolong hospital stays. At the same time, these injuries also carry medicolegal risks for health personnel. Furosemide is a potent diuretic that is commonly used in emergency departments for volume overload conditions. To the best of our knowledge, there have been no cases reported in the literature of furosemide-induced extravasation injury with subsequent compartment syndrome that has required surgical intervention. Presented herein is the case of a 70-year-old female patient who was administered intravenous furosemide from the dorsum of the left hand and whose extravasation injury progressed to compartment syndrome requiring an emergency fasciotomy.

Intraoperative acute compartment syndrome of the upper limb secondary to extravasation

A woman in her 50s was undergoing a repeat liver resection surgery for recurrence of liver metastasis when the intravenous fluid flow was noted to be sluggish on multiple occasions. On the third examination of the right hand where the intravenous cannula was located, surgery was halted as there was extensive swelling from the hand to the biceps and the hand had started turning blue. A diagnosis of acute upper limb compartment syndrome secondary to extravasation exacerbated by metaraminol was made by the anaesthetist and surgeon. Fasciotomies of the right upper limb were performed, and perfusion was restored. A hand surgeon arrived shortly after and completed decompressing the upper limb compartments.A literature review revealed risk factors such as communication barriers, age and chemotherapy were present in this case. Enhanced monitoring is needed in the context of unsatisfactory infusion flow rates perioperatively.

Dextrose 50% versus Dextrose 10% or Dextrose Titration for the Treatment of Out-of-Hospital Hypoglycemia: A Systematic Review

INTRODUCTION

Paramedics commonly administer intravenous (IV) dextrose to severely hypoglycemic patients. Typically, the treatment provided is a 25g ampule of 50% dextrose (D50). This dose of D50 is meant to ensure a return to consciousness. However, this dose may cause harm and lead to difficulties regulating blood glucose levels (BGLs) post-treatment. It is hypothesized that a lower concentration, such as 10% dextrose (D10), may improve symptoms while minimizing harm.

METHODS

PubMed, Embase, CINAHL, and Cochrane Central were systematically searched on September 15, 2020. The PRISMA guidelines were followed. GRADE and risk of bias were applied to determine the certainty of the evidence. Primary literature investigating the use of IV dextrose in hypoglycemic diabetic patients presenting to paramedics or the emergency department was included. Outcomes of interest included safety, efficacy (symptom resolution), and BGL.

RESULTS

Of 680 abstracts screened, 51 full-text articles were reviewed, with eleven studies included. Data from three randomized controlled trials (RCTs) and eight observational studies were analyzed. A single RCT comparing D10 to D50 was identified. The primary significant finding of the study was an increased post-treatment glycemic profile by 3.2mmol/L in the D50 group; no other outcomes had significant differences between groups. When comparing pooled data from all the included studies, there was greater symptom resolution in the D10 group (95.9%) compared to the D50 group (88.8%). However, the mean time to resolution was approximately four minutes longer in the D10 group (4.1 minutes [D50] versus 8.0 minutes [D10]). There was a greater need for subsequent doses with the use of D10 (19.5%) compared to D50 (8.1%). The post-treatment glycemic profile was lower in the D10 group at 6.2mmol/L versus 8.5mmol/L in the D50 group. Both treatments had nearly complete resolution of hypoglycemia: 98.7% (D50) and 99.2% (D10). No adverse events were observed in the D10 group (0/1057) compared to 13/310 adverse events in the D50 group.

CONCLUSION

Studies show D10 may be as effective as D50 at resolving symptoms and correcting hypoglycemia. Although the desired effect can take several minutes longer, there appear to be fewer adverse events. The post-D10-treatment BGL may result in fewer untoward hyperglycemic episodes.

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.

Assessment of dextrose 50 bolus versus dextrose 10 infusion in the management of hyperkalemia in the ED

INTRODUCTION

Hypoglycemia is a common adverse effect when intravenous (IV) insulin is administered for hyperkalemia. A prolonged infusion of dextrose 10% (D10) may mitigate hypoglycemia compared to dextrose 50% (D50) bolus. Our objective was to evaluate whether D10 infusion is a safe and effective alternative to D50 bolus for hypoglycemia prevention in hyperkalemic patients receiving IV insulin.

METHODS

We conducted a retrospective review of patients ≥ 18 years who presented to the emergency department (ED) with hyperkalemia (K⁺ > 5.5) and received IV insulin and D10 infusion or D50 bolus within 3 h. The primary endpoint was incidence of hypoglycemia, defined as blood glucose (BG) ≤ 70 mg/dL, in the 24 h following IV insulin administration for hyperkalemia.

RESULTS

A total of 134 patients were included; 72 in the D50 group and 62 in the D10 group. There was no difference in incidence of hypoglycemia between the D50 and D10 groups (16 [22%] vs. 16 [26%], p = 0.77). Symptomatic hypoglycemia, severe hypoglycemia, and hyperglycemia rates in the D50 and D10 groups were [5 (7%) vs. 2 (3%), p = 0.45], [5 (7%) vs. 1 (2%), p = 0.22], and [34 (47%) vs. 23 (37%), p = 0.31] respectively. Low initial BG was a predictor for developing hypoglycemia.

CONCLUSIONS

In our study, D10 infusions appeared to be at least as effective as D50 bolus in preventing hypoglycemia in hyperkalemic patients receiving IV insulin. In context of ongoing D50 injection shortages, D10 infusions should be a therapeutic strategy in this patient population.

A Comparison of 10% Dextrose and 50% Dextrose for the Treatment of Hypoglycemia in the Prehospital Setting

BACKGROUND

Hypoglycemia is a frequent cause of emergency medical services (EMS) activation; however, limited evidence exists to support optimal prehospital treatment.

OBJECTIVE

This study sought to compare the safety and efficacy of the administration of 10% dextrose (D10) intravenously (IV) versus 50% dextrose (D50) IV for the treatment of hypoglycemia in the prehospital setting.

METHODS

This was a retrospective cohort study of patients who received IV dextrose by EMS and were transported to an academic teaching hospital emergency department between 2014 and 2017.

RESULTS

Four hundred seventy-eight eligible patients were reviewed, with 161 patients receiving D10 and 150 patients receiving D50. There was no significant difference found regarding the need for dextrose retreatment prior to hospital arrival between the D10 and D50 groups (0.6% vs 2.0%; P = .565). The prehospital reassessment glucose in the D50 group was a significantly higher than the D10 group (151.9 vs 124.6 mg/dL, P = .001) and this difference was maintained on hospital arrival (129.5 vs 108.0 mg/dL, P = .011). No significant difference was found between groups with regard to hospital admission, length of stay, or in-hospital mortality.

CONCLUSION

When comparing D10 with D50 for the treatment of hypoglycemia by EMS, there were no significant differences in the need for dextrose retreatment prior to hospital arrival. The use of D50 resulted in a significantly higher blood glucose concentrations both in the prehospital setting and upon hospital arrival. Further study is needed in larger patient populations to evaluate the use of D10, the need for dextrose readministration, and its impact on clinical outcomes.

Forearm Compartment Syndrome: Evaluation and Management

Compartment syndrome of the forearm is uncommon but can have devastating consequences. Compartment syndrome is a result of osseofascial swelling leading to decreased tissue perfusion and tissue necrosis. There are numerous causes of forearm compartment syndrome and high clinical suspicion must be maintained to avoid permanent disability. The most widely recognized symptoms include pain out of proportion and pain with passive stretch of the wrist and digits. Early diagnosis and decompressive fasciotomy are essential in the treatment of forearm compartment syndrome. Closure of fasciotomy wounds can often be accomplished by primary closure but many patients require additional forms of soft tissue coverage procedures.