Extravasation injuries in adults

Describing Intravenous Extravasation Injuries in Children (DIVE2 Study)

Background

Extravasation is the erroneous delivery of IV medication or fluid into the extravascular space. Complications ranging from mild injury to amputation can result, depending on the physical and pharmacologic properties of the infusate. Children are at increased risk for extravasation injuries. There is a paucity of data on the treatment and outcomes of extravasation injuries, particularly in terms of the role of pharmacologic antidotes.

Objectives

To describe the incidence of extravasation at a tertiary pediatric care centre (as an update to a previous study), to identify the agents most commonly involved in extravasation injuries, to describe the antidotes used for management of injuries and their related adverse drug effects, and to describe complications related to injuries.

Methods

The medical records of pediatric patients who experienced an extravasation injury at the BC Children's and BC Women's Hospitals, between September 1, 2008, and September 30, 2020, were reviewed. Data regarding management (adherence with institutional protocol) and outcomes of injuries were collected.

Results

The 242 charts included in the analysis noted a total of 245 extravasation injuries, for an extravasation incidence of 0.04% per patient-day. Of the 242 patients, 110 were excluded from secondary outcome analysis due to lack of data detailing the extravasation event. Of the remaining 132 patients, the majority were neonates (n = 54, 40.9%), infants (n = 33, 25.0%), and children (n = 34, 25.8%), and more than a third were treated on general pediatric wards (n = 50, 37.9%). The medications most frequently involved were total parenteral nutrition with lipids (36/132, 27.3%), vancomycin (36/132, 27.3%), and IV fluids (35/132, 26.5%). Most of the patients had mild outcomes and recovered without complications. No adverse drug events from antidotes were reported.

Conclusions

The incidence of extravasation at the study institution remained low, with the medications involved being similar to those reported in the literature and the majority of patients having mild outcomes. Additional prospective studies are needed to assess the efficacy and safety of antidotes administered for extravasation injuries.

Chemotherapy Extravasation Causing Soft-Tissue Necrosis Mimicking Infection: A Longitudinal Case Study

Extravasation injuries are uncommon, underreported, and often misdiagnosed in patients. The signs and symptoms of extravasation injuries vary from simple pain and tenderness to tissue necrosis and potentially fatal secondary infections. Extravasation may progress to more severe conditions such as necrotizing fasciitis (NF) or cellulitis, so special care is needed by physicians to identify and treat these injuries correctly. Here, we explore a case study on extravasation injuries mimicking NF leading to infectious complications and discuss the proper diagnosis and treatment of extravasation injuries as well as other NF-mimicking diseases. We present a case of a 44-year-old Hispanic male with a history of B-cell acute lymphoblastic leukemia who underwent inpatient chemotherapy treatment via a chest port.

A temperature-responsive intravenous needle that irreversibly softens on insertion

The high stiffness of intravenous needles can cause tissue injury and increase the risk of transmission of blood-borne pathogens through accidental needlesticks. Here we describe the development and performance of an intravenous needle whose stiffness and shape depend on body temperature. The needle is sufficiently stiff for insertion into soft tissue yet becomes irreversibly flexible after insertion, adapting to the shape of the blood vessel and reducing the risk of needlestick injury on removal, as we show in vein phantoms and ex vivo porcine tissue. In mice, the needles had similar fluid-delivery performance and caused substantially less inflammation than commercial devices for intravenous access of similar size. We also show that an intravenous needle integrated with a thin-film temperature sensor can monitor core body temperature in mice and detect fluid leakage in porcine tissue ex vivo. Temperature-responsive intravenous needles may improve patient care.

Sensing Technologies for Extravasation Detection: A Review

Peripheral intravenous catheters are administered for various purposes, such as blood sampling or the infusion of contrast agents and drugs. Extravasation happens when the catheter is unintentionally directed outside of the vein due to movement of the intravascular catheter, enhanced vascular permeability, or occlusion of the upstream vein. In this article, extravasation and its mechanism are discussed. Subsequently, the sensorized devices (e.g., single sensor and multimodal detection) to identify the extravasation phenomena are highlighted. In this review article, we have shed light on both physiological and engineering points of view of extravasation and its detection approaches. This review provides an overview on the most recent and relevant technologies that can help in the early detection of 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.

Safety and Tolerability of 23.4% Hypertonic Saline Administered Over 2 to 5 Minutes for the Treatment of Cerebral Herniation and Intracranial Pressure Elevation

BACKGROUND

Hyperosmolar therapy is the cornerstone of medical management of sustained elevated intracranial pressure from cerebral edema. Acute intracranial hypertension and herniation is a medical emergency that requires rapid treatment and stabilization to prevent secondary brain injury or death. Intravenous hypertonic sodium chloride (NaCl) 23.4% is an effective treatment modality commonly used in this setting. Because of its high osmolarity, use has historically been limited primarily to central venous line administration as an intermittent infusion due to concerns about thrombophlebitis, injection site pain, and tissue necrosis or injury with extravasation. The objective of this analysis was to prospectively evaluate the safety of administration of 23.4% NaCl as a rapid intravenous push over 2-5 min.

METHODS

A prospective analysis of patients admitted between April 2021 and December 2021 who received 23.4% NaCl intravenous push over 2-5 min in a central or peripheral line was performed. Safety end points included incidence of new onset hypotension [defined as systolic blood pressure (SBP) < 90 mm Hg or SBP decrease of at least 20 mm Hg], bradycardia (defined as heart rate < 50 beats per minute), and infusion site reactions documented within 1 h of administration. For secondary safety outcomes, highest and lowest SBP and lowest heart rates documented within 1 h before 23.4% NaCl administration were compared with values collected within 1 h post administration and evaluated by mixed-design analysis of variance test with adjustment for peripheral versus central line administration.

RESULTS

We identified 32 patients who received 79 administrations of 23.4% NaCl through a central line or peripheral line during the study period. An SBP decrease of at least 20 mm Hg was observed in 13% of patients, an SBP < 90 mm Hg occurred in 16% of patients, and bradycardia occurred in 3% of patients who received 23.4% NaCl. Injection site pain was reported by one patient without documented thrombophlebitis, cellulitis, or tissue damage. Pain was not reported during two subsequent administrations in the same patient. There was no documented occurrence of soft tissue injury or necrosis in any patient. Compared with baseline vital signs before 23.4% NaCl administration, no difference in vital signs post administration was observed.

CONCLUSIONS

Central and peripheral administration of 23.4% NaCl over 2-5 min was well tolerated, and incidence of hypotension, bradycardia, or infusion site-related adverse events was rare.

A novel use for the biodegradable temporizing matrix

Biodegradable Temporising Matrix (BTM), a skin substitute, has been recently developed as a novel adjunct to the plastic surgeon’s reconstructive repertoire. Its use has been described in literature in a variety of settings and complex wounds, including those that previously would have been described as “non-graftable”, with favourable outcomes. We present the case of a patient with a wound to the right foot and ankle following extravasation injury. Following surgical debridement, this injury was managed with BTM, which allowed granulation and production of a “neo-dermis”. A split-thickness skin graft was subsequently applied. The characteristics of the BTM allowed the resulting skin graft and scar to be pliable, avoiding tendon tethering and joint contracture. To the authors’ knowledge, this skin substitute has not been reported in a wound of this aetiology before. It is our hope that this report will provide evidence to colleagues that this is a valuable adjunct that may be used in complex wounds.

Level of evidence: Level V, therapeutic study.

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.

Peripheral intravenous catheters in the care of oncology and haematology patients

Aim

To determine peripheral intravenous catheter (PIVC) characteristics, complications and risk factors among patients in cancer units.

Methods

A secondary analysis of a global, cross-sectional study (127 hospitals in 24 countries). Participants (≥18 years) admitted to cancer units were assessed once for PIVC characteristics and the presence of complications. Variables included patient demographics, device characteristics, treatment details, and device and/or site complications. PIVC characteristics were presented using qualitative descriptors; mixed-effects logistic regression models determined risk factors for PIVC complications.

Results

In total, 1,807 participants (1,812 PIVCs) were included; 12% (n=215) of PIVCs presented with complications. Risk factors included: insertion by doctors; insertion in ED and ambulance/other locations; poor PIVC dressing integrity; dwell time ≥49 hours; and administration of colloids/blood products and antiemetics.

Conclusions

At least one in ten PIVCs in cancer units present with complications; regular PIVC assessment and improved dressing integrity is likely to reduce risk and improve outcomes.

Intravenous antimicrobial administration through peripheral venous catheters - establishing risk profiles from an analysis of 5252 devices

INTRODUCTION

Peripheral venous catheters (PVCs) are used to administer antimicrobials, but many fail prior to completion of therapy. While some antimicrobials are known to increase the PVC failure rate, risk profiles for many are unclear.

OBJECTIVE

To synthesize data from prospective PVC studies conducted between 2013 and 2019 to determine associations between common antimicrobials and PVC failure.

METHODS

A secondary analysis was undertaken of seven randomized controlled trials and two prospective cohort studies from three quaternary hospitals (two adult and one paediatric) in Australia between 2013 and 2019. The primary outcome was PVC failure due to vessel injury (occlusion, infiltration or extravasation) or irritation (pain or phlebitis). Associations between antimicrobial use and PVC failure were explored using multi-variable Cox regression.

RESULTS

In total, 5252 PVCs (4478 patients) were analysed; vessel injury and irritations occurred in 19% and 11% of all PVCs, respectively. Vessel injury was significantly associated with cefepime hydrochloride [hazard ratio (HR) 2.50; 95% confidence interval (CI) 1.44-4.34], ceftazidime pentahydrate (HR 1.91, 95% CI 1.11-3.31), flucloxacillin sodium (HR 1.84, 95% CI 1.45-2.33), lincomycin hydrochloride (HR 1.67, 95% CI 1.10-2.52) and vancomycin hydrochloride (HR 1.73, 95% CI 1.25-2.40). Irritation was significantly associated with flucloxacillin sodium (HR 2.58, 95% CI 1.96-3.40).

CONCLUSIONS

This study identified several antimicrobials associated with increased PVC failure, including some that were already known to be associated and some that had not been identified previously. Research is needed urgently to determine superior modes of delivery (e.g. dilution, infusion time, device type) that may prevent PVC failure.

Peripheral IV Administration of Hypertonic Saline: Single-Center Retrospective PICU Study

OBJECTIVES

To determine the frequency and characteristics of complications of peripherally administered hypertonic saline (HTS) through assessment of infiltration and extravasation.

DESIGN

Retrospective cross-sectional study.

SETTING

Freestanding tertiary care pediatric hospital.

PATIENTS

Children who received HTS through a peripheral IV catheter (PIVC).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We conducted a single-center retrospective review from January 2012 to 2019. A total of 526 patients with 1,020 unique administrations of HTS through a PIVC met inclusion criteria. The primary endpoint was PIVC failure due to infiltration or extravasation. The indication for the administration of HTS infusion was collected. Catheter data was captured, including the setting of catheter placement, anatomical location on the patient, gauge size, length of time from catheter insertion to HTS infusion, in situ duration of catheter lifespan, and removal rationale. The administration data for HTS was reviewed and included volume of administration, bolus versus continuous infusion, infusion rate, infusion duration, and vesicant medications administered through the PIVC. There were 843 bolus infusions of HTS and 172 continuous infusions. Of the bolus administrations, there were eight infiltrations (0.9%). The continuous infusion group had 13 infiltrations (7.6%). There were no extravasations in either group, and no patients required medical therapy or intervention by the wound care or plastic surgery teams. There was no significant morbidity attributed to HTS administration in either group.

CONCLUSIONS

HTS administered through a PIVC infrequently infiltrates in critically ill pediatric patients. The infiltration rate was low when HTS is administered as a bolus but higher when given as a continuous infusion. However, no patient suffered an extravasation injury or long-term morbidity from any infiltration.

Outcomes and Management of Peripheral Intravenous Infiltration Injuries

Background: Although intravenous (IV) infiltration is relatively common, data regarding complications and outcomes of this problem remain limited. In addition, there is wide variation in institutional protocols for the management of IV infiltrations. Through retrospective review, we aim to delineate complications and outcomes, and propose an algorithm for the management of these injuries. Methods: We performed a retrospective review of all patients who had an IV infiltration at a tertiary care center's inpatient and outpatient facilities between January 1, 2016, and December 31, 2018. Results: In all, 479 patients with 495 infiltrations were included, with a mean age of 36.7 years. The upper extremity was involved in 89.6% of events. Of all the events, 8.6% led to a superficial soft tissue infection, 3.2% led to necrosis or eschar formation, and 1.9% led to ulceration or full-thickness wound formation. There were zero cases of compartment syndrome. Only 5.1% resulted in any long-term defects; none resulted in a functional defect of the extremity. Patients with vascular disease did not experience worse outcomes compared with healthy individuals. Plastic or orthopedic surgery was consulted in 25.3% of events. No emergent surgical intervention was required, 7 (1.4%) required bedside procedures, and 7 (1.4%) patients underwent nonacute operations. Conclusions: A specialist was consulted in about one-quarter of IV infiltrations, yet none were surgical emergencies. Instead, most complications could be monitored and managed by a primary team. Therefore, we propose algorithms involving nursing staff, wound care teams, and primary physicians with limited specialist consultation to manage these injuries.

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.

A rare case report of neonatal calcinosis cutis induced by distant and delayed extravasation of intravenous calcium gluconate

A 3,480 g male neonate showed tachypnea symptom with a serum ionized calcium level of 0.66 mmol/L by routine clinical analysis. He was injected calcium gluconate intravenously through femoral vein catheter to treat the hypocalcemia. On second day after the injection, he started to show erythema in the flank area. The lesion became firm and changed into whitish crust consist of small crystals. Abdominal X-ray and ultrasonography showed the accumulation of calcium deposit in the subcutaneous layer of the lesion. Surgical debridement was performed to remove the crust with calcium deposit and acellular fish skin graft rich in omega-3 (Kerecis) was applied to the defect site for secondary intention of the defect wound. After 2 months, the skin and soft tissue defect were fully covered with healthy normal skin without depression or contracture. This report is a first case of iatrogenic calcinosis cutis without extravasation symptom.

Possibility of Taking an Offensive Stance in Extravasation Injury: Effects of Fat Injection in Vesicant (Doxorubicin) Induced Skin Necrosis Model in Rats

INTRODUCTION

Extravasation injuries are one of the most feared complications of intravenous drug administration. The most common drugs associated with extravasation injury include chemotherapy agents and contrast media. Natural course of vesicant extravasation is discomfort, pain, swelling, inflammation, and ultimately skin ulceration. While diligence is the principle approach in prevention, immediate bed-side measures are as important in controlling the extent of tissue damage. Various options, either medical or interventional are next steps in treatment of the condition including antidotes, volume dilution, flushing, suction, hyperbaric oxygen therapy, and surgery.

MATERIALS AND METHODS

12 male Wistar albino rats were divided into two groups; one group received fat injections following subdermal doxorubicin infiltration in their right thighs, while other group received saline injection following subdermal doxorubicin infiltration in their right thighs for dilution. Left thighs of both groups were left untreated following subdermal doxorubicin infiltration. Total area of necrosis, as well as resultant epidermal thicknesses were assessed. Histological analyses were conducted using modified Verhofstad scoring system for comparison.

RESULTS

Mean necrotic area was significantly smaller in the fat injection group compared to other groups. Median Verhofstad score was lesser in the fat injection group as well. Median epidermal thickness, on the other hand, was greater in the fat injection group.

CONCLUSION

Injection of fat grafts following vesicant extravasation might be beneficial in preventing the progression of tissue damage, if employed early.

'Pinholes in my arms': the vicious cycle of vascular access

BACKGROUND

Vascular access devices (VADs) are essential for delivery of intravenous therapies. There are notable gaps in the literature regarding a focus on patient experience and meaning-making related to living with a VAD, specifically a central venous access device (CVAD).

AIMS

To explore how patients make sense of living with a CVAD.

METHODS

This study followed an interpretive phenomenological analysis (IPA) approach. Purposive sampling was used to identify 11 cancer patients who had a CVAD in situ. One-to-one semi-structured interviews were performed. Interviews were digitally recorded, transcribed and analysed by the lead author.

FINDINGS

Four superordinate themes were identified: the self under attack; being rescued/being robbed; protection of others/protection of self; bewilderment and dismay at lack of staff competence.

CONCLUSION

Having a CVAD affects the psychological, social, and personal self and impacts on self-esteem and self-image. Despite this, CVADs are accepted by patients and are eventually 'embodied' by them.

A Unique Treatment for Compartment Syndrome After Intravenous Catheter Extravasation: A Case Report

Intravenous cannulation is performed on nearly every patient presenting for an anesthetic. Complications of the procedure include infiltration and extravasation, which can have a varied impact on the patient. Here, we present a case of severe intravenous (IV) extravasation, resulting in compartment syndrome of the hand. Rather than treating the compartment syndrome with fasciotomies as is standard, we utilized compression therapy via an Esmarch surgical dressing wrapped distal to proximal on the effected limb, which resulted in marked decrease in swelling and return of perfusion to the hand.

Efficacy of combination of localized closure, ethacridine lactate dressing, and phototherapy in treatment of severe extravasation injuries: A case series

BACKGROUND

The management of severe extravasation injuries is still controversial. Extravasation injuries can be treated in many ways.

AIM

To present a series of patients with severe extravasation injuries due to infusion who were managed with ethacridine lactate dressing combined with localized closure and phototherapy.

METHODS

In this study, we evaluated the data of eight patients, including six from the Department of Burn, one (with colorectal carcinoma) from the Veteran Cadre Department, and one (with leukemia) from the Hematology Department. Of these, three patients were male and five were female. Age of the patients ranged from 10 mo to 72 years, including two children (10 and 19 mo of age). In this study, the infusion was stopped immediately when the extravasation was identified. The extravasation event was managed routinely using a blocking solution. A ring-shaped localized closure was performed using the blocking agents. Moreover, ethacridine lactate dressing and phototherapy were applied for 3-5 d.

RESULTS

In this study, the drugs contained in the infusates were iodixanol, norepinephrine, alprostadil, amino acids, fat emulsion, cefoselis, cefoxitin, and potassium chloride + concentrated sodium chloride. All of the patients achieved complete healing after treatment and no obvious adverse reactions were observed.

CONCLUSION

The treatment of severe extravasation injuries using a combination of localized closure, ethacridine lactate dressing, and phototherapy resulted in satisfactory outcomes in patients.

Safety and Efficacy of 23.4% Sodium Chloride Administered via Peripheral Venous Access for the Treatment of Cerebral Herniation and Intracranial Pressure Elevation

BACKGROUND

Sodium chloride (NaCl) 23.4% solution has been shown to reduce intracranial pressure (ICP) and reverse transtentorial herniation. A limitation of 23.4% NaCl is its high osmolarity (8008 mOsm/l) and the concern for tissue injury or necrosis following extravasation when administered via peripheral venous access. The use of this agent is therefore often limited to central venous or intraosseous routes of administration. Our objective was to evaluate the safety and efficacy of administration of 23.4% NaCl via peripheral venous access compared with administration via central venous access.

METHODS

We reviewed pharmacy records to identify all administrations of 23.4% NaCl at our institution between December 2017 and February 2020. Medical records were then reviewed to identify complications, such as extravasation, soft tissue injury or necrosis, hypotension (mean arterial pressure less than 65 mm Hg), pulmonary edema, hemolysis, and osmotic demyelination. We also compared the change in physiological variables, such as ICP, mean arterial pressure, cerebral perfusion pressure, and heart rate, as well as laboratory values, such as sodium, chloride, bicarbonate, creatinine, and hemoglobin, following administration of 23.4% NaCl via the peripheral and central venous routes.

RESULTS

We identified 299 administrations of 23.4% NaCl (242 central and 57 peripheral) in 141 patients during the study period. There was no documented occurrence of soft tissue injury or necrosis in any patient. One patient developed hypotension following central administration. Among the 38 patients with ICP monitoring at the time of drug administration, there was no significant difference in median ICP reduction (- 13 mm Hg [central] vs. - 24 mm Hg [peripheral], p = 0.21) or cerebral perfusion pressure augmentation (16 mm Hg [central] vs. 15 mm Hg [peripheral], p = 0.87) based on route of administration.

CONCLUSIONS

Peripheral venous administration of 23.4% NaCl is safe and achieves a reduction in ICP equivalent to that achieved by administration via central venous access.

Novel Conformal Skin Patch with Embedded Thin-Film Electrodes for Early Detection of Extravasation

Extravasation is a complication of intravenous (IV) cannulation in which vesicant drugs leak from a vein into the surrounding subcutaneous tissue. The severity of extravasation depends on the type, concentration, and volume of drugs that accumulate in the subcutaneous tissue. Rapid detection of extravasation can facilitate prompt medical intervention, minimizing tissue damage, and preventing adverse events. In this study, we present two portable sensor patches, namely gold- and carbon-based sensing patches, for early detection of extravasation. The gold-based sensor patch detected extravasated fluid of volume as low as 2 mL in in vivo animal models and human clinical trials; the patch exhibited a resistance change of 41%. The carbon-based sensor patch exhibited a resistance change of 51% for 2 mL of extravasated fluid, and fabrication throughput and cost-effectiveness are superior for this patch compared with the gold-based sensing patch.

Medical-Grade Honey for the Treatment of Extravasation-Induced Injuries in Preterm Neonates: A Case Series

INTRODUCTION

Preterm neonates often depend on peripheral intravenous administration of nutrition and medication. Since their skin is not fully developed and very vulnerable, extravasation injury is a risk. Medical-grade honey (MGH) possesses antimicrobial activity and stimulates wound healing; although its use in neonatal patients is limited.

CLINICAL FINDINGS

We present a case series of 7 preterm neonates (28-36 weeks of gestation) with extravasation injuries secondary to peripheral intravenous administration of total parental nutrition and medication.

PRIMARY DIAGNOSIS

Extravasation injury following the unintentional leakage of total parenteral nutrition, and medication into the surrounding tissue. Signs of extravasation include local pain, erythema, burning, pruritus, and/or swelling.

INTERVENTIONS

All extravasation injuries were treated with daily cleaning and application of MGH. Some of the cases needed additional surgical intervention or assisted debridement.

OUTCOMES

After treatment, all extravasation injury wounds presented with granulation tissue formation progressed to normal epithelialization and closed in 7 to 67 days (median: 32 days). Upon initial application, peripheral edema and inflammation decreased. When present, necrotic tissue was effectively debrided, slough was removed, and no signs of infection were detected, irrespective of initial wound presentations. Cicatrization was minimal, and the full range of motion was preserved in all cases.

PRACTICE RECOMMENDATIONS

Continuous and thorough assessment of peripheral intravenous line placement for malposition, leaking, and signs of extravasation is needed for fast discovery and prevention of further damage.

CONCLUSION

Medical-grade honey possesses antimicrobial, anti-inflammatory, and antioxidative activity, enhancing wound healing. Medical-grade honey was safe and effective for treating extravasation-induced injuries, independent of location and severity. We recommend MGH for treating extravasation wounds and consideration for other types of wounds.

Skin ulceration as a complication from unexpected extravasation injury: A case report

Background

Extravasation injury (EVI) is common, yet it is always underestimated and underreported. Severity varies ranging from thrombophlebitis up to disability. Unrecognised EVI is a potential medicolegal case in medicine.

Case presentation

We experience a 47-year-old lady who developed an unrecognised EVI after being admitted for sepsis. The EVI turned out to be a huge and sloughy skin ulcer. A series of wound debridement with vacuum dressing were conducted until the wound was able to be closed.

Discussion

The EVI can be categorised according to Amjad EVI grading and Loth and Eversmann's EVI classification. Adult EVI tends to be overlooked, especially during critical care because patients cannot complain upon sedation and ventilation. In order to prevent EVI, firstly prevention is better than cure. Secondly, if EVI is recognised early, infusion should be stopped immediately. Thirdly, analgesia is mandatory. Finally, the plastic team needs to be engaged if it is deemed required.

Conclusion

Prevention and early intervention before the occurrence of progressive tissue damage is the key to treatment. Early radical wound debridement and immediate or delayed wound coverage with skin graft or skin flap are indicated in full thickness skin necrosis, persistent pain, and chronic ulcer.

Managing Chemotherapy Extravasation Across Transitions of Care: A Clinical Nurse Specialist Initiative

Chemotherapy extravasation can lead to serious patient harm in patients with cancer. For nurses who administer vesicant chemotherapy, extravasation is a primary concern. Regardless of nurse experience level and despite prevention strategies, extravasations occur. Literature related to nurse management of chemotherapy extravasation beyond initial treatment is lacking, and no descriptors are available for a formalized process. Communication gaps and a lack of standardized follow-up within a 1400-bed, quaternary care academic medical institution contributes to challenges in care continuity when patients transition between hospital and ambulatory settings. With chemotherapy extravasation, the site does not immediately exhibit signs of tissue injury, leading to a false sense of security. As a result, tissue damage can be significant by the time the patient returns for his or her regular appointment. Two oncology clinical nurse specialists (CNSs) recognized an opportunity to bridge the gap and overcome the challenges by addressing patient needs postextravasation. Between 2015 and 2016, a formal consult process was designed, approved, and implemented to observe, manage, and make recommendations for timely care and follow-up. Since implementation of the process, the oncology CNSs have received multiple requests for consultations. Nursing staff report increased comfort levels with this process in place. A formalized process for managing chemotherapy extravasations increases patient safety and patient and nurse satisfaction.

Nested graft for chronic ulcer in scar tissue after heroin extravasation in a drug addict

INTRODUCTION

Nested graft is a surgical technique that allows to manage difficult-to-treat medical conditions such as chronic cutaneous ulcers, thanks to the high efficacy it has in reverting the fibroblasts senescence. Because of its peculiar regenerative property, nested graft is a surgical technique suitable also for the treatment of cutaneous ulcers developing on fibrotic scar tissue.

CASE REPORT

We reported the case of a 45-year-old man, drug-addict, with a large ulcer on the back of the right forearm in the context of scar fibrotic tissue. This lesion resulted from a previous heroin extravasation treated with a dermo-epidermal skin graft, that was accidentally scratched away by mechanical trauma. After several therapeutic failures with topical medications, we decided to treat the ulcer performing a skin graft using the nested graft technique. No adverse events were reported by the patient during or after the surgery. At the clinical evaluation performed three years later the wound was completely healed.

CONCLUSIONS

Nested graft represents a safe and easy-to-use technique that can be successfully used to treat ulcers on scar tissue, ensuring the achievement and the long-term maintenance of optimal resistance and aesthetic results.

Infusion Site Reactions: Classification in the Setting of Fosaprepitant Administration With Chemotherapy

BACKGROUND

Studies report a wide range of incidence and severity of infusion site adverse events (ISAEs) following fosaprepitant administration.

OBJECTIVES

The purposes of this study were (a) to determine the incidence of suspected extravasation in patients with cancer receiving fosaprepitant infusions with chemotherapy and (b) to determine whether the documented signs, symptoms, and management strategies aligned with the diagnostic criteria for extravasation versus non-extravasation ISAEs.

METHODS

Electronic health records were used to identify patients who received fosaprepitant infusion with chemotherapy and had documentation for suspected extravasation. Chart reviews were conducted for a sample of patients to determine whether documentation was consistent with extravasation.

FINDINGS

About 3% (n = 460 of 15,667) of patients who received fosaprepitant had documentation for suspected extravasation. Among a random sample of patients (N = 110) with suspected extravasation, 6% (n = 6) had documentation consistent with extravasation.

Adverse cutaneous reactions to chemotherapeutic drugs

Drug reactions resulting from chemotherapy agents are common and frequently affect the skin. Although often benign, a select few of these cutaneous reactions may necessitate immediate changes to the antineoplastic regimens. Given the diversity of chemotherapeutic skin reactions and their complex implications on patient management, an organized conceptual schema is imperative for proper patient care. We evaluate a number of commonly seen chemotherapy-induced skin toxicities organized by pathogenic mechanism and drug class, providing a framework for the identification and categorization of adverse events to prevent unrecognition. Groupings of these reactions include direct cytotoxicity and/or drug accumulation, immunologic hypersensitivity, and aberrant molecular signaling.

Peripheral intravenous cannulation: reducing pain and local complications

Caring for patients with peripheral intravenous cannulas/catheters (PIVCs) is an important part of the nurse's role and insertion of PIVCs has traditionally been a post-registration nursing skill. With the introduction of the Nursing and Midwifery Council Standards of Proficiency for Registered Nurses in 2018, insertion of PIVCs is to be incorporated in pre-registration nursing programmes for all four fields of nursing practice. Although IV cannulation is a commonly performed clinical procedure, it is associated with significant risks and complications, which can cause pain for patients. This article outlines the factors that can cause pain for adult patients requiring a PIVC and recommends that the use of local anaesthetics be more widely considered when inserting a cannula. The identification, prevention and clinical management of commonly occurring painful local complications that can arise post-PIVC insertion are also discussed.

Utility of color flow Doppler ultrasound to identify peripheral intravenous catheter position in adult surgical patients

Objective:

To evaluate color flow Doppler flow ultrasound compared to standard clinical techniques, to detect the intravascular position of peripheral intravenous catheters in adult surgical patients.

Methods:

A prospective study was conducted in adult (>18 years old) patients scheduled to undergo elective surgery. Peripheral intravenous catheter position was evaluated with standard clinical techniques (free flow of fluid from a hanging bag, easy saline injection, and aspiration of blood), and with color flow Doppler ultrasound proximal to the insertion site to identify intravascular catheter position. Comparative test performance was carried out.

Results:

In total, 174 patients were enrolled. The venous catheter was deemed to be intravascular in 92.53% (n = 161) and 90.23% (n = 157) based on clinical evaluation and color flow Doppler, respectively (p = 0.206). Moderate to substantial agreement between the two approaches was found. Cohen’s kappa was 0.64 (95% CI 0.43–0.83). Specificity of clinical judgment to detect catheter extravascular position was only 58.82%, when the color flow Doppler technique was set as the gold standard. Free flow from a hanging bag method showed the best agreement with color flow Doppler to determine intravascular position of a catheter (p = 0.3173, kappa = 0.68), with sensitivity of 98.09% and specificity of 64.71%.

Conclusion:

Color flow Doppler is a specific tool complementary to sensitive clinical indicators to detect peripheral venous catheter infiltration. The ability of color flow Doppler to accurately determine the position of a peripheral venous catheter depends on experience and familiarity with the tool by providers, who can master the technique with education and training.

Extravasation of Noncytotoxic Drugs

Objective: Commonly used drugs may be dangerous in case of extravasation. The lack of information from health care teams can lead to delays in both diagnosis and treatments. This review aims at alerting health care professionals about drugs and risk factors for extravasation and outlines recommendations for the diagnosis and treatment of extravasation. Data Source: A literature search of MEDLINE/PubMed, Scopus, the Cochrane Library, and Google Scholar was performed from 2000 to December 2019 using the following terms: extravasation, central venous line, peripheral venous line, irritant, and vesicant. Study Selection and Data Extraction: Overall, 140 articles dealing with drug extravasation were considered potentially relevant. Each article was critically appraised independently by 2 authors, leading to the inclusion of 80 relevant studies, guidelines, and reviews. Articles discussing incidents of extravasation in the neonatal and pediatric population of patients were excluded. Data Synthesis: Training of health care teams and writing care protocols are important for an optimal management of extravasations. A prompt consultation should be achieved by a specialist surgeon. The surgical procedure, if necessary, will consist of wound debridement followed by an abundant lavage. Relevance to Patient Care and Clinical Practice: This review discusses the management of drug extravasations according to their mechanism(s) of toxicity on tissues. It highlights the importance of a close monitoring of patients and the training of health care teams likely to face this type of adverse event. Conclusions: Extravasations still contribute to significant morbidity and mortality. A good knowledge of risk factors and the implementation of easily and quickly accessible standardized care protocols are 2 key elements in both prevention and treatment of extravasations.

Intraosseous Administration of 23.4% NaCl for Treatment of Intracranial Hypertension

BACKGROUND/OBJECTIVE

Prompt treatment of acute intracranial hypertension is vital to preserving neurological function and frequently includes administration of 23.4% NaCl. However, 23.4% NaCl administration requires central venous catheterization that can delay treatment. Intraosseous catheterization is an alternative route of venous access that may result in more rapid administration of 23.4% NaCl.

METHODS

Single-center retrospective analysis of 76 consecutive patients, between January 2015 and January 2018, with clinical signs of intracranial hypertension received 23.4% NaCl through either central venous catheter or intraosseous access.

RESULTS

Intraosseous cannulation was successful on the first attempt in 97% of patients. No immediate untoward effects were seen with intraosseous cannulation. Time to treatment with 23.4% NaCl was significantly shorter in patients with intraosseous access compared to central venous catheter (p < 0.0001).

CONCLUSIONS

Intraosseous cannulation resulted in more rapid administration of 23.4% NaCl with no immediate serious complications. Further investigations to identify the clinical benefits and safety of hypertonic medication administration via intraosseous cannulation are warranted.

Contrast Extravasation using Power Injectors for Contrast-Enhanced Computed Tomography in Children: Frequency and Injury Severity

PURPOSE

To evaluate the safety of power injectors for contrast-enhanced computed tomography (CT) in children, namely: the prevalence and injury severity of contrast extravasations related to power injectors and the factors associated with these events.

METHODS

The need to obtain informed consent was waived for this HIPAA-compliant and IRB approved retrospective study. Around 2429 contrast-enhanced CT performed with a power injector were identified during a 3-year period. Data collected included patient demographic, power injector, and contrast agent information. The patients' symptoms, severity of injury and treatment with contrast extravasation were recorded. Around 1496 cases (823 boys, 673 girls) were included in the analysis. Independent-sample t test and Chi-square were used. For a sub-analysis using the extravasation cases, nonparametric tests were used.

RESULTS

The mean age was 9.5 ± 6.1 years. The most common access site, catheter site, and contrast agent used were the antecubital fossa, 22 gauge and Iohexol. The mean peak pressure was 68.9 ± 62.3 psi and the flow rate was 1.7 ± 0.9 mL/s. Eighteen cases of contrast extravasation were identified with a mean age of 11.2 ± 6.2 years. There were seven mild, six moderate, and five severe. Cases with extravasation had significantly higher peak pressure (p < 0.001) and flow rate (p < 0.001) compared to those without extravasation. Patients who received Iohexol-350 had significantly more contrast extravasation compared to those who used Iohexol-300 (p = 0.03). However, after post-hoc correction, only peak pressure (p < 0.01) and flow rate (p = 0.01) remained significant.

CONCLUSION

The use of power injectors in children undergoing contrast-enhanced CT is associated with a low rate of extravasation and of long-term injury.

The impact of flushing with pre-filled saline syringes on the incidence of peripheral venous catheter failure: A quasi-experimental study

BACKGROUND

Short peripheral venous catheters are one of the most frequently used devices in hospitals. Peripheral venous catheter failure, defined as the unscheduled dysfunction of peripheral venous catheter, is common and frequently entails a new invasive procedure. Flushing the catheter maintains patency and could prolong peripheral venous catheter dwell time. The introduction of pre-filled saline flushing syringes as compared to manually filled saline flushing syringes could facilitate the frequency of catheter flushing, and subsequently it could reduce peripheral venous catheter failure rate.

OBJECTIVE

To demonstrate differences in overall peripheral venous catheter failure rates before and after the introduction of pre-filled saline flushing syringes and to assess the risk factors for peripheral venous catheter failure.

METHODS

Quasi-experimental design, before-and-after intervention study. Intervention: introduction of pre-filled saline syringes for flushing. Multicenter study conducted in medical and surgical wards of three European hospitals during a 9-month period (4 months pre-intervention, 5 months intervention). A multivariate Cox proportional model was used to identify factors associated with the occurrence of peripheral venous catheter failure.

RESULTS

Data from 3853 peripheral venous catheters in 1915 patients were analyzed. Compared to pre-intervention period, a significant decrease in peripheral venous catheter failure rate was observed in the intervention period (57% vs 43.4%, p < 0.001). Independent factors associated with peripheral venous catheter failure were as follows: Charlson score ⩾4 (hazard ratio: 1.648; 95% confidence interval: 1.069-2.527), days of hospital stay ⩾10 (hazard ratio: 1.468; 95% confidence interval: 1.172-1.837), and catheter "D" (hazard ratio: 1.758; 95% confidence interval: 1.058-2.919).

CONCLUSION

The use of pre-filled saline syringes significantly reduced peripheral venous catheter failure and increased catheter dwell time. Thus, it is important to reinforce the use of the pre-filled syringes for flushing to reduce the incidence of peripheral venous catheters' failure.

Health professionals' lack of knowledge of central venous access devices: the impact on patients

BACKGROUND

the literature on the patient experience of living with a central venous access device (CVAD) is growing, but remains sparse. It suggests that patients accept having a CVAD as it should reduce episodes of repeated cannulations. However, a recent doctoral study found the reality did not live up to this hope.

AIM

the study objective was to uncover the global, cross-disease experience of patients with CVADs.

METHOD

an online survey was sent to an international sample of people living with CVADs.

FINDINGS

74 people from eight countries responded. Respondents corroborated the PhD findings: painful cannulation attempts continued after CVAD insertion because of a lack of clinical knowledge. Participants lost trust in clinicians and feared complications due to poor practice.

CONCLUSION

clinicians often lack the necessary skills to care and maintain CVADs. This leads to a negative patient experience.

Inadvertent intra-arterial injection of deoxycholic acid: A case report and proposed protocol for treatment

Deoxycholic acid (ATX-101) is a secondary bile acid that was approved as an injectable drug for the reduction of submental fat. Necrosis, an uncommon but serious adverse event, can occur due to inadvertent superficial injection or intra-arterial injection of the acid. The management of the intra-arterial injection of deoxycholic acid has not been well characterized. Here, we discuss methods to decrease the risk of such injections and draw on existing protocols for the inadvertent intra-arterial injection of sclerotherapy solutions and dermal fillers to propose a safe, practical approach to treatment. A case report is presented of a 42-year-old woman who received a deoxycholic acid injection for the correction of submental fullness, which was complicated by the inadvertent intra-arterial injection of the acid. The adaptation of published treatment protocols for the inadvertent injection of sclerosing solutions and dermal fillers allowed for a good outcome in this patient. The inadvertent intra-arterial injection of deoxycholic acid is a rare event. The risk of such injections can be reduced with attention to injection technique and can be managed successfully following the adaptation of protocols in the literature for similar events from vascular compromise due to dermal fillers and sclerosing solutions.

Surgical treatment of extravasation injuries: experience of the Hospital das Clínicas, Faculty of Medicine, University of São Paulo

OBJECTIVE

to report the experience of the Division of Plastic Surgery of the Hospital das Clínicas of the Medical School of the University of São Paulo in the treatment of cutaneous lesions due to accidental extravasation of drugs.

METHODS

we included patients with lesions due to extravasation of drugs over a period of 18 months. We retrospectively evaluated the following parameters: age, diagnoses during hospitalization and comorbidities, serum levels of albumin and hemoglobin, place of hospitalization, drug involved, anatomic segment affected, therapeutic management and death during hospitalization.

RESULTS

we followed-up 14 patients. The main drug involved was noradrenaline (21%). All patients underwent debridement of tissue necrosis. Three patients were submitted to flaps after preparation of the wound bed with negative pressure therapy, with good results. Seven patients had no definitive treatment of their lesions due to lack of clinical conditions.

CONCLUSION

in patients with favorable clinical conditions, the definitive treatment with flaps was adequate for cases of wounds due to extravasation of drugs in the subcutaneous tissue when there was exposure of noble structures.

A Primer on the Acute Management of Intravenous Extravasation Injuries for the Plastic Surgeon

Intravenous therapy is a common practice among many specialties. Intravenous therapy extravasation is a potential complication to such therapy. Hospitals without a dedicated wound care team trained in these interventions will often default to plastic surgical consultation, making an understanding of available interventions essential to the initial evaluation and management of these injuries. The goal of this article was to provide plastic surgeons and health care providers with a general overview of the acute management of intravenous infiltration and extravasation injuries. Though the decision for surgical versus nonsurgical management is often a clear one for plastic surgeons, local interventions, and therapies are often indicated and under-utilized in the immediate postinfiltration period. Thorough knowledge of these interventions should be a basic requirement in the armamentarium of plastic surgery consultants.

Contrast media extravasations in patients undergoing computerized tomography scanning: a systematic review and meta-analysis of risk factors and interventions

OBJECTIVE

To identify risk factors and interventions preventing or reducing contrast medium extravasation.

INTRODUCTION

Computed tomography (CT) is a radiological examination essential for the diagnosis and monitoring of many diseases. It is often performed with the intravenous (IV) injection of contrast agents. Use of these products can result in a significant complication, extravasation, which is the accidental leakage of IV material into the surrounding tissue. Patients may feel a sharp pain and skin ulceration or necrosis may develop.

INCLUSION CRITERIA

This review considered studies that included patients (adults and children) undergoing a CT with IV administration of contrast media. The risk factors considered were patient demographics, comorbidities and medication history. This review also investigated any strategies related to: contrast agent, injection per se, material used for injection, apparatus used, healthcare professionals involved, and patient risk assessment performed by the radiology personnel. The comparators were other interventions or usual care. This review investigated randomized controlled trials and non-randomized controlled trials. When neither of these were available, other study designs, such as prospective and retrospective cohort studies, case-control studies and case series, were considered for inclusion. Primary outcomes considered were: extravasation frequency, volume, severity and complications.

METHODS

The databases PubMed, CINAHL, Embase, the Cochrane Register of Controlled Trials, Web of Science PsycINFO, ProQuest Dissertations and Theses A&I, TRIP Database and ClinicalTrials.gov were searched to find both published and unpublished studies from 1980 to September 2016. Papers were assessed by two independent reviewers for methodological validity using the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI). Data were extracted using the standardized data extraction tool from JBI SUMARI. In one case, quantitative data from two cohort studies were pooled in a statistical meta-analysis. However, generally, statistical pooling was not possible due to heterogeneity of the interventions, populations of interest or outcomes. Accordingly, the findings have been presented in narrative form.

RESULTS

Fifteen articles were selected from a total of 2151 unique studies identified. Two were randomized controlled trials and 13 were quasi-experimental and observational studies. The quality of these studies was judged to be low to moderate. Some patient characteristics, such as female sex and inpatient status, appeared to be risk factors for extravasation. Additionally, injection rate, venous access site and catheter dwelling time could affect the volume extravasated. Preliminary studies seemed to indicate the potential of extravasation detection accessories to identify extravasation and reduce the volume extravasated. The other interventions either did not result in significant reduction in the frequency/volume of extravasation, or the results were mixed across the studies.

CONCLUSIONS

The majority of the studies included in this review evaluated the outcomes of extravasation frequency and volume. Given the quality of the primary studies, this systematic review identified only potential risk factors and interventions. It further highlighted the research gap in this area and the importance of conducting trials with solid methodological designs.

Iatrogenic intratendinous ganglion cyst of the extensor digitorum tendon following intravenous cannulation

Peripheral venous cannulation is one of the most commonly performed medical procedures in hospital medicine. The dorsal metacarpal veins are typically used for cannulation as they are easily accessible. We present the first case of an iatrogenic intratendinous ganglion cyst of the extensor digitorum tendon of the middle finger following intravenous cannulation.

Cutaneous manifestations of phosphate solution extravasation

Extravasation injuries are common in patients receiving multiple intravenous infusions. Although such injuries are closely associated with the infusion of cytotoxic chemotherapy, they have also been been associated with extravasation of noncytotoxic drugs. Extravasation injuries can lead to skin ulceration and nerve and tendon damage, and therefore to permanent disability. We report three cases of phosphate solution extravasation leading to unusual cutaneous manifestations.

Alternative Pharmacological Management of Vasopressor Extravasation in the Absence of Phentolamine

Vasopressor extravasation is a rare adverse drug reaction that can lead to tissue damage, ischemia, and necrosis of the affected area when vasopressors are administered peripherally. Phentolamine, a nonselective, reversible alpha antagonist, is the current standard treatment for this adverse reaction, but it is often unavailable for use. This review seeks to synthesize the available data in order to recommend alternative pharmacological options for use when phentolamine is not available. After an extensive literature search, 16 publications were reviewed. A treatment algorithm was created that recommends a combination of subcutaneous terbutaline, a selective beta₂ agonist, and topical nitroglycerin, an organic nitrate, for adults; and topical nitroglycerin monotherapy for children younger than 2 years of age. However, further research and case reports are required in order to establish a new standard of care for the treatment of vasopressor extravasation.

Epirubicin extravasation: consequences of delayed management

Epirubicin is an anthracycline chemotherapy agent used for treatment of several cancers including oesophageal, breast and gastric. Extravasation is a well-recognised and serious complication of any intravenous therapies but especially chemotherapeutic agents. Signs of the injury can be subtle and without prompt recognition and treatment there can be extensive tissue damage and depending on location of injury this can result in significant functional loss. In this article, a case of delayed management of epirubicin extravasation from a cannula situated at the dorsum of the hand is discussed. Successful surgical reconstruction of the resulting substantial tissue damage using a radial forearm flap 21 days following injury is described.

In-line pressure monitoring in IV infusions: benefits for patients and nurses

Intravenous (IV) infusions are an essential part of hospital patient care, but occlusions in peripheral cannulae are common. One of the most dangerous consequences of occlusion (blockage) is extravasation-the non-intentional leakage of infused vesicant fluid into the tissue surrounding the vein-as it can lead to long-term, or even permanent, tissue damage. Adults and children are affected, with preterm neonates being particularly vulnerable. In-line pressure monitoring (ILPM) can help identify occlusions early and help prevent complications such as extravasation and infiltration. Occlusions cause a rise in pressure in the IV line, so IV pumps fitted with ILPM are able to detect this rise in pressure early and sound an alarm, allowing the user to take corrective measures before the patient suffers any serious chemical damage. ILPM also helps prevent or minimise other consequences of in-line occlusions such as suboptimal medicine dosing, patient distress, and economic costs to NHS trusts.