Management of Extravasation Injuries: A Focused Evaluation of Noncytotoxic Medications

Abstract

Extravasations are common manifestations of iatrogenic injury that occur in patients requiring intravenous delivery of known vesicants. These injuries can contribute substantially to patient morbidity, cost of therapy, and length of stay. Many different mechanisms are behind the tissue damage during extravasation injuries. In general, extravasations consist of four different subtypes of tissue injury: vasoconstriction, osmotic, pH related, and cytotoxic. Recognition of high-risk patients, appropriate cannulation technique, and monitoring of higher risk materials remain the standard of care for the prevention of extravasation injury. Prompt interdisciplinary action is often necessary for the treatment of extravasation injuries. Knowledge of the mechanism of extravasation-induced tissue injury, agents for reversal, and appropriate nonpharmacologic treatment methods is essential. The best therapeutic agent for treatment of vasopressor extravasation is intradermal phentolamine. Topical vasodilators and intradermal terbutaline may provide relief. Intradermal hyaluronidase has been effective for hyperosmotic extravasations, although its use largely depends on the risk of tissue injury and the severity of extravasation. Among the hyperosmotic agents, calcium extravasation is distinctive because it may present as an acute tissue injury or may possess delayed clinical manifestations. Extravasation of acidic or basic materials can produce significant tissue damage. Phenytoin is the prototypical basic drug that causes a clinical manifestation known as purple glove syndrome (PGS). This syndrome is largely managed through preventive and conservative treatment measures. Promethazine is acidic and can cause a devastating extravasation, particularly if administered inadvertently through the arteriolar route. Systemic heparin therapy remains the accepted treatment option for intraarteriolar administration of promethazine. Overall, the evidence for managing extravasations due to noncytotoxic medications is nonexistent or limited to case reports. More research is needed to improve knowledge of patient risk, prompt recognition of the extravasation, and time course for tissue injury, and to develop prevention and treatment strategies for extravasation injuries.

Consequences of radiopharmaceutical extravasation and therapeutic interventions: a systematic review

“…Therefore, we consider it safe to be conservative in treatment of extravasation of these tracers. Attention should only be focused on early complications of the extravasation that are not attributable to the radioactivity, such as skin necrosis and compartment syndrome [65, 66]. Other diagnostic radiopharmaceuticals were reported to cause at least mild skin lesions, notably 201 Th-thallous chloride and 131 I-iodine-iodocholesterol.…”

“…Only few were applied in reported cases. Dispersive actions can be effective in extravasation non-radiopharmaceutic agents [65, 66]. It can be debated if all listed dispersive interventions can be applied to radiopharmaceuticals.…”

“…A more careful approach has been chosen with relatively harmless preventive measures for diagnostic tracers combined with follow-up, in case of tracers for which adverse events have been reported, notably 201 Tl-thallous chloride, and for tracers no literature of extravasation was found at all. Although in general radiopharmaceutical administration volume is limited, severe consequences have been reported in non-radiopharmaceutical extravasation, such as tissue necrosis and compartment syndrome [65, 66]. Therefore, in case of any of the symptoms listed in Table 5, the plastic surgeon is consulted.…”

The development of a nurse-driven protocol for the safe administration of vasopressors through peripheral intravenous catheters

“…Prompt recognition of extravasation and initiation of the reversal agents were vital in the prevention of long-term complications. [14,23] The nursing and medical teams were educated on the protocol prior to its initiation, with emphasis on strict adherence to ensure patient safety.…”

Evaluation of Risk of Injury by Extravasation of Hyperosmolar and Vasopressor Agents in a Rat Model

“…In these guidelines, cytotoxic agents are classified into three categories according to the severity of skin injury after extravasation: vesicants, irritants, and non-tissue-damaging agents. [1][2][3] Vesicants are agents that cause tissue necrosis even at small volumes of extravasation owing to their inherent toxicity to cells. Irritants cause inflammation without necrosis at the extravasation site.…”