Skin Necrosis After Intravenous Calcium Chloride Administration as a Complication of Parathyroidectomy for Secondary Hyperparathyroidism: Report of Four Cases

Abstract

Intravenous (i.v.) calcium chloride is usually given to treat symptomatic hypocalcemia; however, the extravasation of calcium solution may cause soft tissue and skin necrosis. After parathyroidectomy and autotransplantation for secondary hyperparathyroidism associated with end-stage renal failure, i.v. calcium infusion is often necessary to treat severe postoperative hypocalcemia. We reviewed 371 patients who underwent parathyroidectomy for secondary hyperparathyroidism between January 2000 and June 2005, 96 of whom received i.v. calcium postoperatively for symptomatic hypocalcemia. We report the cases of three (3%) of our own patients and of one patient referred to our hospital, who suffered skin necrosis after i.v. calcium solution administration. These reports show that i.v. calcium should be administered into large veins, or via a central line, and diluted in an appropriate volume of solution. Moreover, the calcium solution infusion should be ceased if the patient complains of tenderness over the injection site. If skin necrosis develops, we suggest early debridement and a simple split thickness skin graft to repair the skin defect. We report our experience to remind surgeons of the danger of calcium chloride injection and to discuss ways of preventing and treating this complication.

Management of Extravasation Injuries: A Focused Evaluation of Noncytotoxic Medications

“…Other pharmacotherapies for norepinephrine extravasation have remained largely ineffective or are underreported. Hyaluronidase, an enzyme that facilitates the degradation of the extracellular matrix, should be Total parenteral nutrition 42,48,53,54 Calcium chloride 10% (2040 mOsm/L) 48,55,56,59 Calcium gluconate (669 mOsm/L) 48,55,56,59 All agents: Direct cellular damage due to osmotic shifts from cellular membrane, cell volume dysregulation, DNA damage, apoptosis, and inflammation. Other agents: Aminophylline (10 mOsm/L) 48 Dextrose 10-50% (504-2520 mOsm/L) 49 Mannitol 20% (1369 mOsm/L) 43 Hypertonic saline (concentration dependent) Dry heat and elevation remain treatment of choice for pH-related extravasations…”

“…Patients will frequently present with erythema and papules proximal to the injection site, usually within a few hours to a day after the infiltration. 56 Progression of injury varies because necrosis induced by the cationic agent can be deep; penetration may occur into underlying fascia and skeletal muscle layers. 4,55,56 Eschar formation occurs within 48-72 hours of initial injury, although necrosis may take as long as a few weeks to develop.…”

“…56 Progression of injury varies because necrosis induced by the cationic agent can be deep; penetration may occur into underlying fascia and skeletal muscle layers. 4,55,56 Eschar formation occurs within 48-72 hours of initial injury, although necrosis may take as long as a few weeks to develop. 55,56 Acute calcium extravasations have been successfully managed with hyaluronidase by the subcutaneous or intradermal route.…”

“…4,55,56 Eschar formation occurs within 48-72 hours of initial injury, although necrosis may take as long as a few weeks to develop. 55,56 Acute calcium extravasations have been successfully managed with hyaluronidase by the subcutaneous or intradermal route. 48,55 Due to the penetrating nature of the calcium salts, hyaluronidase may be only effective if used within 60 minutes of calcium extravasation.…”

A Case of Skin Necrosis after Extravasation of Intravenous Immunoglobulin

“…Not only commonly used fluid such as normal saline and dextrose water, but also electrolytes, calcium, anticancer drugs are causes of these injuries [2,3]. The extravasation happens more in children whose blood vessels are small and cannot express their pain and in the elderly whose blood vessels and skin are fragile [4].…”