Atlas of Procedures in Neonatology, 4th Edition

Vascular Access

27

Management of Extravasation Injuries

Jayashree Ramasethu

Extravasation or inadvertent infiltration of intravenously (IV)-administered solutions into subcutaneous tissue is a common adverse event in intensive care nurseries and may result in partial or complete skin loss, infection, and nerve and tendon damage, with the potential risk of cosmetic and functional impairment (1,2 and 3). Parenteral alimentation fluids, antibiotics such as nafcillin, calcium, potassium, and sodium bicarbonate solutions, and vasopressor agents are often implicated (1,4,5). Early identification and appropriate management are vital to minimize damage (6).

  1. Assessment (Figs. 27.1; see also Figs. 26.5 and 26.6)
  2. Staging of extravasations is recommended for objective evaluation to determine the degree of intervention required, but detailed descriptions or digital photographs provide better documentation of the extent of the wound and the healing process (Table 27.1) (7,8).
  3. Fussiness, crying, or withdrawal of the limb when flushing the IV cannula are early warning signs, but these may be absent in an infant who is sedated or critically ill.
  4. Blistering and discoloration of skin often portend at least partial skin loss, but visible skin changes do not always indicate the severity of underlying injury, which may evolve over several days.
  5. Management

The degree of intervention is determined by the stage of extravasation, the nature of the infiltrating solution, and the availability of specific antidotes. There is no consensus on management of Stage 3 or 4 lesions. In the absence of randomized controlled trials, some institutions have established management protocols to guide therapy, based on local experience, case series, and anecdotal evidence (1,7,8,9,10,11 and12).

  1. In all cases:
  2. Stop the IV infusion promptly.
  3. Remove constricting bands that may act as tourniquets (e.g., armboard restraint).
  4. Elevation of the limb may help to reduce edema.
  5. The application of warm or cold packs is controversial. Warm packs may, by local vasodilation, help to reabsorb infiltrating solutions. However, warm moist packs have been reported to cause maceration of the skin (9).
  6. Stage 1 or 2 extravasation:
  7. Remove IV cannula.
  8. Consider antidote (see below).
  9. Stage 3 or 4 extravasation:
  10. Leave the IV cannula in place and, using a 1-mL syringe, aspirate as much fluid as possible from the area.
  11. Remove the cannula unless it is needed for administration of the antidote.
  12. Consider use of hyaluronidase (4) or a specific antidote (see below).
  13. Multiple-puncture technique (10):In infants who develop tense swelling of the site with blanching of the skin owing to infiltration of acidic or hyperosmolar solutions, multiple punctures of the edematous area using a blood-drawing stylet (and strict aseptic technique) has been used to allow free drainage of the infiltrating solution, decrease the swelling, and prevent necrosis. The area is then dressed with saline soaks to aid drainage.
  14. Saline flushout:A technique of saline flushing of the subcutaneous tissue has been advocated by some authors (2,6,11,12). After cleaning and infiltrating the area with 1% lignocaine, 500 to 1000 U of hyaluronidase is injected subcutaneously. Four small stab incisions are then made in the tissue plane with a scalpel blade at the periphery of the area. Saline is injected through a blunt cannula inserted subcutaneously through one of the puncture sites and flushed through the other puncture sites, massaging the fluid toward the incisions to facilitate removal of the extravasated material.
  15. Hyaluronidase:Dispersing agent effective in extravasations involving calcium, parenteral alimentation fluids, antibiotics, sodium bicarbonate, etc. Although standard reference manuals state that hyaluronidase is not recommended for treatment of vasopressor extravasation injury (13), there have

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been reports of successful treatment of such extravasations with a combination of hyaluronidase and saline irrigations, as described above (2,11).

  1. Mechanism of action:Breakdown of hyaluronic acid, the ground substance or intercellular cement of tissues; minimizes tissue injury by enhancing dispersion and reabsorption of extravasated fluids

TABLE 27.1 Staging of Extravasation Injury (7,8)

Stage

Characteristics

1

Pain at site—crying when IV cannula is flushed
IV cannula flushes with difficulty
No redness or swelling

2

Pain
Redness and slight swelling at site
Brisk capillary refill

3

Pain
Moderate swelling
Blanching of area
Skin cool to touch
Brisk capillary refill below site
Good pulse below site

4

Pain
Severe swelling around site
Blanching of area
Skin cool to touch
Area of skin necrosis or blistering
Prolonged capillary refill time (>4 s)
Decreased or absent pulse

 

FIG. 27.1. A: Stage IV extravasation injury with blistering of skin. B: Same area 2 weeks later, with eschar formation.

  1. Most effective within 1 hour; may be used up to 12 hours
  2. Administration:Use 25- or 26-gauge needles to inject 1 mL (150 USP units/mL) as five separate 0.2-mL injections around the periphery of the extravasation site.
  3. Adverse effects:None reported in neonates, rare sensitivity reactions reported in adults
  4. Specific antidotes
  5. Phentolamine (14,15)
  6. Effective in treating extravasations of vasopressors such as dopamine and epinephrine, which cause tissue damage by intense vasoconstriction and ischemia
  7. Effect should be seen almost immediately; most effective within 1 hour but may be used up to 12 hours. The biologic half-life of subcutaneous phentolamine is less than 20 minutes.
  8. Mechanism of action: Competitive alpha-adrenergic blockade, leading to smooth muscle relaxation and hyperemia
  9. Doses have not been established for newborn infants. The exact dose is dependent on the size of the lesion and the size of the infant.
  10. Recommended doses range from 0.01 mg/kg per dose to 5 mL of 1-mg/mL solution (13,16).
  11. Administration: 0.5 to 1 mg/mL of solution injected subcutaneously into infiltrated area, after removal of IV catheter
  12. Precautions: Hypotension, tachycardia, and dysrythmias may occur; use with extreme caution

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in preterm infants; consider using repeated small doses.

  1. Topical nitroglycerine (17,18)
  2. Effective in treating injury due to extravasation of dopamine
  3. Mechanism of action: Vascular smooth muscle relaxant
  4. Application: 2% nitroglycerine ointment, 4 mm/kg body weight, applied over the affected area, may be repeated every 8 hours if perfusion has not improved (17)
  5. Transderm–nitro patches have also been used (7).
  6. Precautions: Absorption through the skin may lead to hypotension.
  7. Terbutaline
  8. Effective in treating peripheral ischemia resulting from extravasation of vasopressors in adults and older children; no neonatal cases reported (19)
  9. Mechanism of action: Peripheral vasodilation by b2-adrenoreceptor activation
  10. Administration: Subcutaneous injection of terbutaline in concentration of 0.5 to 1 mg/mL; doses in adults vary from 0.5 to 1 mg.
  11. Wound management
  12. The goal of wound management in neonates who have partial- or full-thickness skin loss is to achieve primary or secondary healing while avoiding scarring, contractures, and operative intervention. Wound care regimens differ among experts and institutions (1,3,7,20).
  13. Clean area with sterile saline.
  14. Apply silver sulfadiazine cream to affected area and change dressing every 8 hours with gentle cleansing of wound and reapplication of cream. Sulphonamides increase the risk of kernicterus and therefore are contraindicated in infants in the first 30 days of life.
  15. Amorphous hydrogels consisting of carboxymethylcellulose polymer, propylene glycol, and water have been shown to keep the wound moist and facilitate wound healing (20). They are available in the form of gels or sheets, which may be applied directly to the wound surface and held in place by a secondary dressing. The gel is easily removed with saline and is generally changed every 3 days. More frequent dressing changes may be required if there is excessive exudation.
  16. Wet-to-dry saline dressings and povidone-iodine dressings may also be effective (9). The liberal use of povidone-iodine on open wounds is not recommended in very low-birthweight infants, because absorption of iodine from the skin may suppress thyroid function.
  17. The role of antibacterial ointments is unclear.
  18. Evaluate wound healing every day. Time to heal ranges from 7 days to 3 months.
  19. If the scar involves a flexion crease, passive range-of-motion exercises with each diaper change may help to prevent contractures.
  20. Plastic surgical consultation
  21. Recommended for all full-thickness and significant partial-thickness extravasation injuries
  22. Enzymatic or surgical débridement or skin grafting may be required (3,21 and 23).

References

  1. Wilkins CE, Emmerson AJB.Extravasation injuries in regional neonatal units. Arch Dis Child Fetal Neonatal Ed. 2004;89:
  2. Casanova D, Bardot J, Magalon G.Emergency treatment of accidental infusion leakage in the newborn: report of 14 cases. Br J Plast Surg. 2001;54:396–399.
  3. Friedman J.Plastic surgical problems in the neonatal intensive care unit. Clin Plast Surg. 1998;25:599–617.
  4. Zenk KE, Dungy CI, Greene GR.Nafcillin extravasation injury. Use of hyaluronidase as an antidote. Am J Dis Child. 1981;135:1113–1114.
  5. Chen JL, O'Shea M.Extravasation injury associated with low dose dopamine. Ann Pharmacother. 1998;32:545–548.
  6. Gault DT.Extravasation injuries. Br J Plast Surg. 1993;46:91–96.
  7. Flemmer L, Chan JSL.A pediatric protocol for management of extravasation injuries. Pediatr Nurs. 1993;19:355–358.
  8. Montgomery LA, Hanrahan K, Kottman K.Guideline for IV infiltrations in pediatric patients. Pediatr Nurs. 1999;25:167–180.
  9. Brown AS, Hoelzer DJ, Piercy SA.Skin necrosis from extravasation of intravenous fluids in children. Plast Reconstruct Surg.1979;64:145–150.
  10. Chandavasu O, Garrow D, Valda V, et al. A new method for the prevention of skin sloughs and necrosis secondary to intravenous infiltration. Am J Perinatol.1986;3:4–6.
  11. Harris PA, Bradley S, Moss ALH.Limiting the damage of iatrogenic extravasation injury in neonates. Plast Reconstruct Surg.2001;107:893–894.
  12. Davies J, Gault D, Buchdahl R.Preventing the scars of neonatal intensive care. Arch Dis Child. 1994;70: F50–F51.
  13. Young TE, Magnum B.Neofax®: A Manual of Drugs Used in Neonatal Care. 18th ed. Raleigh, NC: Acorn; 2005:209.
  14. Subhani M, Sridhar S, DeCristafaro JD.Phentolamine use in a neonate for the prevention of dermal necrosis caused by dopamine: a case report. J Perinatol. 2001;21:324–326.
  15. Siwy BK, Sadove AM.Acute management of dopamine infiltration injury with regitine. Plast Reconstruct Surg. 1987;80:610–612.
  16. Gomella TL, Cunningham MD, Eyal FG, Zenk KE.Neonatology: Management, Procedures, On-Call Problems, Diseases and Drugs.5th ed. New York: Lange Medical Books/McGraw-Hill; 2004:629.

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  1. Wong AF, McCullough LM, Sola A.Treatment of peripheral tissue ischemia with topical nitroglycerine ointment in neonates. J Pediatr. 1992;121:980–983.
  2. Denkler KA, Cohen BE.Reversal of dopamine extravasation injury with topical nitroglycerine ointment. Plast Reconstruct Surg.1989;84:811–813.
  3. Stier PA, Bogner MP, Webster K, et al. Use of subcutaneous terbutaline to reverse peripheral ischemia. Am J Emerg Med.1999;17:91–94.
  4. Cisler-Cahill L.A protocol for the use of amorphous hydrogel to support wound healing in neonatal patients: an adjunct to nursing care. Neonatal Network. 2006;25:267–273.
  5. Falcone PA, Barrall DT, Jeyarajah DR, Grossman JAI.Nonoperative management of full thickness intravenous extravasation injuries in premature neonates using enzymatic debridement. Ann Plastic Surg. 1989;22:146–149.
  6. Tiras U, Erdeve O, Karabulut AA, et al. Debridement via collagenase application in two neonates. Pediatr Dermatol. 2005; 22:472–475.
  7. Schafer T, Kukies S, Stokes TH, et al. The prepuce as a donor site for reconstruction of an extravasation injury to the foot in a newborn. Ann Plast Surg.2005;54:664–666.