PROPOFOL EXTRAVASATION: A CASE OF SOFT TISSUE INJURY

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SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: A complication of any medication given via a peripheral intravenous catheter (IV) is the administration of the medication into the surround perivascular tissue. This can be associated with adverse events such as tissue necrosis, increased risk of infection, and acute compartment syndrome. Propofol is a sedative-hypnotic IV anesthetic that has a rapid onset of action, rapid recovery, neutral pH, and is isotonic. Due to these properties, adverse events related to the use of propofol are relatively rare. We report a case of propofol extravasation resulting in prolonged sedation requiring mechanical ventilation and soft tissue injury. CASE PRESENTATION: A 51-year-old female with past medical history of cervical stenosis underwent an elective anterior cervical discectomy and fusion. During the procedure, she was noted to require increasing amounts of sedation and received approximately 700 mL of propofol (10mg/ml concentration). After surgery, extravasation of the propofol was noted in the left forearm with significant edema, erythema, and warmth from the elbow to the wrist. Scattered superficial skin wounds with superficial partial thickness depth were present on the elbow, forearm, and wrist. There was no evidence of necrosis with a palpable distal radial pulse. Post-operatively, the patient remained unresponsive and required prolonged mechanical ventilation for an additional 12 hours. She was initially managed with broad spectrum antibiotics and 1% silver sulfadiazine; however, antibiotics were quickly discontinued as her condition improved and there was no suspicion of underlying infection. She was discharged in stable condition on hospital day 4. DISCUSSION: Despite the favorable chemical properties of propofol, there have been recent case reports of tissue necrosis related to propofol extravasation. Patient co-morbidities such as malnutrition, peripheral vascular disease, and diabetes may predispose to tissue necrosis secondary to poor vascular supply and delayed healing. Moreover, propofol is an excellent culture medium for bacterial growth secondary to its high lipid content. Extrinsic contamination's of propofol preparations have been reported in literature resulting in post-operative septic shock and wound infections. Increased pressure within a closed fascial compartment can lead to compartment syndrome. Management involves immediate termination of the propofol infusion. A surgical consult should be obtained for the management of tissue necrosis and chemical burn injury. Some authors advocate for aspiration of propofol before withdrawing the infusion needle and washing the area with isotonic fluids. CONCLUSIONS: Even though propofol is a fairly benign anesthetic, physicians need to be aware of the complications associated with its use. There needs to be a high index of suspicion for IV infiltration in patients requiring increasing doses of sedation for any procedure. Reference #1: Leblanc JM, Lalonde D, Cameron K, Mowatt JA. Tissue necrosis after propofol extravasation. Intensive Care Medicine. 2013;40(1):129-130. https://doi.org/10.1007/s00134-013-3137-z. Reference #2: Kalraiya AJ, Madanipour S, Colaco H, Cobiella C. Propofol extravasation: a rare cause of compartment syndrome. BMJ Case Rep. 2015;2015:bcr2015209360. Published 2015 May 7. https://doi.org/10.1136/bcr-2015-209360. Reference #3: Sharma R, Yoshikawa H, Abisaab J. Chemical burn secondary to propofol extravasation. West J Emerg Med. 2012;13(1):121-2. DISCLOSURES: No relevant relationships by Abdullah Al Twal, source=Web Response No relevant relationships by Jason Cohen, source=Web Response No relevant relationships by Kristin Fless, source=Web Response No relevant relationships by Sasa Ivanovic, source=Web Response No relevant relationships by Nirav Mistry, source=Web Response No relevant relationships by Vagram Ovnanian, source=Web Response No relevant relationships by Fariborz Rezai, source=Web Response No relevant relationships by Paul Yodice, source=Web Response