Extravasation Injury Research Articles

The use of peripheral vasopressors and its implications for hospital medicine.

Vasopressor medications for circulatory shock have historically been administered through central venous catheters due to concern for extravasation injury when given peripherally. However, recent studies have demonstrated the safety of peripheral administration of vasopressor medications at lower doses and for a limited duration. Peripheral use of vasopressors is appealing to both patients and providers, as obtaining central access is an invasive procedure associated with the risk of pneumothorax, bleeding, and infection. Furthermore, waiting to initiate these medications until central access is obtained can lead to delays in care. Conversely, valid concerns remain regarding the risk of tissue extravasation associated with peripheral vasopressors, which can be life and limb threatening. We discuss the guidelines and data for optimal dose, duration, intravenous line (IV) size, IV location, and nursing IV site monitoring for peripheral vasopressors. We then explore adverse events associated with peripheral vasopressors. Finally, we describe how this practice change may impact hospital medicine providers.

238 Management of Extravasation Injuries Referred to the Plastic Surgery Department in a Regional Centre

238 Management of Extravasation Injuries Referred to the Plastic Surgery Department in a Regional Centre

Nursing Management of Extravasation Complications Related to Intravenous Catheters: A Narrative Review

Background: The existing literature on nursing management of extravasation complications is fragmented, inconsistent, and outdated. When it comes to nursing management of extravasation complications, there are several gaps that need to be addressed as generally of study participants had poor knowledge of the prevention and management of cytotoxic extravasation, a high number of nurses were not were not trained on cytotoxic extravasation. Methods: We conducted a narrative review by searching the following databases for relevant clinical practice guidelines published from Oct 2013 to Oct 2023: PubMed, Cochrane Library, CINAHL, Scopus and Clinical practice guidelines developed by institutes, hospitals, associations, and cancer groups, based on systematic and evidence-based review. We used the AMSTAR 2 tool for assessing the quality of systematic reviews, and summarized the characteristics and findings of the included studies in a narrative synthesis including year of publication, title, Institution/authors, key highlight (assessment, management, prevention). Results and discussions: These Clinical practice guidelines have some similarities and differences in their scope, methods, recommendations, and quality. They all aim to provide evidence-based and standardized guidance for the prevention and management of extravasation, and to improve the quality and safety of intravenous therapy. Conclusions: In conclusion, while significant progress has been made in understanding and managing extravasation injuries, there is still much work to be done. By continuing to research, educate, and apply evidence-based practices, healthcare professionals can significantly improve the care and outcomes for patients at risk of extravasation injuries

Describing Intravenous Extravasation Injuries in Children (DIVE2 Study).

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. 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. 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. 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. 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.

The surgical management of peripheral IV extravasation injuries in infants and children

The surgical management of peripheral IV extravasation injuries in infants and children

Alternating rabacfosadine and doxorubicin for treatment of naïve canine lymphoma.

The current standard of care treatment for canine lymphoma is a multi-agent, CHOP-based chemotherapy protocol. Single agent doxorubicin (DOX) is less burdensome; however, multi-agent chemotherapy protocols are often superior. The recently approved drug rabacfosadine (RAB, Tanovea) provides an attractive option for combination therapy with DOX, as both drugs demonstrate efficacy against lymphoma and possess different mechanisms of action. A previous study evaluating alternating RAB/DOX reported an overall response rate (ORR) of 84%, with a median progression-free survival time (PFS) of 194 days. The aim of this prospective trial was to evaluate the same protocol in an additional population of dogs. Fifty-nine dogs with treatment naïve lymphoma were enrolled. RAB (1.0 mg/kg IV) was alternated with DOX (30 mg/m2 IV) every 21 days for up to six total treatments (3 cycles). Response assessment and adverse event (AE) evaluation were performed every 21 days using VCOG criteria. The ORR was 93% (79% CR, 14% PR). The median time to maximal response was 21.5 days; median PFS was 199 days. T cell immunophenotype and lack of treatment response were predictive of inferior outcomes. AEs were mostly gastrointestinal. Six dogs developed presumed or confirmed pulmonary fibrosis; four were grade 5. One dog experienced grade 3 extravasation injury with RAB that resolved with supportive treatment. These data mirror those of the previously reported RAB/DOX study, and support the finding that alternating RAB/DOX is a reasonable treatment option for canine lymphoma.

Increased risk of complications in lower versus upper limb peripheral intravenous cannulation in children with severe neurological impairment.

Obtaining peripheral intravenous catheter (PIVC) access in children with severe neurological impairment (SNI) is often challenging and commonly associated with complications, including dislodgement, phlebitis and extravasation. In severe cases, extravasation injury may lead to tissue necrosis, ulceration and long-term morbidity. The aim of this study was to determine the relative incidence of PIVC complications secondary to lower limb cannulation, compared to upper limb, in children with SNI. A single centre, retrospective, observational review was conducted. Patients with SNI, admitted at a tertiary paediatric centre over 6months between July and December 2022, were included. One-hundred fifty-five PIVC procedures were conducted in 110 children over the study period. Complications were more common in lower limb PIVCs (12/16, 75%) compared to upper limb (58/139, 42%), p = 0.01. Upper limb cannulation is preferred in children with SNI.

Complications Related to the Securement Device in Peripheral Intravenous Catheters: A Randomized Study.

Studies have not demonstrated the effectiveness of the different types of dressings in reducing the rate of complications. The purpose of this study was to determine which type of dressing is most beneficial in reducing the rate of complications. A total of 281 patients requiring a peripheral intravenous catheter were randomized to receive partially reinforced dressings or fully reinforced dressings (dressings with integral catheter securement). Patients were followed throughout their entire catheter course, and complications included infection, occlusion, phlebitis, accidental dislodgement, extravasation, and medical adhesive-related skin injury. Catheter outcome data were compared to determine whether statistically significant differences existed between the 2 groups. The groups had equivalent demographic characteristics and catheter indications. The average securement time with partially reinforced dressings was 2.72days, and that for fully reinforced dressings was 2.64days. However, catheters secured with fully reinforced dressings were associated with fewer total complications, such as infectious phlebitis (P =.043) and accidental dislodgement (P =.03). The fully reinforced securement device significantly reduced the rate of complications related to accidental dislodgement of the device and cases of infectious phlebitis. The use of fully reinforced dressings could reduce catheter-associated complications and improve the quality of patient care.

Vesiculobullous Eruption due to Extravasation of Intravenous Fluid: A Brief Review

Abstract Introduction: Intravenous (IV) cannulation for peripheral or central venous access is a commonly done procedure in hospitals. Extravasation of IV fluids is one of the iatrogenic complications encountered. Extravasation injury may range from mild benign injury most of the time to edema, bullous lesion, severe tissue necrosis, and compartment syndrome. Methods: “Extravasation” and “Intravenous fluid” are searched in PubMed, PubMed Central, and Medline with articles published in the past 5 years. Few off topics such as “blood extravasation,” “extravasation injury to brain,” animal studies, and “extravasation of anticancer drugs” are excluded from the study. Twenty-one articles including review, meta-analysis, and case reports are selected for review. Results: While much of the focus is on peripheral venous access, for central venous catheters, extravasation is less frequent but potentially more dangerous because the anatomical structures escape attention. Along with mechanical factors such as volume of fluid administered and wrong placement of cannula, underlying diseases such as cancer, diabetes, and inherent property of IV fluid or infusion may be responsible for extravasation injury. Pain, paresthesia, pallor, and pulse to be examined and monitored while suspecting an extravasation injury. Ultrasonography and color Doppler might help to identify early lesions, but a high degree of clinical suspicion is necessary for unconscious patients in the intensive care unit. A detailed discussion on this topic is followed in this article. Conclusion: Patients should have their infusion site routinely inspected. The prevention of potentially fatal consequences depends on careful adherence to recommended procedures and prompt recognition of signs and symptoms.

Contrast media extravasation injury: a prospective observational cohort study

ObjectiveTo identify the risk factors for moderate and severe contrast media extravasation and provide effective guidance to reduce the degree of extravasation injuries.MethodsWe observed 224 adult patients who underwent contrast media extravasation at Xiangya Hospital of Central South University, Hunan Provincial Maternal and Child Healthcare Hospital, and Xiangya Changde Hospital, Hunan Province between January 1, 2018 and December 31, 2022. Risk factors for moderate extravasation injuries were evaluated using univariate and multivariate logistic regression.ResultsAmong 224 patients, 0 (0%) had severe, 18 (8.0%) had moderate, and 206 (92.0%) had mild contrast media extravasation injury. Multivariate logistic regression analysis revealed malignant tumors (odds ratio [OR] = 6.992, 95% confidence interval [CI]: 1.674–29.208), Iohexol (OR = 9.343, 95% CI 1.280–68.214), large-volume (> 50 mL) extravasation (OR = 5.773, 95% CI 1.350‒24.695), and injection site (back of the hand) (OR = 13.491, 95% CI 3.056–59.560) as independent risk factors for moderate injury.ConclusionRisk factors for moderate contrast media extravasation injury are malignant tumors, iohexol, large-volume (> 50 mL) extravasation, and back-of-the-hand injection. Analysis of these risk factors can help reduce the degree of injury after extravasation.Clinical relevance statementHigh-risk patients with extravasation support should choose the appropriate contrast media type, avoiding back-of-the-hand injections. We recommend that patients with cancer be implanted with a high-pressure resistant central venous catheter and receive effective measures to timely detect and reduce extravasation.

Management of Epirubicin Extravasation Injuries of the Hand with Debridement and Flap Cover-A Case Series.

Chemotherapy extravasation injury is an iatrogenic injury due to extravasation of the drug from the vessel during infusion therapy. Among various chemotherapeutic drugs, DNA binding vesicants like epirubicin and doxorubicin can lead to extensive tissue necrosis following extravasation. They are commonly used in many chemotherapy regimens including those for carcinoma breast. We present our case series in the management of these wounds with aggressive debridement and regional (pedicled groin)/free flaps (superficial circumflex iliac artery perforator, lateral arm) for cover in five patients. All flaps healed well with patient returning to further treatment in 3 to 4 weeks post-surgery with preservation of hand function. Thus, early recognition of the type of drug that has extravasated is crucial. Regional and free flaps are superior to local flaps because there are no extra incisions and grafts on the limb that has already been injured.

Management of Extravasation Injury in Infants: A Systematic Review of Clinical Trials

Context: One of the common procedures in the neonatal intensive care unit (NICU) is the insertion of a venous catheter, and one of the most important and serious complications is extravasation, which is a leading cause of death in hospitalized infants. Based on the researcher’s experience in the NICU and the necessity of extravasation injury management in infants, this review study focused on extravasation injury management in infants. Methods: The literature was searched in ProQuest, Scopus, and PubMed databases using the terms “extravasation” OR “vascular leakage” OR “Peripheral Infiltration” AND “Neonatal” OR “Newborn” OR “Infants” OR “NICU.” The search procedure was performed in the title, abstract, and full text of articles published in English from 2000 to 2022. Results: In the initial search, 3414 articles were extracted. After removing the duplicates and searching the titles and abstracts of the articles, 132 related articles were found, and their full texts were studied. Finally, 20 articles entered the final analysis stage. Nine case report studies, five case series studies, three clinical trials, and three retrospective review studies were found. The results showed that various treatment methods are available, including elevating limbs, pain relief, hot and cold compresses, flush-out technique with saline, dressings (hydrocolloid, hydrogel, and hydrocellular foam), medications (2% nitroglycerin ointment and subcutaneous administration of hyaluronidase and phentolamine), and new methods such as amniotic membranes, omega-3-rich fish skin (Kerecis), active leptospermum honey (ALH), PRP, and surgical removal. Conclusions: Despite many medical advances, there is still no specific approach to managing extravasation in infants. The ideal approach to extravasation injuries is still to prevent them initially. The best next step is to minimize the damage using antidotes or hyaluronidase. Using saline to remove the solution and physically minimize damage can be useful. Thus, more studies are needed to address extravasation management in infants.

Contrast Agent Administration as a Source of Liability: A Legal Database Analysis.

Background Radiology ranks high in terms of specialties implicated in medical malpractice claims. While most radiologists understand the risks of liability for missed findings or lapses of communication, liability for the use of contrast agents in imaging procedures may be underappreciated. Purpose To review the clinical context and outcomes of lawsuits alleging medical malpractice for contrast-related imaging procedures. Materials and Methods Two large U.S. legal databases were queried using the terms "Contrast" and "Radiology OR Radiologist" from database inception to October 31, 2022, to identify cases with published decisions or settlements related to medical malpractice in patients who underwent contrast-related imaging procedures. The search results were screened to include only those cases involving the practice area of health care law where there was at least one claim of medical negligence against a health care institution or provider. Data on the medical complications alleged by patients after contrast agent administration and on the trial were extracted and reported using descriptive statistics. Results A total of 151 published case summaries were included in the analysis. Anaphylactic reaction following contrast agent administration was the most common medical complication observed (30% [45 of 151 cases]), of which failure to diagnose developing anaphylaxis or failure to treat the anaphylactic reaction made up the majority of allegations (93% [42 of 45]). Inappropriate management of contrast media extravasation (27% [41 of 151]) and alleged contrast agent-induced acute kidney injury (13% [19 of 151]) were the next most frequent causes of lawsuits. Of the 11 cases of alleged kidney injury that went to trial, all resulted in a judgment in favor of the defense. Conclusion This study highlights the key reasons for medical malpractice lawsuits associated with use of contrast media and outcomes from these lawsuits. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Trop in this issue.

An interdigitated capacitive sensor for early detection of contrast media extravasation

Contrast Media Extravasation (CMEV) is a well-known complication of intravenous administration of contrast media during computed tomography (CT) scans. It refers to the leakage of contrast media from the blood vessel into the surrounding soft tissues. As contrast media are vesicant solutions, extravasation can result in the development of adverse side effects such as erythema, tissue necrosis, and compartment syndrome. Therefore, there is an urgent clinical need to develop a device that can detect extravasation early and minimize the severity of extravasation injuries. In this work, we present a cost-effective and wearable sensor patch to aid in the early detection of extravasation via capacitive sensing. The technical feasibility of the proposed sensor was then evaluated through a series of bench-top tests and ex-vivo tests. The results showed that the sensor patch is able to distinguish between normal contrast media administration and contrast media extravasation scenarios. Our proposed sensor has shown potential for early detection of CMEV, with a decrease in capacitance being a promising indicator of extravasation. This sensor also has the potential to reduce the occurrence of extravasation events in the hospital, especially for patients at risk of extravasation. Future work includes optimizing the sensor and validating it through a clinical trial to bring it a step closer to actual commercial use.

Evaluating the Efficacy of Amniotic Membrane in Treating Neonatal Extravasation.

Extravasation is leakage of material from a peripheral venous access into adjacent tissue, which results in tissue damage ranging from local irritation to necrosis and scar formation. Neonates are at extravasation risk with IV treatment because of their small, fragile veins and the long treatment period required. In this report, investigators assessed the efficacy of amniotic membrane (AM) as a biological dressing to heal extravasation wounds in neonates. This case series includes six neonates who presented with extravasation injuries from February 2020 to April 2022. Neonates born at any gestational age diagnosed with a wound secondary to extravasation were recruited. Neonates with skin disorders and those who had stage 1 or 2 wounds were excluded. Providers covered infection- and necrosis-free wounds with AM and assessed the wounds after 48 hours. Five days after placement, providers removed and replaced the AM; they continued to replace the bandages every 5 to 7 days until healed. The average gestational age of included neonates was 33.6 weeks. Average healing time was 12.5 days (range, 10-20 days), and no adverse reactions were observed. All neonates healed completely without scar formation. This preliminary report suggests that the application of AM in treating extravasation in neonates is safe and effective. However, controlled trials with larger sample sizes are needed to evaluate this outcome and determine implications for practice.

Management of noncytotoxic extravasation injuries: A focused update on medications, treatment strategies, and peripheral administration of vasopressors and hypertonic saline.

Extravasation is the leakage of intravenous solutions into surrounding tissues, which can be influenced by drug properties, infusion techniques, and patient-related risk factors. Although peripheral administration of vesicants may increase the risk of extravasation injuries, the time and resources required for central venous catheter placement may delay administration of time-sensitive therapies. Recent literature gathered from the growing use of peripheral vasopressors and hypertonic sodium suggests low risk of harm for initiating these emergent therapies peripherally, which may prevent delays and improve patient outcomes. Physiochemical causes of tissue injury include vasoconstriction, pH-mediated, osmolar-mediated, and cytotoxic mechanisms of extravasation injuries. Acidic agents, such as promethazine, amiodarone, and vancomycin, may cause edema, sloughing, and necrosis secondary to cellular desiccation. Alternatively, basic agents, such as phenytoin and acyclovir, may be more caustic due to deeper tissue penetration of the dissociated hydroxide ions. Osmotically active agents cause cellular damage as a result of osmotic shifts across cellular membranes in addition to agent-specific toxicities, such as calcium-induced vasoconstriction and calcifications or arginine-induced leakage of potassium causing apoptosis. A new category has been proposed to identify absorption-refractory mechanisms of injury in which agents such as propofol and lipids may persist in the extravasated space and cause necrosis or compartment syndrome. Pharmacological antidotes may be useful in select extravasations but requires prompt recognition and frequently complex administration strategies. Historically, intradermal phentolamine has been the preferred agent for vasopressor extravasations, but frequent supply shortages have led to the emergence of terbutaline, a β2 -agonist, as an acceptable alternative treatment option. For hyperosmolar and pH-related mechanisms of injuries, hyaluronidase is most commonly used to facilitate absorption and dispersion of injected agents. However, extravasation management is largely supportive and requires a protocolized multidisciplinary approach for early detection, treatment, and timely surgical referral when required to minimize adverse events.

Extravasation injuries in the intravenous therapy with drugs with properties vesicants and irritants in the veterinary medicine of small animals

The extravasation injuries are uncommon complications during the administration of intravenous therapy in the small animal veterinary clinic. However, the efflux of drugs with vesicant or irritant properties can cause severe and/or irreversible functional and aesthetic changes. The correct catheterization technique and vigilance during intravenous administration of drugs with vesicant or irritant properties are fundamental in preventing the appearance of iatrogenic injuries. The therapeutic approach to this iatrogenic complication involves the combination of non-pharmacological, pharmacological, and surgical measures. In small animal veterinary medicine, there are no uniform recommendations about the best strategy could be adopted, and the interventions described in the literature lack evidence of effectiveness based on scientific studies.

Photobiomodulation Therapy for Treatment of Extravasation Injuries in Cancer Chemotherapy

Photobiomodulation Therapy for Treatment of Extravasation Injuries in Cancer Chemotherapy

Spinal anesthesia for a neonate with complex congenital heart disease for lower limb surgery

A neonate with complex congenital heart disease was referred for patent ductus arteriosus (PDA) stenting, who had an ulceration of the dorsum of the foot secondary to extravasation injury. Echo showed situs solitus, levocardia, atrioventricular concordance, double-outlet right ventricle, large inlet with conoventricular ventricular septal defect, bidirectional shunt, D-posed aorta, pulmonary atresia, confluent good-sized branch pulmonary arteries, left arch, no coarctation, and tortuous PDA arising from the base of arch supplying the branch pulmonary artery confluence. Three days later, PDA stenting was done. As limb ulceration progressed to cellulitis, he was posted for debridement and VAC application 6 days after PDA stenting. It was performed under subarachnoid block with 0.5% bupivacaine heavy 0.6 ml through L4-L5 interspace using a 24G needle. Intraoperatively, saturation and hemodynamic variables remained stable. Skin grafting was performed 3 days later under spinal anesthesia with an unremarkable intraoperative and postoperative period.

Peripheral venous extravasation injury

Extravasation is the inadvertent administration or leakage of blood, lymph or other fluid (including medication) into the subcutaneous or subdermal tissues, instead of the intended vascular or lymphatic pathways.1,2