Techniques for Prevention of Extravasation Injury

 

Steps in decision making:

(1) Determine the risk of significant extravasation injury.

(2) Determine the amount of adipose tissue and localized extravasate.

 

Agents capable of causing extravasation injury:

(1) intravenous hyperalimentation fluid

(2) vesicant chemotherapy agents

(3) antibiotics

(4) vasoconstricting agent

(5) bicarbonate, calcium, potassium or other salt

(6) 10% dextrose

 

Determinants of severity of injury:

(1) type of extravasated fluid

(2) volume of fluid

(3) anatomic location (hand more susceptible to disabling injuries)

(4) susceptibility of the patient to injury (premature infant, etc.)

 

Methods reported in the literature to manage extravasation:

(1) injection of an antidote (see chapter on radiation and chemotherapeutic agents)

(2) injection of hyaluronidase to aid drug absorption

(3) dilution with normal saline (clysis)

(4) application of ice or heat

(5) application of steroid cream

(6) surgical debridement followed by skin grafting

(7) "wait and see"

 

Technique 1 - Liposuction

(1) This is suitable for areas with abundant adipose tissue and a localized extravasation.

(2) The skin surface at the extravasation site and the surrounding region is carefully cleaned with surgical scrub.

(3) Anesthesia is provided, either as injection of a local anesthetic or as general anesthesia.

(4) A small incision is made at the edge of the zone of extravasation.

(5) A liposuction cannula with side holes is inserted and manipulated to remove as much adipose tissue and extravasated fluid as possible.

(6) This may be followed by saline flushout (next) for significant extravasations.

 

Technique 2 - Saline flushout

(1) This is suitable for areas with little adipose tissue like the back of the hand.

(2) The skin surface at the extravasation site and the surrounding region is carefully cleaned with surgical scrub.

(3) If the patient is immunosuppressed then prophylactic antibiotic therapy is given.

(4) The site of extravasation is infiltrated with hyaluronidase to depolymerise the connective tissue and make it more permeable to fluid.

(5) Anesthesia is provided, either as injection of a local anesthetic or as general anesthesia.

(6) 4 small incisions are made around the zone of extravasation.

(7) A blunt-ended cannula (the author used a Verres needle) is introduced into the first hole and an aliquot of normal saline (10 - 50 mL) is injected into the area of extravasation.

(8) The injected saline is then pushed out through the remaining 3 holes.

(9) The cannula is then introduced into each hole in sequence and the process repeated until 500 mL of saline has been flushed through the area.

(10) The small incisions are not sutured but are allowed to heal on their own.

(11) The site is covered with betadine soaked gauze and the limb is elevated for the next 24 hours.

 

The material recovered from each technique can be analyzed for the toxic material to confirm removal.

 

NOTE: I wonder if injection of a nontoxic dye (as is used in sentinel lymph node biopsy) into the site of extravasation would help guide the interventions.