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

Abstract

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

A neonate with aseptic cutaneous necrosis related to the migration of the proximal central venous catheter infusion port

“… Patient safety considerations of CVC placement in neonates must consider the proximal port distance relative to the vessel entry point for reliable intraluminal durability. Neonatal loose soft tissue and edema during extended CVC use along with patient positioning changes could cause extravascular extrusion of the CVC proximal port. CVC monitoring should include insertion site inspection, blood aspiration from all ports when possible, infusion line pressure monitoring, and obtaining anticipated clinical response from the infusion. Infusions should be immediately discontinued when extravasation is suspected followed by immediate investigation and activation of mitigation measures to minimize patient morbidity 4 …”

When I use a word . . . Medical definitions: Pharmacovigilance signals

“…● a specific anatomical location or pattern of injury; examples include damage due to extravasation of a drug at an intravenous administration site7 and ulceration due to topical aspirin8; this is analogous to witnessing the culprit committing the crime;…”

Ultrasound-guided placement of Midline catheters performed by Neurosurgery resident as a substitute for conventional central venous catheter placement in Neurosurgical Intensive Care Unit patients

“…Mannitol is frequently administered for neurosurgical ICU patients. In our institution, we use 15% mannitol with an osmolarity of 823 mOsm/L (Baxter, Deerfield, IL, USA), which is lower than the 20% (1369 mOsm/L) osmolarity of definite irritants in a recent study 25) . Administration of hypertonic saline through a CVC is also preferred 10) .…”

“…Administration of hypertonic saline through a CVC is also preferred 10) . However, access may be limited in urgent situations for IICP control 25) . Recent studies have shown an acceptable safety profile for peripherally administered hypertonic saline even with bolus injection 26,27) .…”

“…Vasopressors induce local vasoconstriction and elevation of hydrostatic pressure, especially in small veins, and subsequently disintegrate adjacent tissues 25) . This potential harm is particularly concerning with respect to the accumulation of drugs in peripheral IV administration because the venous flow in the peripheral vein is slower than that in the central vein 25) . A meta-analysis of adverse events resulting from peripheral infusion of vasopressors showed no significant difference in complications between peripheral IV and CVC 28) .…”