Treatment of extravasation injuries in infants and young children: a scoping review and survey

Abstract

BackgroundExtravasation injuries are caused by unintended leakages of fluids or medicines from intravenous lines, but there is no consensus on the best treatment approaches.ObjectivesTo identify which treatments may be best for treating extravasation injuries in infants and young children.DesignScoping review and survey of practice.PopulationChildren aged < 18 years with extravasation injuries and NHS staff who treat children with extravasation injuries.InterventionsAny treatment for extravasation injury.Main outcome measuresWound healing time, infection, pain, scarring, functional impairment, requirement for surgery.Data sourcesTwelve database searches were carried out in February 2017 without date restrictions, including MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature) Plus and EMBASE (Excerpta Medica dataBASE).MethodsScoping review – studies were screened in duplicate. Data were extracted by one researcher and checked by another. Studies were grouped by design, and then by intervention, with details summarised narratively and in tables. The survey questionnaire was distributed to NHS staff at neonatal units, paediatric intensive care units and principal oncology/haematology units. Summary results were presented narratively and in tables and figures.ResultsThe evidence identified in the scoping review mostly comprised small, retrospective, uncontrolled group studies or case reports. The studies covered a wide range of interventions including conservative management approaches, saline flush-out techniques (with or without prior hyaluronidase), hyaluronidase (without flush-out), artificial skin treatments, debridement and plastic surgery. Few studies graded injury severity and the results sections and outcomes reported in most studies were limited. There was heterogeneity across study populations in age, types of infusate, injury severity, location of injury and the time gaps between injury identification and subsequent treatment. Some of the better evidence related to studies of flush-out techniques. The NHS survey yielded 63 responses from hospital units across the UK. Results indicated that, although most units had a written protocol or guideline for treating extravasation injuries, only one-third of documents included a staging system for grading injury severity. In neonatal units, parenteral nutrition caused most extravasation injuries. In principal oncology/haematology units, most injuries were due to vesicant chemotherapies. The most frequently used interventions were elevation of the affected area and analgesics. Warm or cold compresses were rarely used. Saline flush-out treatments, either with or without hyaluronidase, were regularly used in about half of all neonatal units. Most responders thought a randomised controlled trial might be a viable future research design, though opinions varied greatly by setting.LimitationsPaucity of good-quality studies.ConclusionsThere is uncertainty about which treatments are most promising, particularly with respect to treating earlier-stage injuries. Saline flush-out techniques and conservative management approaches are commonly used and may be suitable for evaluation in trials.Future workConventional randomised trials may be difficult to perform, although a randomised registry trial may be an appropriate alternative.FundingThe National Institute for Health Research Health Technology Assessment programme.

Surgical intervention for paediatric infusion-related extravasation injury: a systematic review

“…Uncertainty remains over whether there is a difference in the outcomes of children who are treated conservatively or surgically and the case series that exist on conservative management cover a number of treatments for a range of injuries from swelling to full-thickness defects. However, a recent scoping review found that the outcomes used and results detailed were generally limited, 6 making it difficult for clinicians to rely on those studies in deciding who to treat conservatively. This is why we have focused solely on studies describing invasive interventions: the Gault technique, debridement and further surgery, and hyaluronidase injections.…”

“…It is therefore not known which of these treatments are effective, harmful or at the very least, necessary; a conclusion supported by a recent scoping review of interventions. 6 That review highlighted the fact that the lack of consensus extended to published guidelines. Their survey also showed wide variation in the frequency of use of the saline washout techniques in neonatal units across the National Health Service in the UK.…”

Surgical Intervention for Paediatric Infusion-Related Extravasation Injury: A Systematic Review

“…Uncertainty remains over whether there is a difference in the outcomes of children who are treated conservatively or surgically and the case series that exist cover a number of treatments for a range of injuries from swelling to full-thickness defects. However, a recent scoping review found that the outcomes used and results detailed were generally limited, 6 making it difficult for clinicians to rely upon those studies in deciding who to treat conservatively. This is why we have focused solely on surgical interventions.…”

“…It is therefore not known which of these treatments are effective, harmful or at the very least, necessary; a conclusion supported by a recent scoping review of interventions. 6 That review highlighted the fact that the lack of consensus extended to published guidelines. Their survey also showed wide variation in the frequency of use of the saline washout techniques in neonatal units across the National Health Service (NHS) in the UK.…”

Treating extravasation injuries in infants and young children: a scoping review and survey of UK NHS practice

“…This paper presents a more succinct account of a study of treatments for extravasation injuries in infants and children which has also been reported in full as an NIHR HTA report. [1]…”