Treatment of extravasation injury

Extravasation of intravenous drugs and infusions can cause serious soft tissue loss and scarring around nerves, joints and tendons.^1-4 Anaesthetists who work in theatre and intensive care, and perform cardiopulmonary resuscitation, are likely to see this complication relatively frequently.

A variety of regimens are currently advocated: topical application of ice,^5,6 injection of hyaluronidase,⁷ local injection of steroid to combat inflammation,⁸ injection of small amounts of saline to dilute the toxic agent (clysis)⁹ and injection of specific antidotes such as phentolamine in the case of extravasation of vasopressor agents.

It is worrying to permit a potentially harmful material to remain in the subcutaneous perivenous space whether diluted, cooled or treated with a specific antidote. Early surgical debridement and skin grafting was recommended ^10,11 but it is not possible to predict at an early stage whether or not a soft tissue complication will occur. It is preferable to remove recently extravasated material without resort to skin excision. This can be achieved by infiltration of the area of extravasation with hyaluronidase and the construction of several exit stab wounds around the zone of extravasation. Normal saline is flushed through the subcutaneous space to cleanse it. A liposuction cannula is then inserted and some or all of the extravasated material and subcutaneous fat is sucked out. This can simply be performed under a brachial plexus block. The vasodilatation induced by the latter may also help to prevent tissue ischaemia and accelerate vascular absorption of the extravasated substance.

We have observed the effectiveness of this treatment in patients in whom highly irritant cytotoxic drugs, electrolyte solutions (potassium, calcium) and concentrated parenteral nutrition fluid had extravasated. The patients were referred and treated on the day of the extravasation. Hand function is preserved and skin ulceration prevented in all cases. There is no evidence of any soft tissue damage.

We emphasise the importance of referral of extravasation injuries to a plastic surgeon at the earliest possible opportunity because of the unpredictability of even the most trivial of extravasations. A wait-and-see policy runs the risk that established tissue necrosis and irreversible soft tissue damage will develop.

P.M. MURPHY, D.T. GAULT

The Hospital for Sick Children, Great Ormond Street, London WC] 3JH