Extravasation Injuries
Management of Vasopressor Extravasation
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Stop injection/infusion immediately; leave the catheter in place
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Place immediate substitute IV access; resume vasopressors
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Slowly aspirate as much of the drug as possible
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Elevate the area & apply warm compresses for 48 hours
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Consult plastic surgery & vascular surgery for opinion & ongoing management
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Reversal:
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First line: phentolamine subcutaneously
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Dilute phentolamine 5 mg in 10 mL 0.9% sodium chloride
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A dose of 0.1-0.2 mg/kg (up to a maximum of 10 mg) should then be injected through the catheter & subcutaneously around the site
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Use 25 g or smaller needle
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Additional injections may be required if blanching returns
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Systemic hypotension may occur
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Other options:
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Topical nitroglycerin 2% 1-inch strip applied to the site of ischemia (redose q8h PRN)
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Terbulatine subcutaneously 1mg in 10ml NS, inject locally across symptomatic sites
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Consider sympathetic block, e.g. stellate ganglion (case reports of success)
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Consider a saline-wash out method or liposuction:
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Saline wash out:
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Probably the most effective way of removing drug from the site of extravasation & has been shown to reduce tissue injury
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Under sterile conditions with local or general anaesthesia, four to six stab incisions are made around the area of extravasation
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A blunt-ended cannula is inserted through one of the incisions & a large volume of saline flushed through the subcutanous tissues
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The saline exits through the other incisions
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Liposuction:
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Blunt-ended liposuction cannula is inserted into the area of extravasation & used to aspirate fat & extravasated material
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Less effective than saline washout
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Prevention
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Avoid IVs in the hand/wrist
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Avoid unreassuring IVs
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Perform protocolized extremity checks
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Keep antidotes & worksheet in the room with the patient
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10 mg of phentolamine mesylate can be added to each liter of solution containing norepinephrine (the vasopressor effect of norepinephrine is not affected)