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Extravasation Injuries

 

 

Management of Vasopressor Extravasation

 

  • Stop injection/infusion immediately; leave the catheter in place

  • Place immediate substitute IV access; resume vasopressors

  • Slowly aspirate as much of the drug as possible

  • Elevate the area & apply warm compresses for 48 hours

  • Consult plastic surgery & vascular surgery for opinion & ongoing management

  • Reversal:

    • First line: phentolamine subcutaneously

      • Dilute phentolamine 5 mg in 10 mL 0.9% sodium chloride

      • 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

      • Use 25 g or smaller needle

      • Additional injections may be required if blanching returns

      • Systemic hypotension may occur

    • Other options:

      • Topical nitroglycerin 2% 1-inch strip applied to the site of ischemia (redose q8h PRN)

      • Terbulatine subcutaneously 1mg in 10ml NS, inject locally across symptomatic sites

  • Consider sympathetic block, e.g. stellate ganglion (case reports of success) 

  • Consider a saline-wash out method or liposuction:

    • ​Saline wash out:

      • Probably the most effective way of removing drug from the site of extravasation & has been shown to reduce tissue injury

      • Under sterile conditions with local or general anaesthesia, four to six stab incisions are made around the area of extravasation 

      • A blunt-ended cannula is inserted through one of the incisions & a large volume of saline flushed through the subcutanous tissues

      • The saline exits through the other incisions

    • Liposuction:

      • Blunt-ended liposuction cannula is inserted into the area of extravasation & used to aspirate fat & extravasated material

      • Less effective than saline washout

 

 

Prevention

 

  • Avoid IVs in the hand/wrist

  • Avoid unreassuring IVs

  • Perform protocolized extremity checks

  • Keep antidotes & worksheet in the room with the patient

  • 10 mg of phentolamine mesylate can be added to each liter of solution containing norepinephrine (the vasopressor effect of norepinephrine is not affected)

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