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1
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Wolfe RC. Rescue Agents for Perioperative Vasoplegia. J Perianesth Nurs 2025; 40:454-456. [PMID: 40185568 DOI: 10.1016/j.jopan.2025.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2025] [Accepted: 01/18/2025] [Indexed: 04/07/2025]
Affiliation(s)
- Rachel C Wolfe
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, MO.
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2
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Mori K, Hirata R, Tago M. Extravasation-induced subcutaneous tissue injury due to remdesivir in older COVID-19 patients. BMJ Case Rep 2025; 18:e264317. [PMID: 40132931 DOI: 10.1136/bcr-2024-264317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2025] Open
Affiliation(s)
- Kazumi Mori
- Department of General Medicine, Saga University Hospital, Saga, Japan
- Department of General Medicine, Saga Memorial Hospital, Saga, Japan
| | - Risa Hirata
- Department of General Medicine, Saga University Hospital, Saga, Japan
| | - Masaki Tago
- Department of General Medicine, Saga University Hospital, Saga, Japan
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3
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Flynn GE, Riffe CI, Aicher KM, Wheeler LR. Phentolamine Infusion for the Treatment of Norepinephrine Extravasation in a Dog. J Vet Emerg Crit Care (San Antonio) 2025:e13461. [PMID: 40127428 DOI: 10.1111/vec.13461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2024] [Revised: 03/02/2025] [Accepted: 03/11/2025] [Indexed: 03/26/2025]
Abstract
OBJECTIVE To describe a case of clinically significant norepinephrine extravasation in a dog with a successful outcome following the use of subcutaneous phentolamine infusion. CASE SUMMARY An 8-year-old male neutered Labrador Retriever experienced norepinephrine extravasation from a cephalic, peripheral intravenous catheter while under anesthesia for an exploratory laparotomy. Upon recognition of norepinephrine extravasation, moderate subcutaneous edema and a painful dermal plaque were apparent at the extravasation site. Ten milligrams of phentolamine mesylate, a potent alpha-adrenergic receptor antagonist, were diluted in 10 mL of sterile saline and administered subcutaneously in small aliquots at multiple sites in the area of extravasation. The patient remained hemodynamically stable during and after the infusion. Most phentolamine injections produced instantaneous erythematous macules that resolved 24-36 h later, and the integument in the extravasation area rapidly changed from a "blanched" to a "pink" color. The subcutaneous edema gradually resolved within 7 days post-extravasation. At 12 h following extravasation, the dermal plaque progressed into a necrotic focus, which later developed into an ulcer (36 h), then a small crust (7 days), and finally healed epidermis (9 days). When the patient was euthanized 10 days after surgery due to continued decline secondary to systemic disease, there remained only a small superficial crust at the site of extravasation. UNIQUE INFORMATION To the authors' knowledge at the time of submission, this case report documented the first reported clinical use of subcutaneous phentolamine infusion for the management of norepinephrine extravasation in a veterinary species.
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Affiliation(s)
- Grace E Flynn
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Cody I Riffe
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Kathleen M Aicher
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Lance R Wheeler
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Texas A&M University, College Station, Texas, USA
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4
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McDonald JS, Schmitz JJ, McDonald RJ. Hyaluronidase Injection for Prevention of Moderate or Severe Complications After Contrast Media Extravasation: A Propensity Score-Matched Analysis. AJR Am J Roentgenol 2025; 224:e2431986. [PMID: 39475197 DOI: 10.2214/ajr.24.31986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2025]
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Le CK, Stevens CA, Park JH, Clark RF. Promethazine: A Review of Therapeutic Uses and Toxicity. J Emerg Med 2025; 70:127-133. [PMID: 39947973 DOI: 10.1016/j.jemermed.2024.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 09/17/2024] [Accepted: 09/30/2024] [Indexed: 03/10/2025]
Abstract
BACKGROUND Promethazine was first approved in 1951 and has since been used as a treatment option for a variety of indications. A histamine H1 receptor competitive antagonist with antihistaminic, sedative, anti-kinetotic, antiemetic, and antimuscarinic effects, promethazine is utilized for the treatment of nausea and vomiting, a common reason for emergency department (ED) visits. OBJECTIVE This review of promethazine explores its pharmacology and history of toxicities, and discusses current recommendations from patient safety organizations, which implicate its role in therapy. DISCUSSION Injectable promethazine utilization should take into consideration patient-specific factors, institutional policies, medication shortages of alternative agents, and the efficacy and toxicities of injectable promethazine itself. For decades, injectable promethazine has been associated with rare but serious limb-threatening adverse effects after extravasation or inadvertent intra-arterial injection. Patient safety organizations have called for hospitals to remove injectable promethazine from formularies, and the U.S. Food and Drug Administration acted in December of 2023 to change the product labeling, adding dilution and administration recommendations for intravenous administration and stating a preference for intramuscular administration. CONCLUSION Promethazine offers a suitable alternative antiemetic for use in the ED due to its distinct mechanism of action. Injectable promethazine, however, must be used with caution to minimize risk of serious patient harm in the event of intra-arterial or perivascular extravasation when given parenterally.
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Affiliation(s)
| | | | | | - Richard F Clark
- Department of Emergency Medicine, Division of Medical Toxicology, UC San Diego Health, San Diego, California
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6
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Blazquez-Vidal M, Garcia-Del Valle I, Amoros-Reboredo P, Diaz-Herrera MA, Val-Prat L, Sanmartin-Suñer M. Real world data on the management of non-cytotoxic drug extravasation: An observational retrospective study in paediatric and adult patients. Nurs Crit Care 2025; 30:e70020. [PMID: 40109134 DOI: 10.1111/nicc.70020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Revised: 02/21/2025] [Accepted: 03/07/2025] [Indexed: 03/22/2025]
Abstract
BACKGROUND The extravasation of non-cytotoxic drugs is a risk posed by intravenous therapy, particularly in critically ill patients who often require multiple intravenous medications. This risk must be promptly addressed to prevent morbidity, increased therapy costs and prolonged length of stay, especially in critical care units. Therefore, it is critical to define the specific measures that should be undertaken to approach each situation. AIM The aim of this research was to describe the extravasation of non-cytotoxic drugs occurring in a tertiary hospital and to assess the effectiveness and safety of the internal protocol applied. STUDY DESIGN This was a single-centre, retrospective, observational study based on real world data from adult and paediatric patients experiencing extravasation of a non-cytotoxic drug between June 2018 and June 2023. To perform the analysis, demographic, patient, intravenous therapy, extravasation and treatment variables were collected and computed using descriptive statistics. RESULTS The analysis included 61 patients. The median age was 63.0 (IQR 3.5-74.5) years, and participants were grouped into neonates, children and adults. Among the subjects studied, 80% had at least one risk factor that made them liable to experience an extravasation. Drug groups involved were radiological contrasts (42.6%), parenteral nutrition and electrolytes (29.5%), vasoactive and cardiovascular system drugs (14.8%), antibiotics (8.2%), other analgesics and antipyretics (1.6%), expectorants (1.6%) and alimentary tract and metabolism drugs (1.6%). Adequacy of the protocol was reported in 73.8% of the cases with complete recovery. CONCLUSIONS The work reported here contributes to improving evidence about the management of extravasation episodes. Our findings suggest that patient-centred team-based protocolizing is a key strategy to achieve the effectiveness and safety of non-cytotoxic drugs in real world practice. This protocol could allow other institutions to enhance safety related to intravenous therapy. Moreover, maintaining a surveillance strategy will enable the continuous collection of data on these adverse events, facilitating ongoing improvement and reinforcement of good practices. RELEVANCE TO CLINICAL PRACTICE Implementing a standardized protocol for managing non-cytotoxic drug extravasation can significantly enhance patient safety and improve outcomes in both adult and paediatric populations in critical care settings.
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Affiliation(s)
- Marta Blazquez-Vidal
- Pharmacy Department, Hospital Uiversitari General de Catalunya-Quironsalud, Barcelona, Spain
| | - Ines Garcia-Del Valle
- Pharmacy Department, Hospital Uiversitari General de Catalunya-Quironsalud, Barcelona, Spain
| | - Patricia Amoros-Reboredo
- Pharmacy Department, Hospital de Sant Pau, Digital Impulse, Strategy and Transformation Area, Hospital de Sant Pau, Institut de Recerca Sant Pau (IR SANT PAU), PHAGEX: Pharmacotherapy, Genomics and Exposomics Research Group, Blanquerna, Universitat Ramon Llull, Barcelona, Spain
| | - Miguel Angel Diaz-Herrera
- Pharmacy Department, Hospital Uiversitari General de Catalunya-Quironsalud, Barcelona, Spain
- Complex Wounds South Metropolitan Primary Care, Institut Català de la Salut, Barcelona, Spain
- Department of Fundamental and Clinical Nursing, Faculty of Nursing, Universitat de Barcelona, Barcelona, Spain
| | - Laura Val-Prat
- Pharmacy Department, Hospital Uiversitari General de Catalunya-Quironsalud, Barcelona, Spain
| | - Monica Sanmartin-Suñer
- Pharmacy Department, Hospital Uiversitari General de Catalunya-Quironsalud, Barcelona, Spain
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7
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Kumar A, Singh K, Kumar A, Sinha C, Mandal P. Novel application of 5% lignocaine patch for the treatment of vesicant extravasations. J Perioper Pract 2025:17504589241311883. [PMID: 39840480 DOI: 10.1177/17504589241311883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2025]
Affiliation(s)
- Amarjeet Kumar
- Department of Anesthesiology, All India Institute of Medical Sciences, Patna, India
| | - Kunal Singh
- Department of Anesthesiology, All India Institute of Medical Sciences, Patna, India
| | - Ajeet Kumar
- Department of Anesthesiology, All India Institute of Medical Sciences, Patna, India
| | - Chandni Sinha
- Department of Anesthesiology, All India Institute of Medical Sciences, Patna, India
| | - Purnaa Mandal
- Department of Anesthesiology, All India Institute of Medical Sciences, Patna, India
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Vasquez MP, Daly M, Boyd CJ, Crandell DE, Hall KE, Mays EL, Ngwenyama T, Ortolani J, Smith MR, Hoehne SN, Martin L, Davidow EB. Multicenter retrospective evaluation of norepinephrine extravasation in dogs and cats (2015-2021): 14 cases. J Vet Emerg Crit Care (San Antonio) 2025; 35:73-80. [PMID: 39957707 DOI: 10.1111/vec.13442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 10/27/2023] [Accepted: 11/04/2023] [Indexed: 02/18/2025]
Abstract
OBJECTIVE To document clinical complications and intervention options associated with norepinephrine (NE) extravasation in dogs and cats. DESIGN Cases were identified between 2015 and 2021. Because this is an uncommon complication, the findings are compiled as a descriptive retrospective study. SETTING Cases were provided from 4 universities and 2 private practice groups in the United States, Canada, and Australia. ANIMALS Fourteen patients (13 dogs, 1 cat) that experienced extravasation events (16 total). INTERVENTIONS Small animal patients were included where extravasation of a NE constant rate infusion (CRI) was documented. Records were reviewed for information, including suspected underlying condition, description of the interventions pursued after identification of extravasation, clinical signs after extravasation, and survival to discharge or reason for patient death or euthanasia. When available, information was collected pertaining to the NE dose, dilution, total duration of CRI, and duration of CRI before extravasation was recognized. MEASUREMENTS AND MAIN RESULTS The most commonly reported clinical signs after extravasation of NE were skin necrosis (n = 9 [64.3%]) and swelling (n = 6 [42.9%]). In 10 of 16 events (62.5%), discontinuation of the NE CRI and/or application of a warm compress to the extravasation site were performed; these were the most common nonpharmacological rescue measures. Two patients received subcutaneous phentolamine, and 1 patient underwent hyperbaric oxygen therapy. While surgical intervention was recommended for 4 dogs, 2 improved without surgical debridement. The overall survival rate from underlying disease processes was 57% (n = 8), with only 1 patient (7%) euthanized due to an injury from the extravasation. CONCLUSIONS Severe lesions can result from NE extravasation in dogs and cats, leading to euthanasia. Although phentolamine remains the treatment of choice, lesions may heal with alternative supportive measures.
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Affiliation(s)
- Maria P Vasquez
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, Washington, USA
| | | | - Corrin J Boyd
- School of Veterinary Medicine, Murdoch University, Murdoch, Western Australia, Australia
| | | | - Kelly E Hall
- Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Erin Long Mays
- Department of Veterinary Clinical Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
| | - Tandi Ngwenyama
- Oregon State University Veterinary Teaching Hospital, Corvallis, Oregon, USA
| | - Jennifer Ortolani
- VCA SouthPaws Veterinary Specialists and Emergency Center, Fairfax, Virginia, USA
| | - M Ryan Smith
- Department of Veterinary Clinical Sciences, Louisiana State University, Baton Rouge, Louisiana, USA
| | - Sabrina N Hoehne
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, Washington, USA
| | - Linda Martin
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, Washington, USA
| | - Elizabeth B Davidow
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, Washington, USA
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Duggan JL, Lechtig A, Watkins IT, Lans J, von Keudell A, Zhang D. Characteristics of Intravenous Fluid Infiltration and Factors Associated With Adverse Events: A Multicenter Retrospective Study. Hand (N Y) 2024:15589447241302359. [PMID: 39668421 PMCID: PMC11638929 DOI: 10.1177/15589447241302359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2024]
Abstract
BACKGROUND Peripheral intravenous (PIV) infiltration and extravasation are common complications of intravenous fluid administration. Here, we aim to investigate risk factors associated with major adverse events following PIV infiltration, which may help risk stratify those who require early surgical consultation. METHODS Retrospectively, patients were identified who had a documented PIV infiltration or extravasation event at 3 academic hospitals between 2015 and 2022. A major adverse advent was defined as a full-thickness injury requiring operative management (deep infection, compartment syndrome). A minor adverse event was defined as superficial injury (cellulitis, superficial thrombosis). RESULTS In total, 160 patients with PIV infiltration events were included (37.5% men), with an average age of 64.1 years. A surgical consult for a hand specialist was placed 35% of the time: orthopedic surgery in 46.4% of cases and plastic surgery in 42.9%. Among these consults, 87.5% recommended supportive treatment (elevation, warm/cold compresses, serial examinations). Major adverse events occurred in 4.4% (n = 7) of patients, and minor adverse events occurred in 11.3% (n = 18). Both intensive care unit (ICU) admission and current intubation status (ie, intubated, sedated, and nonexaminable) at the time of infiltration were significantly associated with adverse events (P = .02 and P = .03, respectively). Current intubation status was significantly associated with operative management (P = .001). CONCLUSION Robust characterization of PIV infiltration events may facilitate early identification of patients at risk of serious complications. We found ICU admission and current intubation both to be associated with adverse events following PIV infiltration. Further work should be done to evaluate the risk of infiltration with different fluid types (vesicant, nonvesicant).
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Affiliation(s)
| | - Aron Lechtig
- Harvard Combined Orthopaedic Residency Program, Boston, MA, USA
| | - Ian T. Watkins
- Harvard Combined Orthopaedic Residency Program, Boston, MA, USA
| | - Jonathan Lans
- Harvard Combined Orthopaedic Residency Program, Boston, MA, USA
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10
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Shahsavari S, Rad MB, Hajiaghajani A, Rostami M, Hakimian F, Jafarzadeh S, Hasany M, Collingwood JF, Aliakbari F, Fouladiha H, Bardania H, Otzen DE, Morshedi D. Magnetoresponsive liposomes applications in nanomedicine: A comprehensive review. Biomed Pharmacother 2024; 181:117665. [PMID: 39541790 DOI: 10.1016/j.biopha.2024.117665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 11/03/2024] [Accepted: 11/07/2024] [Indexed: 11/16/2024] Open
Abstract
Safe and effective cancer therapy requires a suitable nanocarrier that can target particular sites, such as cancer cells, in a selective manner. With the tremendous growth in nanotechnology, liposomes, among various competing nanocarriers, have shown promising advances in cancer therapy. Magnetic nanoparticles and metal ions are wide-reaching candidates for conferring magnetic properties and for incorporation into liposomes. Combining liposomes with magnetic structures enables construction of magnetoresponsive liposomes, allowing stimuli-responsiveness to an alternating magnetic field, magnetic targeting, and tracking by magnetic resonance imaging, which could all occur in parallel. This review presents a comprehensive analysis of the practical advances and novel aspects of design, synthesis and engineering magnetoresponsive liposomes, emphasizing their diverse properties for various applications. Our work explores the innovative uses of these structures, extending beyond drug delivery to include smart contrast agents, cell labeling, biosensing, separation, and filtering. By comparing new findings with earlier studies, we showcase significant improvements in efficiency and uncover new potentials, setting a new benchmark for future research in the field of magnetoresponsive liposomes.
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Affiliation(s)
- Shayan Shahsavari
- Iran Nanotechnology Innovation Council, Nanoclub Elites Association, Tehran, Iran
| | - Mohammad Behnam Rad
- Department of Biophysics, Institute of Biochemistry and Biophysics, University of Tehran, P.O. Box 13145-1384, Tehran, Iran
| | - Amirhossein Hajiaghajani
- School of Electrical Engineering, Iran University of Science and Technology, Tehran 1684613114, Iran
| | | | - Fatemeh Hakimian
- Department of Biophysics, Institute of Biochemistry and Biophysics, University of Tehran, P.O. Box 13145-1384, Tehran, Iran
| | - Sina Jafarzadeh
- Department of Energy Conversion and Storage, Technical University of Denmark, Anker Engelunds Vej, Lyngby 2800 Kgs, Denmark
| | - Masoud Hasany
- Department of Civil and Mechanical Engineering, Technical University of Denmark, Lyngby 2800 Kgs, Denmark
| | | | - Farhang Aliakbari
- National Institute of Genetic Engineering and Biotechnology, Shahrak-e Pajoohesh, km 15 Tehran - Karaj Highway, P.O.Box:14965/161, Tehran, Iran; Molecular Medicine Research Group, Robarts Research Institute, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Hamideh Fouladiha
- Department of Biotechnology, College of Science, University of Tehran, Tehran, Iran
| | - Hassan Bardania
- Cellular and Molecular Research Center, Yasuj University of Medical Sciences, Yasuj, Iran.
| | - Daniel E Otzen
- Interdisciplinary Nanoscience Centre (iNANO) and Department of Molecular Biology and Genetics, Aarhus University, Gustav Wieds Vej 14, Aarhus C DK-8000, Denmark.
| | - Dina Morshedi
- National Institute of Genetic Engineering and Biotechnology, Shahrak-e Pajoohesh, km 15 Tehran - Karaj Highway, P.O.Box:14965/161, Tehran, Iran.
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11
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Gorski LA, Ong J, Van Gerpen R, Nickel B, Kokotis K, Hadaway L. Development of an Evidence-Based List of Non-Antineoplastic Vesicants: 2024 Update. JOURNAL OF INFUSION NURSING 2024; 47:290-323. [PMID: 39250767 DOI: 10.1097/nan.0000000000000568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
Infiltration of a vesicant, called extravasation, can result in severe patient injuries. Recognition of vesicants and their relative risk of injury is essential to extravasation prevention, early recognition, and appropriate treatment. In this article, the Vesicant Task Force (VTF) updates the previously published Infusion Nurses Society (INS) vesicant list from 2017. The 2024 INS list diverges from earlier vesicant lists, such as the 2017 VTF list, by adopting a risk stratification approach based upon documented patient outcomes, in contrast to the reliance on expert consensus or only surrogate risk indicators, such as pH and osmolarity. The methodology used to create the updated list is explained, and the criteria for high- and moderate-risk vesicants and cautionary vesicants are defined.
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Affiliation(s)
- Lisa A Gorski
- Author Affiliations: Ascension at Home, Brentwood, Tennessee (Gorski); Bryan Medical Center, Lincoln, Nebraska (Ong); Retired from Bryan Medical Center, Lincoln, Nebraska (Van Gerpen); Omaha, Nebraska (Nickel); Retired from BD Medical, Munster, Indiana (Kokotis); Lynn Hadaway Associates, Inc., Milner, Georgia (Hadaway)
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12
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Leeuwerik AF, van Merendonk LN, de Boer MA, Wilhelm AJ, Kolkman A, Bet PM. A new approach to drug intravenous compatibility research: the case of obstetric parenteral drugs. Eur J Hosp Pharm 2024; 31:455-460. [PMID: 36931718 DOI: 10.1136/ejhpharm-2022-003577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/07/2023] [Indexed: 03/19/2023] Open
Abstract
OBJECTIVES The product information and literature does not provide confirmation of compatibility for co-administration of all commonly used drug pairs in obstetrics. However, there is a need for co-administration of these drugs over one lumen for this group of patients. Therefore, this study focuses on Y-site compatibility. Since different conditions between clinical and laboratory settings can lead to discrepancies in results, a novel approach for drug intravenous compatibility testing was designed to reflect clinical conditions. The aim was to study the compatibility of nine commonly used drug pairs in obstetrics and to evaluate the clinical value of the designed method. METHODS The clinical situation was reflected by using different temperature ranges (20°C and 37°C), actual Y-site flow ratios, clinically relevant drug pairs and an observation time of 120 min. The clinically relevant drugs pairs include atosiban, nicardipine, amoxicillin/clavulanic acid, oxytocin, remifentanil, labetalol and magnesium sulpfate. Drug pairs were visually assessed according to the European Pharmacopoeia (Ph. Eur.) and pH was measured. When incompatibility of a drug pair seemed likely based on literature review or observed abnormalities during visual assessment, subvisual analysis was performed using a particle counter. Y-site compatibility applied for drug pairs when no visual changes occurred or when no additional particles were formed during the observation time. RESULTS Eight of the nine combinations showed no visual changes or noticeable changes in pH during the observation time. The amoxicillin/clavulanic-acid-oxytocin combination showed a colour change at 37°C at the actual Y-site flow ratio. However, subvisual particle counting showed no formation of additional particles. CONCLUSIONS Y-site compatibility was established for all tested drug pairs. The new clinical approach for analysing Y-site compatibility provides a high certainty of outcomes for clinical practice. In this way, clinical complications and use of several additional intravenous catheters can be avoided.
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Affiliation(s)
- A F Leeuwerik
- Department of Clinical Pharmacology and Pharmacy, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - L N van Merendonk
- Department of Clinical Pharmacology and Pharmacy, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - M A de Boer
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, Amsterdam, Netherlands
- Reproduction and Development Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - A J Wilhelm
- Department of Clinical Pharmacology and Pharmacy, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - A Kolkman
- Laboratory of the Dutch Pharmacists, The Royal Dutch Pharmacists Association (KNMP), The Hague, Netherlands
| | - P M Bet
- Department of Clinical Pharmacology and Pharmacy, Amsterdam University Medical Center, Amsterdam, Netherlands
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Stampfl M, DeBlieux P. A Clinical Review of Vasopressors in Emergency Medicine. J Emerg Med 2024; 67:e31-e41. [PMID: 38789351 DOI: 10.1016/j.jemermed.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 01/22/2024] [Accepted: 03/06/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Vasopressor medications raise blood pressure through vasoconstriction and are essential in reversing the hypotension seen in many critically ill patients. Previously, vasopressor administration was largely limited to continuous infusions through central venous access. OBJECTIVES OF THE REVIEW This review addresses the clinical use of vasopressors in various shock states, including practical considerations and innovations in vasopressor administration. The focus is on the clinical administration of vasopressors across a range of shock states, including hypovolemic, distributive, cardiogenic, and obstructive shock. DISCUSSION Criteria for starting vasopressors are not clearly defined, though early use may be beneficial. A number of physiologic factors affect the body's response to vasopressors, such as acidosis and adrenal insufficiency. Peripheral and push-dose administration of vasopressors are becoming more common. Distributive shock is characterized by inappropriate vasodilation and vasopressors play a crucial role in maintaining adequate blood pressure. The use of vasopressors is more controversial in hypovolemic shock, as the preferred treatment is correction of the volume deficit. Evidence for vasopressors is limited in cardiogenic shock. For obstructive shock, vasopressors can temporize a patient's blood pressure until definitive therapy can reverse the underlying cause. CONCLUSION Across the categories of shock states, norepinephrine has wide applicability and is a reasonable first-line agent for shock of uncertain etiology. Keeping a broad differential when hypotension is refractory to vasopressors may help to identify adjunctive treatments in physiologic states that impair vasopressor effectiveness. Peripheral administration of vasopressors is safe and facilitates early administration, which may help to improve outcomes in some shock states.
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Affiliation(s)
- Matthew Stampfl
- UW Health Med Flight, Madison, Wisconsin; BerbeeWalsh Department of Emergency Medicine, Madison, Wisconsin.
| | - Peter DeBlieux
- Louisiana State University Medical Center, New Orleans, Louisiana; Tulane University School of Medicine Department of Surgery, New Orleans, Louisiana
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14
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Shamel S, Zarkesh MR. Acyclovir extravasation in a newborn: a case report. J Med Case Rep 2024; 18:271. [PMID: 38845030 PMCID: PMC11157697 DOI: 10.1186/s13256-024-04585-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 05/08/2024] [Indexed: 06/09/2024] Open
Abstract
OBJECTIVE Extravasation of infused drugs is not a rare problem in medical practice. Acyclovir is a vesicant and an antiviral medication commonly used for young children. In the present study, we presented a neonate with soft tissue damage due to acyclovir extravasation. CASE REPORT A female newborn (Iranian, Asian) with gestational age 37+2 weeks and breech presentation was born by Cesarean delivery from a mother with a recent history of Herpes simplex virus (HSV) infection (Yas Women's Hospital, Tehran, Iran). Intravenous administration of acyclovir was initiated through a peripheral catheter inserted on the dorsal side of the left hand. A few minutes after the second dose, the patient showed a diffused firm swelling, local discoloration, and induration in the dorsum of the hand. The peripheral catheter was removed immediately. Hyaluronidase was injected subcutaneously in five different regions around the catheterization site. Intermittent limb elevation and cold compression (for 10 minutes) were applied. Serial follow-ups and examinations were performed hourly to check limb inflammation, ischemia, and compartment syndrome. The limb swelling and discoloration significantly improved 4 hours after the second dose of hyaluronidase. CONCLUSION Early diagnosis of acyclovir extravasation and immediate management could prevent severe complications in neonates. Further studies are needed to suggest a standard approach and treatment protocol for acyclovir extravasation.
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Affiliation(s)
- Shirin Shamel
- Department of Neonatology, Yas Hospital Complex, Tehran University of Medical Sciences, Sarv Ave., North Nejatolahi Street, Tehran, 1598718311, Iran
| | - Mohammad Reza Zarkesh
- Department of Neonatology, Yas Hospital Complex, Tehran University of Medical Sciences, Sarv Ave., North Nejatolahi Street, Tehran, 1598718311, Iran.
- Maternal, Fetal, and Neonatal Research Center, Family Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
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15
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Christensen J, Andersson E, Sjöberg F, Hellgren E, Harbut P, Harbut J, Sjövall F, von Bruhn Gufler C, Mårtensson J, Rubenson Wahlin R, Joelsson-Alm E, Cronhjort M. Adverse Events of Peripherally Administered Norepinephrine During Surgery: A Prospective Multicenter Study. Anesth Analg 2024; 138:1242-1248. [PMID: 38180886 DOI: 10.1213/ane.0000000000006806] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024]
Abstract
BACKGROUND Perioperative treatment of hypotension by intravenous administration of norepinephrine in a peripheral vein can lead to adverse events, for example, tissue necrosis. However, the incidence and severity of adverse events during perioperative administration are unknown. METHODS This was a prospective observational study conducted at 3 Swedish hospitals from 2019 to 2022. A total of 1004 patients undergoing surgery, who met the criteria for perioperative peripheral norepinephrine administration, were included. The infusion site was inspected regularly. If swelling or paleness of skin was detected, the infusion site was changed to a different peripheral line. Systolic blood pressure and pulse frequency were monitored during the infusion time and defined as adverse events at >220 mm Hg and <40 beats•min -1 . In case of adverse events, patients were observed for up to 48 hours. The primary outcome was prevalence of extravasation, defined as swelling around the infusion site. Secondary outcomes were all types of adverse events and associations between predefined clinical variables and risk of adverse events. RESULTS We observed 2.3% (95% confidence interval [CI], 1.4%-3.2%) extravasation of infusion and 0.9% (95% CI, 0.4%-1.7%) bradycardia. No cases of tissue necrosis or severe hypertension were detected. All adverse events had dissipated spontaneously within 48 hours. Proximal catheter placement was associated with more adverse events. CONCLUSIONS Extravasation of peripherally administrated norepinephrine in the perioperative period occurred at similar rates as in previous studies in critically ill patients. In our setting, where we regularly inspected the infusion site and shifted site in case of swelling or paleness of skin, we observed no case of severe adverse events. Given that severe adverse events were absent, the potential benefit of this preventive approach requires confirmation in a larger population.
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Affiliation(s)
- Jens Christensen
- From the Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Elisabeth Andersson
- From the Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Fredric Sjöberg
- From the Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Elisabeth Hellgren
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Piotr Harbut
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Anaesthesia and Intensive Care, Danderyd Hospital, Stockholm, Sweden
| | - Joanna Harbut
- Department of Anaesthesia and Intensive Care, Danderyd Hospital, Stockholm, Sweden
| | - Fredrik Sjövall
- Department of Intensive and Perioperative Care, Skåne University Hospital, Malmö, Sweden
| | | | - Johan Mårtensson
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Section of Anaesthesia and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Rebecka Rubenson Wahlin
- From the Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Eva Joelsson-Alm
- From the Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Maria Cronhjort
- From the Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Anaesthesia and Intensive Care, Danderyd Hospital, Stockholm, Sweden
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16
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Amabile A, Col AD, Grigatti M, Montanari A, Tiengo C, Bassetto F. The multiple strategies adopted in a complex case of calcium extravasation in a child: a case report. Case Reports Plast Surg Hand Surg 2024; 11:2337746. [PMID: 38616947 PMCID: PMC11011224 DOI: 10.1080/23320885.2024.2337746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/28/2024] [Indexed: 04/16/2024]
Abstract
Extravasation of calcium solution is a common adverse event in children in intensive care units. The lack of adequate and timely treatment can lead to important functional sequelae. Here, we report the case of calcium extravasation in a child and we discuss the multiple therapeutic strategies adopted.
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Affiliation(s)
- Antonio Amabile
- Plastic and Reconstructive Surgery Unit, Department of Neurosciences, University of Padua, Padua, Italy
| | - Alessia De Col
- Plastic and Reconstructive Surgery Unit, Department of Neurosciences, University of Padua, Padua, Italy
| | - Martina Grigatti
- Plastic and Reconstructive Surgery Unit, Department of Neurosciences, University of Padua, Padua, Italy
| | - Alvise Montanari
- Plastic and Reconstructive Surgery Unit, Department of Neurosciences, University of Padua, Padua, Italy
| | - Cesare Tiengo
- Plastic and Reconstructive Surgery Unit, Department of Neurosciences, University of Padua, Padua, Italy
| | - Franco Bassetto
- Plastic and Reconstructive Surgery Unit, Department of Neurosciences, University of Padua, Padua, Italy
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17
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Nguyen M, Borders L, Wesolow JT, Greene J. Chemotherapy Extravasation Causing Soft-Tissue Necrosis Mimicking Infection: A Longitudinal Case Study. Cureus 2024; 16:e55333. [PMID: 38434604 PMCID: PMC10906345 DOI: 10.7759/cureus.55333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/29/2024] [Indexed: 03/05/2024] Open
Abstract
Extravasation injuries are uncommon, underreported, and often misdiagnosed in patients. The signs and symptoms of extravasation injuries vary from simple pain and tenderness to tissue necrosis and potentially fatal secondary infections. Extravasation may progress to more severe conditions such as necrotizing fasciitis (NF) or cellulitis, so special care is needed by physicians to identify and treat these injuries correctly. Here, we explore a case study on extravasation injuries mimicking NF leading to infectious complications and discuss the proper diagnosis and treatment of extravasation injuries as well as other NF-mimicking diseases. We present a case of a 44-year-old Hispanic male with a history of B-cell acute lymphoblastic leukemia who underwent inpatient chemotherapy treatment via a chest port.
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Affiliation(s)
- Michael Nguyen
- Internal Medicine, Morsani College of Medicine, University of South Florida Health, Tampa, USA
| | - Luke Borders
- Internal Medicine, Morsani College of Medicine, University of South Florida Health, Tampa, USA
| | | | - John Greene
- Internal Medicine, Moffitt Cancer Center, Tampa, USA
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18
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Azoury SC, Matros E. Top 25 Medications the Plastic and Reconstructive Surgery Trainee Should Know for an Emergency Medicine Department Consult. Plast Reconstr Surg 2024; 153:474e-489e. [PMID: 37141488 DOI: 10.1097/prs.0000000000010609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
SUMMARY Plastic surgery trainees are often called to render care in the emergency department (eg, for established patients, trauma, burns). Broad-based knowledge in pharmacotherapeutics during these encounters is critical. This includes an understanding of pain medications, anxiolytics, local anesthetics, antibiotics, anticoagulants, antidotes, and more to ensure optimal patient care. The purpose of this report is to describe 25 frequently used and other important medications that plastic surgery trainees should know for an adult emergency department encounter.
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Affiliation(s)
- Saïd C Azoury
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
| | - Evan Matros
- Division of Plastic Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center
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19
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Güler S, Kocaşaban DÜ. A case report of furosemide extravasation in the hand: a rare cause of compartment syndrome. Clin Exp Emerg Med 2023; 10:446-449. [PMID: 36410744 PMCID: PMC10790067 DOI: 10.15441/ceem.22.325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/18/2022] [Accepted: 06/22/2022] [Indexed: 11/23/2022] Open
Abstract
In emergency departments, many drugs, fluids, and materials for medical examinations and treatment are typically administered to patients intravenously. One of the most common complications of the intravenous bolus or infusion of drugs is extravasation injuries. These injuries may cause certain morbidities for the patient, increase the cost of treatment, and prolong hospital stays. At the same time, these injuries also carry medicolegal risks for health personnel. Furosemide is a potent diuretic that is commonly used in emergency departments for volume overload conditions. To the best of our knowledge, there have been no cases reported in the literature of furosemide-induced extravasation injury with subsequent compartment syndrome that has required surgical intervention. Presented herein is the case of a 70-year-old female patient who was administered intravenous furosemide from the dorsum of the left hand and whose extravasation injury progressed to compartment syndrome requiring an emergency fasciotomy.
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Affiliation(s)
- Sertaç Güler
- Department of Emergency Medicine, Ankara Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Dilber Üçöz Kocaşaban
- Department of Emergency Medicine, Ankara Training and Research Hospital, University of Health Sciences, Ankara, Turkey
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20
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Montague T, Weaver SB, Wingate LT. Extravasation of Non-Cytotoxic Drugs in Older People. Sr Care Pharm 2023; 38:457-464. [PMID: 37885098 DOI: 10.4140/tcp.n.2023.457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Objective To describe the risk factors of extravasation, its impact on the pharmacokinetics of non-cytotoxic drugs, and management of extravasation in older individuals. Extravasation occurs when vesicants leak from blood vessels into surrounding tissue causing severe injury such as tissue necrosis while infiltration is caused by leakage of an irritant that causes injury but does not lead to tissue necrosis. Extravasation occurs in approximately 0.01% to 6% of patients, particularly with cytotoxic agents. However, there is limited documentation about extravasation of non-cytotoxic agents, particularly in older people. Data Sources A literature search of Pubmed and Medline was performed using the following search items: "extravasation," "infiltration," "elderly," and "non-cytotoxic drugs," as well as a combination of these terms. Conclusion It is important to recognize, identify, and manage extravasation early since it can have deleterious consequences for older people. It is more important to prevent extravasation than manage it using standardized evidence-based protocols, and this can be implemented in the nursing facility and acute care setting.
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21
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Matula E, Mastrocco A, Prittie J, Weltman J, Keyserling C. Microorganism colonization of peripheral venous catheters in a small animal clinical setting. J Vet Emerg Crit Care (San Antonio) 2023; 33:509-519. [PMID: 37585353 DOI: 10.1111/vec.13328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/16/2022] [Accepted: 06/30/2022] [Indexed: 08/18/2023]
Abstract
OBJECTIVE To compare the incidence of microorganism colonization of peripheral venous catheters (PVCs) placed in the Emergency Department (ED) to those placed in a routine preoperative setting. The relationship between catheter tip colonization and patient urgency (as assessed by triage priority) was also evaluated. DESIGN Prospective, observational study from January 2021 to October 2021. SETTING Emergency room and clinical areas of a large, urban, tertiary referral center. ANIMALS Three hundred dogs and 94 cats with a PVC in place for a minimum of 24 hours were enrolled in the study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two hundred and eighty-eight PVCs were placed in the ED and 106 were placed preoperatively. The overall colonization rate was 10.4% (41/394). Sixteen bacterial and 1 fungal genera were cultured. Eight of these bacterial genera (25/51 [49%] bacterial isolates) were resistant to at least 1 antimicrobial class. Twenty-nine of 288 (10.1%) catheters positive for colonization were placed in the ED, whereas 12 of 106 (11.3%) were placed preoperatively. There was no association between microorganism growth on catheters and clinical area of catheter placement. There was also no association between ED patient urgency and positive catheter tip culture. No significant risk factors were identified predisposing to colonization of PVCs. CONCLUSIONS The overall incidence of microorganism colonization of PVCs in this study population was equivalent to, or lower than, previously reported in veterinary literature. There was no statistical difference between the catheters placed in the ED and those placed for routine surgical procedures. Patient urgency did not affect the incidence of positivity of peripheral catheter tip cultures.
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Affiliation(s)
- Erica Matula
- Emergency and Critical Care, The Animal Medical Center, New York, New York, USA
| | - Alicia Mastrocco
- Emergency and Critical Care, The Animal Medical Center, New York, New York, USA
| | - Jennifer Prittie
- Emergency and Critical Care, The Animal Medical Center, New York, New York, USA
| | - Joel Weltman
- Emergency and Critical Care, The Animal Medical Center, New York, New York, USA
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22
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Weimer DS, Jones S, Ramadoss T, Milovanovic U, Shoja MM, Schwartz G. Compartment Syndrome Secondary to Calcium Gluconate Extravasation. Cureus 2023; 15:e42237. [PMID: 37609086 PMCID: PMC10440588 DOI: 10.7759/cureus.42237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 07/20/2023] [Indexed: 08/24/2023] Open
Abstract
This case report highlights a rare yet severe complication of calcium gluconate extravasation, namely, compartment syndrome. We present the case of an 86-year-old female who developed compartment syndrome following an extravasation of intravenously administered calcium gluconate for the management of hyperkalemia. Initially, mild erythema and edema were observed at the site of extravasation, which eventually progressed to severe pain, a reduction in the joint range of motion due to increased compartment pressure. Despite undergoing a series of fasciotomies, the patient's condition did not improve, and extensive tissue necrosis and gangrene necessitated amputation. This case emphasizes that calcium gluconate extravasation can lead to life-threatening complications, such as compartment syndrome, underscoring the critical importance of employing proper infusion techniques.
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Affiliation(s)
- Derek S Weimer
- Department of Medical Education, Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Sydney Jones
- Department of Medical Education, Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Tanya Ramadoss
- Department of Medical Education, Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Una Milovanovic
- Department of Medical Education, Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Mohammadali M Shoja
- Department of Medical Education, Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Gary Schwartz
- Department of Medical Education, Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
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23
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Brown CS, Rabinstein AA, Zhao Y, Wieruszewski ED. Safety of peripheral 3% hypertonic saline bolus administration for neurologic emergency. Am J Emerg Med 2023; 69:83-86. [PMID: 37079938 DOI: 10.1016/j.ajem.2023.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/02/2023] [Accepted: 04/03/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND/OBJECTIVE Hypertonic sodium chloride (HTS) is used for emergent treatment of acute cerebral edema and other neurologic emergencies. Central access is not commonly available in emergent situations and 3% HTS is utilized peripherally. Many studies have shown the safety of its administration at rates up to 75 mL/h, but there is a lack of data to establish the safety of peripherally administered, rapid bolus dosing in emergent situations. The objective of this study is to describe the safety of rapid, peripherally administered (≥ 250 mL/h) 3% HTS for neurologic emergencies. METHODS This is a retrospective, cohort study including adult patients receiving 3% HTS via a peripheral IV site for elevated intracranial pressure, cerebral edema, or other neurological emergencies at a rate of at least 250 m/h between May 5, 2018 - September 30, 2021. Patients were excluded if they simultaneously received another hypertonic saline fluid. Baseline characteristics collected included HTS dose, rate and site of administration, indication for use and patient demographics. The primary safety outcome was incidence of extravasation and phlebitis within one hour of HTS administration. RESULTS There were 206 patients receiving 3% HTS who were screened, and 37 patients met inclusion criteria. The most common reason for exclusion was administration at a rate < 250 m/h. The median age was 60 (IQR 45, 72) with 51.4% being male. The most common indications for HTS were traumatic brain injury (45.9%) and intracranial hemorrhage (37.8%). The most common administration location was the emergency department (78.4%). The median IV-gauge (n = 29) was 18 (IQR 18, 20), with the most common placement site being antecubital (48.6%). The median dose of HTS was 250 mL (IQR 250, 350), with a median administration rate of 760 mL/h (IQR 500, 999). There were no episodes of extravasation or phlebitis noted. CONCLUSIONS Rapid, peripheral administration of 3% HTS boluses is a safe alternative for treatment of neurologic emergencies. Administration at rates up to 999 mL/h did not result in extravasation or phlebitis.
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Affiliation(s)
- Caitlin S Brown
- Mayo Clinic, Department of Pharmacy Services, Rochester, MN, USA
| | | | - Yanjun Zhao
- Mayo Clinic, Department of Pharmacy Services, Rochester, MN, USA
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24
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Atay S, Üzen Cura Ş, Efil S. Nurses' knowledge and experience related to short peripheral venous catheter extravasation. J Vasc Access 2023; 24:848-853. [PMID: 34590526 DOI: 10.1177/11297298211045589] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The majority of hospitalized patients receive a Peripheral Venous Catheter (PVC) in the course of their treatment. Extravasation injury is a serious complication of intravenous treatment. OBJECTIVE This cross-sectional survey designed study aims to investigate nurses' knowledge and experience related to short peripheral venous catheter extravasation. METHOD The study sample included 145 nurses working in a university hospital in the west of Turkey. A questionnaire developed in accordance with the literature was used for data collection. The data were assessed by frequency and proportions. RESULTS Of the nurses included in this study, 26.2% reported they had experienced extravasation injury in a patient; 74.5% said they had received no instruction in the management of extravasation during their in-service training program; and 85.5% stated they did not keep a record of extravasation. 89.7% of the nurses reported infused medications as a cause of extravasation, and 81.4% reported catheter sites as a cause. Among the medications reported by the nurses as causing extravasation: 89.7% reported contrast agents; 84.8% TPN solutions; 71.0% cytotoxic agents; and 65.1% mannitol. The symptoms of extravasation reported by nurses included: swelling (97.9%), redness (97.2%), pain (92.4%), rise in temperature (65.5%), and ulceration (60.0%). In responding to the occurrence of extravasation, interventions reported by the nurses included: stopping the flow of fluid (98.6%), elevation (89.7%), cold application (76.6%), and aspiration of drug (40.7%). CONCLUSION Based on these results, it is recommended that guidelines are developed for the management of extravasation, that periodic in-service training programs are provided and that observational studies are carried out into the administration of vesicant drugs.
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Affiliation(s)
- Selma Atay
- Nursing Department at School of Health, Çanakkale Onsekiz Mart University, Canakkale, Turkey
| | - Şengül Üzen Cura
- Nursing Department at School of Health, Çanakkale Onsekiz Mart University, Canakkale, Turkey
| | - Sevda Efil
- Nursing Department at School of Health, Çanakkale Onsekiz Mart University, Canakkale, Turkey
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25
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Ho H, Mohan S. Tissue injury secondary to peripheral xenobiotic administration. J Am Coll Emerg Physicians Open 2023; 4:e12972. [PMID: 37220475 PMCID: PMC10200258 DOI: 10.1002/emp2.12972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/03/2023] [Indexed: 05/25/2023] Open
Affiliation(s)
- Hung Ho
- Division of Medical ToxicologyDepartment of Emergency MedicineNorthwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/NorthwellQueensNew YorkUSA
| | - Sanjay Mohan
- Division of Medical ToxicologyDepartment of Emergency MedicineNorthwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/NorthwellQueensNew YorkUSA
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26
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Madieh J, Hasan B, Khamayseh I, Hrizat A, Salah T, Nayfeh T, Gharaibeh K, Hamadah A. The Safety of Intravenous Peripheral Administration of 3% Hypertonic Saline: A Systematic Review and Meta-analysis. Am J Med Sci 2023:S0002-9629(23)01181-3. [PMID: 37192695 DOI: 10.1016/j.amjms.2023.04.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/24/2023] [Accepted: 04/11/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND AND OBJECTIVES Three percent hypertonic saline (3% HTS) is used to treat several critical conditions such as severe and symptomatic hyponatremia and increased intracranial pressure. It has been traditionally administered through a central venous catheter (CVC). The avoidance of peripheral intravenous infusion of 3% HTS stems theoretically from the concern about the ability of the peripheral veins to tolerate hyperosmolar infusions. The aim of this systematic review and meta-analysis is to assess the rate of complications associated with the infusion of 3% HTS using peripheral intravenous access. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a systematic review and meta-analysis to assess the rate of complications related to the peripheral infusion of 3% HTS. We searched several databases for available studies that met the criteria until February 24th, 2022. We included ten studies conducted across three countries examining the incidence of infiltration, phlebitis, venous thrombosis, erythema, and edema. The overall event rate was calculated and transformed using the Freeman-Tukey arcsine method and pooled using the DerSimonian and Laird random-effects model. I 2 was used to evaluate heterogeneity. Selected items from Newcastle-Ottawa Scale 12 were used to assess the risk of bias in each included study. RESULTS A total of 1200 patients were reported to have received peripheral infusion of 3% HTS. The analysis showed that peripherally administered 3% HTS has a low rate of complications. The overall incidence of each of the complications was as follows: infiltration 3.3%, (95% C.I. = 1.8-5.1%), phlebitis 6.2% (95% C.I. = 1.1-14.3%), erythema 2.3% (95% C.I. = 0.3-5.4%) edema 1.8% (95% C.I. = 0.0-6.2%) and venous thrombosis 1% (95% C.I. = 0.0-4.8%). There was one incident of venous thrombosis preceded by infiltration resulting from peripheral infusion of 3% HTS. CONCLUSION Peripheral administration of 3% HTS is considered a safe and possibly preferred option as it carries a low risk of complications and is a less invasive procedure compared to CVC.
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Affiliation(s)
- Jomana Madieh
- Queen's medical centre, Nottingham University Hospitals NHS Trust, Nottingham, UK.
| | - Bashar Hasan
- Evidence-based practice Research Program, Mayo Clinic, Rochester, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
| | | | - Alaa Hrizat
- Department of Pathology, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Tareq Salah
- Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA.
| | - Tarek Nayfeh
- Evidence-based practice Research Program, Mayo Clinic, Rochester, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
| | - Kamel Gharaibeh
- Department of Internal Medicine, Faculty of Medicine, Al-Quds University, Abu Dis, Palestine; Division of Pulmonary and Critical Care, University of Maryland, Baltimore, MD, USA.
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27
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Pourmoghaddas Z, Rastegarnasab F, Sabzghabaee AM, Abtahi-Naeini B. Scalp necrotic wound and hyperinflammatory shock related to COVID-19: Topical sucralfate as a promising topical agent. Int Wound J 2023; 20:1328-1330. [PMID: 36002913 PMCID: PMC9538305 DOI: 10.1111/iwj.13936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 08/09/2022] [Indexed: 11/28/2022] Open
Affiliation(s)
- Zahra Pourmoghaddas
- Pediatric Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
- Pediatrics Infectious Diseases Department, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Ali Mohammad Sabzghabaee
- Isfahan Clinical Toxicology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Bahareh Abtahi-Naeini
- Pediatric Dermatology Division of Department of Pediatrics, Imam Hossein Children's Hospital, Isfahan University of Medical Sciences, Isfahan
- Skin Diseases and Leishmaniasis Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Stefanos SS, Kiser TH, MacLaren R, Mueller SW, Reynolds PM. Management of noncytotoxic extravasation injuries: A focused update on medications, treatment strategies, and peripheral administration of vasopressors and hypertonic saline. Pharmacotherapy 2023; 43:321-337. [PMID: 36938775 DOI: 10.1002/phar.2794] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/03/2023] [Accepted: 02/05/2023] [Indexed: 03/21/2023]
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 agents cause cellular damage as a result of osmotic shifts across cellular membranes in addition to agent-specific toxicities, such as calcium-induced vasoconstriction and calcifications or arginine-induced leakage of potassium causing apoptosis. A new category has been proposed to identify absorption-refractory mechanisms of injury in which agents such as propofol and lipids may persist in the extravasated space and cause necrosis or compartment syndrome. Pharmacological antidotes may be useful in select extravasations but requires prompt recognition and frequently complex administration strategies. Historically, intradermal phentolamine has been the preferred agent for vasopressor extravasations, but frequent supply shortages have led to the emergence of terbutaline, a β2 -agonist, as an acceptable alternative treatment option. For hyperosmolar and pH-related mechanisms of injuries, hyaluronidase is most commonly used to facilitate absorption and dispersion of injected agents. However, extravasation management is largely supportive and requires a protocolized multidisciplinary approach for early detection, treatment, and timely surgical referral when required to minimize adverse events.
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Affiliation(s)
- Sylvia S Stefanos
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Robert MacLaren
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Scott W Mueller
- Department of Pharmacy, University of Colorado Health, Aurora, Colorado, USA
| | - Paul M Reynolds
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
- Department of Pharmacy, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
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Sheng J, Ebeling C. Management of a patient with unintended intravenous dihydroergotamine infusion extravasation causing brachial artery vasospasm. Proc AMIA Symp 2023; 36:400-402. [PMID: 37091758 PMCID: PMC10120444 DOI: 10.1080/08998280.2023.2167187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
We present a patient being treated with intravenous dihydroergotamine (DHE) complicated by brachial artery vasospasm secondary to extravasation of DHE from an infiltrated peripheral intravenous catheter. She subsequently developed symptomatic vasospasm of the brachial artery, which ultimately required surgical intervention. Severe vasospasm remains a rare but serious risk of intravenous DHE extravasation, but there is currently limited data on proper management of this complication. This case report documents our management that led to full recovery of the patient. We recommend the use of reliable catheters for DHE infusions and prompt vascular surgery consult if there is suspicion for unintended extravasation.
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Affiliation(s)
- Jim Sheng
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Callie Ebeling
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
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30
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Safety of peripherally administered 3% hypertonic saline. Am J Emerg Med 2023; 63:127-131. [PMID: 36371934 DOI: 10.1016/j.ajem.2022.10.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 10/26/2022] [Accepted: 10/31/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Administration of 3% sodium chloride through a peripheral venous catheter is associated with risk of infusion-related adverse events (IRAE) due to its high osmolarity. Given this concern and the paucity of data regarding these events, many hospitals have policies that require central line administration of 3% sodium chloride. OBJECTIVE The objective of this analysis was to evaluate the incidence of IRAE associated with peripheral administration of 3% sodium chloride. METHODS This analysis included patients who received 3% sodium chloride via a peripheral venous catheter between May 2017 and August 2019. The major endpoint of this analysis was the overall incidence of IRAE, defined as the documentation of infiltration or phlebitis. A multivariable logistic regression was performed to identify potential risk factors (e.g., age, infusion rate, infusion duration, peripheral venous catheter location, and needle gauge) for development of IRAE. RESULTS A total of 706 administrations in 422 patients were included. Seventy-four (10.5%) administrations were associated with a documented event. Based on the Infusion Nurses grading scale for infiltration or phlebitis, 48% of the events in this analysis were grade 1 in severity. Duration of infusion of 3% sodium chloride was found to be associated with an increased odds of an IRAE (OR per 1 h 1.02, 95% CI 1.01-1.02) in the multivariable analysis. Age, infusion rate, peripheral venous catheter location, and needle gauge were not independently associated with an increased risk of an IRAE. CONCLUSION These data suggest that IRAE occurred more frequently when 3% sodium chloride was administered over a longer duration and the majority of events were mild with no permanent tissue injury. It may be reasonable to consider peripheral administration of 3% sodium chloride in the acute care setting for a short duration, although additional studies are needed to continue to evaluate its safety.
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Whelan AJ, Ricci M, Harthan AA, Deshpande G. Calcium Responsive Pediatric Septic Shock Refractory to Isotonic Crystalloids and Inotropic Agents. J Pediatr Pharmacol Ther 2022; 27:765-769. [PMID: 36989008 PMCID: PMC9674360 DOI: 10.5863/1551-6776-27.8.765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 01/05/2022] [Indexed: 11/18/2022]
Abstract
Pediatric septic shock is a life-threatening condition with significant rates of morbidity and mortality. Standard management includes fluid resuscitation, timely antimicrobial administration, and epinephrine or norepinephrine if unresolved with initial management. Additional therapies are not well defined and include vasopressin, hydrocortisone, phenylephrine, levosimendan, dopamine, and others. Many of these agents modify cellular effects of calcium in the smooth muscle. The use of a calcium infusion may improve vasoactivity in the smooth muscle without the use of signaling pathways. Children are more susceptible to the effects of calcium, which may predispose them to enhanced vasoconstriction with the administration of intravenous calcium. We present a case in which a patient on chronic calcium channel blocker therapy presented with septic shock. She continued to remain hypotensive after fluid resuscitation, antibiotics, epinephrine, and norepinephrine. Her blood pressure improved with the initiation of a continuous calcium chloride infusion. Norepinephrine and epinephrine doses were decreased after the initiation of the calcium infusion.
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Affiliation(s)
- Aviva J. Whelan
- Department of Clinical Pediatrics (AJW), OSF Healthcare Children's Hospital of Illinois, Peoria, IL
| | - Morgan Ricci
- Department of Emergency Medicine (MR), OSF Healthcare Children's Hospital of Illinois, Peoria, IL
| | - Aaron A. Harthan
- Department of Clinical Pharmacy (AAH), OSF Healthcare Children's Hospital of Illinois, Peoria, IL
| | - Girish Deshpande
- Division of Pediatric Critical Care Medicine (GD), Department of Pediatrics, University of Illinois College of Medicine at Peoria, OSF Healthcare Children's Hospital of Illinois, Peoria, IL
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Chen YM, Fan XW, Liu MH, Wang J, Yang YQ, Su YF. Risk factors for peripheral venous catheter failure: A prospective cohort study of 5345 patients. J Vasc Access 2022; 23:911-921. [PMID: 33985394 PMCID: PMC9585540 DOI: 10.1177/11297298211015035] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE The objective of this study was to determine the independent risk factors associated with peripheral venous catheter (PVC) failure and develop a model that can predict PVC failure. METHODS This prospective, multicenter cohort study was carried out in nine tertiary hospitals in Suzhou, China between December 2017 and February 2018. Adult patients undergoing first-time insertion of a PVC were observed from catheter insertion to removal. Logistic regression was used to identify the independent risk factors predicting PVC failure. RESULTS This study included 5345 patients. The PVC failure rate was 54.05% (n = 2889/5345), and the most common causes of PVC failure were phlebitis (16.3%) and infiltration/extravasation (13.8%). On multivariate analysis, age (45-59 years: OR, 1.295; 95% CI, 1.074-1.561; 60-74 years: OR, 1.375; 95% CI, 1.143-1.654; ⩾75 years: OR, 1.676; 95% CI, 1.355-2.073); department (surgery OR, 1.229; 95% CI, 1.062-1.423; emergency internal/surgical ward OR, 1.451; 95% CI, 1.082-1.945); history of venous puncture in the last week (OR, 1.298, 95% CI 1.130-1.491); insertion site, number of puncture attempts, irritant fluid infusion, daily infusion time, daily infusion volume, and type of sealing liquid were independent predictors of PVC failure. Receiver operating characteristic curve analysis indicated that a logistic regression model constructed using these variables had moderate accuracy for the prediction of PVC failure (area under the curve, 0.781). The Hosmer-Lemeshow goodness of fit test demonstrated that the model was correctly specified (χ2 = 2.514, p = 0.961). CONCLUSION This study should raise awareness among healthcare providers of the risk factors for PVC failure. We recommend that healthcare providers use vascular access device selection tools to select a clinically appropriate device and for the timely detection of complications, and have a list of drugs classified as irritants or vesicants so they can monitor patients receiving fluid infusions containing these drugs more frequently.
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Affiliation(s)
- Ya-mei Chen
- Department of Emergency, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiao-wen Fan
- Nursing College, Soochow University, Suzhou, China
| | - Ming-hong Liu
- Department of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jie Wang
- Department of Nursing, The First Affiliated Hospital of Soochow University, Medical Centre of Soochow University, Suzhou, China
| | - Yi-qun Yang
- Department of Nursing, The First Affiliated Hospital of Soochow University, Medical Centre of Soochow University, Suzhou, China,Yi-qun Yang, Department of Nursing, The First Affiliated Hospital of Soochow University, No. 188 Shizi Street, Suzhou 215006, China.
| | - Yu-fang Su
- Department of Orthopaedic, The First Affiliated Hospital of Soochow University, Suzhou, China
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Dufficy M, Takashima M, Cunninghame J, Griffin BR, McBride CA, August D, Ullman AJ. Extravasation injury management for neonates and children: A systematic review and aggregated case series. J Hosp Med 2022; 17:832-842. [PMID: 36039964 PMCID: PMC9804918 DOI: 10.1002/jhm.12951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/07/2022] [Accepted: 08/09/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Pediatric extravasation injuries are significant healthcare-associated injuries, with sometimes significant sequelae. Evidence-based guidance on management is necessary to prevent permanent injury. PURPOSE A systematic review of the literature, including aggregated case series, investigating extravasation injury management of hospitalized pediatric patients. DATA SOURCES PubMed, Cummulative Index to Nursing and Allied Health Literature (CINAHL), and Excerpta Medica database (EMBASE) were searched on December 13, 2021. STUDY SELECTION Primary research investigating extravasation injury management of hospitalized pediatric patients (to 18 years), published from 2010 onwards and in English, independently screened by two authors, with arbitration from a third author. DATA EXTRACTION Data regarding the study, patient (age, primary diagnosis), extravasation (site, presentation, outcome), and treatment (first aid, wound management) were extracted by two authors, with arbitration from a third author. DATA SYNTHESIS From an initial 1769 articles, 27 studies were included with extractable case data reported in 18 studies, resulting in 33 cases. No clinical trials were identified, instead, studies were primarily case studies (52%) of neonates (67%), with varied extravasation symptoms. Studies had good selection and ascertainment, but few met the causality and reporting requirements for quality assessments. Signs and symptoms varied, with scarring (45%) and necrosis (30%) commonly described. Diverse treatments were categorized into first aid, medical, surgical, and dressings. CONCLUSIONS Despite infiltration and extravasation injuries being common within pediatric healthcare, management interventions are under-researched, with low-quality studies and no consensus on treatments or outcomes.
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Affiliation(s)
- Mitchell Dufficy
- School of Nursing, Midwifery and Social WorkThe University of QueenslandBrisbaneQueenslandAustralia
- Centre for Children's Health ResearchChildren's Health Queensland Hospital and Health ServiceBrisbaneQueenslandAustralia
| | - Mari Takashima
- School of Nursing, Midwifery and Social WorkThe University of QueenslandBrisbaneQueenslandAustralia
- Centre for Children's Health ResearchChildren's Health Queensland Hospital and Health ServiceBrisbaneQueenslandAustralia
| | - Jacqueline Cunninghame
- School of Nursing, Midwifery and Social WorkThe University of QueenslandBrisbaneQueenslandAustralia
- Centre for Children's Health ResearchChildren's Health Queensland Hospital and Health ServiceBrisbaneQueenslandAustralia
| | - Bronwyn R. Griffin
- Centre for Children's Health ResearchChildren's Health Queensland Hospital and Health ServiceBrisbaneQueenslandAustralia
- School of Nursing and MidwiferyGriffith UniversityBrisbaneQueenslandAustralia
| | - Craig A. McBride
- School of Nursing, Midwifery and Social WorkThe University of QueenslandBrisbaneQueenslandAustralia
- Centre for Children's Health ResearchChildren's Health Queensland Hospital and Health ServiceBrisbaneQueenslandAustralia
| | - Deanne August
- School of Nursing, Midwifery and Social WorkThe University of QueenslandBrisbaneQueenslandAustralia
- Centre for Children's Health ResearchChildren's Health Queensland Hospital and Health ServiceBrisbaneQueenslandAustralia
- Grantley Stable Neonatal UnitRoyal Brisbane and Women's HospitalBrisbaneQueenslandAustralia
| | - Amanda J. Ullman
- School of Nursing, Midwifery and Social WorkThe University of QueenslandBrisbaneQueenslandAustralia
- Centre for Children's Health ResearchChildren's Health Queensland Hospital and Health ServiceBrisbaneQueenslandAustralia
- School of Nursing and MidwiferyGriffith UniversityBrisbaneQueenslandAustralia
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Taogoshi T, Shibata Y, Uno H, Yokooji T, Tanaka M, Hide M, Matsuo H. Classification of Skin Injury Risk Caused by Extravasation of Electrolyte Solutions or Infusions in a Rat Model. Biol Pharm Bull 2022; 45:1254-1258. [DOI: 10.1248/bpb.b22-00170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Takanori Taogoshi
- Department of Pharmaceutical Services, Hiroshima University Hospital
| | - Yuuka Shibata
- Department of Pharmaceutical Services, Hiroshima University Hospital
| | - Hiromi Uno
- School of Pharmaceutical Sciences, Hiroshima University
| | - Tomoharu Yokooji
- Department of Pharmaceutical Services, Graduate School of Biomedical and Health Sciences, Hiroshima University
| | - Maiko Tanaka
- Department of Dermatology, Hiroshima Prefectural Hospital
| | | | - Hiroaki Matsuo
- Department of Pharmaceutical Services, Hiroshima University Hospital
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35
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Lin R, Jin Y, Li RR, Jiang C, Ping J, Charles CJ, Kong YL, Ho JS. Needle-integrated ultrathin bioimpedance microsensor array for early detection of extravasation. Biosens Bioelectron 2022; 216:114651. [DOI: 10.1016/j.bios.2022.114651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/04/2022] [Accepted: 08/18/2022] [Indexed: 11/24/2022]
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Evaluation of Peripheral Administration of 10% Calcium Chloride in a Retrospective, Single-Center Electronic Health Record Cohort. J Emerg Nurs 2022; 48:484-491. [PMID: 35787779 DOI: 10.1016/j.jen.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 12/11/2021] [Accepted: 12/14/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Calcium chloride is commonly used in emergency departments in the treatment of a variety of emergencies. Historically, administration via central venous catheters has been preferred owing to its high osmolarity and vesicant properties. Although preferred, central access may not always be available in time-sensitive, emergent situations leading to many instances of peripheral administration. The objective of this analysis was to evaluate the charted safety of peripheral venous administration of 10% calcium chloride. METHODS A single-center retrospective chart review was performed in patients who received 10% calcium chloride in the adult emergency department evaluating for the incidence of infusion-related adverse events. Patients were excluded if they were less than 18 years of age or had a lack of catheter documentation during 10% calcium chloride administration or if the 10% calcium chloride was documented as given through a central venous catheter. RESULTS A total of 72 administrations were evaluated. Patients were predominantly male (67%), with a median age of 55 years and body mass index of 29.2. The primary outcome demonstrated that 4 infusion-related adverse events occurred (6%) with grade 1 (n = 1) and grade 0 (n = 3) documented incidence of infusion-related adverse events. None of the documented incidence of infusion-related adverse events resulted in permanent tissue injury, and all patients had conservative management. DISCUSSION This study demonstrated that administration of 10% calcium chloride via peripheral venous catheters may be feasible and seemed to carry a low incidence of documented complications. Further prospective studies are needed to confirm study observations.
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Keritam O, Juhasz V, Schöfer C, Thallinger C, Aretin MB, Schabbauer G, Breuss J, Unseld M, Uhrin P. Determination of Extravasation Effects of Nal-Iri and Trabectedin and Evaluation of Treatment Options for Trabectedin Extravasation in a Preclinical Animal Model. Front Pharmacol 2022; 13:875695. [PMID: 35721106 PMCID: PMC9204062 DOI: 10.3389/fphar.2022.875695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/09/2022] [Indexed: 11/18/2022] Open
Abstract
Background: Extravasation during chemotherapy administration can lead to dangerous adverse effects ranging from pain to tissue necrosis. Evidence-based data about prevention and treatment of extravasation injuries of some clinically used compounds still remains elusive. This work aimed to investigate, in a preclinical mouse model, the effects of extravasation of two chemotherapeutic agents, nanoliposomal irinotecan (nal-Iri) and trabectedin. In addition, we aimed to study treatment options for injuries induced by extravasation of these substances. Methods: Mice were subcutaneously injected with nal-Iri or trabectedin applied in clinically used concentration. Doxorubicin was used as a positive control. In subsequently performed experiments, hyaluronidase, DMSO and tacrolimus were tested as potential treatments against extravasation-induced injuries by trabectedin. Systemic effects were analyzed by observation and documentation of the health status of mice and local reactions were measured and graded. In addition, hematoxylin-eosin stained histological sections of the treated skin areas were analyzed. Results: Of the two tested substances, only trabectedin showed vesicant effects. Subcutaneous injection of trabectedin caused erythema formation in mice by day two that was progressing to skin ulcerations by day five. Furthermore, we found that topical treatment of mice with tacrolimus or DMSO reduced the vesicant effects of trabectedin. The results observed in vivo were supported microscopically by the analysis of histological sections. Conclusions: We recommend classifying trabectedin as a vesicant agent and nal-Iri as a non-vesicant agent. Furthermore, our results obtained in a preclinical model suggest that tacrolimus and DMSO might be suitable treatment options of trabectedin extravasations, a finding that might be further utilized in clinical studies.
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Affiliation(s)
- Omar Keritam
- Institute of Vascular Biology and Thrombosis Research, Center for Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Viktoria Juhasz
- Institute of Vascular Biology and Thrombosis Research, Center for Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Christian Schöfer
- Department for Cell and Developmental Biology, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Christiane Thallinger
- Clinical Division of Infectious Disease, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | | | - Gernot Schabbauer
- Institute of Vascular Biology and Thrombosis Research, Center for Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Johannes Breuss
- Institute of Vascular Biology and Thrombosis Research, Center for Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Matthias Unseld
- Clinical Division of Palliative Care, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Pavel Uhrin
- Institute of Vascular Biology and Thrombosis Research, Center for Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
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Kurimoto T, Yonishi R, Uehara H, Fukuzato H, Seki S, Shimoji Y, Nakayama O, Ohba C, Nakazato I, Ohshiro T. Vascular injury due to a peripherally inserted central catheter in a neonate born during the 24 th week of gestation. Clin Case Rep 2022; 10:e5991. [PMID: 35765292 PMCID: PMC9207233 DOI: 10.1002/ccr3.5991] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/08/2022] [Indexed: 11/07/2022] Open
Abstract
We investigated a case of a peripherally inserted central venous catheter associated with iliolumbar venous extravasation in an infant. Hyperosmolar infusion and calcium gluconate caused phlebitis and vascular perforation. Daily monitoring of the catheter length at the insertion site and serial radiography may aid in detecting catheter movement.
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Affiliation(s)
- Tomonori Kurimoto
- Neonatology, Okinawa Prefectural Nanbu Medical Center and Children's Medical CenterHaebaruJapan
| | - Ryo Yonishi
- Neonatology, Okinawa Prefectural Nanbu Medical Center and Children's Medical CenterHaebaruJapan
| | - Hirotaka Uehara
- Neonatology, Okinawa Prefectural Nanbu Medical Center and Children's Medical CenterHaebaruJapan
| | - Hayato Fukuzato
- Neonatology, Okinawa Prefectural Nanbu Medical Center and Children's Medical CenterHaebaruJapan
| | - Satoko Seki
- Neonatology, Okinawa Prefectural Nanbu Medical Center and Children's Medical CenterHaebaruJapan
| | - Yoshikazu Shimoji
- Neonatology, Okinawa Prefectural Nanbu Medical Center and Children's Medical CenterHaebaruJapan
| | - Okitaka Nakayama
- Neonatology, Okinawa Prefectural Nanbu Medical Center and Children's Medical CenterHaebaruJapan
| | - Chiaki Ohba
- Neonatology, Okinawa Prefectural Nanbu Medical Center and Children's Medical CenterHaebaruJapan
| | - Iwao Nakazato
- Pathology, Okinawa Prefectural Nanbu Medical Center and Children's Medical CenterHaebaruJapan
| | - Tatsuo Ohshiro
- Neonatology, Okinawa Prefectural Nanbu Medical Center and Children's Medical CenterHaebaruJapan
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Marques CG, Mwemerashyaka L, Martin K, Tang O, Uwamahoro C, Ndebwanimana V, Uwamahoro D, Moretti K, Sharma V, Naganathan S, Jing L, Garbern SC, Nkeshimana M, Levine AC, Aluisio AR. Utilisation of peripheral vasopressor medications and extravasation events among critically ill patients in Rwanda: A prospective cohort study. Afr J Emerg Med 2022; 12:154-159. [PMID: 35505668 PMCID: PMC9046616 DOI: 10.1016/j.afjem.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 02/14/2022] [Accepted: 03/28/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction In high-income settings, vasopressor administration to treat haemodynamic instability through a central venous catheter (CVC) is the preferred standard. However, due to lack of availability and potential for complications, CVCs are not widely used in low- and middle-income countries. This prospective cohort study evaluated the use of peripheral vasopressors and associated incidence of extravasation events in patients with haemodynamic instability at the Centre Hospitalier Universitaire Kigali, Rwanda. Methods Patients ≥18 years of age receiving peripheral vasopressors in the emergency centre (EC) or intensive care unit (ICU) for >1 hour were eligible for inclusion. The primary outcome was extravasation events. Patients were followed hourly until extravasation, medication discontinuation, death, or CVC placement. Extravasation incidence with 95% confidence intervals (CI) were calculated using Poisson exact tests. Results 64 patients were analysed. The median age was 49 (Interquartile Range [IQR]:33-65) and 55% were female. Distributive shock was the most frequent aetiology (47%). Intravenous (IV) location was most commonly antecubital fossa/upper arm (31%) and forearm/hand (43%). IV gauges ≤18 were used in 58% of locations. Most patients were treated with adrenaline (66%) and noradrenaline (41%), and 11% received multiple vasopressors. The median treatment duration was 19 hours (IQR:8.5-37). Treatment discontinuation was predominantly due to mortality (41%) or resolution of instability (36%). There were two extravasation events (2.9%), both limited to soft tissue swelling. Extravasation incidence was 0.8 events per 1000 patient-hours (95% CI:0.2-2.2). Conclusion Extravasation incidence with peripheral vasopressors was low, even with long use durations, suggesting peripheral infusions may be an acceptable approach when barriers exist to CVC placement.
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Affiliation(s)
- Catalina G. Marques
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA USA
- Corresponding author.
| | - Lucien Mwemerashyaka
- Department of Anaesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Kyle Martin
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, RI USA
| | - Oliver Tang
- Brown University Warren Alpert Medical School, Providence, RI USA
| | - Chantal Uwamahoro
- Department of Anaesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Vincent Ndebwanimana
- Department of Anaesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Doris Uwamahoro
- Department of Anaesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Katelyn Moretti
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, RI USA
- Brown University Warren Alpert Medical School, Providence, RI USA
| | - Vinay Sharma
- Michigan State University College of Human Medicine, East Lansing, Michigan USA
| | - Sonya Naganathan
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, RI USA
- Brown University Warren Alpert Medical School, Providence, RI USA
| | - Ling Jing
- Case Western Reserve University School of Medicine, Cleveland, Ohio USA
| | - Stephanie C. Garbern
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, RI USA
- Brown University Warren Alpert Medical School, Providence, RI USA
| | - Menelas Nkeshimana
- Department of Anaesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Adam C. Levine
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, RI USA
- Brown University Warren Alpert Medical School, Providence, RI USA
| | - Adam R. Aluisio
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, RI USA
- Brown University Warren Alpert Medical School, Providence, RI USA
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Viola P, Marcianò G, Casarella A, Pisani D, Astorina A, Scarpa A, Siccardi E, Basile E, De Sarro G, Gallelli L, Chiarella G. The Pharmacological Treatment of Pediatric Vertigo. CHILDREN 2022; 9:children9050584. [PMID: 35626761 PMCID: PMC9139449 DOI: 10.3390/children9050584] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/09/2022] [Accepted: 04/15/2022] [Indexed: 12/25/2022]
Abstract
Vertigo in children is a challenging topic. The lack of dedicated trials, guidelines and papers causes inhomogeneity in the treatment of vertigo in children. Meniere’s disease, migraine equivalents, vestibular neuritis, paroxysmal positional benign vertigo (BPPV), persistent postural-perceptual dizziness (PPPD) and motion sickness may affect children with various degrees of incidence and clinical severity compared to adults. Several drugs are proposed for the management of these conditions, even if their use is subordinated to the child’s age. In this review, we summarize the existing evidence related to the use of drugs for this clinical condition in children as a start point for new trials, stating the urgent need for international guidelines.
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Affiliation(s)
- Pasquale Viola
- Unit of Audiology, Regional Centre of Cochlear Implants and ENT Diseases, Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy; (P.V.); (D.P.); (A.A.)
| | - Gianmarco Marcianò
- Clinical Pharmacology and Pharmacovigilance Unit, Department of Health Science, School of Medicine, University of Catanzaro, Mater Domini Hospital, 88100 Catanzaro, Italy; (G.M.); (A.C.); (E.B.); (G.D.S.); (L.G.)
| | - Alessandro Casarella
- Clinical Pharmacology and Pharmacovigilance Unit, Department of Health Science, School of Medicine, University of Catanzaro, Mater Domini Hospital, 88100 Catanzaro, Italy; (G.M.); (A.C.); (E.B.); (G.D.S.); (L.G.)
| | - Davide Pisani
- Unit of Audiology, Regional Centre of Cochlear Implants and ENT Diseases, Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy; (P.V.); (D.P.); (A.A.)
| | - Alessia Astorina
- Unit of Audiology, Regional Centre of Cochlear Implants and ENT Diseases, Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy; (P.V.); (D.P.); (A.A.)
| | - Alfonso Scarpa
- Department of Medicine and Surgery, University of Salerno, 84081 Baronissi, Italy;
| | | | - Emanuele Basile
- Clinical Pharmacology and Pharmacovigilance Unit, Department of Health Science, School of Medicine, University of Catanzaro, Mater Domini Hospital, 88100 Catanzaro, Italy; (G.M.); (A.C.); (E.B.); (G.D.S.); (L.G.)
| | - Giovambattista De Sarro
- Clinical Pharmacology and Pharmacovigilance Unit, Department of Health Science, School of Medicine, University of Catanzaro, Mater Domini Hospital, 88100 Catanzaro, Italy; (G.M.); (A.C.); (E.B.); (G.D.S.); (L.G.)
- Research Center FAS@UMG, Department of Health Science, Magna Graecia University, 88100 Catanzaro, Italy
| | - Luca Gallelli
- Clinical Pharmacology and Pharmacovigilance Unit, Department of Health Science, School of Medicine, University of Catanzaro, Mater Domini Hospital, 88100 Catanzaro, Italy; (G.M.); (A.C.); (E.B.); (G.D.S.); (L.G.)
- Research Center FAS@UMG, Department of Health Science, Magna Graecia University, 88100 Catanzaro, Italy
- Medifarmagen SRL, Department of Health Science, Magna Graecia University, 88100 Catanzaro, Italy
| | - Giuseppe Chiarella
- Unit of Audiology, Regional Centre of Cochlear Implants and ENT Diseases, Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy; (P.V.); (D.P.); (A.A.)
- Correspondence: ; Tel.: +39-0961364-7124
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Conde-Estévez D, Barrantes-González M, Cotrina Soliz MR, Grau S. Successful management of remdesivir extravasation. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2022; 35:229-230. [PMID: 35118854 PMCID: PMC8972699 DOI: 10.37201/req/147.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 11/26/2021] [Indexed: 06/14/2023]
Affiliation(s)
- D Conde-Estévez
- David Conde Estévez, Department of Pharmacy, Hospital Universitari del Mar. Passeig Marítim 25-29, E-08003, Barcelona, Spain.
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Safety of Vasopressor Medications through Peripheral Line in Pediatric Patients in PICU in a Resource-Limited Setting. Crit Care Res Pract 2022; 2022:6160563. [PMID: 35402044 PMCID: PMC8991380 DOI: 10.1155/2022/6160563] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/10/2021] [Accepted: 02/12/2022] [Indexed: 12/12/2022] Open
Abstract
Objective Central venous catheter (CVC) placement in children in resource-limited settings (RLSs) can be a difficult task. Timely administration of vasopressor medications (VMs) through peripheral intravenous line (PIV) can help overcome this limitation. We aim to determine the safety of administration of vasopressor medications through PIVs in children admitted to pediatric intensive care unit (PICU) in a RLS. Design Prospective observational study. Setting. An eight-bedded PICU of a tertiary care hospital. Patients. Children aged 1 month to 18 years admitted to the PICU. Intervention. None. Measurements and Main Results. All children (aged 1 month–18 years) who received VMs through PIV line from January 2019 to December 2019 were prospectively followed for the development of extravasation, conversion to CVC, duration of infusion, maximum dose of VMs used, maximum vasopressor inotropic score (VIS), and coadministration of vasopressor medication through PIV line. Results are presented as means with standard deviation and frequency with percentages. A total of 369 patients were included in the study, 221 (59.9%) were males, and the median age of the study population was 24 months (IQR; 6–96). Epinephrine was the most frequently used vasopressor medication (n = 279, 75.6%), followed by milrinone (n = 93, 25.2%), norepinephrine (n = 42, 11.4%), and dopamine (n = 32, 8.7%). The maximum dose of vasopressor medication was 0.25 µg/kg/min (epinephrine), 0.2 µg/kg/min (norepinephrine), 15 µg/kg/min (dopamine), and 0.8 µg/kg/min (milrinone). Extravasation was observed in 8 (2.2%) patients, while PIV line was converted to CVC in 127 (34.4%) children. Maximum dose of epinephrine, norepinephrine, VIS score, and PRISM Score was associated with conversion to CVC (p < 0.001), while none of them was associated with risk for extravasation. Conclusion Vasopressor medication through PIV line is a safe option in patients admitted to the PICU.
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Smith SA, Fitzpatrick CT, Olesky CL, Litchfield AB. Management of Ketamine Extravasation in a Pediatric Patient During Procedural Sedation. J Pediatr Pharmacol Ther 2022; 27:292-295. [PMID: 35350155 DOI: 10.5863/1551-6776-27.3.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 08/16/2021] [Indexed: 11/11/2022]
Abstract
Ketamine is a commonly used intravenous and intramuscular medication for procedural sedation within pediatric emergency medicine. There is limited availability of data on the rate of absorption and use of subcutaneous ketamine administration. We describe the case of a 12-year-old male who was sedated after extravasation and subsequent absorption of ketamine 1 mg/kg from a peripheral intravenous line (PIV). Despite being an unintended route, absorption of subcutaneous ketamine resulted in satisfactory procedural sedation with no complications. Given limited data on subcutaneous ketamine pharmacokinetics, the aim of this case report is to present the observed absorption of subcutaneous ketamine due to extravasation of PIV during a pediatric procedural sedation.
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Affiliation(s)
- Samantha A Smith
- Department of Pediatrics (SAS, CTF, ABL), Cabell Huntington Hospital, Huntington, WV
| | - Casey T Fitzpatrick
- Department of Pediatrics (SAS, CTF, ABL), Cabell Huntington Hospital, Huntington, WV
| | - Courtney L Olesky
- Department of Pharmacology (CLO), Cabell Huntington Hospital, Huntington, WV
| | - Ashley B Litchfield
- Department of Emergency Medicine (ABL), Cabell Huntington Hospital, Huntington, WV.,Department of Pediatrics (SAS, CTF, ABL), Cabell Huntington Hospital, Huntington, WV
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Tirrell AR, Nigam M, Hung RW. Isolated Compartment Syndrome of the Hand After Intravenous Doxycycline Infiltration Injury. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 4:239-243. [PMID: 35880147 PMCID: PMC9308158 DOI: 10.1016/j.jhsg.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 12/08/2021] [Indexed: 11/01/2022] Open
Abstract
Isolated compartment syndrome of the hand, although uncommon, can lead to considerable functional deficits if not treated promptly. The most common etiologies are related to trauma, burns, or electric injuries; however, some cases have been reported after intravenous infiltration events, particularly rapid intravenous contrast injection. In this case report, we describe the development of compartment syndrome in the hand of a critically ill patient with COVID-19 pneumonia and sepsis 16 days after doxycycline infiltration injury. She presented with worsening pain, swelling, bullous eruption, and intrinsic minus hand posturing. Emergent surgical release of intrinsic hand compartments and evacuation of a hematoma resolved her symptoms and preserved hand function. Early recognition and surgical intervention of compartment syndrome of the hand after infiltration injury in medically complex patients will reduce morbidity in this patient population.
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45
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Gong Z, Zhang J, Hou J, Chen S, Hu Z, Kong X, Ma G, Luo L. Drug Extravasation in a Large General Hospital in Hunan, China: A Retrospective Survey. Risk Manag Healthc Policy 2021; 14:4931-4938. [PMID: 34924775 PMCID: PMC8674494 DOI: 10.2147/rmhp.s318832] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 10/27/2021] [Indexed: 11/23/2022] Open
Abstract
Background and Aim Drug extravasation is one of the most common complications of intravenous therapy, which can lead to severe tissue injury if inappropriately treated. This study analyzes the current situation of extravasation and the risk factors affecting the severity of extravasation to provide a theoretical basis for carrying out prospective research, reducing the severity of drug extravasation, and strengthening the management of drug extravasation. Materials and Methods We retrieved the data on extravasation from January 2016 to December 2020 from the hospital’s safe infusion management system. We used nonparametric tests to assess the differences in the severity of drug extravasation among each variable and performed a multivariate analysis using multivariate ordered logistic regression. Results Extravasation occurred in 0.038% (263/694,043) of patients, including 203 cases of mild extravasation (77.2%), 57 cases of moderate extravasation (21.7%), and 3 cases of severe extravasation (1.1%). The main diseases of the patients with extravasation were cancer (24.7%), neurological-related diseases (19.4%), circulatory-related diseases (14.8%), and digestive-related diseases (14.1%); the main extravasated drugs were hypotonic or hypertonic drugs (31.9%) and contrast media (27.8%); the infusion tools of extravasation were indwelling needles (92.0%) and steel needles (8.0%). The multi-factor analysis showed that close to joints, patients’ age ≤6 or age >65, cancer, neurological-related diseases, circulatory-related diseases, antineoplastic agents, hypotonic or hypertonic drugs and strong acid or alkali drugs were independent risk factors for more severe extravasation. The nurses’ age and first identified by nurse were nurse-related factors that influenced the severity of drug extravasation. Conclusion To prevent the occurrence of drug extravasation and reduce its severity, the nurses should strengthen the learning of emergency plans related drug extravasation, strengthen inspections of high-risk patients. Besides, the managers should strengthen the risk warning management of high-risk extravasated drugs.
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Affiliation(s)
- Zhihong Gong
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, Hunan, People's Republic of China
| | - Jinghui Zhang
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, Hunan, People's Republic of China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, Hunan, People's Republic of China.,Xiangya Nursing School, Central South University, Changsha, Hunan, People's Republic of China
| | - Jianmei Hou
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, Hunan, People's Republic of China.,Department of Thoracic Oncology, Xiangya Hospital of Central South University, Changsha, Hunan, People's Republic of China
| | - Shujie Chen
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, Hunan, People's Republic of China
| | - Zixin Hu
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, Hunan, People's Republic of China
| | - Xiaoya Kong
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, Hunan, People's Republic of China
| | - Guiyuan Ma
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, Hunan, People's Republic of China
| | - Lingxia Luo
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, Hunan, People's Republic of China.,Department of Emergency Medicine, Xiangya Hospital of Central South University, Changsha, Hunan, People's Republic of China
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46
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Roca-Sarsanedas J, Galimany-Masclans J, Regidor-Braojos AM, Falcó-Pegueroles A. Topical treatment of tissue damage due to extravasation of iodinated contrast using thermal compresses. J Tissue Viability 2021; 31:135-141. [DOI: 10.1016/j.jtv.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 11/30/2021] [Accepted: 12/21/2021] [Indexed: 10/19/2022]
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47
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Yan G. Extravasation of Concentrated Potassium Chloride: A Case Report. CURRENT THERAPEUTIC RESEARCH 2021; 95:100646. [PMID: 34745392 PMCID: PMC8554452 DOI: 10.1016/j.curtheres.2021.100646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 09/25/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The extravasation of potassium chloride will cause serious harm, especially if it is not diagnosed or treated promptly. Objective:to report the clinical course of a patient who was suffering a potassium extravasation and to discuss steps that can be done to decrease the chances of this event from occurring in other patients. METHODS After discontinuation of infusion device and withdrawal of intravenous catheter, wet packing with magnesium sulfate and local injection of papaverine and lidocaine were applied. RESULTS After 11 days, the extravasation injury had recovered. CONCLUSIONS To avoid a repeat of such an adverse event, proper sites for administering, accurate dilution of potassium chloride solutions, close observation, and increased awareness of trained personnel of extravasation dangers are vital. Once extravasation occurs, timely wet application with magnesium sulfate and local injection of papaverine and lidocaine may have been useful in producing a favorable recovery.
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Affiliation(s)
- Guifang Yan
- Burn and Plastic Department, the First Affiliated Hospital of Chengdu Medical College, Sichuan, China
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48
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Kleidon TM, Schults JA, Wainwright C, Mihala G, Gibson V, Saiyed M, Byrnes J, Cattanach P, Macfarlane F, Graham N, Shevill E, Ullman AJ. Comparison of midline catheters and peripherally inserted central catheters to reduce the need for general anesthesia in children with respiratory disease: A feasibility randomized controlled trial. Paediatr Anaesth 2021; 31:985-995. [PMID: 34053159 DOI: 10.1111/pan.14229] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/19/2021] [Accepted: 05/24/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND The optimal intravenous device for antibiotic administration for children with respiratory disease is uncertain. We assessed the feasibility of a randomized controlled trial comparing midline catheters with peripherally inserted central catheters. METHODS Prospective, two-arm, feasibility randomized controlled trial in an Australian tertiary, pediatric hospital. Random assignment of 110 children (<18 years) to receive (i) midline catheter and (ii) peripherally inserted central catheters. Primary outcome was feasibility (eligibility, recruitment, retention, protocol adherence, and acceptability), and the primary clinical outcome was general anesthesia requirement for intravenous catheter insertion. SECONDARY OUTCOMES insertion time, treatment delays, infusion efficiency, device failure, complications, and cost. RESULTS There was 80% recruitment, 100% retention, no missing data, and high patient/staff acceptability. Mean patient experience assessed on a 0-10 numeric rating scale was 8.0 peripherally inserted central catheters and 9.0 (midline catheters), respectively. Participant eligibility was not achieved (49% of screened patients) and moderate protocol-adherence across groups (89% peripherally inserted central catheters vs. 76% midline catheter). Insertion of midline catheter for pulmonary optimization reduced the requirement for general anesthesia compared to peripherally inserted central catheters (10% vs. 69%; odds ratio = 0.01, 95% confidence interval: 0.00-0.09). Midline catheters failed more frequently (18.1 vs. 5.5 peripherally inserted central catheters per 1000 catheter-days); however, this reduced over trial duration. Midline catheter insertion compared to peripherally inserted central catheters saved AUD$1451 per pulmonary optimization episode. CONCLUSIONS An efficacy trial is feasible with expanded eligibility criteria and intensive staff training when introducing a new device. Midline catheter for peripherally compatible infusions is acceptable to patients and staff, might negate the need for general anesthesia and results in significant cost savings.
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Affiliation(s)
- Tricia M Kleidon
- Department of Anesthesia and Pain Management, Vascular Assessment and Management Service (VAMS, Queensland Children's Hospital, South Brisbane, Qld, Australia.,Menzies Health Institute Queensland, Alliance for Vascular Access Teaching and Research Group, Southport, Qld, Australia.,School of Nursing and Midwifery, Griffith University, Nathan, Qld, Australia
| | - Jessica A Schults
- Department of Anesthesia and Pain Management, Vascular Assessment and Management Service (VAMS, Queensland Children's Hospital, South Brisbane, Qld, Australia.,Menzies Health Institute Queensland, Alliance for Vascular Access Teaching and Research Group, Southport, Qld, Australia.,School of Nursing and Midwifery, Griffith University, Nathan, Qld, Australia
| | - Claire Wainwright
- Child Health Research Centre, Queensland Children's Hospital, The University of Queensland and Respiratory Medicine, South Brisbane, Qld, Australia
| | - Gabor Mihala
- Menzies Health Institute Queensland, Alliance for Vascular Access Teaching and Research Group, Southport, Qld, Australia.,School of Medicine, Griffith University, Nathan, Qld, Australia.,Menzies Health Institute Group, Centre for Applied Health Economics, Nathan, Qld, Australia
| | - Victoria Gibson
- Department of Anesthesia and Pain Management, Vascular Assessment and Management Service (VAMS, Queensland Children's Hospital, South Brisbane, Qld, Australia.,Menzies Health Institute Queensland, Alliance for Vascular Access Teaching and Research Group, Southport, Qld, Australia
| | - Masnoon Saiyed
- School of Medicine, Griffith University, Nathan, Qld, Australia.,Menzies Health Institute Group, Centre for Applied Health Economics, Nathan, Qld, Australia
| | - Joshua Byrnes
- School of Medicine, Griffith University, Nathan, Qld, Australia.,Menzies Health Institute Group, Centre for Applied Health Economics, Nathan, Qld, Australia
| | - Paula Cattanach
- Department of Anesthesia and Pain Management, Vascular Assessment and Management Service (VAMS, Queensland Children's Hospital, South Brisbane, Qld, Australia.,Menzies Health Institute Queensland, Alliance for Vascular Access Teaching and Research Group, Southport, Qld, Australia
| | - Fiona Macfarlane
- Department of Anesthesia and Pain Management, Vascular Assessment and Management Service (VAMS, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Nicolette Graham
- Department of Pharmacy, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Elizabeth Shevill
- Child Health Research Centre, Queensland Children's Hospital, The University of Queensland and Respiratory Medicine, South Brisbane, Qld, Australia
| | - Amanda J Ullman
- Department of Anesthesia and Pain Management, Vascular Assessment and Management Service (VAMS, Queensland Children's Hospital, South Brisbane, Qld, Australia.,Menzies Health Institute Queensland, Alliance for Vascular Access Teaching and Research Group, Southport, Qld, Australia.,School of Nursing and Midwifery, Griffith University, Nathan, Qld, Australia.,Child Health Research Centre, Queensland Children's Hospital, The University of Queensland and Respiratory Medicine, South Brisbane, Qld, Australia
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Patel S, Dexter F. Narrative review of neuraxial potassium chloride administration errors: clinical features, human factors, and prevention measures. Reg Anesth Pain Med 2021; 46:904-908. [PMID: 34380745 DOI: 10.1136/rapm-2021-102933] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/29/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Administration of the wrong drug via the epidural or intrathecal route can cause devastating consequences. Because of the commonality of potassium replacement therapy coupled to its potential neurotoxic profile, we suspected that injuries related to this drug error would be present in the literature. OBJECTIVES We aimed to identify clinical characteristics associated with the inadvertent administration of potassium chloride (KCl) during neuraxial anesthesia. Our secondary objective was to identify human factors that may have been associated. EVIDENCE REVIEW Published reports of neuraxial administration of KCl in humans were searched using Medline and Google Scholar. Error reports in any language were included. FINDINGS 25 case reports/series reported administration of KCl via epidural (25 patients) or intrathecal routes (three patients). There were six cases during interventional pain procedures, five cases in operating rooms and 17 in wards or intensive care units. Neuraxial KCl caused paraplegia in 22 patients. Mechanical ventilation was instituted in 11 of 28 patients. Three patients died. Epidural (eight patients) and spinal (two patients) lavage were performed to minimize consequences. A correctly prepared KCl infusion was connected to the epidural catheter for nine patients on wards (32%; 95% upper confidence limit: 48%) due to epidural-intravenous line confusion. Among the other 19 errors, KCl was confused with normal saline for 13 patients or local anesthetic in three patients. A wide range of concentrations and doses of KCl were administered. Variable use of intravenous steroid (13 patients) and epidural saline (eight patients) was found among patients who received epidural KCl. Human factors identified included incorrect visual perception, inadequate monitoring of infusions and substandard practice related to neuraxial anesthesia or analgesia. CONCLUSIONS KCl administration via epidural or intrathecal route has been reported to cause catastrophic consequences.
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Affiliation(s)
- Santosh Patel
- Department of Anaesthesia, Tawam Hospital, Al Ain, UAE
| | - Franklin Dexter
- Department of Anesthesia, University of Iowa, Iowa City, Iowa, USA
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50
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Evidence-Based Medicine G, Neonatologist S, Chinese Medical Doctor A. [Guidelines for neonatal skin management in the neonatal intensive care unit (2021)]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23:659-670. [PMID: 34266521 PMCID: PMC8292657 DOI: 10.7499/j.issn.1008-8830.2106004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 06/22/2021] [Indexed: 06/13/2023]
Abstract
Neonates are easily suffering from local or systematic infections due to their vulnerable skin barrier function, which leads to the increasing risk of death. Therefore, it is important to protect neonatal skin integrity and prevent neonatal skin injury in the neonatal intensive care unit (NICU). Based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) and current evidence, the guidelines for neonatal skin management in the NICU were developed to provide recommendations on routine skin care and prevention and treatment of iatrogenic skin injury of neonates for health care providers.
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