Cardiovascular Journal of Africa: Vol 24 No 2 (March 2013)

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CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 2, March 2013 AFRICA e13
Localised bullous eruptions after extravasation of
normal saline in the forearm during left ventricular
device-assisted surgery
CHIH-HSIEN LEE, CHENG-HSI CHANG, CHING-WEN WU, JENG WEI, YI-TING TSAI
Abstract
Peripheral infusion of intravenous agents is a daily routine
in hospitals. Extravasation is an unintended complication
associated with intravenous infusion where accidental injec-
tion or leakage of fluid occurs into the perivascular or
subcutaneous space. Extravasation is fairly common but is
usually without serious consequences. This has led clinicians
to underestimate the potentially serious consequences of
extravasation. Extravasation injury results from a combina-
tion of factors, including cytotoxicity of the solution, osmo-
lality, vasoconstrictor effects, infusion pressure and other
factors. We describe a case of upper extremity localised
bullous eruptions resulting from the pressurised infusion
of crystalloid solutions through an intravenous catheter,
placed in the operating room during left ventricular device-
assisted surgery. Peri-operative management of acute local-
ised bullous eruptions requires surveillance for unforeseen
consequences. Early recognition, diagnosis and intervention
averted potential complications and morbidity.
Keywords: bullous eruptions, extravasation, ventricular assisted
device
Submitted 30/5/12, accepted 16/10/12
Published online 13/11/12
Cardiovasc J Afr 2013; 24: e13–e15
DOI: 10.5830/CVJA-2012-073
Extravasation is defined as the unintentional leakage of solutions
from the vein. This may cause damage to the surrounding tissue
during intravenous infusions. Subcutaneous extravasation is
a known complication of intravenous infusion of iodinated
contrast solutions or cancer chemotherapy.1,2 We describe a
case of upper extremity localised bullous eruptions resulting
from pressurised infusion of crystalloid solutions through an
intravenous catheter, placed in the operation room during left
ventricular device-assisted surgery.
Emergency peri-operative management of unstable surgical
patients frequentlydeparts fromthe routine of elective anaesthesia.
In the operating room, however, on-going assessment and
management of potential complications are the responsibility
of the anaesthesiologist. He/she may also rely on colleagues
in the cardiovascular team for patient care. Extravasation is
fairly common but is usually without serious consequences.
This has led clinicians to underestimate the potentially serious
consequences of extravasation.
Case report
A 51-year-old man had a history of dilated cardiomyopathy,
with regular out-patient follow up since 2008. He had suffered
from sudden-onset dyspnoea and chest tightness. Because of
his persistent symptoms, the patient visited our hospital for
evaluation and treatment.
On the second day after admission, the patient complained
of progressive dyspnoea and echocardiography showed an
ejection fraction of 7%. Cardiogenic shock was diagnosed and
a large dose of dopamine and norepinephrine was administrated.
Emergency extracorporeal membrane oxygenation (ECMO) was
set up.
He received a left ventricular assistance device on the second
day after ECMO. On arrival in the operation room, routine
monitors were attached and general anaesthesia was maintained,
with a non-invasive blood pressure (NIBP) cuff positioned on
the upper right arm. A right antecubital 16-gauge intravenous
catheter was inserted. The operative procedure was performed
without any problems.
Unstable vital signs were noted after cardiopulmonary bypass
was stopped. His blood pressure (BP) decreased rapidly from
100/60 to 60/40 mmHg, as determined by the NIBP device.
Approximately 2 000 ml of normal saline was infused into the
right antecubital vein using pressure bags inflated to 150 mmHg.
Dopamine, norepinephrine and blood products were added to the
Department of Cardiac Surgery, Tungs’ Taichung
MetroHarbor Hospital, Taiwan
CHIH-HSIEN LEE, MD,
CHENG-HSI CHANG, MD
CHING-WEN WU, MD
Department of Biological Science and Technology, National
ChiaoTung University, Taiwan
CHIH-HSIEN LEE, MD
Heart Centre, Cheng Hsin General Hospital, Taiwan
JENG WEI, MD, PhD
Division of Cardiovascular Surgery, Department of Surgery,
Tri-Service General Hospital, National Defense Medical
Center, Taiwan
CHIH-HSIEN LEE, MD
YI-TING TSAI, MD
Case Report