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CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 2, March 2013
AFRICA
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evaluation and diagnosis can avoid potential complications and
morbidity.
The clinical manifestations of extravasation of solutions can
range from mild redness and swelling of the tissue to necrosis
associated with progressive oedema of the skin.
2
Pain, swelling
or local hyperthermia are not reliable predictors of the degree
of tissue damage.
1,2
Furthermore, agents that cause pain during
intravascular injection may not necessarily cause tissue injury
upon extravasation.
Tissue damage after extravasation may be slight and may
involve a limited local inflammatory response or may be large
and involve necrosis of the skin and underlying soft tissues.
1
The degree of damage depends on the localisation of the
extravasation, the physicochemical characteristics of the agent
administered, and the duration of soft tissue exposure to the
agent.
1
In some cases, extravasation accidents have caused
injuries ranging from painful swelling to deep necrotic lesions
with damage to nerves, tendons and vessel. Local skin necrosis
after extravasation of chemotherapy drugs is responsible for
0.5–6% of extravasation cases.
1
Most cases of subcutaneous extravasastion occur due to small
volumes of extravasation of contrast, causing pain, minimum
swelling and localised erythema, which rapidly subsides.
2
If
larger volumes are extravasated, extensive tissue and skin
necrosis may occur.
2
Although extravasation is a frequent but
usually benign injury, one should carefully evaluate the patient
for the classic 5Ps: pain, paresthesias, paresis, pallor and pulses.
There is no general agreement regarding the best approach for
the management of extravasation. Most surgeons believe that a
large proportion of injuries caused by extravasation heal without
surgery and recommend a conservative approach.
2
In the face
of the devastating consequences of tissue destruction, flushing
and drainage of the affected area should be strongly considered.
1
Once a harmful extravasation is noticed, the infusion should be
stopped immediately and aspiration of the extravasated solution
with a syringe should be attempted before the wandering needle
is removed.
Themost important measure tominimise complications caused
by extravasation is not to insert intravenous catheters outside
the visual area and observation limits of the anaesthesiologist.
Multiple punctures of the same vein, high infusion pressure,
tourniquet effect, and peripheral access sites in close proximity
to tendons, nerves or arterial vessels should be avoided.
1
Larger veins in the forearm without a blood pressure cuff are
recommended sites for intravenous access. All venous accesses
should be visible and checked regularly, and nurses should
be educated to recognise abnormalities with venous-access
cannulas to allow early treatment of extravasation during surgery.
After an extravasation has occurred and been recognised, an
immediate systematic approach may help to prevent extensive
tissue injury.
1
Most (86%) of the patients reported by Schummer
and colleagues healed without any soft tissue loss.
1
Elevation of the limb is often useful to reduce oedema,
and cooling the injection site with ice packs is useful to limit
inflammation.
2
Corticosteroids, vasodilators and a variety of
other drugs have also been proposed for the treatment of
extravasation, but most studies have not shown their efficacy.
2
There are contradictory reports on the efficacy of treating
extravasations with topically applied drugs.
1
Even when extravasation is recognised, underestimation of the
risk for subsequent tissue damage is common.
1
This often results
in inadequate management. In addition, to evaluate the extent of
deep-tissue damage, magnetic resonance imaging is advised.
1
The risk of extravasation can be reduced. Prompt and
appropriate intervention is important to avoid or minimise
extensive tissue injury. Treatment options are outlined and
emphasis is made on prevention of this iatrogenic complication.
2
Clear information to patients and prompt recognition of the
complication can allow for other non-surgical treatment options.
Conclusion
Infusion sites should be inspected regularly where possible in
patients under general anaesthesia. Medical personnel should be
made aware of the possibility of extravasation incidents so that
early diagnosis and treatment can be carried out. However, the
best way of treating an extravasation injury is to prevent it.
References
1.
Schummer W, Schummer C, Bayer O, Müller A, Bredle D, Karzai W.
Extravasation injury in the perioperative setting.
Anesth Analg
2005;
100
: 722–727.
2.
Belzunegui T, Louis CJ, Torrededia L, Oteiza J. Extravasation of radio-
graphic contrast material and compartment syndrome in the hand: a
case report.
Scand J Trauma Resusc Emerg Med
2011;
19
: 9–12.
3.
Khan MS, Holmes JD. Reducing the morbidity from extravasation
injuries.
Ann Plast Surg
2002;
48
: 628–632.
4.
Kumar RJ, Pegg SP, Kimble RM. Management of extravasation injuries.
Aust NZ J Surg
2001;
71
: 285–289.