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• Necrosis in Extravasation incidents is a tip of the iceberg
  Saroj Kumar Patnaik
  Published on: 22 March 2016

• Published on: 22 March 2016

  Necrosis in Extravasation incidents is a tip of the iceberg

  • Saroj Kumar Patnaik, Paediatrician
  • Other Contributors:
    • Suprabha K Patnaik

  Dear Editor

  Some of the extravasation incidents are unavoidable owing to a compromised vascular integrity arising from prematurity and the injury resulting from a variety of pharmacological agents infused. However, a prevalence of 38 per 1000 of necrotic extravasation incidents as reported by Wilkins and Emmerson represents only tip of the iceberg.[1]

  It would have been more relevant to have a document...

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  Dear Editor

  Some of the extravasation incidents are unavoidable owing to a compromised vascular integrity arising from prematurity and the injury resulting from a variety of pharmacological agents infused. However, a prevalence of 38 per 1000 of necrotic extravasation incidents as reported by Wilkins and Emmerson represents only tip of the iceberg.[1]

  It would have been more relevant to have a documentation of all extravasation incidents followed by an analysis of the proportion that progressed to skin necrosis. This would generate meaningful data regarding the incriminating agents and their propensity for causing necrosis. Since there is no universal standardized protocol for management of such extravasation incidents, studies designed to address interventions carried out at the point of detection of extravasation prior to the noticeable necrosis so as to gauge any contributory role of these interventions themselves become important.

  Extravasation incidents reflect the level of nursing care in the neonatal unit. Majority of such incidents is preventable by a hypervigilant approach to monitoring of the intravenous access. Hence the knowledge of the staffing pattern of the neonatal units is equally important which unfortunately is not brought out in the survey by Wilkins and Emmerson.[1] Vigilance would be directly proportional to the nurse: neonate ratio as well as the supervisory attitudes of the residents and consultants in the unit apart from the individual sensitization of the caregiver. In units with a highly unfavorable nurse: neonate ratio or with a combined nursing with a single sister looking after a busy pediatric ward as well as the neonatal unit as encountered by us, constant supervision of the intravenous access has been possible only by a combination of education and sensitization of the nursing staff working in the pediatric complex coupled to a almost paranoid approach towards these events by the consultants. A strict policy of the intravenous access being a mandatory item in handing taking over of patients during change of shifts, looking for early signs of a ‘burst’ intravenous access viz. erythema, even minimal apparent swelling and induration distal to the intravenous site and prompt changing of the access site are the vital ingredients.

  More often extravasation is detected too late – patency of intravenous access is assumed by the unwary based on an infusion pump that seems to be working without any flow resistance indicator signal and an evident backflow in the intravenous cannula. It needs to be stressed the chances of extravasation are more with an infusion pump than with a infusion microdrip – the former is able to push fluids in the face of significant interstitial pressures while the microdrip being a gravity dependent device the flow stops earlier. Backflow in the cannula can continue inspite of extravasation for sometime – hence any signs of extravasation should prompt corrective measures. With these measures, in our unit we had necrotic extravasation in 5 out of 102 babies (26 – 40 weeks) admitted to the Neonatal unit over a period of 12 months giving a prevalence of ~ 49 per 1000 which is not very high considering a single sister per shift for whole pediatric complex. Of course a better staffing pattern should lower the rates.

  Amongst the implicated infusions reported in the Wilkins and Emmerson study where > 33% were intensive care cots with ‘an expected high proportion of sickest preterms’, it is surprising to find no incidents involving any vasopressor drips viz. dopamine, dobutamine or adrenaline which are expected to be needed in some of the sickest preterm neonates and are expected to result in necrosis due to tissue ischemia. In our neonatal unit, 10% dextrose calcium, sodium bicarbonate, cloxacillin and dopamine have been the commonest agents implicated in the extravasation events. There was only one incident involving a peripherally inserted central line without any necrotic sequel. There was no incident involving blood products and parenteral nutrition probably because of sparse need for the latter in our babies majority of whom were > 1500 grams. Wherever feasible, two lines are maintained by us – one for antibiotics and other agents to be given over short time interval and another for maintenance fluids.

  In our unit, the necrotic areas are kept covered with loose dressings incorporating betadine ointment with good healing. Local application of heparin cream at extravasation sites and limb elevation are the other measures carried out. Barring one baby with multiple cutaneous abscesses, no baby ended up with any scar. The luxury of special wound care nurses didn’t exist with us. We haven’t have had any experience with hyaluronidase because of nonavailability in our setup. It should be remembered that hyaluronidase is ineffective for vasopressor extravasations.[2] Phentolamine as well as local nitroglycerine patch have been found useful to revert the vasospasm with dopamine extravasationsd.[2,3] radiologic evidence of calcinosis can be useful in calcium extravasations for determining the extent of injury.[4]

  As a policy, we routinely take wound swabs for culture from the necrotic site. In one baby with coagulase negative staphylococcal sepsis, wound swabs grew E. Coli, which was followed by positive blood cultures for E. Coli after 72 hours. The neonate continued to have positive blood cultures for 03 weeks with multiple cutaneous abscesses at all old extravasation/intravenous access sites. I propose that apart from the physicochemical injury by the extravasated agent, in neonates with septicemia the extravasated sites become a sanctuary site for seeding of bacteria and the local inflammatory response may have a variable role in the necrosis observed clinically. Conversely an infected necrotic ulcer can be an initiating focus of septicemia as observed in our baby.Though Gault's procedure: saline flush-out and liposuction has had good results,[5] the wisdom of local infiltration of saline and hyaluronidase is questionable in a septic baby – the needle pricks themselves can be potential sites of sepsis initiation if there is an inadvertent break in asepsis.. Local application of betadine to all puncture sites is meticulously followed by us to prevent any local infection at the needle entry site at an area of extravasation.

  Finally, future studies need to address the cost economics of extravasation incidents in neonatal units addressing factors like prolongation of hospital stay attributable to extravasation incidents, cost of therapy of sequel of extravasation and the overall effect on the neonatal morbidity and mortality.

  References

  1. C E Wilkins and A J B Emmerson Extravasation injuries on regional neonatal units. Arch Dis Child Fetal Neonatal Ed. 2004 May;89(3):F274-5

  2. Dawodu T, Douma C, Patnode R. Hyaluronidase. In Appendix A.Common NICU medication guidelines In: Cloherty JP, Eichenwald EC, Stark AR, ed. Manual of Neonatal Care.5th Ed.Philadelphia: Lippincott Williams & Wilkins, 2004 ; 731.

  3.Wong AF, McCulloch LM, Sola A.Treatment of peripheral tissue ischemia with topical nitroglycerin ointment in neonates.J Pediatr. 1992 Dec;121(6):980-3.

  4.Mu SC, Lin CH, Sung TC.Calcinosis cutis following extravasation of calcium gluconate in neonates.Acta Paediatr Taiwan. 1999 Jan-Feb;40(1):34- 5.

  5. Casanova D, Bardot J, Magalon G.Emergency treatment of accidental infusion leakage in the newborn: report of 14 cases.Br J Plast Surg. 2001 Jul;54(5):396-9

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  Conflict of Interest:
  None declared.

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