What is the treatment for extravasation injury?

Treatment of Extravasation Injury

Early recognition and immediate treatment with specific antidotes based on the extravasated agent is essential for managing extravasation injuries and preventing tissue necrosis. 1

General Measures for All Extravasations

1. Initial Steps (Immediate):

   • Stop administration immediately
   • Leave the cannula in place
   • Attempt to gently aspirate as much extravasated solution as possible
   • Avoid manual pressure over the extravasated area (may spread the agent) 1, 2

2. Supportive Care:

   • Elevate the affected limb
   • Apply dry cold compresses for 20 minutes several times daily for 1-2 days
   • Administer analgesia as needed 1, 2

3. Documentation:

   • Patient information
   • Date and time of extravasation
   • Name of drug extravasated and diluent
   • Signs and symptoms
   • Description of IV access
   • Extravasation area and approximate amount
   • Management steps with time and date
   • Photographic documentation (if possible) 1

Specific Antidotes Based on Extravasated Agent

Anthracyclines (doxorubicin, epirubicin, etc.)

• First-line treatment: Dexrazoxane IV in a 3-day schedule (1000, and 500 mg/m²) starting within 6 hours of extravasation 1
  • Reduce dose to 50% if creatinine clearance <40 ml/min
  • Remove topical cooling 15 minutes before and during administration
  • Administer in a large vein away from extravasation site
• Alternative: Topical DMSO 99% (four drops per 10 cm² of skin surface, repeated every 8 hours for 1 week) 1, 3

Vinca Alkaloids (vincristine, vinblastine)

• Hyaluronidase: 1-6 ml of 150 U/ml solution injected through existing IV line
• Standard dose: 1 ml hyaluronidase solution per 1 ml of extravasated drug 1

Mechlorethamine

• Immediate subcutaneous administration of sodium thiosulfate
• 2 ml of 1/6 molar solution (mix 4 ml of 10% sodium thiosulfate with 6 ml sterile water)
• Inject 2 ml for each milligram of mechlorethamine extravasated 1

Hyperosmolar Solutions and Electrolytes

• Hyaluronidase may be effective for hyperosmotic extravasations 4
• Calcium extravasation requires special attention as it may present with delayed manifestations 4

Vasopressors and Vasoconstrictors

• Intradermal phentolamine is the best therapeutic agent
• Topical vasodilators or intradermal terbutaline may provide relief 4

Thermal Applications

• Cold application: For vesicant drugs, vasoconstrictors, and hyperosmolar solutions
• Warm application: For vasopressors (to increase drug dispersion and dilution)
• Application schedule: 15-20 minutes every 4 hours for 24-48 hours 5

Surgical Management

• Indicated for:

  • Unresolved tissue necrosis
  • Pain lasting more than 10 days
  • Failed conservative therapy 1

• Surgical procedure:

  • Wide three-dimensional excision of all involved tissue
  • Temporary coverage with biologic dressing
  • Delayed application of split-thickness skin graft (2-3 days) 1

• Subcutaneous wash-out procedure:

  • Alternative technique for delayed presentations (2-14 days)
  • Involves flushing the infiltrated area with 300-500 ml normal saline through multiple stab incisions
  • Not recommended as routine management in non-experienced surgical units 1, 6

Follow-up and Monitoring

• Initial follow-up within 24-48 hours for severe extravasations
• Routine follow-up within 7 days for mild to moderate cases
• Extended monitoring for 3-4 weeks with vesicant agents 2

Common Pitfalls to Avoid

1. Applying manual pressure over the extravasated area
2. Using subcutaneous corticosteroids (may increase need for surgical debridement)
3. Inadequate documentation
4. Delayed recognition and treatment
5. Using alcohol compresses (may cause further tissue irritation)
6. Applying DMSO when dexrazoxane is being administered for anthracycline extravasation 1, 2

Early intervention is crucial as extravasation injuries can lead to significant morbidity, increased healthcare costs, and prolonged hospital stays if not managed promptly and appropriately 7, 4.