What is the treatment for calcium chloride extravasation, specifically using hyaluronidase?

Treatment of Calcium Chloride Extravasation with Hyaluronidase

Hyaluronidase should be administered immediately for calcium chloride extravasation by injecting 150 units subcutaneously in multiple sites around the extravasation area to prevent tissue necrosis. 1, 2

Immediate Management Protocol

Stop the Infusion and Assess

• Discontinue IV administration immediately at the affected site 1
• Assess the extent of extravasation (volume and area involved) 1
• Do not attempt to aspirate the extravasated calcium chloride through the existing IV line 1

Hyaluronidase Administration Technique

• Inject 150 units of hyaluronidase subcutaneously in a circumferential pattern around the extravasation site using a 27-gauge needle 3, 2
• For larger extravasations (>50 mL), use multiple 150-unit aliquots distributed in a circle around the affected area 3
• Administer as soon as possible after extravasation is recognized—efficacy is highest when given within the first hour 3, 2
• The hyaluronidase degrades hyaluronic acid in the interstitial barrier, allowing rapid diffusion and absorption of the extravasated calcium chloride away from concentrated areas 2

Dosing Considerations

• The standard effective dose is 150 units per injection site, with maximal protection achieved at 75-150 units total for small extravasations 4
• For extensive infiltrations involving large volumes (≥100 mL), use up to 750 units total (five 150-unit vials) distributed around the perimeter 3
• Higher doses beyond 150 units per site do not provide additional benefit 4

Adjunctive Measures

Local Infiltration with Anesthetic

• Infiltrate the affected area with 1% procaine hydrochloride to reduce venospasm and dilute remaining calcium in tissues 1
• Hyaluronidase may be added directly to the procaine solution for combined administration 1
• This combination addresses both pain and tissue damage mechanisms 1

Heat Application

• Apply local heat to the affected area after hyaluronidase administration 1
• Heat promotes vasodilation and enhances absorption of the extravasated fluid 1

Evidence Supporting Hyaluronidase Use

Mechanism and Efficacy

• Animal studies using calcium chloride extravasation in immature pig skin (which closely resembles human skin) demonstrated that hyaluronidase significantly reduced necrosis area compared to controls (P <0.01) 2
• The protective effect was maintained even when controlling for diluent volume, confirming hyaluronidase's specific enzymatic action rather than simple dilution 2
• Dose-response studies show maximal protection at 75 units, with no additional benefit from higher doses up to 900 units 4

Clinical Experience

• Hyaluronidase has successfully treated large-volume extravasations (100 mL of contrast media), with marked improvement within 4 hours and near-complete resolution within 16 hours 3
• The FDA drug label for calcium chloride specifically recommends hyaluronidase as part of the treatment protocol for perivascular infiltration 1
• Multiple case reports and animal studies support its use for preventing tissue necrosis from various vesicant extravasations 5, 6, 2

Monitoring and Follow-up

Immediate Assessment (First 4 Hours)

• Reassess the extravasation site within 2-4 hours for signs of improvement (reduced swelling, erythema, pain) 3
• Document the area of involvement with measurements or photography 7
• Monitor for signs of compartment syndrome in extremity extravasations 3

Extended Monitoring (24-48 Hours)

• Continue observation for 24-48 hours to ensure progressive improvement 3
• Most cases treated promptly with hyaluronidase show near-complete resolution within 16-24 hours 3
• If tissue necrosis develops despite treatment, surgical consultation may be necessary 7

Common Pitfalls to Avoid

• Do not delay hyaluronidase administration—efficacy decreases significantly after the first hour post-extravasation 3, 2
• Do not use ice or cold compresses for calcium chloride extravasation—heat is preferred to promote absorption 1
• Do not inject hyaluronidase directly into the center of the extravasation—circumferential subcutaneous injection around the perimeter is the correct technique 3, 2
• Do not assume small-volume extravasations are benign—calcium chloride is highly caustic and can cause full-thickness skin loss even with modest volumes 2