How should I manage a severe intravenous infiltration in the upper arm of a female patient undergoing laparoscopic obstetric‑gynecologic surgery?

Management of Severe IV Infiltration in Upper Arm During Laparoscopic Surgery

Immediate Intraoperative Actions

Stop the infusion immediately and discontinue the IV catheter as soon as infiltration is recognized, as this is the most critical first step to prevent further tissue damage. 1, 2

Assessment and Documentation

• Evaluate the extent of infiltration by assessing for swelling, blanching, coolness, pain/discomfort, and tissue firmness at the site 1, 2
• Document the infusate type, estimated volume infiltrated, and appearance of the affected area, as this information guides subsequent management and is essential for medicolegal purposes 1
• Assess neurovascular status distal to the infiltration site, checking for pulses, capillary refill, sensation, and motor function 2

Initial Treatment Measures

• Elevate the affected extremity above heart level to promote fluid reabsorption and reduce edema 2, 3
• Apply warm or cold compresses depending on the infiltrated solution: warm compresses for most crystalloid solutions to promote vasodilation and reabsorption; cold compresses for vesicant medications to reduce metabolic demand and limit tissue damage 2, 3
• Do NOT attempt to aspirate fluid from the infiltration site through the existing catheter, as this is ineffective and delays appropriate management 2

Pharmacologic Interventions for Specific Infiltrates

Hyaluronidase Administration

• For hypertonic solutions (dextrose >10%, calcium, potassium, contrast media, or large-volume infiltrations), inject hyaluronidase subcutaneously into the infiltrated area using established techniques 3, 4
• Hyaluronidase breaks down hyaluronic acid in connective tissue, facilitating fluid dispersion and reabsorption, particularly effective when administered early 3, 4
• Standard dosing involves mixing hyaluronidase with normal saline and injecting subcutaneously around the periphery of the infiltration 4

Phentolamine for Vasopressor Extravasation

• If vasopressors were being infused, consider phentolamine injection to reverse alpha-adrenergic vasoconstriction and prevent tissue necrosis 3

Postoperative Monitoring Protocol

Daily Assessment Requirements

• Inspect the infiltration site at least daily for progression of injury, including development of blisters, skin discoloration, necrosis, or eschar formation 5
• Monitor for signs of compartment syndrome (though exceedingly rare with peripheral infiltration), including severe pain out of proportion, paresthesias, paralysis, and pulselessness 5
• Assess for superficial soft tissue infection, which occurs in approximately 8.6% of infiltration cases 5

Expected Outcomes and Complications

• Most infiltrations resolve without long-term sequelae; only 5.1% result in any permanent defect, and functional impairment is extremely rare 5
• Necrosis or eschar formation occurs in approximately 3.2% of cases, while ulceration or full-thickness wounds develop in 1.9% 5
• Compartment syndrome requiring emergent fasciotomy is exceptionally rare with peripheral IV infiltration, occurring in zero cases in a large retrospective series of 495 infiltrations 5

Specialist Consultation Criteria

When to Involve Plastic Surgery or Hand Surgery

• Consultation is NOT required for most infiltrations, as approximately 75% can be managed by the primary team with nursing and wound care support 5
• Consult a specialist if:
  • Full-thickness skin necrosis develops requiring debridement 5, 3
  • Extensive tissue damage with necrotic tissue that requires surgical debridement followed by oxidized regenerative cellulose/collagen dressings 3
  • Functional impairment of the extremity develops 2
  • Complex regional pain syndrome is suspected, requiring long-term pain management 2

Surgical Intervention Requirements

• No emergent surgical intervention is typically required for IV infiltration injuries 5
• Only 1.4% of infiltrations require bedside procedures, and 1.4% require non-acute operations 5
• Most complications can be monitored and managed conservatively by the primary team with wound care support 5

Prevention of Future Infiltrations

Site Selection and Catheter Choice

• Use upper extremity sites preferentially over lower extremity sites in adults, which aligns with the current case 6
• Avoid steel needles for medications that might cause tissue necrosis if extravasation occurs 6
• Consider midline catheters or peripherally inserted central catheters (PICCs) when IV therapy duration will exceed 6 days 6

Monitoring During Infusion

• Evaluate catheter insertion sites daily by palpation through the dressing to detect tenderness, even when using transparent dressings 6
• Instruct patients to report pain, burning, or discomfort immediately, as these are the earliest warning signs of infiltration 1, 2
• Replace peripheral venous catheters every 72-96 hours in adults to prevent phlebitis, which increases infiltration risk 6, 7

Critical Pitfalls to Avoid

• Do NOT delay removing the infiltrated catheter once infiltration is recognized, as continued infusion dramatically worsens tissue damage 1, 2
• Do NOT apply topical antibiotic ointments to the infiltration site, as these promote fungal infections and antimicrobial resistance without benefit 8
• Do NOT routinely consult specialists for uncomplicated infiltrations, as this increases costs without improving outcomes; most cases resolve with conservative management 5
• Do NOT assume all infiltrations require surgical intervention, as none are true surgical emergencies and most heal with elevation, compresses, and wound care 5