What is the management of potassium chloride (KCl) extravasation and thrombophlebitis?

From the Guidelines

Management of potassium chloride (KCl) extravasation or thrombophlebitis requires immediate intervention to prevent tissue damage, with the first step being to stop the infusion immediately and elevate the affected limb. For KCl extravasation, apply warm compresses to the area for 20-30 minutes every 4-6 hours to enhance vasodilation and drug absorption, as recommended by the ESMO-EONS clinical practice guidelines 1. Consider infiltrating the area with 5-10 mL of normal saline to dilute the extravasated KCl, followed by 1% lidocaine (without epinephrine) for pain relief. Hyaluronidase (150-200 units in 1 mL saline) can be administered subcutaneously around the extravasation site to enhance drug dispersion and reduce tissue damage.

Key Considerations

• For thrombophlebitis, remove the IV catheter and apply warm compresses to reduce inflammation and pain.
• Non-steroidal anti-inflammatory drugs like ibuprofen (400-600 mg orally every 6-8 hours) can help manage pain and inflammation, as suggested by general medical knowledge.
• Topical anti-inflammatory agents such as diclofenac gel 1% applied 3-4 times daily may provide additional relief.
• Prevention is crucial - always dilute KCl to concentrations below 40 mEq/L for peripheral administration, use central lines for higher concentrations, and monitor infusion sites regularly, as emphasized by the guidelines 1.

Treatment Options

• Leaving the cannula in place, try to gently aspirate as much extravasated solution as possible, and record the volume removed in patient records, as recommended by the guidelines 1.
• Avoid manual pressure over the extravasated area, and consider topical DMSO as a treatment option for extravasations occurred during anthracyclines, mitomycin C, or platin salts infusion 1.
• Subcutaneous corticoids are not recommended due to potential deleterious effects, as noted in a retrospective series of 175 cases of extravasation 1.

Important Notes

• KCl is particularly damaging to tissues because it's hypertonic and causes cellular dehydration, leading to tissue necrosis if not promptly addressed.
• The management of extravasations is largely based on non-biopsy confirmed data, and many recommendations date back to a drug's original registration, which can be several decades ago when requirements for approval were less strict, as highlighted by the guidelines 1.

From the Research

Management of KCl Extravasation/Thrombophlebitis

• The management of KCl extravasation involves immediate stoppage of IV fluid administration, disconnection of the IV tube, aspiration of remaining drug, and administration of a drug-specific antidote 2.
• Local thermal treatments, such as cooling with ice packs, can aid in vasoconstriction and limit drug dispersion, although the benefit of thermal applications has not been clearly demonstrated 2.
• The recommended application schedule for thermal treatments is 15 to 20 minutes, every 4 hours, for 24 to 48 hours 2.
• Health professionals should be familiar with extravasation management guidelines and regularly check extravasation kits, assess patients for sensory changes, and pay attention to patient reports 2.

Prevention of Extravasation

• Prevention of extravasation is crucial, and health professionals should be educated on the risks and management of extravasation 3.
• Careful selection and monitoring of infusion sites, particularly in geriatric patients, can help prevent extravasation 4.
• Patient-specific factors, pharmacological implications, and vascular assessment are essential in preventing extravasation 4.

Treatment of Extravasation

• Treatment of extravasation involves medication discontinuation, cannula removal, and application of topical dressings, such as magnesium sulfate or hydrogel dressings 4.
• Wound debridement, ongoing dressings, and moderate exercises can lead to complete wound resolution 4.
• Pharmacological antidotes, such as hyaluronidase, phentolamine, or terbutaline, may be useful in select extravasations, but require prompt recognition and complex administration strategies 5, 6.
• Supportive care, including topical anesthetics, antimicrobials, and vasodilators, may also be used in the management of extravasation 5, 6.

Risk Factors for Extravasation

• Risk factors for extravasation include drug properties, such as pH, osmolarity, and vasoactive properties, as well as patient-related factors, such as reduced tissue elasticity and sensitivity 3, 5, 6.
• Certain medications, including potassium chloride, calcium gluconate, and phenytoin, are associated with a higher risk of extravasation 5.