Ain Shams University Maternity Hospital -NICU

Supervised by: by:

Dr.Shadia Abed Prof Dr.Hisham Awad

Presented by:

Dr. Nesma Badry Allam

Neonatal Intravenous Extravasations Guidelines

The aim of this guideline is to define the grading and management of extravasation injuries, it is intended to use for neonates by medical and nursing staff to minimize and overcome tissue damage The degree of tissue damage due to extravasation is dependent upon:  the volume of the infusate. infusate.  pH & osmolarity of the infusate. infusate.  the dissociation constant .  pharmacological action.

Examples of commonly used solutions with the potential to cause skin necrosis:
Alkali solutions Acidic solutions Hyperosmolar solutions

phenytoin pH 12 Amphotericin - pH 8

TPN solutions - all are pH 6 Normal saline pH 5 Dopamine pH 2.5-4.5

Potassium chloride. Calcium gluconate. gluconate. TPN. X-ray contrast. (Ultravist)

Preventive Measures
cots. Always expose the IV site if the baby is in a cot.

Avoid dorsum of foot in active babies, especially larger babies in

Secure site being clearly visible. Tape loosely enough to maintain circulation. Limit glucose concentrations to 12..5% and Amino acids to 25% . 12 25% Dilute medications per drug protocol. Assess catheter site and distal region hourly. hourly. Stop infusion immediately if signs of infiltration are
present.

Assessment
Grade 1
Pain at infusion site

Grade 2
Pain at infusion site Swelling No skin blanching Normal capillary refill and peripheral pulsation

Grade 3
Pain at infusion site Swelling Skin blanching Cool blanched area Normal capillary refill and peripheral pulsation

Grade 4
Pain at infusion site Swelling Skin blanching Cool blanched area Reduced capillary refill +/+/- Arterial occlusion +/+/- Blistering

Investigations
No specific investigations are required. However, if the wound appears infected, a wound swab, full blood count, CRP and blood culture should be taken and the infant commenced on intravenous vancomycin and gentamicin.

Management :
 Treatment is determined by :
The stage of extravasation The nature of the infiltrating solution the availability of specific antidotes

Firstly:
Stop the intravenous infusion . Remove any constricting bands . Elevation of the limb is recommended to reduce edema.

Grade 1
Stop infusion Remove cannula and splints/tapes Consider antidote Elevate limb

Grade 2
Stop infusion Remove cannula and splints/tapes Consider antidote Elevate limb

Grade 3
Stop infusion Leave cannula in situ and ,using 1ml1mlsyringe ,aspirate as much fluid as possible from the area Remove constricting tapes Consider use of hyaluronidase or specific antidote Elevate limb

Grade 4
Stop infusion Leave cannula in situ, and, using 1mlmlsyringe,aspirate as much fluid as possible from area Remove constricting tapes Consider use of hyaluronidase or specific antidote Elevate limb inform plastic sugery. sugery.

Most extravasation injuries are of Grades 1 & 2 and do not require extensive intervention to prevent long-term skin and longsoft tissue damage. Grade 3 & 4 injuries have a greater potential for skin necrosis, compartmental syndrome and need for future plastic surgery, depending on the type of solution extravasated.

Is there an available antidote or not? NO

Consider multiple puncture technique

yes
Use specific antidote
What is the extravasated material?

Calcium, TPN, Penicillin, Gentamicin, Aminophylline, potassium, radiographic dye, sodium bicarbonate and mannitol

vasopressors
Phentolamine Topical Nitroglycerine

Consider using hyaluronidase

Multiple Puncture technique

Indication
In infant who develop tense swelling of the site with blanching of the skin owing to infiltration of acidic or hyperosmolar solutions

Technique
Multiple punctures of the edematous area using a blood drawing stylet (strict aseptic technique) has been used to allow free drainage of the infiltrating solution, decrease swelling, and prevent necrosis. The area then dressed with saline soaks to aid drainage.

HYALURONIDASE (Hyalase) (Hyalase)

 Indication
management of IV extravasations (leakage of an IV fluid out of a vein and into surrounding tissue). NOT for the management of extravasation due to vasoactive medications (e.g. dobutamine, dopamine, dobutamine, epinephrine, nor epinephrine, phenylephrine). phenylephrine).

Pharmacology Hyaluronidase is an enzyme that breaks down hyaluronic acid, which is a major component of the normal interstitial barrier of the body's connective tissues, this results in the diffusion of the extravasated fluids, causing a dilution effect and a reduction in tissue destruction .

HYALURONIDASE (Hyalase) (Hyalase)

Pharmacology the interstitial barrier is reported to be completely restored within 24 to 48 hours first described in 1929 and referred to as a "spreading factor" hyaluronidase has been shown to be effective with extravasation of calcium, parenteral nutrition, penicillin, gentamicin, aminophylline, potassium, radiographic dye, sodium bicarbonate and mannitol most effective if administered within 1 hour of the extravasation, but may still be beneficial as long as 12 hours later in less than 10 minutes hyaluronidase use results in diffusion of the extravasated fluid over an area 3 to 5 times larger than if the injury was left untreated. Stability after dilution is only for 24hrs. 24hrs.

Side Effects
Possible side effects include tachycardia, hypotension, erythema, vomiting, erythema, urticaria. urticaria.

Warning !
NOT the agent of choice for management of extravasation of vasoactive
medications.

Do NOT inject around infected area.

HYALURONIDASE (Hyalase) (Hyalase)

 Dose
Reconstitute and then dilute to a final concentration of 15 unit/mL using unit/mL 0.9% NaCl Reconstitution and dilution directions:
Reconstitute a 1,500 unit ampoule with 1 mL 0.9% NaCl (concentration = 1,500 units / mL) mL) Draw up 0.1mL (of 1,500 units/mL solution) and add to 9.9 mL 0.9% NaCl units/mL (concentration = 150 units / 10mL = 15 units / mL) 10mL mL)

may be given by 2 methods according to the grade of extravasation: Directly through IV catheter (grade 3 & 4) only
leave IV catheter or needle in place aspirate the infiltrated IV fluid, if possible pull back the IV catheter or needle 1-2 mm to remove it from the vein, but leaving it in the subcutaneous tissue inject 1 mL (15 units/mL) of hyaluronidase through the catheter, then remove the units/mL) catheter

Subcutaneous (sc) injection around affected area (grade 1,2,3&4)

inject 0.2 mL (15 units/ mL) sc in up to 5 separate sites around the affected area mL) (see Diagram) the needle (use 25 g or smaller) should be changed after each injection .

HYALURONIDASE (Hyalase) (Hyalase)

 Supplied
1,500 units ampoule (lyophilized powder) trade name is Hyalase available at Seif pharmacy price 110 L.E

Injection
Inject hyalase 15 unite / ml in 0.2 amounts around infiltrated site. Point needle toward center of site 0.2cc

Infiltrated IV site

0.2cc

0.2cc

0.2cc

HYALURONIDASE (hyalase) (hyalase)

HYALASE

Before

After

HYALURONIDASE (hyalase) (hyalase)

BEFORE

After

Phentolamine (Rogitine) Rogitine)

 Indication
Effective in treating extravasations of vasopressors such as dopamine and epinephrine,which cause tissue damage by itense vasoconstriction and ischemia

 Dose
The recommended dose of phentolamine varies from 0.01 mg/kg per dose up to 5 of a 1 mg/mL solution, depending on the size of mg/mL the infiltrate.

 Administration:
0.5 to 1mg/ml solution of phentolamine diluted in normal saline ,
Draw up 1mL (of 10mg/ml) and add to 9.9 mL 0.9% NaCl . 10mg/ml) (concentration = 10mg/ 10mL = 1 mg / mL) . 10mg/ 10mL mL)

inject 0.2ml subcutaneously in five sites around the leading area of infilterate using 25-or 27-gauge needle. Change the needle after 25- 27each skin entry into infiltrated area.

Phentolamine (rogitine) (rogitine)

 Precautions
Hypotension, tachycardia, and dysrrythmia may occur; use with extreme caution

 Supplied
Ampoule 10mg/ml 10mg/ml Trade name is (Rogitine) Rogitine) OR (rogitamine) rogitamine) price 15 L.E Price 30 L.E

Topical nitroglycerine
 Indication  Dose

Effective in treating injuries due to extravasation of dopamine.

2% nitroglycerine ointment, 4mg/kg,applied over the affected area, mg/kg,applied may be reapeted every 8hrs if perfusion has not improved.  Precautions
Absorption through skin may lead to hypotension

 Supplied

Topical ointment . Price 30L.E 30L.E

wound management :

The goal

of wound management in neonates who have partial or full thickness skin loss is to achieve primary or secondary healing while avoiding scarring, contracture and operative intervention. Wound management is simple to perform, involves the use of a sterile hydro gel applied to the affected area in a sterile polythene bag forming a "glove" or "boot". If such equipment is not available, sterile urine collection bags may be used. Gel is applied liberally to the injury and the affected limb is placed inside the plastic bag. If required, additional gel may be delivered into the bag with a syringe to make sure that the wound remains covered at all times and that the bag does not come into contact with the wound surface. This hyrdrocolloids gel provide a moist wound healing environment include improving healing rate, increase epithilization, reduce infection. Enhance collagen synthesis, and earlier appearance of macrophages in the wound bed.

In the current application, the gel also prevents dehydration of damaged tissue and limits further devitalisation of exposed dermis. These properties are particularly important in view of the high room and incubator temperatures which are required in a special care baby unit. The use of the gel also appears to decrease or prevent excessive wound contraction and scarring, achieving the same effect as the massage technique described previously. It is interesting to speculate whether in an uncovered wound the production and subsequent contraction of myofibroblasts is initiated or enhanced by the partial dehydration of the granulation bed as a result of the loss of water vapors from the exposed tissue. When used in the manner described, the gel would prevent this water loss, inhibit contraction and maintain the viability of the wound and surrounding tissue.

* Wet to dry saline dressings and betadine dressings may also be effective. * The liberal use of povidone iodine on open wound is not recommended in very low birth weight infants, because absorption of iodine from the skin may suppress thyroid function . * Then apply hydrogel as we mention before. * this dressing technique could be changed every 3 days . * Daily monitoring of the wound . * If the scar involves a flexion crease , passive range motion exercise with each diaper change may help to prevent contracture.