Download Extravasation Injury of the Upper Limb by Intravenous Clindamycin

Case Report
Extravasation Injury of the Upper Limb by
Intravenous Clindamycin
Dahal P,* Shrestha JM**
*Consultant surgeon, Associate Proffesor, TUTH
ABSTRACT
Intravenous drug administration is a common practice in all hospitals. It can cause minor complications
like thrombophlebitis to severe complications like local skin necrosis, and severe soft tissue necrosis. It
can also cause severe disability. Attention and caution is necessary in the intravenous administration
of irritant drugs.
INTRODUCTION
I
ntravenous fluids and drugs administration is a routine
procedure for nurses. Extravasation or infiltration
occurs when fluids or medications administered by
the intravenous route penetrates the perivascular or
subcutaneous space. All intravenous fluids can cause
tissue injury following extravasation. However, certain
substances such as cytotoxic or vasoactive drugs and
hyperosmolar agents are associated with a greater
risk of tissue injury. The complications may range from
minor (ecchymosis, hematoma and phlebitis) to severe
form (extravasation causing tissue necrosis).
The reported incidence of complications of
extravasation is very difficult to obtain in the literatures.
Some studies have reported the extravasation of
vesicant chemotherapy in children by 11% and in
adults by 22%.1But there are different case reports
on extravasation of different cytotoxic agents in the
literatures but no literature was found about the tissue
injury due to extravasation of intravenous clindamycin.
Extravasation induces prolonged hospital stay
of patient, unnecessary diagnostic procedures,
treatment, disability and stress in the life of the
patients andto their relatives. The economic loss and
medico legal complications areanother important
Correspondence :
Dr Peeyush Dahal
Burn& Plastic Surgery Unit
National Academy of Medical Sciences
Bir Hospital, Kathmandu
Email: [email protected]
factor.In this article, a patient with extravasation of
intravenous Clindamycin is described with literature
review.
CASE REPORT
A 14 years boy was admitted to the hospital for the
treatment of empyema thoracic with sepsis. He had
the history of seizure disorders in the past and he was
regularly taking phenytoin orally. At the time of hospital
admission peripheral intravenous line was open and
intravenous Clindamycin(Dalacin) and Amikacin was
administered. He developed painful swelling in the
right forearm immediately after administration of drug.
When the swelling and pain increased this intravenous
line was removed. Central venous pressure line was
placed, thoracotomy was done but the swelling of
forearm increased gradually and extended up to the
lower part of arm. The skin became black(Figure: 1) on
the seventh day.Then hewas referred to plastic surgery
unit with wrist drop on the 15th day after thoracotomy.
Figure 1.
The wound was debrided immediately. Common
extensor muscles were necrosed at their proximal part
and were necrosed partially at the distal part. Upper
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PMJN
Postgraduate Medical
Journal of NAMS
Extravasation Injury of the Upper Limb by Intravenous Clindamycin
part of theradius was exposed and the elbow joint
space was opened (figure: 2).
Figure 2.
The raw area was covered with thick split thickness skin
graft and the bone was covered with fasciocutaneous
abdominal flap(Figure 3&4).
Figure 3.
Figure 4.
Flap was detached after four weeks (Figure 5) and
he was discharged by planning for tendontransfer to
correct the wrist drop.
Figure 5.
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PMJN
Postgraduate Medical
Journal of NAMS
Volume 11│Number 2│Jul-Dec 2011
DISCUSSION
Extravasation is defined either as the escape of
a chemotherapeutic agent from a vessel into
the surrounding tissues by leakage or as an
involuntary injection of a drug into the tissues2. The
chemotherapeutic agents may be vesicants or the
irritants and extreme ph causes decrease vein tolerance
and rupture leading to extravasation. Author could
not find a single literature regarding extravasation of
intravenous clindamycin.
Irritants are drugs that can cause an inflammatory
reaction, aching, swelling, pain or phlebitis at the
injection site or along the vein. Generally symptoms
are self-limiting and usually there are no long-term
sequelae. But Symptoms may arise immediately
orseveral days or weeks after extravasation of vesicant
drugs. The severity of tissue injury is dependent on
the type, concentration and quantities of the injected
chemotherapeutic agent. It may cause severe and
lasting tissue injury and necrosis and sometimes
leading to disability.
Review of the literature has revealed case reports of
devastating tissue injuries(skin with or without muscle
necrosis following cysplatin3, Mitomycin4 phenytoin5
extravasation. It is also found that the antibiotic,
diuretics, dextrose extravasation has induced severe
tissue injuries requiring reconstructive surgery.6
There different modalities of the treatment of the
acute stage of this complication which include general
measures like elevation of the involved extremity
and application of coldcompresses to minimize the
inflammatory reactions7, 8. The use hyaluronidase,
phentolamineinjections and glyceryl trinitrate patches
topromote drug absorption are also found9, 10, 11, 12.
Saline flush-outhas been used to dilute the drug. Some
authorsadvocate specific antidotes as the mainstay
of treatment8.Early surgical debridement and skin
grafting have also beenrecommended13.
The systemic approach with some guide lines help for
prompt and effective management. For this purpose
Millam’s Classification (Table no.1)6 would be useful.
Millam proposed conservative treatment for Stages
I and II, and intervention for Stages III and IV. Stages
III and IV infiltrates require prompt and aggressive
intervention. Some exit stab incisions under local or
general anesthesiaare made around the periphery
Extravasation Injury of the Upper Limb by Intravenous Clindamycin
of the area of extravasation and saline isinjected for
flushing.Hyaluronidase, glyceryltrinitrate are other
agents to reduce the ongoing tissue injury. There are
specific antidotes for specific agents like anthracyclines,
mitomycin C and mustine14.
Table 1. Staging of intravenous (IV) infiltrates
Stage Features
I
Painful IV site
No erythema
No swelling
II
Painful IV site
Slight swelling (0%–20%)
No blanching
Good pulse below infiltration site
Brisk capillary refill below infiltration site
III
Painful IV site
Marked swelling (30%-50%)
Blanching
Skin cool to touch
Good pulse below infiltration site
Brisk capillary refill below infiltration site
IV
Painful IV site
Very marked swelling (75%)
Blanching
Skin cool to touch
Decreased or absent pulse*
Capillary refill > four seconds*
Skin breakdown or necrosis
* The presence of any one of these characteristics
constitutes a Stage IV infiltrate.
CONCLUSION
Intravenous extravasations of clindamycin may cause
devastating complication as other chemotherapeutic
agents. Safe Medication practices, precaution,
awareness and intravenous drug administration
guideline should be established to minimize
extravasations. Prompt recognition and intervention
also reduce the incidence of tissue necrosis leading to
disability.
REFERENCES
1. L. Hadaway, Infiltration and extravasation, preventing a
complication of IV catheterization. AJN, 2007, 107 (8):
64-72,
2. D. L.Schrijvers Extravasation: a dreaded complication of
chemotherapy. Annals of Oncology 14 (Supplement 3):
26–30, 2003.
3. O. Bairey, M. Shakali, J. Bashara. Severe tissue necrosis
after Cysplatin Extravavasation at Low Concerntration:
possible “Immediate Recall Phenomenon”.J Natl Cancer
Inst 1997, 89 (16): 1233-1234.
4. E. U. Avdal, N. Aydinoğlu. Extravasations of Vesicant /
Non- Vesicant Drugs andEvidence – Based Management:
Int J Caring Sciences 2012, 5(2): 192-202.
5. J. J. Edwards, V Bosek. Extravasation Injury of the Upper
Extremity by intravenous phenytoinAnesthAnalg 2002,
94; 672-3.
6. REC Rose, R Felix, A Crawford-Sykes, R Venugopal, G
Wharfe, G Arscott; Extravasation Injuries; West Indian
Med J 2008; 57 (1): 40-47
7. DLLarson. What is the appropriate management of tissue
extravasationby antitumor agents? Plast Reconstr Surg
1985; 75: 397–405.
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of accidentalinfusion leakage in the newborn: report of
14 cases. Br J Plast Surg2001; 54: 396–9
9. DCasanova, J Bardot, G Magalon. Emergency treatment
of accidentalinfusion leakage in the newborn: report of
14 cases. Br J Plast Surg2001; 54: 396–9.
10.R.G. Dufresne. Skin necrosis from intravenously infused
materials.Cutis 1987; 39: 197–8
11.L. Flemmer, JSL Chan. A pediatric protocol for
management of extravasation injuries. Pediatr Nrusing
1993; 19: 355–8, 424.
12.
24. O’Reilly C, McKay FMA, Duffy P, Lloyd DJ.
Glyceryl trinitrate in skinnecrosis caused by extravasation
of parenteral nutrition. Lancet 1988;2: 565–6.
13.
Linder RM, Upton J, Osteen R. Management
of extensive doxorubicinhydrochloride extravasation
injuries. J Hand Surg 1983; 8: 32–8.
14.Bertelli G. Prevention, management of extravasation of
cytotoxicdrugs. Drug Saf 1995; 12: 245–55.
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PMJN
Postgraduate Medical
Journal of NAMS