Extravasation of noncytotoxic medications in the ED

I must admit that I rarely read the primary publication in the pharmacy world (Pharmacotherapy) because of its general lack of anything new or interesting.  Ground breaking clinical research is simply not published in this journal, but it does have excellent review articles that are so over the top, hyper-detail oriented and nauseatingly thorough and make obsessive clinical pharmacists drool.  The latest review (Management of Extravasation Injuries: A Focused Evaluation of Noncytotoxic Medications) is a prime example. But all sarcastic ranting aside, this is an excellent article for a number of reasons. For us in the ED, it’s not so much about reviewing general vasopressor type extravasation (whoopee!), but rather remembering that many other drugs we administer routinely in the ED can cause devastating extravasation due to either hyperosmolarity or acidic/alkaline properties.  And remember, we do administer a number of these medications, undiluted in small peripheral lines.
Table 4 in the manuscript is the case and point example (and I wish the authors expanded further on these medications, not the tried an true vasopressor/calcium stuff).  But from that list here are the agents you may find familiar:
Aminophylline (10 mOsm/L) – the only hypotonic med on the list
Dextrose 50% Water (D50W) – 2520 mOsm/L
Mannitol 20% – 1369 mOsm/L
Hypertonic saline 3% – 1026 mOsm/L
Hypertonic saline 23.9% – 8008 mOsm/L!
Sodium Bicarb 8.4% – 2000 mOsm/L
Propylene glycol – a hyperosmolar vehicle found in various medicaions in the ED, namely: Etomidate, lorazepam, diazepam, nitroglycerin, digoxin
Phenytoin – pH 10-12, > 700 mOsm/L
  
The paper discusses hyaluronidase as an option to manage hyperosmolar extravasations.  But again, the critical information is found at the bottom footnote of Table 4, which is how the heck to administer to a patient (I mean its great to know the mechanism and kinetics and all, but administration tends to be an often overlooked, unsexy factor).
“Hyaluronidase is commonly diluted to a 1:10 ratio (0.1 ml reconstituted hyaluronidase, 0.9 ml normal saline). A series of five injections of 0.2 ml is then administered with a tuberculin syringe until all 15 units are given. Dosage is expressed in turbidity reducing units (TRUs ). One TRU will allow the dispersion of volumes up to 50 ml from the subcutaneous compartment.”
I fortunately have not had any experience with this in the ED, so can’t comment on the ease or feasibility of effectively determining the volume of extravasated drug and subsequent estimation of dose.  I would imagine it is more of a guess and empiric dose than anything.
I would encourage any ED pharmacists to review the article, since it is quite a good review, but be ready to do some heavy reading and digging into the references for the best outcomes. 
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3 thoughts on “Extravasation of noncytotoxic medications in the ED

  1. Craig,Some heavy hitters on that author list for sure. I very much enjoyed your assessment of the article, as well as Pharmacotherapy in general. I must admit, that one sits in the “if I have time” pile, and I do not have a lot of time…. This is actually quite a timely post, I was pushing for some hyaluronidase last night due to an eptifibatide extravasation (based on… I don't know… a tingly feeling?… and one of the nastiest extravasations the RN had ever seen) and was laughing looking at the dosing recommendations. I came up with either 150 units/ml drawn to 1 ml to infiltrate in 5 0.2ml aliquots for a total of 150 units, or to dilute 150 units with 9 ml NS as you mention above and infiltrate a total of 15 units in 5 aliquots of 0.2 ml. Depends on the source, I suppose. I also was going to give the initial aliquot through the aspirated catheter, but looking back on my sources, I don't know where I saw that…I also want to mention that I strongly agree with your distaste for the overlook of medication administration. I mention to every student who rotates with me, “the team does not need another “medical” student/resident who knows a little less about diagnosis, it is your job to supplement the team with unique knowledge and abilities that only YOU can offer.” While we often duplicate efforts in order to double check the physician and nurse, we also need to bring something different and unique to the effort. If we can't do that, our only function is a double-check for POE order entry errors…I am tired of reading supposed pharmacy journals with doses and administration put in as footnotes, if at all. We can throw a great protocol together, but then you get that first call from the RN asking, “Yeah, I know what to do, but HOW do I do it?”. Then we see how well you actually know something.At this point I am rambling, but great post.

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  2. Thanks for the comment Steve! I couldn't have said it better making students aware that THEY need to be the medication expert and learning their role in the medical team. I've had some great mentors that have drilled the “HOW” you mentioned into my head and wish there was a better way we could express (and make them want to publish the 'meat and potatoes' stuff) that in the heavy hitter pharmacy journals.

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