Extravasation of noncytotoxic medications update

A long time ago in a blogger far, far away, I wrote a short post about extravasation of noncytotoxic medications in the ED. But a new article in Annals of Pharmacotherapy has inspired a resurrection and update of this old post.

At the time, I was reviewing a paper from Pharmacotherapy (Management of Extravasation Injuries: A Focused Evaluation of Noncytotoxic Medications). This article was a terrific resource for those in the ED and caused us to remember 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. Some of the commonly administered potentially harmful medications in extravasation included in this paper were:

  • 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 medications in the ED, namely: Etomidate, lorazepam, diazepam, nitroglycerin, digoxin
  • Phenytoin – pH 10-12, > 700 mOsm/L

Recently in Annals of Pharmacotherapy, another comprehensive review of the topic provided some additional information and useful resources. While nothing within the paper could be considered in the realm of groundbreaking, it is still rather useful as a reminder. But the most high-yield information is the warm vs cold compress question.

WarmColdWarm or Cold
CaCl (10%)
CaGluc (10%)
Diazepam 5 mg/mL
Dobutamine 12.5 mg/mL
Dopamine 80 mg/mL
Epinephrine 1 mg/mL (ie, code epi)
MgSulfate (But only if it's 50% or 500mg/mL)
Metronidazole 5 mg/mL
Norepinephrine 1 mg/mL
KCl 2mEq/mL (ED is usually NMT 0.1 mEq/mL)
NaHCO3 8.4%
Digoxin 0.25 mg/mL
Furosemide 10mg/mL
Nicardipine 2.5 mg/mL (normal infusions are 0.1 mg/mL)
Propofol 10 mg/mL
Amiodarone 50 mg/mL

This is a good list to keep handy for any unfortunate extravasation events, although the complete manuscript is worth a read.


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