Extravasation of propofol is associated with tissue necrosis in small children

Management of noncytotoxic extravasation injuries: A focused update on medications, treatment strategies, and peripheral administration of vasopressors and hypertonic saline

Extravasation is the leakage of intravenous solutions into surrounding tissues, which can be influenced by drug properties, infusion techniques, and patient-related risk factors. Although peripheral administration of vesicants may increase the risk of extravasation injuries, the time and resources required for central venous catheter placement may delay administration of time-sensitive therapies. Recent literature gathered from the growing use of peripheral vasopressors and hypertonic sodium suggests low risk of harm for initiating these emergent therapies peripherally, which may prevent delays and improve patient outcomes. Physiochemical causes of tissue injury include vasoconstriction, pH-mediated, osmolar-mediated, and cytotoxic mechanisms of extravasation injuries. Acidic agents, such as promethazine, amiodarone, and vancomycin, may cause edema, sloughing, and necrosis secondary to cellular desiccation. Alternatively, basic agents, such as phenytoin and acyclovir, may be more caustic due to deeper tissue penetration of the dissociated hydroxide ions. Osmotically active agents cause cellular damage as a result of osmotic shifts across cellular membranes in addition to agent-specific toxicities, such as calcium-induced vasoconstriction and calcifications or arginine-induced leakage of potassium causing apoptosis. A new category has been proposed to identify absorption-refractory mechanisms of injury in which agents such as propofol and lipids may persist in the extravasated space and cause necrosis or compartment syndrome. Pharmacological antidotes may be useful in select extravasations but requires prompt recognition and frequently complex administration strategies. Historically, intradermal phentolamine has been the preferred agent for vasopressor extravasations, but frequent supply shortages have led to the emergence of terbutaline, a β2 -agonist, as an acceptable alternative treatment option. For hyperosmolar and pH-related mechanisms of injuries, hyaluronidase is most commonly used to facilitate absorption and dispersion of injected agents. However, extravasation management is largely supportive and requires a protocolized multidisciplinary approach for early detection, treatment, and timely surgical referral when required to minimize adverse events.

Injury due to extravasation of thiopental and propofol: Risks/effects of local cooling/warming in rats

Inadvertent leakage of medications with vesicant properties can cause severe necrosis in tissue, which can have devastating long-term consequences. The aim of this study was to evaluate the extent of extravasation injury induced by thiopental and propofol, and the effects of cooling or warming of local tissue on extravasation injury at macroscopic and histopathologic levels. Rats were administered intradermally thiopental (2.5 mg/100 µL) or propofol (1.0 mg/100 µL). Rats were assigned randomly to three groups: control (no treatment), cooling and warming. Local cooling (18-20 °C) or warming (40-42 °C) was applied for 3 h immediately after agent injection. Lesion sizes (erythema, induration, ulceration, necrosis) were monitored after agent injection. Histopathology was evaluated in skin biopsies taken 24 h after agent injection. Thiopental injection induced severe skin injury with necrosis. Peak lesions developed within 24 h and healed gradually 18-27 days after extravasation. Propofol induced inflammation but no ulceration, and lesions healed within 1-2 days. Local cooling reduced thiopental- and propofol-induced extravasation injuries but warming strongly exacerbated the skin lesions (e.g., degeneration, necrosis) induced by extravasation of thiopental and propofol. Thiopental can be classified as a "vesicant" that causes tissue necrosis and propofol can be classified as an "irritant". Local cooling protects (at least in part) against skin disorders induced by thiopental and propofol, whereas warming is harmful.

Extravasation reactions associated with the administration of pamidronate: 11 cases (2008-2013)

Pamidronate is a bisphosphonate drug widely utilized in veterinary oncologic practice for the palliation of malignant osteolysis. Pamidronate has not been previously reported to cause tissue injury upon extravasation in dogs. The medical records of 11 client-owned dogs undergoing palliative treatment for primary bone tumors with known or suspected pamidronate extravasation reactions were reviewed. The majority of adverse events were low grade in nature, however in some cases, the reactions were severe and led to euthanasia in one instance. Time to complete resolution of lesions ranged from within several days to greater than one and a half months. Aside from the dog that was euthanized, no long-term sequelae of extravasation were identified. Treatments employed to address the reactions varied widely. Pamidronate extravasation reaction appears to be an uncommon, but potentially serious complication of intravenous administration.

The efficacy of intracoelomic fospropofol in red-eared sliders (Trachemys scripta elegans)

Intravenous anesthetic delivery in reptiles can be challenging. Current injectable techniques have varied induction/recovery times and anesthetic quality. This study hypothesized that intracoelomic administration of a new anesthetic, fospropofol, in turtles would result in dose-dependent anesthesia and respiratory depression. A two-part prospective trial using adult red-eared slider turtles (Trachemys scripta elegans) weighing 764 +/- 17 g was conducted to determine an effective anesthetic dose and to evaluate the anesthetic quality, duration, and respiratory effects of an efficacious dose. In part 1, six turtles were randomly administered 25-mg/ kg (low-dose [LD]) and 50-mg/kg (high-dose [HD]) fospropofol in a crossover design. Respiratory rate, immobility, and muscle relaxation scores were evaluated for 180 min. In part 2, eight turtles were administered HD fospropofol. Immobility and muscle relaxation (front and hind limb) scores and time to endotracheal intubation/extubation were evaluated until scores returned to baseline. In part 1, the LD group had significantly lower immobility and muscle relaxation scores versus the HD group over time (both P < 0.05); scores were significantly elevated from baseline for 20-120 min and 15-180 min, respectively (all P < 0.05). Although not significantly different between groups (P > 0.05), respiratory rate was significantly decreased from baseline from 10 to 120 min (all P < 0.05). In part 2, HD fospropofol decreased respiratory rate from 21.5 +/- 2.9 breaths/min to 0.1 +/- 0.1 breaths/min, similar to the results in part 1. Maximal reductions in mobility and front and hind limb motor tone occurred at 39.0 +/- 4.1, 30.8 +/- 3.6, and 24.0 +/- 3.6 min, respectively. Intubation in 7/8 turtles occurred at 45.7 +/- 5.4 min and extubation at 147.0 +/- 23.2 min. However, 2/8 turtles showed prolonged anesthetic effects, requiring resuscitative efforts for recovery. Due to the unpredictable quality and duration of anesthesia with intracoelomic fospropofol, it should be used with caution for general anesthesia in red-eared sliders at the doses and administration route investigated.