The management of infantile extravasation injury using maternal platelet-rich plasma

Recommendations for Management of Noncytotoxic Vesicant Extravasations

To prepare clinicians to treat extravasation of noncytotoxic vesicants with antidotes and thermal compresses, a literature review was performed to identify noncytotoxic vesicants and to create evidence and consensus-based recommendations. The stage of injury and vesicant's mechanism of tissue injury dictate treatment. For a vasopressor extravasation, warm compresses and administration of a vasodilator are recommended. For osmolarity, pH, absorption refractory, and cytotoxic concentration-dependent vesicants, warm compresses and administration of hyaluronidase are recommended. Compared with potentially catastrophic costs of undertreatment, the cost of overtreatment is minimal.

Treatment of extravasation injuries in infants and young children: a scoping review and survey

BACKGROUND

Extravasation injuries are caused by unintended leakages of fluids or medicines from intravenous lines, but there is no consensus on the best treatment approaches.

OBJECTIVES

To identify which treatments may be best for treating extravasation injuries in infants and young children.

DESIGN

Scoping review and survey of practice.

POPULATION

Children aged < 18 years with extravasation injuries and NHS staff who treat children with extravasation injuries.

INTERVENTIONS

Any treatment for extravasation injury.

MAIN OUTCOME MEASURES

Wound healing time, infection, pain, scarring, functional impairment, requirement for surgery.

DATA SOURCES

Twelve database searches were carried out in February 2017 without date restrictions, including MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature) Plus and EMBASE (Excerpta Medica dataBASE).

METHODS

Scoping review - studies were screened in duplicate. Data were extracted by one researcher and checked by another. Studies were grouped by design, and then by intervention, with details summarised narratively and in tables. The survey questionnaire was distributed to NHS staff at neonatal units, paediatric intensive care units and principal oncology/haematology units. Summary results were presented narratively and in tables and figures.

RESULTS

The evidence identified in the scoping review mostly comprised small, retrospective, uncontrolled group studies or case reports. The studies covered a wide range of interventions including conservative management approaches, saline flush-out techniques (with or without prior hyaluronidase), hyaluronidase (without flush-out), artificial skin treatments, debridement and plastic surgery. Few studies graded injury severity and the results sections and outcomes reported in most studies were limited. There was heterogeneity across study populations in age, types of infusate, injury severity, location of injury and the time gaps between injury identification and subsequent treatment. Some of the better evidence related to studies of flush-out techniques. The NHS survey yielded 63 responses from hospital units across the UK. Results indicated that, although most units had a written protocol or guideline for treating extravasation injuries, only one-third of documents included a staging system for grading injury severity. In neonatal units, parenteral nutrition caused most extravasation injuries. In principal oncology/haematology units, most injuries were due to vesicant chemotherapies. The most frequently used interventions were elevation of the affected area and analgesics. Warm or cold compresses were rarely used. Saline flush-out treatments, either with or without hyaluronidase, were regularly used in about half of all neonatal units. Most responders thought a randomised controlled trial might be a viable future research design, though opinions varied greatly by setting.

LIMITATIONS

Paucity of good-quality studies.

CONCLUSIONS

There is uncertainty about which treatments are most promising, particularly with respect to treating earlier-stage injuries. Saline flush-out techniques and conservative management approaches are commonly used and may be suitable for evaluation in trials.

FUTURE WORK

Conventional randomised trials may be difficult to perform, although a randomised registry trial may be an appropriate alternative.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Saline irrigation for the management of skin extravasation injury in neonates

BACKGROUND

Extravasation injury, a complication commonly seen in the neonatal intensive care unit, can result in scarring with cosmetic and functional sequelae. A wide variety of treatments are available, including subcutaneous irrigation with saline (with or without hyaluronidase), liposuction, use of specific antidotes, topical applications, and normal wound care with dry or wet dressings. All such treatments aim to prevent or reduce the severity of complications.

OBJECTIVES

Primary objective To compare the efficacy and safety of saline irrigation or saline irrigation with prior hyaluronidase infiltration versus no intervention or normal wound care for tissue healing in neonates with extravasation injury. Secondary objectives To evaluate by subgroup analysis of controlled trials the influence of type of extravasate, timing of irrigation following extravasation, and postmenstrual age (PMA) of the neonate at the time of injury on outcomes and adverse effects.Specifically, we planned to perform subgroup analysis for the primary outcome, if appropriate, by examining:1. time to irrigation from identified extravasation injury (< 1 hour or ≥ 1 hour);2. type of extravasate (parenteral nutrition fluid or other fluids or medications);3. amount of saline used (< 500 mL or ≥ 500 mL); and4. PMA at injury (< 37 completed weeks or ≥ 37 completed weeks).

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1), MEDLINE via PubMed (1966 to 2 February 2017), Embase (1980 to 2 February 2017), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 2 February 2017). We also searched clinical trial databases, conference proceedings, and reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. We used the Google Scholar search tool for reverse citations of relevant articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-randomised controlled trials comparing saline irrigation with or without hyaluronidase infiltration versus no intervention or normal wound care for the management of extravasation injury in neonates.

DATA COLLECTION AND ANALYSIS

Three review authors independently reviewed and identified articles for possible inclusion in this review. We used the GRADE approach to assess the quality of evidence.

MAIN RESULTS

We found no eligible studies. Our search revealed 10 case reports or case series describing successful outcomes with different interventions for this condition.

AUTHORS' CONCLUSIONS

To date, no RCTs have examined the effects of saline irrigation with or without prior hyaluronidase infiltration for management of extravasation injury in neonates. Saline irrigation is frequently reported in the literature as an intervention for management of extravasation injury in neonates. Research should focus first on evaluating the efficacy and safety of this intervention through RCTs. It will also be important for investigators to determine effect size by examining the timing of the intervention, the nature of the infusate, and severity of injury at the time of intervention.

Severe Extravasation Injuries in Neonates: A Report of 34 Cases

INTRODUCTION

Extravasation injuries are a common and challenging problem in hospitalized newborns. Accidental infusion leakage into the surrounding tissues in immature infants may frequently result in skin necrosis, with significant risk of functional and cosmetic impairment.

MATERIAL AND METHODS

In the present study we reviewed 34 cases of severe extravasation injuries occurring in 1,409 neonates hospitalized in a single neonatal unit over 24 months (incidence 2.4%). Total parenteral nutrition solutions were involved in most cases. All patients were treated within 30 minutes after the injury was recorded using a flush-out technique with normal saline irrigation and occlusive paraffin dressings of the infiltrated area.

RESULTS

The majority of injuries affected preterm, low-birthweight infants (mean gestation 32 wks + 6 days, mean birth weight 1,885 g), with a mean age at the time of injury of 11.6 days and a mean weight of 2,045 g. Neither gestational age (p = 0.87) or birthweight significantly affected (p = 0.07) the incidence of extravasation injuries, although the incidence of skin necrosis had a significant correlation with gestational age (p = 0.009) and birthweight (p < 0.001). All patients responded well to treatment and their wounds healed uneventfully within a maximum of 25 days without the need for secondary surgery for skin coverage.

CONCLUSION

Extravasation injuries in extremely preterm and low-birthweight infants are more likely to lead to skin necrosis. Peripheral venous catheterization should be performed with caution in these patients to prevent such injuries. Immediate irrigation with normal saline is recommended to reduce toxic sequelae in the infiltrated area.