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.

Intravenous contrast medium extravasation: systematic review and updated ESUR Contrast Media Safety Committee Guidelines

NEED FOR A REVIEW

Guidelines for management and prevention of contrast media extravasation have not been updated recently. In view of emerging research and changing working practices, this review aims to inform update on the current guidelines.

AREAS COVERED

In this paper, we review the literature pertaining to the pathophysiology, diagnosis, risk factors and treatments of contrast media extravasation. A suggested protocol and guidelines are recommended based upon the available literature.

KEY POINTS

• Risk of extravasation is dependent on scanning technique and patient risk factors. • Diagnosis is mostly clinical, and outcomes are mostly favourable. • Referral to surgery should be based on clinical severity rather than extravasated volume.

Study on preventing adverse events in neonates (SEPREVEN): A stepped-wedge randomised controlled trial to reduce adverse event rates in the NICU

INTRODUCTION

Adverse events (AE) in care are recognized as a leading cause of mortality and injury in patients. Improving patients' safety is difficult to achieve. Therefore, innovative research strategies are needed to identify errors in subgroups of patients and related severity of outcomes as well as reliably measured efficiency of reproducible strategies to improve safety. This trial aims to evaluate the impact of a combined multiprofessional education program on the rate of AE in neonatal intensive care units (NICUs).

METHODS AND ANALYSIS

This is a stepped-wedge cluster randomised controlled trial with 3 clusters each containing 4 units. The study time period will be 20 months. The education program will be implemented within each cluster following a random sequence with a control period, a 4-month transition period and a post-educational intervention period. Eligibility criteria: for clusters: 6 NICUs from Ile-de-France and 6 NICUs from different regions in France; for patients: in-hospital during the study period (November 23, 2015 and November 2, 2017 [inclusion start dates varying by unit]) in one of the 12 NICUs; corrected gestational age ≤42 weeks upon admission; hospitalization period >2 days; and parents informed and not opposed to the use of their newborn's data. A routine occurrence reporting of medical errors and their consequence will take place during the entire study period. The intervention will combine an education to implement a standardized root cause analysis method, creation of bundles (insertion, daily goals, maintenance bundles) to prevent catheter-associated blood-stream infection and a poster to prevent extravasation injuries.

OUTCOME

We hypothesize a reduction from 60 (control) to 50 (intervention) AE/1000 patient-days. The primary outcome will be the rate of AE/1000 patient-days in the NICU.

TRIAL REGISTRATION NUMBER

NCT02598609, trial registered November 6, 2015. https://clinicaltrials.gov/ct2/show/NCT02598609.

ETHICS AND DISSEMINATION

Study approved by the regional ethic committee CPP Ile-de-France III (no 2014-A01751-46). The results will be published in peer-reviewed journals.

Extravasation (paravasation) of chemotherapy drugs - updated recommendations (2020) for standard care in the Czech Republic from the cooperation of the Supportive Care Group of the Czech Society for Oncology, Czech Society for Hematology, Oncology Section of the Czech Nurses Association and the Society for Ports and Permanent Catheters

BACKGROUNDS

Extravasation (paravasation) of chemotherapy drugs is a very significant complication. Preventive and therapeutic interventions reduce the risk of the complication or the extent of its consequences. A working group of authors from expert groups prepared recommendations for standard care.

PURPOSE

A basic summary of recommended interventions for daily practice, defined on the basis of knowledge from long-term, proven, evidence-based practice or on the consensus opinions of the expert groups representatives.

RESULTS

Preventive measures are essential and include early consideration of long-term venous access devices indications, choice of injection site, venous line control before each chemotherapy drug application, and patient education. The intervention in case of extravasation mainly involves the application of antidotes (DMSO, hyaluronidase, dexrazoxane) and the application of dry cold or heat according to the type of cytostatic drug. Subcutaneous corticosteroids, moist heat or cooling and compression are not recommended.

CONCLUSION

The recommended procedures contribute to reducing the risk and consequences of extravasation. The range of recommended interventions can be expanded individually depending on individual clinical site policy and needs.

Comparison of the Efficacy and Safety of Bone-filling Mesh Container and Simple Percutaneous Balloon Kyphoplasty in the Treatment of Osteoporotic Vertebral Compression Fractures

BACKGROUND

Bone cement leakage in patients with vertebral fracture limits the use of percutaneous kyphoplasty (PKP) and percutaneous vertebroplasty (PVP). Finding a method to reduce bone cement leakage is clinically rather important.

OBJECTIVE

To compare the efficacy and safety of bone-filling mesh containers (BFMCS) and simple percutaneous balloon kyphoplasty in the treatment of osteoporotic vertebral compression fractures.

STUDY DESIGN

A randomized controlled clinical study discussing the effect of 3 methods in the treatment of vertebral fractures.

METHODS

From October 2014 to August 2015, 80 patients with single osteoporotic vertebral compression fractures were admitted in our hospital, including 31 men and 49 women with an average age of 76.2 years (range, 63-82 years). Patients were divided into a percutaneous balloon kyphoplasty group (Group A) and a PVP with dilated balloon placement group (Group B), with 40 cases in each group. The visual analog scale (VAS), Oswestry disability index (ODI), height of the vertebral body and Cobb's angle of the injured vertebrae were observed before operation and at 1 day, 1 month, and 6 months after the operation. Bone cement leakage and postoperative complications were also observed.

RESULTS

Operations were successfully completed in all 80 patients without pulmonary embolism and without spinal cord or nerve root injury. The operation time was (32.6 ± 6.1) minutes in Group A and (31.8 ± 5.8) minutes in Group B. Operation time did not significantly differ between the 2 groups (P > 0.05). Both groups differed significantly when comparing the results with those measured before treatment. In Group A, the ODIs before operation and at 1 day, 1 month, and 6 months after the operation were 84.125 ± 8.821, 29.300 ± 8.951, 16.175 ± 6.748, and 11.400 ± 6.164, respectively, and those in Group B were 84.300 ± 8.768, 29.200 ± 9.121, 15.975 ± 6.811, and 11.575 ± 6.460, respectively. Cobb's angle values in Group A before and after treatment were (19.225 ± 5.881)° and (13.900 ± 3.720)°, respectively, and those in Group B were (19.275 ± 6.210)° and (14.225 ± 4.016)°, respectively.

CONCLUSION

Both bone-filling mesh bag and simple percutaneous balloon kyphoplasty for treating osteoporotic vertebral compression fractures can relieve pain effectively and correct the Cobb angle. The bone-filling mesh container can effectively prevent bone cement leakage and reduce the incidence of bone cement leakage.

LIMITATIONS

The study has limitations due to the small number of cases and short period of follow-up time. Further studies are needed to determine whether the mesh bag can limit the distribution of bone cement within the vertebral body.

KEY WORDS

Bone-filling mesh container, kyphoplasty, osteoporosis, vertebral compression fracture.

Remember the risks of intravenous therapy and know how to reduce them

Nicola Brooks, Associate Dean, Faculty of Health and Life Sciences, De Montfort University, reflects on the potential problems that can occur with the administration of intravenous therapy.

Infusion-related risks associated with chemotherapy

This article provides a comprehensive overview of the risks associated with the administration of chemotherapy, monoclonal antibodies and targeted or biological therapies in the management of solid tumours. The main physiological actions of these agents are discussed, with reference to the immediate infusion-related side effects and complications that may arise from an extravasation injury. The article focuses on the identification and early recognition of these risk factors to implement preventive measures and appropriate management strategies.

[Extravasation of Cytostatic Drugs - Prevention and Best Practices]

Extravasation is the leakage of a drug (intended primarily for intravenous administration) into tissues surrounding the vascular system. The damage to surrounding varies depending on the nature and volume of extravasation. Cytostatic extravasation is associated with poor outcomes for patients. This paper summarizes the types of risk associated with cytostatic extravasation, and the preventative measures that can be used when such an event occurs. We also provide information on potential treatments. However, justification for their use has only been substantiated in papers with different levels of significance and these papers are not available in all countries. We summarize current international recommendations for actions to be taken in the event of extravasation.

Devices and dressings to secure peripheral venous catheters to prevent complications

BACKGROUND

A peripheral venous catheter (PVC) is typically used for short-term delivery of intravascular fluids and medications. It is an essential element of modern medicine and the most frequent invasive procedure performed in hospitals. However, PVCs often fail before intravenous treatment is completed: this can occur because the device is not adequately attached to the skin, allowing the PVC to fall out, leading to complications such as phlebitis (irritation or inflammation to the vein wall), infiltration (fluid leaking into surrounding tissues) or occlusion (blockage). An inadequately secured PVC also increases the risk of catheter-related bloodstream infection (CRBSI), as the pistoning action (moving back and forth in the vein) of the catheter can allow migration of organisms along the catheter and into the bloodstream. Despite the many dressings and securement devices available, the impact of different securement techniques for increasing PVC dwell time is still unclear; there is a need to provide guidance for clinicians by reviewing current studies systematically.

OBJECTIVES

To assess the effects of PVC dressings and securement devices on the incidence of PVC failure.

SEARCH METHODS

We searched the following electronic databases to identify reports of relevant randomised controlled trials (RCTs): the Cochrane Wounds Group Register (searched 08 April 2015): The Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), Ovid MEDLINE (1946 to March 7 2015); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, March 7 2015); Ovid EMBASE (1974 to March 7 2015); and EBSCO CINAHL (1982 to March 8 2015).

SELECTION CRITERIA

RCTs or cluster RCTs comparing different dressings or securement devices for the stabilisation of PVCs. Cross-over trials were ineligible for inclusion, unless data for the first treatment period could be obtained.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed trial quality and extracted data. We contacted study authors for missing information. We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included six RCTs (1539 participants) in this review. Trial sizes ranged from 50 to 703 participants. These six trials made four comparisons, namely: transparent dressings versus gauze; bordered transparent dressings versus a securement device; bordered transparent dressings versus tape; and transparent dressing versus sticking plaster. There is very low quality evidence of fewer catheter dislodgements or accidental removals with transparent dressings compared with gauze (two studies, 278 participants, RR 0.40; 95% CI 0.17 to 0.92, P = 0.03%). The relative effects of transparent dressings and gauze on phlebitis (RR 0.89; 95% CI 0.47 to 1.68) and infiltration (RR 0.80; 95% CI 0.48 to 1.33) are unclear. The relative effects on PVC failure of a bordered transparent dressing and a securement device have been assessed in only one small study and these were unclear. There was very low quality evidence from the same single study of less frequent dislodgement or accidental catheter removal with bordered transparent dressings than securement devices (RR 0.14, 95% CI 0.03 to 0.63) but more phlebitis with bordered dressings (RR 8.11, 95% CI 1.03 to 64.02) (very low quality evidence). A small single study compared bordered transparent dressings with tape and found very low quality evidence of more PVC failure with the bordered dressing (RR 1.84, 95% CI 1.08 to 3.11) but the relative effects on dislodgement were not clear (very low quality evidence). The relative effects of transparent dressings and a sticking plaster have only been compared in one small study and are unclear. More high quality RCTs are required to determine the relative effects of alternative PVC dressings and securement devices.

AUTHORS' CONCLUSIONS

It is not clear if any one dressing or securement device is better than any other in securing peripheral venous catheters. There is a need for further, independent high quality trials to evaluate the many traditional as well as the newer, high use products. Given the large cost differences between some different dressings and securement devices, future trials should include a robust cost-effectiveness analysis.

Intravenous contrast extravasation during CT: a national data registry and practice quality improvement initiative

PURPOSE

Establish 3 performance benchmarks for intravenous contrast extravasation during CT examinations: extravasation frequency, distribution of extravasation volumes, and severity of injury. Evaluate the effectiveness of implementing practice quality improvement (PQI) methodology in improving performance for these 3 benchmarks.

METHODS

The Society of Abdominal Radiology and ACR developed a registry collecting data for contrast extravasation events. The project includes a PQI initiative allowing for process improvement.

RESULTS

As of December 2013, a total of 58 radiology practices have participated in this project, and 32 practices have completed the 2-cycle PQI. There were a total of 454,497 contrast-enhanced CT exams and 1,085 extravasation events. The average extravasation rate is 0.24%. The median extravasation rate is 0.21%. Most extravasations (82.9%) were between 10 mL and 99 mL. The majority of injuries, 94.6%, are mild in severity, with 4.7% having moderate and 0.8% having severe injuries. Data from practices that completed the PQI process showed a change in the average extravasation rate from 0.28% in the first 6 months to 0.23% in the second 6 months, and the median extravasation rate dropped from 0.25% to 0.16%, neither statistically significant. The distribution of extravasation volumes and the severity of injury did not change between the first and second measurement periods.

CONCLUSIONS

National performance benchmarks for contrast extravasation rate, distribution of volumes of extravasate, and distribution of severity of injury are established through this multi-institutional practice registry. The application of PQI failed to have a statistically significant positive impact on any of the 3 benchmarks.

[Progress of bone cement augmentation of pedicle screw]

OBJECTIVE

To review the progress of the pedicle screw augmentation technique by bone cement.

METHODS

Recent literature about the pedicle screw augmentation technique by bone cement was reviewed and analysed. The characters were summarized.

RESULTS

Pedicle augmentation technique includes the augmentation of ordinary solid pedicle screw and hollow pedicle screw. Both types could increase the fixation strength and gain satisfactory clinical results. Bone cement leakage had a certain incidence rate, but most of cases were asymptom.

CONCLUSION

Bone cement augmentation of pedicle screw is an effective and safe internal fixation for poor bone condition.

Photochemically crosslinked collagen annulus plug: a potential solution solving the leakage problem of cell-based therapies for disc degeneration

Intra-disc injection of mesenchymal stem cells (MSCs) to treat disc degeneration may lead to unfavorable complications, particularly osteophyte formation. Development of an effective method to block the injection portal, prevent the leakage of injected cells and materials and, hence, prevent osteophyte formation is of the utmost importance before MSC-based therapies can be applied in a clinical setting. Here we seek to alleviate the cell leakage problem and the associated complication osteophyte formation by developing an injectable annulus plug to block the injection portal during intra-disc delivery. Specifically, we fabricated a needle-shaped collagen plug by photochemical crosslinking and successfully delivered it intra-discally, in association with MSCs in collagen microsphere carriers, using a custom-made delivery device. The mechanical performance of the plug and its effectiveness in reducing cell leakage were evaluated ex vivo under compression and in torsion push-out tests. The results demonstrate that the plug survived physiologically relevant loadings and significantly reduced leakage and enhanced retention of the injected materials. Finally, a pilot in vivo study in rabbits was conducted to evaluate the performance of the plug. Microcomputed tomography imaging and histology revealed that the plug significantly reduced osteophyte formation. This work suggests the potential of the annulus plug as an adjunct or annulus closure device for intra-disc delivery of cells and materials.

Quality improvement project to reduce infiltration and extravasation events in a pediatric hospital

A safety event response team at Cincinnati Children's Hospital Medical Center developed and tested improvement strategies to reduce peripheral intravenous (PIV) infiltration and extravasation injuries. Improvement activities included development of the touch-look-compare method for hourly PIV site assessment, staff education and mandatory demonstration of PIV site assessment, and performance monitoring and sharing of compliance results. We observed a significant reduction in the injury rate immediately following implementation of the interventions that corresponded with monitoring compliance in performing hourly assessments on patients with a PIV, but this was not sustained. The team is currently examining other strategies to reduce PIV injuries.

DIALYSATE LEAKAGE IN CAPD PATIENTS

Dialysate leakage may occur through the anterior abdominal wall, the genital organs or the pleural cavity during the early or late stages of dialysis in patients who are on continuous ambulatory peritoneal dialysis (CAPD). This dialysate leakage can reach such an extent that CAPD treatment may need to be halted. Dialysate leakage through the subcutaneous anterior abdominal wall can be caused by a deficiency in the abdominal muscles. In this study, 3 patients on CAPD who had a dialysate leak through the subcutaneous anterior abdominal wall were followed. An exercise programme was offered to strengthen abdominal muscles. CAPD continued but volumes were reduced by 6-25%. Exercise programmes for abdominal muscles may be useful for the prevention of leakage through the subcutaneous anterior abdominal wall, without having to interrupt CAPD treatment.

Contrast media-induced compartment syndrome

Intravascular (IV) contrast media are essential in many cases to enhance the diagnostic capabilities of medical imaging procedures. Much is known about the indications, contraindications, and adverse events associated with their use. This Directed Reading focuses on extravasation and IV contrast media-induced compartment syndrome, a less frequent, although serious, adverse event. In addition to describing the compartments within the forearm, wrist, and hand, the article explains how compartment syndrome develops, techniques used to treat the condition, and prevention strategies.

Practical vascular anatomy in the preparation of radioembolization

As the incidence of primary and metastatic liver cancer continues to increase, the use of minimally invasive techniques as a treatment option is becoming more common. Radioembolization, a form of intra-arterial brachytherapy, is a technique where particles of glass or resin, impregnated with the isotope 90yttrium (90Y), are infused through a catheter directly into the hepatic arteries. This modality is based on the fact that hepatic malignancies receive their blood supply from the hepatic artery, whereas normal hepatocytes are perfused mostly from the portal circulation, which allows delivery of high doses to the tumor vasculature with relative sparing of normal liver tissue. This has been shown to be effective for both primary and metastatic tumors. A variety of complications may be related to hepatic intra-arterial treatments, especially to the gastroduodenal region. These complications are known to come from inadvertent extrahepatic infusion of 90Y particles, through arteries originating from the hepatic arterial branches such as the falciform artery, cystic artery, arteries from the pancreaticoduodenal arcade, gastroduodenal artery, or right gastric artery. Surgeons and interventional radiologists rely on accurate imaging and assessment of the hepatic arterial supply. It is important to know the common anatomic variations and technical considerations before radioembolization. We recommend an aggressive occlusion of all the above-mentioned arteries; further, clinicians should watch out for any other aberrant branches, and if in doubt, they ought to be coiled.

Identifying complications of central venous catheters: infection, thrombosis, occlusion

(1) The signs of infection of implanted port catheters are inflammation along the course of a central catheter, oozing or signs of an abscess of the pocket in which the port is implanted. Catheter-related venous thrombosis should be suspected in the event of pain, oedema, local swelling, a palpable venous cord and development of superficial collateral circulation; (2) The rapid appearance of local signs and symptoms at the time of injection suggests extravasation of the injected drug; (3) Catheter patency should be checked with normal saline, never using too much force if resistance is encountered. If there is a thrombotic occlusion, the catheter can often be unblocked with heparin, or if not, with urokinase. There is only a moderate risk of bleeding if these agents are used carefully.

Double cement-application cavity containment kyphoplasty: technique description and efficacy

Kyphoplasty is an effective surgical treatment for the pain and deformity that can accompany vertebral compression fractures. In certain cases, however, defects or clefts in the vertebral body result either from the original fracture or from expansion of inflatable bone tamps (IBTs). Through such a defect, cement may extrude into the epidural space, paraspinal soft tissues, or disc space. In addition, by virtue of the dynamic nature of certain fracture configurations, the height restored by inflation of the bone tamps may be lost once the tamps are removed for cement placement, despite patient positioning. In our modification of the kyphoplasty technique, we use 2 cement applications to minimize potential extravertebral cement extravasation and maintain the height restoration achieved with the IBTs. After 0.75 to 1.5 cm(3) of cement is deposited, the IBTs are reinserted into the fracture and inflated until the cement cures. Once the cement is cured, the IBTs are again deflated and removed, leaving a cement shell that seals the cracks and supports the endplates. Then, another batch of cement is mixed and is used to fill the cavities, as in the standard technique. Results for our first 21 patients show a mean correction of more than 6 degrees of kyphosis and no cement leaks into the spinal canal. We believe that this modification of the kyphoplasty technique is effective and safe for certain fractures.

[Prevention and treatment of bone cement leakage in percutaneous kyphoplasty for osteoporotic vertebral body compression fracture]

OBJECTIVE

To investigate the causes and preventive methods of the bone cement leakage in percutaneous kyphoplasty (PKP) for osteoporotic vertebral body compression fracture (OVCF).

METHODS

From April 2003 to November 2007, 116 patients with OVCF were treated with PKP, including 57 males and 59 females aged 65-92 years old (average 67.7 years old). All the patients suffered from trauma and the course of disease was 1-14 days (average 5.7 days). There were 159 compressed and fractured vertebral bodies, including one vertebral body in 83 cases, two vertebral bodies in 24 cases, three vertebral bodies in 8 cases, and four vertebral bodies in 1 case. The diagnosis of OVCF was confirmed by imaging examination before operation. All the patients had intact posterior vertebral walls, without symptoms of spinal and nerve root injury. During operation, 3.5-7.1 mL bone cement (average 4.8 mL) was injected into single vertebral body.

RESULTS

The operation time was 30-90 minutes (average 48 minutes). Obvious pain relief was achieved in all the patients after operation. X-rays examination 2 days after operation revealed that the injured vertebral bodies were well replaced without further compression and deformation, and the bone cement was evenly distributed. Fourteen vertebral bodies had bone cement leakage (4 of anterior leakage, 4 of lateral leakage, 3 of posterior leakage, 2 of intervertebral leakage, 1 of spinal canal leakage). The reason for the bone cement leakage included the individuality of patient, the standardization of manipulation and the time of injecting bone cement. During the follow-up period of 12-30 months (average 24 months), all the patients got their normal life back, without pain, operation-induced spinal canal stenosis, obvious height loss of injured vertebral bodies and other complications.

CONCLUSION

For OVCF, PKP is a mini-invasive, effective and safe procedure that provides pain relief and stabilization of spinal stability. The occurrence of bone cement leakages can be reduced by choosing the suitable case, improving the viscosity of bone cement, injecting the proper amount of bone cement and precise location during operation.

Accidental extrusion of sodium hypochlorite into the maxillary sinus

An unusual case is reported of accidental extrusion of sodium hypochlorite solution into the maxillary sinus during instrumentation in the course of root canal treatment of a maxillary premolar. This caused a burning sensation accompanied by nasal bleeding, swallowing of blood, and interrupted breathing. The case was managed by irrigating with sterile saline, arresting nasal bleeding, and administering antibiotics, anti-inflammatory drugs, and decongestants.

Infusion therapy. Part two: Prevention and management of complications

In the second of two articles, the author identifies common complications associated with intravenous (i.v.) therapy and discusses preventive measures. Part one, published last week, provided an overview of i.v. therapy and the types of vascular access devices available.

[Vertebroplasty: state of the art]

Over the last 10 years, there has been much development in the management of metastatic and osteoporotic vertebral compression fractures using vertebroplasty. This percutaneous image-guided interventional radiology procedure allows stabilization of a vertebral body by injection of an acrylic cement and frequently results in significant symptomatic relief. During cement polymerisation, an exothermic reaction may destroy adjacent tumor cells. Advances have been made to reduce complications from extravasation of cement in veins or surrounding soft tissues. Safety relates to experience but also to technical parameters: optimal cement radio-density, adequate digital fluoroscopy unit (single or bi-plane digital angiography unit), development of cements other than PMMA to avoid the risk of adjacent vertebral compression fractures. The rate of symptomatic relief from vertebroplasty performed for its principal indications (vertebral hemangioma, metastases, osteoporotic fractures) reaches 90-95%. The rate of complications is about 2% for metastases and less than 0.5% for osteoporotic fractures. Vertebroplasty plays a major role in the management of specific bone weakening vertebral lesions causing, obviating the need for kyphoplasty.

Extravasation injuries

OBJECTIVES

To evaluate the time and type of treatment following extravasation from intravenous infusion and the sequelae of the injuries.

METHOD

The charts of 12 patients who were referred to the Plastic and Orthopaedic Services at the University Hospital of the West Indies were reviewed. The study period was between May 2003 and January 2007. Data were collected on age, gender, site of extravasation, extravasated agent, treatment of the extravasation, necrosis interval, duration of hospital stay for treatment of injury and whether the intravenous line was resited and at what site in relation to the injury.

RESULTS

The age of patients ranged from three days to 67 years. The female-to-male ratio was 2:1. In five patients, the intravenous infusion was discontinued immediately after the swelling was noticed. In two patients, the intravenous infusion was stopped after seven hours and in five patients it was discontinued within 12 to 22 hours. The necrosis interval ranged from 12 hours to three weeks. Immediate treatment following extravasation and discontinuation of the infusion included limb elevation in three patients and application of cold compresses in one patient. Eleven patients developed skin necrosis of varying severities. There was no skin necrosis in one patient. Ten patients spent an average of 31 extra days in hospital for treatment of the extravasation injury. Two patients were treated in an out-patient clinic.

CONCLUSIONS

Extravenous leaks can cause severe tissue injuries. Morbidity is increased by delay in recognition and treatment of the extravasation. A protocol for the treatment of extravasation is recommended.

Anatomy of sodium hypochlorite accidents

Sodium hypochlorite (NaOCl) in various concentrations is the most widely used endodontic irrigant, but it can be an irritant to vital tissues. There are several reports about the complications of irrigation with NaOCl during root canal therapy. Most of the complications are the result of accidental extrusion of the solution from the apical foramen or accessory canals or perforations into the periapical area. This article is a review and comparison of all reported NaOCl accidents in the literature.

Infiltration and extravasation

The Infusion Nurses Society's national standards of practice require that a nurse who administers IV medication or fluid know its adverse effects and appropriate interventions to take before starting the infusion. A serious complication is the inadvertent administration of a solution or medication into the tissue surrounding the IV catheter--when it is a nonvesicant solution or medication, it is called infiltration; when it is a vesicant medication, it is called extravasation. Both infiltration and extravasation can have serious consequences: the patient may need surgical intervention resulting in large scars, experience limitation of function, or even require amputation. Another long-term effect is complex regional pain syndrome, a neurologic syndrome that requires long-term pain management. These outcomes can be prevented by using appropriate nursing interventions during IV catheter insertion and early recognition and intervention upon the first signs and symptoms of infiltration and extravasation. Nursing interventions include early recognition, prevention, and treatment (including the controversial use of antidotes, and heat and cold therapy). Steps to manage infiltration and extravasation are presented.

Dealing with chemotherapy extravasations: a new technique

Doxorubicin, vincristine, and vinblastine are chemotherapeutic drugs commonly used in the treatment of cancer in pets. It takes technical skill to administer these drugs, because they are caustic sclerotics. If doxorubicin is extravasated into the perivascular tissues, the results may be devastating. The attending nurse and clinician must act vigorously to immediately remove every drop of the drug spilled into the tissues. Unfortunately, little has been written on how to effectively do that, but this paper describes an aggressive technique that can be used to combat such a spill.

Intraosseous drug administration in children and adults during cardiopulmonary resuscitation

OBJECTIVE

To review and assess the available literature on the use of intraosseous (IO) drug administration during cardiopulmonary resuscitation, addressing the benefits and risks of using this method of drug delivery in children and adults.

DATA SOURCES

The MEDLINE (1950-July 2007) database was searched for pertinent abstracts, using the key term intraosseous infusions. Additional references were obtained from the bibliographies of the articles reviewed. Manufacturer Web sites were used to obtain information about IO insertion devices.

STUDY SELECTION AND DATA EXTRACTION

All available English-language clinical trials, retrospective studies, and review articles describing IO drug administration were reviewed. Studies conducted in animal models to evaluate the effectiveness and safety of IO drug administration were also included.

DATA SYNTHESIS

IO access uses the highly vascularized bone marrow to deliver fluids and medications during cardiopulmonary resuscitation. This route, developed in the 1940s, has been revived in the past decade as a means of achieving rapid vascular access when intravenous access cannot be obtained. The primary advantage of IO access is the high success rate (approximately 80%). Most trained providers can place an IO line within 1-2 minutes. A number of small-scale studies and retrospective reviews have established the usefulness of this route for the delivery of many commonly used resuscitation drugs. In addition, animal models have demonstrated rapid drug delivery to the systemic circulation. While all resuscitation drugs can be given by the IO route, administration of ceftriaxone, chloramphenicol, phenytoin, tobramycin, and vancomycin may result in lower peak serum concentrations. The most common adverse effect seen with IO use, extravasation, has been reported in 12% of patients. Compartment syndrome, osteomyelitis, and tibial fracture are rare, but have also been reported.

CONCLUSIONS

IO administration is a safe and effective method for delivering drugs during cardiopulmonary resuscitation. It should be considered whenever intravenous access cannot be rapidly obtained.

Fluid filtration evaluation of 3 obturation techniques

OBJECTIVE

To evaluate coronal leakage and apical material extrusion of 3 obturation techniques.

METHOD AND MATERIALS

The coronal part of 60 freshly extracted human maxillary central incisors was removed, leaving roots 10 mm in length. After instrumentation by hand K-files and smear layer removal, the 60 roots were divided randomly into 3 groups. The roots of each group were obturated using different obturation techniques. The obturation techniques tested were cold lateral condensation, System B, and Thermafil. Leakage measurements were accomplished using fluid filtration methodology. Filling material extrusion was recorded using a yes or no statement. Results were subjected to statistical analysis using chi-square tests.

RESULTS

Fluid filtration results revealed no significant differences among the 3 techniques tested 48 hours after obturation (P >.05). Thermafil tended to extrude significantly more material beyond the apex (P <.05).

CONCLUSIONS

The 3 obturation techniques are equally effective at sealing the root canals. Thermafil's tendency for slight material extrusion should be considered when obturating canals with insufficient apical constriction.

Potential hazards of contrast study diagnosis of esophageal atresia

Delay in the diagnosis of esophageal atresia (EA) is rare. We present a child with EA and distal tracheoesophageal fistula who was diagnosed 9 days from birth after a contrast study performed at the referring hospital. This article aims to highlight the potential hazards of using contrast to diagnose EA.

The Eggshell Technique for Prevention of Cement Leakage During Kyphoplasty

Cement extravasation during kyphoplasty occurs between 4% and 9%, a much lower incidence than with vertebroplasty. However, because of the potential complications of cement in and around the spinal canal, any egress of cement outside the vertebral body is extremely concerning. Aborting the procedure will cease the extraosseous leakage and minimize potential immediate complications. However, the cavity will remain unfilled and the fracture unstable. Rather than aborting, we have devised a technique, called the eggshell technique, to manage the patient's fracture once extravasation is noted so that the procedure can be safely completed.

Vesicant extravasation part II: Evidence-based management and continuing controversies

PURPOSE/OBJECTIVES

To review the literature, synthesize current recommendations, and discuss remaining controversies regarding vesicant extravasation management.

DATA SOURCES

Published evidence-based reports, clinical articles, and anecdotal case reports about antineoplastic and nonantineoplastic vesicant agent management.

DATA SYNTHESIS

Prevention of vesicant extravasation sequelae requires knowledge about vesicant extravasation manifestations and differentiation of vesicant extravasation from other local IV site reactions. When evidence is weak or missing, logical application of data-based or empirical management strategies is critical. Actions may include timely administration of subcutaneous or topical antidotes, comfort measures, and surgical interventions to minimize the extent of tissue damage and morbidity should extravasation occur.

CONCLUSIONS

Vesicant extravasation and sequelae constitute a complex patient problem. Clinicians should strive to prevent extravasation or seek to minimize injury should it occur. To this end, clinicians must demonstrate awareness of its risks and use specialized knowledge when administering vesicant agents.

IMPLICATIONS FOR NURSING

Nurses who administer vesicant agents should understand the nursing and collaborative actions that should be taken to minimize patient morbidity, pain, and disability.

Vesicant extravasation part I: Mechanisms, pathogenesis, and nursing care to reduce risk

PURPOSE/OBJECTIVES

To review the literature regarding the incidence, current practice, guideline recommendations, nursing management, and knowledge gaps relevant to vesicant extravasation.

DATA SOURCES

Published research articles, books, case reports, and national guidelines.

DATA SYNTHESIS

Vesicant extravasation is a relatively rare but significant complication of chemotherapy administration. Extravasation may have a range of consequences that can cause serious physical and quality-of-life effects. Knowledge of risk factors and preventive measures can reduce patient risk. Data-based and empirical management strategies such as immediate local measures (agent withdrawal, comfort measures, and medical interventions) may minimize risk for extravasation, as well as lead to timely recognition and management and decreased morbidity should extravasation occur.

CONCLUSIONS

Vesicant extravasation and sequelae constitute a complex patient problem that clinicians should strive to prevent or to minimize injury should it occur. To this end, clinicians must demonstrate awareness of risks and use specialized knowledge while administering vesicant agents.

IMPLICATIONS FOR NURSING

Only nurses knowledgeable about extravasation and skilled in associated techniques should assume responsibility for vesicant administration.