Significance of antenatal glucocorticoid exposure for pressure injury prevalence in neonates

AIMS

Studies have highlighted that antenatal steroids could have an effect on neonatal skin maturation. This study examined if there was a relationship between the administration of antenatal glucocorticoids for mothers and the skin injuries in their neonates. Data from skin injury audit were extracted from the neonatal database and analyzed to determine differences in the prevalence of neonates with pressure injuries [cases] whose mothers had received antenatal steroids, compared to those without pressure injuries [control].

RESULTS

Of 247 neonates audited, 77 [31%], had documented pressure injuries, 170 [69%] had no documented injury. The median birth weight and gestation were 1400 g [IQR 893-2268 g] and 30.3 weeks [IQR 26.3-40.0 weeks] respectively. Of the neonates born less than 34 weeks, 80% were exposed to antenatal steroids and were equally distributed across patient genders. Within the 77 cases, 53 [66%] were exposed to antenatal steroids compared to controls in which 88 [53%] had not. The effect between cases and controls was not statistically significant [χ2 = 2.81, P = 0.09]. However a difference was noted between genders, as female neonates benefited from the exposure to steroids [OR = 0.317, 95% [CI 0.105-0.956], p value -0.041].

CONCLUSION

Antenatal glucocorticoids appear to be beneficial in reducing pressure injury prevalence in female neonates.

Subcutaneous Injection of Percocet: A Case of Severe Soft Tissue Loss

Prescription drug abuse ranks as the second most common class of illicit drug use in the United States, and one mechanism of opiate abuse involves intravenous injection of enteral narcotics such as oxycodone or hydrocodone. The authors describe a patient who sustained significant soft tissue necrosis after intravenously injecting a solution made from crushed enteral narcotics, with a focus on the operative course that resulted due to a delay in initial definitive treatment. The patient's wounds encompassed 8% total body surface area and covered 247 cm2. A 55-year-old female was admitted to the burn unit (West Penn Burn Center, Western Pennsylvania Hospital, Pittsburgh, PA) after she initially presented with infection and cellulitis to her bilateral upper extremities 3 weeks after intravenously injecting herself with crushed oxycodone/acetaminophen. She underwent numerous sequential operative repairs including initial debridement, placement of dermal replacement templates, and several split-thickness autografts and xenografts. Her total length of stay was 59 days, broken into an initial 47-day stay, and a subsequent 12-day readmission due to graft failure secondary to poor follow-up. As the number of prescription drug abusers rises, it is possible that an increase in attempts to intravenously abuse enteral narcotics may also rise. As such, burn centers should be prepared for the extent of potential limb necrosis and the operative treatment that may ensue.

Effect of Renal Function on the Pharmacokinetics of Palifermin

Palifermin (deltaN23KGF) decreases the incidence, severity, and duration of oral mucositis. The objectives of this open-label study were to evaluate the pharmacokinetics of single-dose palifermin in subjects with varying degrees of renal function. A single 90-mcg/kg intravenous dose of palifermin was administered to 31 subjects with varying levels of renal function (normal to requiring hemodialysis). Pharmacokinetic analyses were conducted using serum palifermin concentrations. There was considerable overlap in mean palifermin serum clearance among the groups, ranging from 318 to 495 mL/h/kg, indicating that the level of renal function did not affect clearance in humans; thus, no dose adjustment of palifermin is indicated for patients with renal dysfunction.

Extravasation of chemotherapeutic agents: prevention and treatment

Most chemotherapeutic agents can cause varying degrees of local tissue injuries when extravasated. The medical treatment of extravasation is based on proper maintenance of the intravenous (IV) line and application of cold or warm compresses, plus the use of antidotes when available. Antidotes for extravasation that have been shown to be useful are sodium thiosulfate for nitrogen mustard, dimethylsulfoxide for anthracyclines and mitomycin, and hyaluronidase for the vinca alkaloids. New treatments include dexrazoxane, sargramostim, and hyperbaric oxygen for doxorubicin extravasations. Tissue damage secondary to drug infiltration occurs as a result of one of two major mechanisms: (1) the drug is absorbed by local cells in the tissue and binds to critical structures (eg, DNA, microtubules), causing cell death; and (2) the drug does not bind to cellular DNA. Damage to immediately adjacent tissue is more readily neutralized than is damage to surrounding tissue.

Extravasation of systemic hemato-oncological therapies

Systemic intravenous chemotherapeutic agents can cause multiple emergency situations including acute and chronic local and systemic reactions. Amongst them, drug extravasation is one of the most devastating complications, as many drugs can cause varying degrees of local tissue injury when extravasated. Although it is difficult to give an accurate measurement, the incidence of extravasation of systemic infusional chemotherapeutic agents has been reported to occur in 0.1-6.5% of cases. Since most extravasations can be prevented with the systematic implementation of careful administration techniques, guidelines have been published for the administration of vesicant drugs. The proper maintenance of intravenous lines, application of local cooling or warming for certain extravasations, and the use of antidotes to prevent the local toxic action of the extravasated drugs are the basis of medical management. The specific antidotes for certain chemotherapeutic agents are also discussed in this article.

[Propane-induced tissue damage: burn or freezing injury?]

Tissue damage due to direct contact of liquid propane with the integument is extremely rare. Only five such cases have been described in the literature. We report the case of a girl who sustained a full-thickness skin necrosis of 14.5 % of her body surface area. There is little agreement about the optimal treatment of these injuries in previous reports. The pathophysiological mechanism suggests a freezing injury. The treatment, however, should be analogous to that of third-degree burns.

Combined ingestion and subcutaneous injection of elemental mercury

A 40-year-old man with a history of schizophrenia and inflammatory soft tissue lesions after self-injection of elemental mercury presented to the Emergency Department. Multiple skin abscesses associated with fever required operative debridement. An incidental finding of oral mercury ingestion was followed clinically and did not result in complications. Exposure to elemental mercury through injection or ingestion is an uncommon event, but one the Emergency Physician may encounter. Subcutaneous mercury injection should be managed with local wound debridement, whereas ingestions are rarely of clinical significance.

The use of phentolamine in the prevention of dopamine-induced tissue extravasation

PURPOSE

The purpose of this study was to determine whether dopamine-induced tissue extravasation injury could be prevented with phentolamine.

MATERIALS AND METHODS

This was a prospective, randomized, blinded, and controlled animal study. Forty rats were evaluated to document the effects of dopamine compared with normal saline on tissue integrity, whether any tissue damage was concentration or volume dependent, and to determine the minimum concentration of dopamine resulting in tissue injury. Dopamine concentrations of 0.8 mg/mL and 3.2 mg/mL were tested. In a second part of this study, an additional 40 rats were evaluated to assess the efficacy of two different doses of phentolamine (0.5 mg and 1 mg) or normal saline, when injected within 10 minutes of dopamine administration to prevent or reverse tissue extravasation. Extravasation sites were evaluated clinically and histologically at 2, 4, 6, and 8 hours and were compared with a baseline sample. Outcome measures were as follows: (1) prebiopsy was ectodermal erythema, induration, and blanching; (2) postbiopsy was bubbling, darkening, pallor, and hematoma of the muscle fascia. Histology included neutrophil migration, mast cell degranulation, edema, and hemorrhage. Fisher's Exact Test with the Bonferroni method were used for statistical analysis.

RESULTS

Dopamine-induced extravasation resulted in tissue injury characterized by blanching and hematoma. Damage did not appear to be volume dependent, but may be related to the duration of infiltration. Subcutaneous injection with either dose of phentolamine appeared to be clinically effective in preventing tissue injury. However, microscopic evaluation of tissue samples was inconclusive.

CONCLUSION

This study clinically supported the use of phentolamine for the prevention of dopamine-induced extravasation injury.

Stress response to chronic inflammation in the horse

Five clinically healthy Thoroughbred geldings were injected with Freund's adjuvant 3 times to induce a chronic inflammatory response. Blood was collected at various times before and after adjuvant administration. Clinical responses (rectal temperature and general demeanor) were also monitored. Adjuvant injection induced increases in rectal temperature and plasma fibrinogen concentration (maximum levels measured were mean +/- s.d. 39.7 +/- 0.5 degrees C and 8.2 +/- 0.3 g/l, respectively), indicative of an inflammatory response. A mild clinical depression was also observed in the horses for 24 h after the first injection of adjuvant only. Plasma cortisol levels decreased significantly from control levels of mean +/- s.d. 187.7 +/- 24.3 nmol/l to a minimum of 80.2 +/- 22.1 nmol/l (P < 0.01) 9 days after the first injection of adjuvant. Conversely, plasma insulin levels increased after the first injection of adjuvant to a maximum (96.7 +/- 15.2 iu/ml; P < 0.01) 12 days later, while plasma glucose concentrations tended to decline. A control group of horses to rule out contemporary environmental influences on the physiological and biochemical indices measured was not included in this study. The results show that chronic inflammation in the horse depressed resting plasma cortisol concentrations.

Infusion site soft-tissue injury after paclitaxel administration

BACKGROUND

Paclitaxel is a diterpenic plant product that has significant activity in several solid tumors, including epithelial ovarian cancer. After promising results in Phase I and II studies, its use has increased dramatically. With this increased use, isolated reports of local tissue reactions to paclitaxel have been described. The purpose of this study was to characterize further the presentation and clinical course of this toxic effect.

METHODS

Nine hundred fifty-five courses of paclitaxel were administered to patients with gynecologic malignancies at M. D. Anderson Cancer Center during a 13-month period. Nineteen (2%) local infusion-site injuries in 17 patients were observed.

RESULTS

The primary disease site was the ovary in 13 patients, the peritoneum in 2, and the endometrium in 2. Paclitaxel was administered as initial therapy in 6 patients and as salvage therapy in 11. Clinical evidence of infiltration was documented during infusion in 8 of 19 (42%) reported episodes. Immediate reactions consisting of mild discomfort, erythema, and edema were observed in six patients, three of whom had complete resolution of the lesion within 1 month. The remaining patients noted initial development of injury between 3 and 13 days after paclitaxel infusion. The typical injury was a discolored, raised, rounded, and indurated lesion that was moderately painful. Two patients (11%) had Grade 1 lesions, 13 (68%) had Grade 2 lesions, and four (21%) had Grade 3 lesions with central ulceration. Cellulitis requiring intravenous antibiotic therapy was associated with two lesions. At last follow-up, 13 injuries had persistent discoloration and induration; one patient had persistent ulceration present at the time of her death 6 months after presentation and one patient underwent excision of a persistent lesion at 12 months.

CONCLUSIONS

Given the incidence of Grade 2 and Grade 3 local reactions, it appears that paclitaxel should be considered a vesicant.

Combined management in the treatment of epidoxorubicin extravasation. A case report

Inadvertent extravasation during intravenous antitumor therapy is not an unusual complication and can cause damage ranging from minor erythema to severe local necrosis. The appropriate management of these iatrogenic accidents as a part of supportive care in oncology has been addressed by several experimental studies, but there has been little clinical study and no conclusive evidence on the best therapeutic strategies to adopt. The case reported here of a patient suffering from severe soft-tissue injury caused by extravasation of epidoxorubicin demonstrates the usefulness of a combined management (medical, surgical and rehabilitative) in the appropriate care of extravasation.

Soft tissue injury associated with intravenous phenytoin in a neonate

A term baby with neonatal convulsions secondary to birth asphyxia was given i.v. phenytoin via a cannula in the dorsum of the hand at 17 h of age. She developed a blue discolouration in the tissues surrounding the i.v. site. The infusion was aborted but the discolouration gradually spread to the rest of the hand. Twenty hours later, improvement could be detected although a blister appeared near the i.v. site. A further attempt two days later to administer phenytoin via an i.v. cannula sited in the left foot was aborted after the appearance of a similar reaction.