Intravenous (IV) extravasation is a medical complication that occurs when an IV-infused, and potentially harmful, medication leaks into the extravascular space around the injection site. The severity of the resulting tissue injury depends on the properties of the extravasated substance, including its pH, osmolarity, and inherent cytotoxicity. The choice of pharmacological treatment, or antidote, is therefore highly specific to the type of drug that has extravasated.
Immediate Steps Before Administering Antidotes
Regardless of the medication involved, swift and standardized action is crucial to minimize damage. Before administering any antidote, healthcare staff should follow a critical sequence of interventions:
- Stop the infusion immediately. Do not flush the line, as this will push more fluid into the tissue.
- Disconnect the IV tubing, but leave the catheter or needle in place to aspirate any residual drug from the extravasation site.
- Elevate the affected limb above heart level to decrease swelling and promote reabsorption.
- Notify the attending physician and consider consulting specialized services, such as a plastic surgeon, for severe injuries.
Antidotes for Vasopressor Extravasation
Vasopressors like norepinephrine, dopamine, and phenylephrine cause significant vasoconstriction, leading to tissue ischemia and potential necrosis upon extravasation. The goal of treatment is to counteract this vasoconstrictive effect.
Phentolamine
Phentolamine is a nonselective alpha-adrenergic antagonist and the primary pharmacological treatment for vasopressor extravasation.
- How it works: It induces vasodilation by blocking alpha-adrenergic receptors, which increases blood flow and reverses the local ischemia.
- Administration: It is administered via multiple small-volume subcutaneous injections circumferentially throughout the extravasation site, often within 12 hours of the event.
- Considerations: Monitor the patient for hypotension following administration.
Topical Nitroglycerin
In situations where phentolamine is unavailable or as an adjunct therapy, topical nitroglycerin ointment is used.
- How it works: It releases nitric oxide, which causes vascular smooth muscle relaxation and vasodilation.
- Administration: A thin layer of 2% nitroglycerin ointment is applied over the ischemic area.
Terbutaline
Terbutaline, a beta-2 adrenergic agonist, is another alternative for treating vasopressor extravasation by stimulating vasodilation. Case reports have shown successful outcomes, particularly with dopamine and dobutamine extravasations.
Antidotes for Hyperosmolar and pH-related Extravasations
Extravasation of agents with high osmolarity or extreme pH levels can cause tissue damage through dehydration, protein precipitation, or chemical inflammation.
Hyaluronidase
Hyaluronidase is an enzyme that depolymerizes hyaluronic acid in the connective tissue, which allows for the rapid dispersal and systemic absorption of the extravasated fluid.
- How it works: By breaking down the interstitial gel barrier, it promotes the diffusion of the extravasated substance, reducing local concentration and toxicity.
- Administration: It is administered via multiple intradermal or subcutaneous injections into the affected area, ideally within one hour of the incident.
- Uses: It is the antidote of choice for extravasation of vinca alkaloids (vincristine, vinblastine), dextrose, total parenteral nutrition (TPN), contrast media, calcium salts, and nafcillin.
- Contraindications: It should not be used for vasopressor extravasations.
Antidotes for Chemotherapy Drug Extravasation
Chemotherapeutic vesicants are particularly dangerous due to their ability to cause severe, progressive tissue damage, often requiring specific antidotes.
Dexrazoxane
Dexrazoxane is the only FDA-approved antidote for extravasation caused by anthracycline chemotherapy drugs, such as doxorubicin, daunorubicin, and epirubicin.
- How it works: It acts as a chelating agent and a catalytic inhibitor of topoisomerase II, potentially preventing anthracycline-induced tissue necrosis.
- Administration: It is administered intravenously following extravasation, with specific protocols dictating the timing and duration of treatment.
Sodium Thiosulfate
This antidote is used for extravasations of alkylating chemotherapy agents, including mechlorethamine and cisplatin.
- How it works: Sodium thiosulfate neutralizes the reactive compounds of the extravasated chemotherapy drug, reducing local toxicity.
- Administration: It is administered via subcutaneous injection into the extravasation site.
Dimethyl Sulfoxide (DMSO)
DMSO is a topical agent used for extravasation of certain chemotherapy drugs, including anthracyclines and mitomycin C.
- How it works: It is thought to act as a free-radical scavenger, reducing cellular damage.
- Administration: A 99% solution is applied topically to the affected area.
Extravasation Management Comparison Table
| Extravasated Drug Class | Examples | Antidote(s) Used | Mechanism of Action | Special Considerations |
|---|---|---|---|---|
| Vasopressors | Norepinephrine, Dopamine, Phenylephrine, Epinephrine | Phentolamine (subcutaneous), Topical Nitroglycerin (ointment), Terbutaline (subcutaneous) | Counteract vasoconstriction by causing local vasodilation | Use warm compresses; avoid cold compresses which worsen vasoconstriction. |
| Vinca Alkaloids | Vincristine, Vinblastine, Vinorelbine | Hyaluronidase (subcutaneous) | Increases tissue permeability to disperse and dilute the drug | Use warm compresses; cold compresses are contraindicated as they may worsen ulceration. |
| Anthracyclines | Doxorubicin, Daunorubicin, Epirubicin | Dexrazoxane (intravenous), Dimethyl Sulfoxide (topical) | Dexrazoxane chelates; DMSO scavenges free radicals | Use cold compresses; DMSO is a topical option. |
| Alkylating Agents | Mechlorethamine, Cisplatin | Sodium Thiosulfate (subcutaneous) | Neutralizes reactive compounds | Use cold compresses. |
| Hyperosmolar / pH Extremes | Dextrose (>10%), Calcium salts, TPN, Phenytoin | Hyaluronidase (subcutaneous/intradermal) | Increases tissue permeability for dispersion | Use warm compresses for most; specific protocols depend on the agent. |
A Comprehensive Approach to Extravasation Management
An effective management strategy requires prompt recognition, specific interventions, and diligent monitoring. The initial steps of stopping the infusion and elevating the limb apply universally. The subsequent choice of antidote hinges entirely on the specific drug involved. For many cytotoxic drugs, cold compresses are used to help localize the agent and reduce inflammation. Conversely, for vasopressors and vinca alkaloids, warm compresses are preferred to promote vasodilation and drug dispersal. Careful documentation of the event, including the extravasated drug, estimated volume, and intervention timing, is crucial for patient safety and outcome tracking. If tissue damage is severe or progresses despite treatment, a surgical consult for potential debridement or wound care is necessary.
Conclusion
Medications used for IV extravasation serve as specific antidotes designed to counteract the damaging effects of various leaked agents. The cornerstone of effective treatment is rapid identification of the extravasated substance and administration of the correct pharmacological agent, such as hyaluronidase for vinca alkaloids, dexrazoxane for anthracyclines, or phentolamine for vasopressors. This targeted approach, combined with immediate, standard first-aid measures, is essential for minimizing tissue damage and improving patient outcomes in cases of IV extravasation. Continued vigilance and education among healthcare staff remain the best preventative measures.
For more detailed protocols, healthcare professionals can refer to specialized resources like the National Institutes of Health (NIH) website for comprehensive guidelines.
