Pelvic ring fractures with concomitant large hematomas: diagnostic investigation with arteriography and eventual embolization in 157 trauma patients, with or without contrast extravasation at emergency CT.

PURPOSE: This study aims to evaluate the diagnostic value of pelvic arteriography in patients with pelvic ring fractures and associated large hematomas, in both cases of positive or negative findings of contrast agent extravasation at emergency CT; in those patients with positive DSA subsequently treated with embolization, correlations with clinical-radiological parameters were investigated. MATERIALS AND METHODS: In this single-center retrospective study, patients with acute blunt pelvic trauma showing at CT pelvic ring fractures with associated large (> 3 cm) hematoma, with or without signs of arterial bleeding, were investigated with DSA. Technical success was considered radiographic bleeding control with disappearance of angiographic bleeding; clinical success was defined as clinical bleeding control hemodynamically stable, before applying other surgical maneuvers. Pelvic ring fractures were evaluated according to Tile classification system. RESULTS: One hundred and fifty-seven patients, mean age 54years, were analyzed. 70.7% had polytrauma; 14.6% patients assumed antiplatelets and/or anticoagulation therapy. False-negative and false-positive rates at CT were 29.6% and 27.1%, respectively. Polytrauma and B3/C1 Tile pattern fractures were significantly associated with bleeding signs at DSA. Seventy-two patients required embolization: 52.8% showed direct signs of DSA bleeding; among these, technical and clinical successes were 88.8% and 81.9%, respectively. CONCLUSIONS: In this study, patients with pelvic ring fractures and concomitant hematomas > 3 cm, with or without contrast extravasation at CT, have been examined in depth with DSA focusing on both direct and indirect angiographic signs of bleeding, finding polytrauma and Tile fracture patterns B3/C1 predictive factors for arterial hemorrhage detection at DSA despite negative CT findings.

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 ß2 -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.

Extravasation injury management for neonates and children: A systematic review and aggregated case series.

BACKGROUND: Pediatric extravasation injuries are significant healthcare-associated injuries, with sometimes significant sequelae. Evidence-based guidance on management is necessary to prevent permanent injury. PURPOSE: A systematic review of the literature, including aggregated case series, investigating extravasation injury management of hospitalized pediatric patients. DATA SOURCES: PubMed, Cummulative Index to Nursing and Allied Health Literature (CINAHL), and Excerpta Medica database (EMBASE) were searched on December 13, 2021. STUDY SELECTION: Primary research investigating extravasation injury management of hospitalized pediatric patients (to 18 years), published from 2010 onwards and in English, independently screened by two authors, with arbitration from a third author. DATA EXTRACTION: Data regarding the study, patient (age, primary diagnosis), extravasation (site, presentation, outcome), and treatment (first aid, wound management) were extracted by two authors, with arbitration from a third author. DATA SYNTHESIS: From an initial 1769 articles, 27 studies were included with extractable case data reported in 18 studies, resulting in 33 cases. No clinical trials were identified, instead, studies were primarily case studies (52%) of neonates (67%), with varied extravasation symptoms. Studies had good selection and ascertainment, but few met the causality and reporting requirements for quality assessments. Signs and symptoms varied, with scarring (45%) and necrosis (30%) commonly described. Diverse treatments were categorized into first aid, medical, surgical, and dressings. CONCLUSIONS: Despite infiltration and extravasation injuries being common within pediatric healthcare, management interventions are under-researched, with low-quality studies and no consensus on treatments or outcomes.

Two Cases of Minor Blunt Splenic Injury Accompanied with Unexpected Fatal Delayed Splenic Rupture.

Contrast blush (CB) is an area with a density higher than the organ parenchyma in the arterial phase of contrast-enhanced computed tomography (CT). CB may be a sign of contrast medium extravasation, pseudoaneurysm, arteriovenous fistula, or other conditions; however, the indications for treatment remain unclear. Nevertheless, CB could be used to indicate a fatal scenario, such as delayed splenic rupture. Here, we present two multiple-injury cases of fatal delayed splenic rupture following the nonoperative management of a minor splenic injury. In both cases, despite morphological CT findings being minor on admission, CB was observed, and both patients could not rest owing to factors such as older age, a head injury, and drunkenness. Furthermore, in the CB case that indicated pseudoaneurysm, delayed splenic rupture occurred much earlier after the injury compared to the other case without the possibility of pseudoaneurysm. In conclusion, we recommend transcatheter arterial embolization be urgently performed in a case wherein the presence of a pseudoaneurysm is highly probable and factors such as multiple injuries and inability to rest are involved.

A new approach to skin extravasation injury management during the neonatal period.

BACKGROUND: To identify a standard protocol for managing extravasation injuries in neonates. METHODS: We recruited all the neonates with extravasation wounds from the neonatal intensive care unit of Shariati hospital, Tehran, Iran, between October 2018 and October 2020. Sixteen patients with grade 3-4 extravasation were evaluated in this retrospective study. All grade 3 and 4 extravasation wounds were injected with hyaluronidase at 5 points of the wound circle; the procedure was repeated every 5 min at different points in a smaller circle to the core. The wound was then covered with a warm compress for 24 h. Twenty-four hours after injection, the cover was changed twice a day with normal saline irrigation. Fibrinolysin ointment was applied on top of the wound. The ulcer was then dressed with phenytoin ointment until healing. RESULTS: Out of 16 neonates who were followed up, 10 of them were male, with the average birth weight being 1.37 (range 1.05-3.75) kg. The mean (± SD) wound healing duration was 13.12 (± 6) (range: 7-29) days. Factors including the cannulation duration before the appearance of the lesion (R:0.2, P = 0.2), birth weight (R = -.37, P = 015), and extravasated substances (p = 0.2) were not associated with the duration of hospital stay. The only exception to this trend is the wound size factor of 7.31(± 7.45) (R = .83, P < 0.001). Continuous and categorical variables were summarized as mean (SD) and proportions, respectively, and the Kruskal-Wallis test and Spearman correlation coefficients were used. CONCLUSIONS: Limited evidence exists on the effects of different protocols on extravasation management in neonates in the NICU. We recommend our method as a standard protocol in NICU for high-stage extravasated lesions because of the shorter duration of healing, non-invasive nature of this procedure, and lack of side effects or surgical involvement.

Emergency evacuation low-pressure suction for the management of extravasation injuries - a case report.

BACKGROUND: Extravasation is the movement of fluid outside its conduit into the extracellular tissue, possibly leading to a local inflammatory reaction, compartment syndrome, tissue necrosis, and full thickness skin loss at the affected area. To prevent these complications, early recognition, referral and treatment of an extravasation injury is of utter importance. CASE REPORT: We present a case, illustrating an extravasation injury into the breast managed by a renovated surgical technique - emergency evacuation low-pressure suction (EELS). A 54-year-old woman attended the emergency department with 1.5 L of total parenteral nutrition leaked into her right breast via a central portal catheter. The patient was seen within 24 hours of the incident, and presented with a diffuse swollen, tender and erythematous right breast but no overlying skin necrosis. Dry EELS via two small stab incisions was performed to evacuate the extravasated total parenteral nutrition and to minimise the aspiration of healthy fat tissue of the breast. Only a few cases of extravasation injuries into the breast have been described and most cases involve chemotherapy extravasation from a central catheter. Presumably there is an underreporting of this complication in the literature. CONCLUSION: This case-report promotes the use of aspiration in the management of diffusely spread extravasated injuries. EELS is a more appropriate term than liposuction, as there is no intention to evacuate healthy fat tissue. This new term is less confusing and might help medical staff and patients to better understand the treatment as it will break the affiliation with an aesthetic procedure. It is an effective and cosmetically satisfactory technique to treat early total parenteral nutrition extravasation injury at the level of the breast.

Extravasation Injuries of the Limbs in Neonates and Children­Development of a Treatment Algorithm

BACKGROUND: Children and neonates very often receive intravenous therapy. There is a lack of systematic data on the incidence of extravasation injuries in children and neonates. Individual studies involving neonates receiving intravenous therapy on intensive care units report incidence rates of 18-46%. Serious complications, such as necrosis and ulceration, develop in 2.4-4% of cases, which in the long term can lead to contractures, deformities, and loss of limb function secondary to unfavorable scar formation. There are no guidelines available to date on the management of pediatric extravasation injuries. METHODS: The present review article is based on a selective search of the literature in PubMed (for the period 1979 until June 2020) and our own clinical experience. RESULTS: There is a lack of randomized controlled studies on the management of pediatric extravasation injuries, so the level of evidence remains restricted to small comparative studies and case series. Conservative, pharmacological or surgical forms of treatment are used, depending on the volume and type of extravasated fluid as well as patient-specific factors. Firstly, an assessment is made as to whether the extravasated fluid is a substance with no primary toxic properties, a tissue irritating (irritant), or a necrosis-inducing (vesicant) substance. Skin and tissue should be examined for damage, skin color, swelling, capillary refill time, and pulse (distal to the injury). Depending on the substance and volume of the extravasated fluid and the degree of tissue damage, treatment options include conservative forms of treatment, administration of antidotes, hyaluronidase or vasodilators (such as phentolamine), the multiple puncture procedure, flushouts, and liposuction. CONCLUSION: Without evidence for the superiority of any particular treatment, therapy remains an individual decision, carrying the risks associated with off-label use.

Monoclonal antibody extravasations: Two case reports and literature review.

INTRODUCTION: Extravasation is a rare complication from intravenous chemotherapy administration. Literature about monoclonal antibody (MoAb) extravasations is scarce and also conflicting in how they are classified. CASE REPORT: We reported two different cases of MoAb extravasations with cetuximab and nivolumab outcome respectively. The administration site appeared inflamed and patients did not report disturbances.Management and outcome: Both extravasations did not require specific treatment. General unspecific measures suffice to properly manage these extravasations and no sequels were observed after long follow-up. Both patients received all further courses of MoAb without any adverse events. DISCUSSION: To our knowledge, we reported the first case-report of nivolumab extravasation in the literature. In addition, the cetuximab extravasation management and outcome was in accordance with previously published reports. Both MoAb may be considered as non-aggressive or neutral. We reviewed published information about MoAb extravasations. In conclusion, not all MoAb should be classified in the same category when extravasated and special precautions are warranted with conjugated MoAb and bevacizumab.

Extravasation of Noncytotoxic Drugs.

Objective: Commonly used drugs may be dangerous in case of extravasation. The lack of information from health care teams can lead to delays in both diagnosis and treatments. This review aims at alerting health care professionals about drugs and risk factors for extravasation and outlines recommendations for the diagnosis and treatment of extravasation. Data Source: A literature search of MEDLINE/PubMed, Scopus, the Cochrane Library, and Google Scholar was performed from 2000 to December 2019 using the following terms: extravasation, central venous line, peripheral venous line, irritant, and vesicant. Study Selection and Data Extraction: Overall, 140 articles dealing with drug extravasation were considered potentially relevant. Each article was critically appraised independently by 2 authors, leading to the inclusion of 80 relevant studies, guidelines, and reviews. Articles discussing incidents of extravasation in the neonatal and pediatric population of patients were excluded. Data Synthesis: Training of health care teams and writing care protocols are important for an optimal management of extravasations. A prompt consultation should be achieved by a specialist surgeon. The surgical procedure, if necessary, will consist of wound debridement followed by an abundant lavage. Relevance to Patient Care and Clinical Practice: This review discusses the management of drug extravasations according to their mechanism(s) of toxicity on tissues. It highlights the importance of a close monitoring of patients and the training of health care teams likely to face this type of adverse event. Conclusions: Extravasations still contribute to significant morbidity and mortality. A good knowledge of risk factors and the implementation of easily and quickly accessible standardized care protocols are 2 key elements in both prevention and treatment of extravasations.

Managing chemotherapy extravasation in totally implantable central venous access: Use of subcutaneous wash-out technique.

BACKGROUND: Totally implanted venous access is widely used in chemotherapy administration. With over 1 million intravenous chemotherapy infusions given worldwide each day, complications are frequent. Accidental cases of extravasation in the presence of a catheter are rare yet very serious and may require discontinuation of chemotherapy. The aim of this study was to evaluate the feasibility and efficacy of the subcutaneous wash-out technique for chemotherapy extravasation treatment. METHODS: We retrospectively reviewed the medical charts of patients who had received chemotherapy and sustained extravasation in our hospital between October 2013 and October 2016. Subcutaneous wash-out treatments were carried out exclusively, without the application of antidotes or the use of specific antidotes. RESULTS: We documented seven cases of chemotherapy extravasation. Two cases were treated with antidotes and suffered necrosis in the following weeks. The five patients treated using subcutaneous wash-out had no necrosis and had a steady decrease in the inflammatory reaction of the cutaneous and subcutaneous soft tissues. For these five patients, chemotherapy was restarted within 1 month following extravasation. CONCLUSION: This study would argue for the feasibility and effectiveness of subcutaneous wash-out in the treatment of chemotherapy extravasations.

A case of mitoxantrone extravasation.

INTRODUCTION: Mitoxantrone is a chemotherapeutic agent approved for various diseases. The literature has been conflicting in classifying mitoxantrone as a vesicant or irritant. CASE REPORT: We report a patient who had an extravasation of mitoxantrone. Mitoxantrone was administered in 50 ml normal saline. After mitoxantrone was completely infused, the site appeared edematous and the blue color of mitoxantrone developed beneath the skin. The patient reported pain. Management and outcome: The extravasation was treated with dexrazoxane and cold compresses. The pain improved each day. However, blistering developed five weeks later and the patient ultimately required surgical intervention for debridement and grafting. DISCUSSION: Extravasation events are rare and there are few controlled studies. Because of the similarities in chemical structures and mechanism of actions between mitoxantrone and anthracyclines, mitoxantrone extravasation is often treated similar to anthracyclines. Mitoxantrone's classification is unclear, as some literature classifies it as a vesicant and others as an irritant. Our case supports the categorization of mitoxantrone as a vesicant.

Provocative angiography for lower gastrointestinal bleeding.

PURPOSE: This study evaluated the results of provocative angiography performed to identify the site of hemorrhage in lower gastrointestinal bleeding to enable transcatheter arterial embolization. MATERIALS AND METHODS: The subjects of this study were 11 patients with acute lower gastrointestinal bleeding who underwent provocative angiography, after contrast agent extravasation could not be identified during conventional angiography. One patient underwent provocative angiography twice, making 12 cases of provocative angiography that were analyzed in this study. Urokinase was used in all cases. Heparin was administered in 2 cases, nicardipine in 3 cases, and alprostadil and isosorbide in 1 case each. RESULTS: Contrast agent extravasation as a result of provocative angiography was observed in 6/12 cases (50%). Selective transcatheter arterial embolization was performed in all 6 cases in which extravasation was apparent, and it was technically successful in all six. Clinical success was achieved in 5 (83.3%) of the 6 cases in which technical success was achieved after provocative angiography. CONCLUSION: Provocative angiography enabled the site of lower gastrointestinal bleeding to be identified in 6 of 12 cases (50.0%) when it could not be identified by conventional angiography, and in all 6 cases hemostasis was effectively achieved by embolization.

Use of Lasers for Iron-Induced Accidental Tattoos: Experience at a Tertiary Referral Center.

BACKGROUND: Awareness of accidental tattoos after iron injections with paravenous leakage is low. No larger patient cohorts have been analyzed. The lesions are a burden to the patients. The only known treatment is laser therapy. OBJECTIVE: To characterize the clinical appearance and development of iron-induced tattoos and to demonstrate safe and efficient removal with quality-switched (QS) and picosecond lasers. MATERIALS AND METHODS: The authors conducted a retrospective systematic analysis on patients who presented at the Dermatology Department of the University Hospital of Zurich between Year 2008 and 2017 with accidental hyperpigmentations after iron injections. From 29 collected patients, 13 received laser treatment and were analyzed with reference to the lasers used, including wavelength, fluence, spot size, intervals, number of sessions, and overall success. The authors defined the latter as a complete removal or as patients' satisfaction. RESULTS: The authors treated 13 patients and completed the treatment in 8 patients, with an average of 5.6 sessions. No complications occurred. CONCLUSION: Spontaneous regression of iron-induced tattoos is possible within 1 to 2 years, but not guaranteed. Removal with QS ruby, Nd:YAG, and picosecond lasers can be achieved within a mean number of 5.6 sessions. Assuring a valid indication before intravenous iron administration is important.

Extravasation (Paravasation) of Chemotherapy Drugs - Recommendations for Standard Care in the Czech Republic based on Consolations between Representatives of the Supportive Care Group of the Czech Society for Oncology, Oncology Section of the Czech Nurses Association, and the Society for Ports and Permanent Catheters.

BACKGROUND: Extravasation (paravasation) of chemotherapy drugs is a very significant complication in the treatment of cancer patients. Preventive and therapeutic interventions reduce the risk of this complication or the extent of its consequences. A working group of authors from expert groups prepared recommendations for standard care. PURPOSE: To prepare a basic summary of recommended interventions for daily practice, based on knowledge from long-term, proven, evidence-based practice or on consensus opinions of representatives of expert groups. RESULTS: Preventive measures are essential and include early consideration of long-term venous access device indications, choice of injection site, venous line control before each chemotherapy drug application, and patient education. Interventions in cases of extravasation mainly involve the application of antidotes (dimethylsulfoxide, hyaluronidase, and dexrazoxane) and the application of dry cold or heat, depending on the type of cytostatic drug. Corticosteroids injected subcutaneously, moist heat or cooling, and compression, are not recommended. CONCLUSION: The recommended procedures will contribute to reducing the risk and consequences of extravasation. The range of recommended interventions can be expanded depending on individual clinical workplace policy and needs. The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers. Submitted: 28. 9. 2019 Accepted: 13. 10. 2019.

Treating extravasation injuries in infants and young children: a scoping review and survey of UK NHS practice.

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, particularly in infants and young children. METHODS: This paper presents a more succinct account of a study of treatments for extravasation injuries in infants and children which has also been reported in full as an NIHR HTA report. A systematic scoping review and survey of UK NHS practice were undertaken. Twelve databases - including MEDLINE and EMBASE - were searched for relevant studies in February 2017. Studies of children with extravasation injuries receiving any treatment for extravasation injury were eligible, providing they reported one of the following outcomes: wound healing time, infection, pain, scarring, functional impairment, and requirement for surgery. Studies were screened in duplicate. Data were extracted by one researcher and checked by another. Studies were summarised narratively. An online questionnaire was distributed to NHS staff at neonatal units, paediatric intensive care units and principal oncology/haematology units. RESULTS: The evidence identified in the scoping review was mostly comprised of 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 many factors. The survey yielded 63 responses from hospital units across the UK. Results indicated that although most units had written documentation for treating extravasation injuries, only one-third of documents included a system for grading injury severity. The most frequently used interventions were elevation of the affected area and analgesics. Saline wash-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. CONCLUSIONS: There is some uncertainty about which are most the promising treatments for extravasation injuries in infants and young children. Saline flush-out techniques and conservative management approaches are commonly used and may be suitable for evaluation in trials. Although conventional randomised trials may be difficult to perform a randomised registry trial may be an appropriate alternative design.

What you should know about prophylaxis and treatment of radiographic and magnetic resonance contrast medium extravasation.

In addition to anaphylactic reactions induced by contrast media (CM), extravasation is an adverse reaction that occurs immediately, requires special treatment, and attention. Since radiologists are often not familiar with either prophylactic or treatment modalities, the goal of this paper is to summarize the major facts and recommendations with respect to CM extravasation under practical clinical aspects.

Contrast Media Extravasation in CT and MRI - A Literature Review and Strategies for Therapy. / Kontrastmittel-Paravasat bei CT und MRT ­ Aktuelle Literaturübersicht und Behandlungsstrategien.

BACKGROUND: Contrast extravasation events in daily radiological routine may lead to serious complications, especially during CT examinations. The resulting symptoms may vary from local pain up to skin ulcers, necrosis or even acute compartment syndrome.There are no uniformly accepted radiological guidelines or recommendations regarding detection and treatment of extravasation events and immanent complications in a timely manner. METHOD: Systematic literature research considering the last 35 years via PubMed using search terms "contrast medium extravasation/paravasation". RESULTS: In the literature, there are conservative management approaches of contrast media extravasation without major evidence base, such as unguent dressings, cooling or splinting. This therapy is mostly symptomatic. Additionally, various invasive techniques are described. We discuss these techniques in the context of contemporary literature, such as the hyaluronidase Injection into the site of extravasation, suction/aspiration technique including flushing of the affected tissue areas and the squeezing technique. However, most citations lack scientific evidence: many articles include anecdotal enumerations, case studies or cite publications from the era, when ionic high osmolar contrast media was state-of-the-art. Besides, many authors derive their extravasation management from studies, where agents other than contrast media were investigated. CONCLUSION: After detailed literature review, we suggest early (plastic) surgical consultation when non-ionic, low-osmolar contrast medium extravasation is about 150 cc or more. In case of extravasation less than 150 cc but in presence of additional symptoms such as impaired perfusion or altered sensibility, the (plastic) surgeon should also be consulted instantly. We do not recommend any invasive first line therapy when contrast media extravasation is less than 150 cc and the patient presents no additional symptoms, besides swelling and local pain. Nevertheless continuous monitoring and accurate conservative management such as active cooling and elevation, splinting of the affected extremity are mandatory as early detection of critical symptoms helps to initiate prompt surgical intervention and avoid sequelae. KEY POINTS: · Morbidity after contrast media extravasation is extremely rare.. · Predicting sequelae after contrast extravasation is difficult at first sight.. · Treatments such as hyaluronidase injection, suction/aspiration, squeeze technique have been described.. · Surgical consultation is recommended for extravasation > 150 cc or when additional symptoms occur.. CITATION FORMAT: · Mandlik V, Prantl L, Schreyer AG. Contrast Media Extravasation in CT and MRI - A Literature Review and Strategies for Therapy. Fortschr Röntgenstr 2019; 191: 25 - 32.