Hypotension in the Emergency Department and Contrast Extravasation on Computerized Tomography Predict Blood Transfusion in Low-Energy Pelvic Fractures.

INTRODUCTION: Although low-energy pelvic fractures seldom present with significant hemorrhage, early recognition of at-risk patients is essential. We aimed to identify predictors of transfusion requirements in this cohort. METHODS: A 7-y retrospective chart review was performed. Low-energy mechanism was defined as falls of ≤5 feet. Fracture pattern was classified using the Orthopedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen system as A, B, or C. Primary outcome was transfusion of ≥2 units of packed red blood cells in the first 48 h. Univariable analysis and logistic regression analysis were performed. A P value ≤0.05 was considered significant. RESULTS: Five hundred forty six patients were included with median (interquartile range) age of 86 (79-91) and median (interquartile range) Injury Severity Score of 5 (4-8). Five hundred forty one (99%) had type A fractures. Twenty six (5%) had the primary outcome and 17 (3%) died. Logistic regression found that systolic blood pressure <100 mmHg at any time in the Emergency Department, Injury Severity Score, and pelvic angiography were predictors of the primary outcome. Seventeen percent of those who had the primary outcome died compared with 2% who did not (P = 0.0004). Three hundred sixty four (67%) received intravenous contrast for computerized tomography scans and of these, 44 (12%) had contrast extravasation (CE). CE was associated with the primary outcome but not mortality. CONCLUSIONS: Hypotension at any time in the Emergency Department and CE on computerized tomography predicted transfusion of ≥2 units packed red blood cells in the first 48 h in patients with low-energy pelvic fractures.

Risk Factors for Contrast Media Extravasation in Intravenous Contrast-Enhanced Computed Tomography: An Observational Cohort Study.

RATIONALE AND OBJECTIVES: To identify the risk factors for contrast media (CM) extravasation and provide effective guidance for reducing its incidence. MATERIALS AND METHODS: We observed adult inpatients (n = 38 281) who underwent intravenous contrast-enhanced computed tomography between January 1, 2018, and December 31, 2022. Risk factors for CM extravasation were evaluated using univariate and multivariate logistic regression. RESULTS: Among the 38 281 inpatients who underwent enhanced computed tomography angiography, 3885 received peripherally inserted central venous catheters (PICCs) and 34 396 received peripheral short catheters. In 3885 cases of PICCs, no CM extravasation occurred, but in five cases, ordinary PICCs that are unable to withstand high pressure were mistakenly used; three of those patients experienced catheter rupture, and eventually, all five patients underwent unplanned extubation. Among 34 396 cases of peripheral short catheters, 224 (0.65%) had CM extravasation. Female sex (odds ratio [OR]=1.541, 95% confidence interval [CI]: 1.111-2.137), diabetes (OR=2.265, 95% CI: 1.549-3.314), venous thrombosis (OR=2.157, 95% CI: 1.039-4.478), multi-site angiography (OR=9.757, CI: 6.803-13.994), and injection rate ≥ 3 mL/s (OR=6.073, 95% CI: 4.349-8.481) were independent risk factors for CM extravasation. Due to peripheral vascular protection measures in patients with malignant tumor, there was a low incidence of CM extravasation (OR=0.394, 95% CI: 0.272-0.570). CONCLUSION: Main risk factors for CM extravasation are female, diabetes, venous thrombosis, multi-site angiography, and injection rate ≥ 3 mL/s. However, patients with malignant tumor have a low incidence of CM extravasation. CLINICAL IMPACT: Analysis of these risk factors can help reduce the incidence of CM extravasation.

Association of Contrast Extravasation Grade With Massive Transfusion in Pediatric Blunt Liver and Spleen Injuries: A Multicenter Retrospective Cohort Study.

BACKGROUND: This study aimed to assess whether the grade of contrast extravasation (CE) on CT scans was associated with massive transfusion (MT) requirements in pediatric blunt liver and/or spleen injuries (BLSI). METHODS: This multicenter retrospective cohort study included pediatric patients (≤16 years old) who sustained BLSI between 2008 and 2019. MT was defined as transfusion of all blood products ≥40 mL/kg within the first 24 h of admission. Associations between CE and MT requirements were assessed using multivariate logistic regression analysis with cluster-adjusted robust standard errors to calculate the adjusted odds ratio (AOR). RESULTS: A total of 1407 children (median age: 9 years) from 83 institutions were included in the analysis. Overall, 199 patients (14 %) received MT. CT on admission revealed that 54 patients (3.8 %) had CE within the subcapsular hematoma, 100 patients (7.1 %) had intraparenchymal CE, and 86 patients (6.1 %) had CE into the peritoneal cavity among the overall cohort. Multivariate analysis, adjusted for age, sex, age-adjusted shock index, injury severity, and laboratory and imaging factors, showed that intraparenchymal CE and CE into the peritoneal cavity were significantly associated with the need for MT (AOR: 2.50; 95 % CI, 1.50-4.16 and AOR: 4.98; 95 % CI, 2.75-9.02, respectively both p < 0.001). The latter significant association persisted in the subgroup of patients with spleen and liver injuries. CONCLUSION: Active CE into the free peritoneal cavity on admission CT was independently associated with a greater probability of receiving MT in pediatric BLSI. The CE grade may help clinicians plan blood transfusion strategies. LEVEL OF EVIDENCE: Level 4; Therapeutic/Care management.

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.

Extent of extravasation: Patients on parenteral plant alkaloids.

BACKGROUND: Plant alkaloids remain an essential part of many chemotherapeutic regimens. Although many adverse effects have been studied with appropriate management guidelines, extravasation (EV) is one adverse event that is yet to be studied at a regional scale to frame population-specific guidelines. METHODOLOGY: A hospital-based observational study was done for 1 year to understand the extent of extravasation among patients on parenteral plant alkaloids. Clinical pharmacists congregated information about patients satisfying the study criteria. The incidence of EV injuries associated with parenteral plant alkaloids was assessed. The severity was scored using the Common Terminology Criteria for Adverse Events (CTCAE) v4.3. The ESMO-EONS guidelines were followed for the classification of chemotherapeutic agents as well as management of the incidents of EV. RESULTS: Among the 80 patients recruited into the study, 26.25% of patients experienced EV injuries, of which 66.67% were grade 2 and 33.33% were grade 3. Females were prevalent at 62% among the injured group. Patients in the age group 31-50 years and 51-60 years sustained 28.57% of the injuries each. In 76.19% of injured patients, ambulation status was positive during the infusion. ESMO-EONS drug classification showed that 54.84% of the drugs prescribed were vesicants. Paclitaxel was seen in 33.33% of prescriptions in the injured group, among other plant alkaloids. CONCLUSION: Our study saw a trend of vesicant-induced extravasation injury among patients prescribed parenteral chemotherapeutic regimens with a combination of plant alkaloids, indicating the significant risk they may pose.

Chemotherapy Extravasation: Incidence of and Factors Associated With Events in a Community Cancer Center.

BACKGROUND: The administration of chemotherapy is a high-risk and nurse-sensitive practice. One complication is extravasation. OBJECTIVES: The purpose of this study was to determine the incidence of and iatrogenic factors associated with extravasation in the ambulatory and inpatient settings of a community cancer center. METHODS: Events were reviewed by agent, route of administration, patient characteristics, and RNs administering the agent. A one-year, retrospective review of electronic health records and pharmacy and nursing reports was conducted. FINDINGS: The number of vesicants, irritants, and irritants with vesicant properties administered was 12,260 in the ambulatory setting and 612 on the inpatient unit, with 21 and 1 extravasation events, respectively. Incidence rates for both settings were 0.001%. The most common agent to extravasate was docetaxel, and all events occurred via peripheral route. The incidence of events was lower than the reported benchmark for National Cancer Institute-designated cancer centers.

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.

Relationship between chronic hyperglycemia and contrast extravasation in revascularization of symptomatic intracranial atherosclerotic stenosis: A retrospective single-center study.

BACKGROUND AND PURPOSE: Contrast extravasation is one of the most common perioperative complications in symptomatic intracranial atherosclerotic stenosis (ICAS) patients after percutaneous transluminal angioplasty and/or stenting (PTAS). This study aimed to investigate the correlations between the relevant serum biochemical indicators of carbohydrate metabolism and the occurrence of contrast extravasation. METHODS: Patients' demographic characteristics, vascular risk factors and laboratory examination data were collected. Blood routine test, blood biochemical examination and hormone level test within 1 week before surgery were measured in all enrolled subjects. Patients underwent non-contrast CT scans immediately after the endovascular procedure. Follow-up non-contrast CT scans were performed in the next 24 h and repeated as per clinical condition. RESULTS: 104 patients who have undergone effective PTAS were involved in this study. 18 patients have identified as contrast extravasation and there was no obvious abnormality in another 86 cases. There were significant differences in the pre-operative HbA1c, fasting blood sugar and cortisol levels in the subjects regardless of gender between two groups (p < 0.001, p < 0.001 and p = 0.001, respectively). Furthermore, there were statistical differences in E2 and testosterone levels between two groups in both male population (p = 0.035 and p = 0.028, respectively) and female population (p = 0.036 and p = 0.003, respectively). Besides, the AUC value of HbA1c, fasting blood sugar and cortisol levels were all over 0.7 (0.858, 0.780 and 0.752, respectively). The highest AUC value of various combinations was obtained from the combination of HbA1c and cortisol level, which was 0.898. CONCLUSIONS: Patient with chronic hyperglycemia is closely related to contrast extravasation after PTAS. Specific mechanisms might be explored and regarded as promising candidates to prevent contrast extravasation.

Prevalence and the predictive performance of the dynamic CT-angiography spot sign in an observational cohort with intracerebral hemorrhage.

The CT-angiography (CTA) spot sign is a predictor of hematoma expansion (HE). We have previously reported on the use of dynamic CTA (dCTA) to detect spot sign, and to study its formation over the acquisition period. In this study, we report the frequency of dCTA spot sign in acute intracerebral hemorrhage, its sensitivity and specificity to predict HE, and explore the rate of contrast extravasation in relation to hematoma growth.We enrolled consecutive patients presenting with primary intracerebral hemorrhage within 4.5 hours. All patients underwent a dCTA protocol acquired over 60 seconds following contrast injection. We calculated frequency of the dCTA spot sign, predictive performance, and rate of contrast extravasation. We compared extravasation rates to the dichotomous definition of significant HE (defined as 6 mL or 33% growth).In 78 eligible patients, dCTA spot sign frequency was 44.9%. In 61 patients available for expansion analysis, sensitivity and specificity of dCTA spot sign was 65.4% and 62.9%, respectively. Contrast extravasation rate did not significantly predict HE (Odds Ratio 15.6 for each mL/min [95% confidence interval 0.30-820.25], P = .17). Correlation between extravasation rate and HE was low (r = 0.297, P= .11). Patients with significant HE had a higher rate of extravasation as compared to those without (0.12 mL/min vs 0.04 mL/min, P = .03).Dynamic CTA results in a higher frequency of spot sign positivity, but with modest sensitivity and specificity to predict expansion. Extravasation rate is likely related to HE, but a single measurement may be insufficient to predict the magnitude of expansion.

Complication of vasopressor infusion through peripheral venous catheter: A systematic review and meta-analysis.

BACKGROUND: Vasopressors are mainstay treatment for patients in shock and are usually infused through central venous catheters (CVCs). However, CVCs are associated with risk of infection or delay from the needs of confirmation of placement. Infusing vasopressor through peripheral venous catheter (PIVs) could be an alternative in the Emergency Departments (ED) but data regarding complications is inconclusive. We performed a random-effects meta-analysis to assess literature involving prevalence of complications from infusing vasopressors via PIVs. METHODS: We searched PubMed, EMBASE and Scopus databases from beginnings to 02/02/2020 to identify relevant randomized control trials, cohort, case-control studies. We excluded case reports. Authors assessed studies' quality with Newcastle-Ottawa Scale and Cochrane Risk of Bias tool. Kappa score was used to assess interrater agreement. Outcome was complications as direct results from infusing vasopressors through PIVs. RESULTS: We identified 325 articles and included 9 studies after reviewing 16 full text articles. Our analysis included 1835 patients whose mean age was 63 (Standard Deviation 12) years and 48% was female. There were 122 (7%) complications, of which 117 (96%) were minor. The meta-analysis with random effects showed the pooled prevalence of complications as 0.086 (95%CI 0.031-0.21). Studies reporting infusion safety guidelines had significantly lower prevalence of complications (0.029, 95%CI 0.018-0.045), compared to those not reporting a safety guideline (0.12, 95%CI 0.038-0.30, p = 0.024). CONCLUSION: There was low prevalence of complications as a direct result from infusing vasopressors through PIVs. Studies with safety guidelines were associated with significantly lower prevalence of complications. Further studies are needed to confirm our observations.

The Role of Postoperative Imaging after Ventral Onlay Buccal Mucosal Graft Bulbar Urethroplasty.

PURPOSE: Our primary objective was to determine the incidence of extravasation on imaging at the time of catheter removal after ventral onlay buccal mucosal graft urethroplasty. MATERIALS AND METHODS: This is a single center retrospective cohort study of patients who underwent ventral onlay buccal mucosal graft bulbar urethroplasty from 2007 to 2017. Patients with imaging at the time of catheter removal were included. Urethroplasty success was defined as the ability to pass a 17Fr cystoscope at the time of followup cystoscopy. RESULTS: A total of 229 patients met the inclusion criteria, including 110 with a ventral onlay buccal mucosal graft and 119 with an augmented anastomotic urethroplasty with a mean stricture length of 4.4 cm. Imaging consisted of a voiding cystourethrogram in 210 and retrograde urethrogram in 19 patients at a median of 21.7 days after surgery. The incidence of extravasation was 3.1% (7/229). Of patients who had a documented followup cystoscopy (60%, 137/229), those with extravasation on imaging had a worse urethroplasty success rate (60%, 3/5) compared to those who did not (94%, 117/130) (p=0.047). On multivariate analysis those who had 5 or more endoscopic interventions were 9.6 times more likely to demonstrate extravasation (OR 9.6, p=0.0080). CONCLUSIONS: The incidence of radiological extravasation after ventral onlay using a single buccal mucosal graft, with or without augmented anastomotic urethroplasty, is 3.1%. Given this low rate it is reasonable to omit routine imaging at the time of Foley removal in this population. It appears that extravasation may be associated with a worse cystoscopic patency rate but does not lead to more complications.

Postoperative urinary extravasation does not impact anterior urethroplasty surgical outcomes: a Latin American large cohort study.

OBJECTIVE: To determine the prevalence of postoperative urinary extravasation (POUE) following anterior urethroplasty, to analyze factors associated with its occurrence, and to study the impact of POUE on surgical success. MATERIALS AND METHODS: Retrospective cohort study including all male patients who have undergone a urethroplasty at our center between 2011 and 2018. Subjects with posterior location stricture, those who did not undergo routine radiographic follow-up, or patients with inadequate follow-up were excluded. Urinary extravasation was defined as presence of evident contrast extravasation on the postoperative voiding cystourethrogram (VCUG). Impact was determined as "need-for-reoperation". Uni- and multivariate analysis were performed to determine clinical and demographic variables associated with occurrence of extravasation and postoperative stricture. RESULTS: A total of 783 men underwent a urethroplasty and 630 fulfilled inclusion criteria. Urinary extravasation prevalence was 12.2%, and there was a "need-for-reoperation" in 1.1% of cases. On uni- and multivariate analysis, greatest stricture length (HR: 1.07 (1-1.2), p = 0.05) and penile urethral location (HR: 2.29 (1.1-4.6), p = 0.021) showed to be POUE predictors. POUE did not show to be a risk factor for postoperative stricture (HR: 1.57, 95% CI (0.8-3), p = 0.173). However, reoperation group  showed to be a risk factor (HR: 6.6, 95% CI 1.4-31, p = 0.019). CONCLUSIONS: Prevalence of POUE was 12.2%. Stricture length and penile urethral strictures were POUE predictors. POUE occurrence with successful conservative management did not appear to have impact on urethroplasty outcomes as it did not predict re-stricture. POUE was reoperation cause in 1.1% of total cases.

Contrast-induced acute kidney injury.

Although major advancements in the field of cardiology have allowed for an increasing number of patients to undergo minimally invasive imaging and interventional procedures, contrast-induced acute kidney injury (CI-AKI) continues to be a dreaded complication among patients receiving intravascular contrast media. CI-AKI is characterized by progressive decline in kidney function within a few days of contrast medium administration. Physiological changes resulting from the direct nephrotoxic effect of contrast media on tubular epithelial cells and release of vasoactive molecules have been implicated in creating a state of increased oxidative stress and subsequent ischemic renal cell injury. Over the last several years, preventive strategies involving intravenous hydration, pharmaceutical agents and renal replacement therapies have resulted in lower rates of CI-AKI. However, due to the evolving paradigm of diagnostic and therapeutic interventions, several unanswered questions remain. This review highlights the epidemiology, pathogenesis and preventive strategies of CI-AKI.

Transcatheter arterial embolization for advanced gastric cancer bleeding: A single-center experience with 58 patients.

To investigate computed tomography and angiography findings and clinical outcomes after transcatheter arterial embolization for acute upper gastrointestinal bleeding from advanced gastric cancers.From January 2005 to December 2014, 58 patients with pathologically proven gastric cancer were treated at our institution with transcatheter arterial embolization due to acute upper gastrointestinal bleeding recalcitrant to endoscopic treatment. The electronic medical records for each patient were reviewed for clinical presentation, endoscopy history, computed tomography and angiographic findings, blood transfusion requirements, and follow-up results.Angiography findings were positive in 13 patients (22.4%): contrast extravasation was found in 9 patients and pseudoaneurysm in 4 patients. All patients with positive angiograms underwent selective embolization treatment. Those with negative angiography findings underwent empirical embolization. Gelfoam, n-butyl cyanoacrylate, coils, or a combination of these were used as embolic agents. The overall clinical success rate was 72.4% (42/58), and the success rate for patients with positive angiography was 53.8% (7/13). The median survival was 97.5 days (range, 7-1415 days), and the 1-month survival rate was 89.6% (52/58). The 1-month survival rate of the clinical success group was 95.2% (40/42), which was significantly higher than that of the clinical failure group (P = .04). The clinical success group also required significantly fewer transfusions (2.43 units, range 0-24 units) (P = .02).Transcatheter arterial embolization is a highly effective treatment for advanced gastric cancer with active bleeding. It should be considered as an additional treatment, especially when endoscopic or surgical treatment fails or when these approaches are difficult.

Association between contrast extravasation on computed tomography scans and pseudoaneurysm formation in pediatric blunt splenic and hepatic injury: A multi-institutional observational study.

PURPOSE: We aimed to examine the association between contrast extravasation (CE) on initial computed tomography (CT) scan and pseudoaneurysm (PSA) development in pediatric blunt splenic and/or liver injury. METHODS: We conducted a multi-institutional retrospective study in cases of blunt splenic and/or hepatic injury who underwent an initial attempt of nonoperative management. A logistic regression model was used to compare PSA formation and CE on initial CT scan, and the area under the receiver operating characteristic curve (AUC) with and without CE was used to assess the predictive performance of CE for PSA formation. RESULTS: Of 236 cases enrolled from 10 institutions, PSA formation was observed in 17 (7.2%). Multivariate analysis showed a significant association between CE on initial CT scan and increased incidence of PSA formation (odds ratio, 4.96; 95% confidence interval, 1.37-18.0). There was no statistically significant association between the grade of injury and PSA formation. The AUC improved from 0.75 (0.64-0.87) to 0.80 (0.70-0.91) with CE. CONCLUSION: Active CE on initial CT scan was an independent predictor of PSA formation. Selective use of follow-up CT in children who showed CE on initial CT may provide early identification of PSA formation, regardless of injury grade. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

Incidence and Clinical Risk of Cement Extravasation in Adult Patients Undergoing Prophylactic Vertebroplasty During Surgical Spine Reconstruction.

OBJECTIVE: To measure the incidence and severity of cement extravasation in adult patients undergoing prophylactic vertebroplasty as part of a spinal reconstruction procedure. METHODS: Consecutive adult patients treated with prophylactic vertebroplasty during a spinal reconstruction procedure were reviewed over a 46-month period. Patients without a postoperative computed tomography scan were excluded. Spine reconstruction was defined as any procedure involving ≥6 levels of fusion or a 3-column osteotomy. Cement extravasation was graded using a novel grading system. Fisher exact tests were performed to identify independent predictors of cement extravasation. RESULTS: Inclusion and exclusion criteria were met by 34 patients comprising 112 vertebral bodies (VB). All 34 patients (100%) had computed tomography evidence of cement extravasation. Of 112 VBs, 103 (92.0%) demonstrated cement extravasation. Thirteen VBs (11.6%) in 9 patients (26.5%) had cement extending to the vena cava or end-organs or cement causing spinal canal stenosis (grade 4 and 5 extravasation). No permanent clinical sequelae were found in these 9 patients. Upper thoracic vertebrae (C7-T6) had significantly higher rates of grade 4 and 5 extravasation than lower thoracic-lumbar vertebrae (T7-L5) (P = 0.004). CONCLUSIONS: Although no patients in this study experienced known long-term consequences of prophylactic vertebroplasty, 26.5% of patients had cement extravasation that threatened end-organs or neural elements. These results prompted us to change our practice from cementing upper thoracic VBs to using hooks instead. Cement injection is associated with serious risks and should be performed selectively. Larger prospective studies are needed to verify these results.

Contrast Extravasation as a Complication of Emergency Nurse-Performed Ultrasound-Guided Peripheral Intravenous Catheter Placement.

INTRODUCTION: Vascular access procedures are among the most commonly performed procedures in the emergency department. The objective of the current study was to compare the contrast extravasation rate for ultrasound-guided peripheral intravenous (USGPIV) catheter placement by emergency nurses with peripheral intravenous catheters placed by standard landmark techniques. METHODS: A retrospective chart review of all ED patients at our urban tertiary-care institution who underwent contrasted computed tomography examination and suffered contrast extravasation events was performed. A logbook of all ED patients who underwent USGPIV placement and an institution-wide electronic patient safety incident-reporting system was reviewed for all contrast extravasation events between May 2014, and February 2017. Data were analyzed using descriptive statistics, Student t-tests for continuous data, and χ2 or Fisher's exact test for categorical data. RESULTS: One thousand five hundred USGPIV catheters were placed by 27 emergency nurses. Contrast material was administered 29,508 times, and, of these, 291 were administered via USGPIV placement. There were 74 peripheral IV lines with documented contrast extravasations (0.25%) as reported in the safety-event database; 12 (4.1%) were from the USGPIV population, and 62 (0.21%) occurred in the standard landmark technique population. Relative risk of contrast extravasation events with USGPIV placement was 19.4 (95% confidence interval [CI], 10.6-35.6), and the absolute risk difference was 3.9% (95% CI 1.6%-6.2%). DISCUSSION: USGPIV placement by trained emergency nurses has higher rates of contrast extravasation than with standard landmark technique placement.

[Analysis of circumstances of occurrence of contrast media in imaging services]. / Analyse des circonstances de survenue des extravasations de produits de contraste en imagerie.

INTRODUCTION: To prevent extravasations in medical imaging, analyses of organizational and professional circumstances of the occurrence of extravasations have been conducted in the Bordeaux University Hospital (BUH). METHOD: Two parallel studies were conducted: (i) clinical practice evaluation (CPE) including practice analysis groups and development of indicator of extravasation occurrence; (ii) Case-control study analyzing the factors associated with the occurrence of extravasations. Cases were constituted with consecutive series of patients with extravasation occurred in the BUH; controls were constituted of series of patients managed in medical imaging in the BUH without any extravasation. Statistical analysis included univariate and multivariate regression logistic models. RESULTS: CPE identified the following circumstances: patient' characteristics (female gender, low blood vessels) and professional situations (lack of check of: peripheral veinous access, contrast media temperature, injection process and lack of matching between injection amount and veinous access diameter). In the case-control analysis, patients' gender and catheter placement in medical imaging were significantly associated with the occurrence of extravasations. Guidelines have been drafted allowing the decrease of extravasation incidence. CONCLUSION: Adherence to guidelines of contrast media preparation and injection process is very important to prevent extravasation and improve patient safety.

Contrast Extravasation using Power Injectors for Contrast-Enhanced Computed Tomography in Children: Frequency and Injury Severity.

PURPOSE: To evaluate the safety of power injectors for contrast-enhanced computed tomography (CT) in children, namely: the prevalence and injury severity of contrast extravasations related to power injectors and the factors associated with these events. METHODS: The need to obtain informed consent was waived for this HIPAA-compliant and IRB approved retrospective study. Around 2429 contrast-enhanced CT performed with a power injector were identified during a 3-year period. Data collected included patient demographic, power injector, and contrast agent information. The patients' symptoms, severity of injury and treatment with contrast extravasation were recorded. Around 1496 cases (823 boys, 673 girls) were included in the analysis. Independent-sample t test and Chi-square were used. For a sub-analysis using the extravasation cases, nonparametric tests were used. RESULTS: The mean age was 9.5 ± 6.1 years. The most common access site, catheter site, and contrast agent used were the antecubital fossa, 22 gauge and Iohexol. The mean peak pressure was 68.9 ± 62.3 psi and the flow rate was 1.7 ± 0.9 mL/s. Eighteen cases of contrast extravasation were identified with a mean age of 11.2 ± 6.2 years. There were seven mild, six moderate, and five severe. Cases with extravasation had significantly higher peak pressure (p < 0.001) and flow rate (p < 0.001) compared to those without extravasation. Patients who received Iohexol-350 had significantly more contrast extravasation compared to those who used Iohexol-300 (p = 0.03). However, after post-hoc correction, only peak pressure (p < 0.01) and flow rate (p = 0.01) remained significant. CONCLUSION: The use of power injectors in children undergoing contrast-enhanced CT is associated with a low rate of extravasation and of long-term injury.

Symptom Resolution and Volumetric Reduction of Abdominal Lymphatic Malformations With Sclerotherapy.

BACKGROUND: Lymphatic malformations (LMs) are congenital and arise from errors in vascular embryogenesis. LMs are categorized by cyst size as microcystic, macrocystic, or combined. Abdominal LMs are rare. Surgical resection of abdominal LMs has been the mainstay of therapy, but recurrence and morbidity are high. We sought to determine the effectiveness of sclerotherapy treatment for abdominal LM. METHODS: A single-center, retrospective review from 2014 to 2018 was conducted evaluating pediatric patients with abdominal LM. RESULTS: Ten patients were included, n = 9 had macrocystic LM and one patient had combined disease. The average age at first treatment was 6.8 y. The most common presenting symptoms were abdominal distention, pain, infection, and anemia. Preprocedural imaging was performed for all patients; median pretreatment volume was 1572.9 cm3 (range, 67.2-13,226.4). LMs were accessed using ultrasound guidance and injected with opacified doxycycline. Patients received a mean of 7.1 sclerotherapy injections. Complications included intraperitoneal doxycycline extravasation (n = 1), managed conservatively, and LM infection (n = 1), treated with intravenous antibiotics and drainage. One patient went on to surgical resection due to inability gain stable intracystic access; follow-up ultrasonography showed no recurrence. Postprocedural imaging was available in n = 8. Volume decreased by 96.7% after sclerotherapy. The median remaining volume was 0 cm3 (range, 0-599.7) (P = 0.016). Postsclerotherapy magnetic resonance imaging was obtained in n = 6, with complete resolution in 83.3%. All patients had resolution of presenting symptoms. Follow-up duration was 12.3 mo. CONCLUSIONS: Initial results demonstrate that sclerotherapy is an effective and durable treatment for symptom resolution and volume reduction of abdominal LM.