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PL Detail-Document #271212
−This PL Detail-Document gives subscribers
additional insight related to the Recommendations published in−
PHARMACIST’S LETTER / PRESCRIBER’S LETTER
December 2011
Treatment for Extravasation of Non-Chemo Drugs
Non-chemotherapy drugs are not generally considered to be vesicants. However, extravasation or
infiltration of non-chemotherapy drugs can still cause harm to skin and soft tissue. This is especially true
for drugs that are intrinsically irritating to tissue such as nafcillin; drugs with higher than physiologic
osmolarity, such as parenteral nutrition and some electrolytes; and drugs with a high pH such as
phenytoin.16,17 Some general advice in the case of extravasation includes immediately stopping the
drug infusion and elevating the affected limb to minimize swelling.1,2,15,17,18 Cold compresses (dry not
moist) may also reduce swelling and are generally preferred for most vesicant or irritant drugs.3,4
Warm compresses (dry not moist) can cause vasodilation and help distribute the drug, reducing local drug
concentrations.5,18 Other treatments can depend on the drug. Hyaluronidase (Vitrase; U.S. only) given
subcutaneously around the affected site can help distribute the drug away from the site. Phentolamine can
counteract local vasoconstriction caused by extravasation of vasoconstrictors. Quicker treatment may
result in better outcomes for patients, but surgical intervention may be required for severe cases of
extravasation.16,17 Treatments for extravasation are generally based on case reports in the literature,
as opposed to more solid evidence. The following chart includes non-chemotherapy drugs that are more
likely to be harmful with extravasation, along with treatments for their extravasation and other relevant
information. Follow your hospital’s policy for extravasation of chemotherapy agents.
Treatmenta,b,c,d
Drug or
Drug Class
Comments
Calcium salts
•
Hyaluronidase4
•
Mechanism: hyperosmolarity4
Contrast media
•
•
•
Mechanism: hyperosmolarity3,6
Tissue damage is more likely with
ionic than with nonionic contrast
agents3,6,7
•
Cold compress or warm compress
for alleviation of symptoms6,7
Cold compress to alleviate
ulceration4,7
Hyaluronidase4
Dextrose (≥10%)
•
Hyaluronidase 4,8
•
Mechanism: hyperosmolarity4,8
Mannitol
•
Hyaluronidase9
•
Mechanism: hyperosmolarity9
Nafcillin
(U.S. only)
Parenteral nutrition
•
Hyaluronidase4,10
•
Mechanism: direct irritant10
•
•
Hyaluronidase1,4
Topical nitroglycerin1,5
•
Mechanism: hyperosmolarity1
•
•
•
Warm compress11
Topical nitroglycerin11
Hyaluronidase12
•
•
Mechanism: high pH11
Extravasation may result in “purple
glove syndrome”11
•
Phenytoin
More. . .
Copyright © 2011 by Therapeutic Research Center
P.O. Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.pharmacistsletter.com ~ www.prescribersletter.com ~ www.pharmacytechniciansletter.com
(PL Detail-Document #271212: Page 2 of 3)
Treatmenta,b,c,d
Drug or
Drug Class
Comments
Potassium salts
•
Hyaluronidase4
•
Mechanism: hyperosmolarity4
Promethazine
•
No proven treatment. Sympathetic
block and heparinization have
been used to manage promethazine
extravasation based on animal
data.19,20
•
Mechanism: direct irritant19,20
Vasoconstrictors
• Dobutamine
• Dopamine
• Epinephrine
• Norepinephrine
• Phenylephrine
• Vasopressin
•
•
Phentolamine4,5,13
Topical nitroglycerin14
•
Mechanism: restriction of local
blood flow13
a. Cold or warm compresses should generally be applied for 20 minutes, every six to eight hours, for
up to three days.2,4
b. The dose of hyaluronidase (U.S. only) for adults for extravasations is generally 150 units/mL, 0.2
mL intradermally or subcutaneously at each of five sites of the edges surrounding the affected area.4,8
A concentration of 15 units/mL (same instructions as above) has also been used for non-chemo
agents.4 Hyaluronidase should be used within about one hour of extravasation.18
c. The dose of phentolamine for adults is generally 5 to 10 mg diluted in 10 to 15 mL of normal saline
injected subcutaneously into the area of extravasation as ten 1 mL injections. It should be used within
12 hours of extravasation.4
d. Different formulations of topical nitroglycerin have been used (per case reports) for extravasation
including 2% topical nitroglycerin ointment.14
Users of this PL Detail-Document are cautioned to use their own professional judgment and consult any other
necessary or appropriate sources prior to making clinical judgments based on the content of this document. Our
editors have researched the information with input from experts, government agencies, and national organizations.
Information and internet links in this article were current as of the date of publication.
More. . .
Copyright © 2011 by Therapeutic Research Center
P.O. Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.pharmacistsletter.com ~ www.prescribersletter.com ~ www.pharmacytechniciansletter.com
(PL Detail-Document #271212: Page 3 of 3)
Project Leader in preparation of this PL DetailDocument:
Stacy A. Hester, R.Ph., BCPS,
Assistant Editor
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
Gil ME, Mateu J. Treatment of extravasation from
parenteral nutrition solution. Ann Pharmacother
1998;32:51-5.
Wang RY. Extravasation of xenobiotics. In:
Nelson LS, Lewin NA, Howland MA, et al, Eds.
th
Goldfrank's Toxicologic Emergencies. 9 ed. New
York, NY: McGraw-Hill, 2010.
Belzunegui T, Louis CJ, Torrededia L, Oteiza J.
Extravasation of radiographic contrast material and
compartment syndrome in the hand: a case report.
Scand J Trauma Resusc Emerg Med 2011;19:9.
University of Illinois at Chicago.
Drug
extravasation: management summary and update.
http://www.uic.edu/pharmacy/centers/drug_informa
tion_center/faq/extravasation.php.
(Accessed
November 10, 2011).
The National Extravasation Information Service.
www.extravasation.org.uk/.
June 30, 2001.
(Accessed November 10, 2011).
Maddox TG.
Adverse reactions to contrast
material: recognition, prevention, and treatment.
Am Fam Physician 2002;66:1229-34.
Schwartz DT. Diagnostic imaging. In: Nelson LS,
Lewin NA, Howland, MA, et al, Eds. Goldfrank's
Toxicologic Emergencies. 9th ed. New York, NY:
McGraw-Hill, 2010.
Wiegand R, Brown J.
Hyaluronidase for the
management of dextrose extravasation. Am J
Emerg Med 2010;81:257.e1-2.
Kumar MM, Sprung J. The use of hyaluronidase to
treat mannitol extravasation.
Anesth Analg
2003;97:1199-200.
10. Zenk KE, Dungy CI, Greene GR.
Nafcillin
extravasation injury. Use of hyaluronidase as an
antidote. Am J Dis Child 1981;135:1113-4.
11. Edwards JJ, Bosek V. Extravasation injury of the
upper extremity by intravenous phenytoin. Anesth
Analg 2002;94:672-3.
12. Sokol DK, Dahlmann A, Dunn DW. Hyaluronidase
treatment for intravenous phenytoin extravasation.
J Child Neurol 2998;13:246-7.
13. Bey D, El-Chaar GM, Bierman F, Valderrama E.
The use of phentolamine in the prevention of
dopamine-induced tissue extravasation. J Crit
Care 1998;13:13-20.
14. Denkler KA, Cohen BE. Reversal of dopamine
extravasation injury with topical nitroglycerin
ointment. Plast Reconstr Surg 1989;84:811-3.
15. Wickham R, Engelking C, Sauerland C, Corbi D.
Vesicant extravasation part II: evidence-based
management and continuing controversies. Oncol
Nurs Forum 2006;33:1143-50.
16. Khan MS, Holmes JD. Reducing the morbidity
from extravasation injuries.
Ann Plast Surg
2002;48:628-32.
17. Rosenthal K. Reducing the risks of infiltration and
extravasation. Nursing 2007 Fall;37 Suppl Med:48.
18. Dougherty L.
Extravasation:
prevention,
recognition, and management.
Nurs Stand
2010;52:48-55.
19. Product information for Phenergan. West-ward.
Eatontown, NJ 07724. May 2011.
20. Product monograph for promethazine. Sandoz
Canada. Boucherville, QC J4B 7K8. March 2010.
Cite this document as follows: PL Detail-Document, Treatment for Extravasation of Non-Chemo Drugs.
Pharmacist’s Letter/Prescriber’s Letter. December 2011.
Evidence and Recommendations You Can Trust…
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Copyright © 2011 by Therapeutic Research Center
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