Extravasation Injuries of the Limbs in Neonates and Children—Development of a Treatment Algorithm

Abstract

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.

Figure 1

Treatment algorithm for the emergency management of an extravasation injury * for example, consultant pediatric surgeon, plastic surgeon or hand surgeon

Figure 2

Figure 2: Preterm neonate (33 + 3 weeks gestation, birth weight 1740 g) with pulmonary artery atresia. Extravasation of glucose in the third week of life at the right forearm/wrist. Initial presentation three days after extravasation (a) with development of severe necrosis (b). Healed appearance after four months of extensive conservative management with the typical constellation of a critically ill neonate and operability only with purely vital indication, rendering early elective plastic reconstruction impossible. Image (c) shows findings six months after injury and conservative scar treatment. Surgical intervention is to be expected over time to avoid contractures/soft-tissue deformities.