Severe phlebitis and cutaneous necrosis following peripheral administration of high-concentration potassium chloride: A case report and vascular access management implications

Abstract

Electrolyte imbalance management is crucial in diverse clinical scenarios, with intravenous potassium repletion often required. High-concentration infusions can pose severe complications if extravasation occurs, leading to phlebitis, local tissue damage, or in severe cases, cutaneous necrosis. This risk is elevated in geriatric patients due to factors like reduced tissue elasticity and sensitivity. We report a case of phlebitis and skin necrosis in an elderly woman after peripheral KCl infusion (6% [800 mmol/L]). A woman in her early 70 s presented with obstructive jaundice and critically low potassium levels. A peripheral intravenous administration of 6% KCl was initiated to rectify hypokalemia. Due to superficial venous site selection and the patient's reduced sensitivity, phlebitis developed unnoticed, leading to cutaneous necrosis. Management involved medication discontinuation, cannula removal, application of a magnesium sulfate dressing, limb elevation, and a hydrogel dressing. Despite initial necrosis, wound debridement, ongoing dressings, and moderate hand exercises led to a complete wound resolution. This case underscores the importance of careful selection and monitoring of infusion sites during administration of irritant solutions like concentrated KCl, particularly in geriatric patients. Patient-specific factors, pharmacological implications, and the necessity for adequate vascular assessment are emphasized. Further, the case highlights the necessity for prompt and multifaceted management strategies to handle complications, including patient and caregiver education, careful wound management, and proactive nursing care. The event underscores the need for established protocols regarding the administration of high-risk drugs to prevent severe sequelae.

Keywords: Potassium chloride extravasation; case report; cutaneous necrosis; phlebitis; wound debridement.

Figure 1.

On day 1, at 21:00, nurse identified a region of the patient's right hand, proximal to the injection site, (a) exhibiting erythema along the venous pathway, (b) measuring approximately 9cm × 1 cm.

Figure 2.

On day 13, a lesion measuring 2 cm by 1 cm surfaced at the location of the venous catheter insertion on the dorsal aspect of the patient's hand, with purulent discharge noted from the ulcerated site.

Figure 3.

On day 27, a discernable ulceration, approximately 3 cm by 1 cm in dimension, manifested at the peripheral venous catheter insertion site on the patient's dorsal hand surface, exposing subjacent necrotic vasculature.

Figure 4.

On day 28, (a) initial cleansing with saline, (b) ligation, and (c) excision of necrotic vessels, (d) subsequent sterilization employing isotonic saline and a povidone-iodine solution, (e) implementation of a drainage system and an alginate dressing, and (f) final envelopment with gauze and an elastic bandage.

Figure 5.

The respective statuses of the patient's wound recuperation on (a) day 34, (b) day 38, (c) day 43, and (d) day 48.

Figure 6.

Patient's medical progression timeline.