pediatric

blisters

extravasation

Issue: Volume 65 - Issue 3 - March 2019 ISSN 2640-5245

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Introduction

Extravasation occurs when a vesicant or chemotherapeutic drug accidentally infiltrates the surrounding intravenous (IV) site. Vesicants can cause tissue destruction and/or blistering; the most common vesicants include total parenteral nutrition fluids, antibiotics, antiseizure medications, and vasopressors. A peripheral intravenous line (PIV) is placed in 70% of patients admitted to neonatal intensive care units; of those, 18% to 33% became extravasations, most in babies <28 weeks’ gestation. 

Despite such frequent use of PIV, evidence on best practice, injury prevention, management, and treatment is scarce. Most available literature recommends treating moderate to severe extravasations with an antidote. Two (2) antidotes available are phentolamine for vasopressors and recombinant human hyaluronidase for everything else (not including antineoplastic medications) given as multiple subcutaneous injections (total 1 mL) circumferentially around the area of the biggest infusate pocket. 

In my institution, we stage extravasations based on 3 factors: degree of swelling (in %), physical findings (Infusion Nurses Society-type scale), and type of infusate (vesicant vs. nonvesicant). Moderate and severe categories receive treatment. Most literature recommends against cold and hot compresses in neonatal extravasations. Despite treatment, 5% to 10% of extravasation lead to wounds.

Treatment

Initial management options. For intact blisters, if the blister is small, nontense, and not located in a joint area, I recommend leaving the blister intact. Endogenous inflammatory mediators may decrease the area of injury, similar to burn care,1 while providing a natural protective biologic dressing. The blister should be covered with a nonadhesive, silicone outer dressing. Large, tense, or over-the-joint blisters should be punctured in 1 to 2 spots with a large bore angiocath to allow decompression, with care not to deroof the blister. The area should be checked every shift to initiate timely management once the blister opens, at which time it should be gently debrided.

If there is an open wound, my first preference is medical-grade (active Leptospermum) honey (ALH) in the form of gel or a honey-impregnated hydrocolloid. For a very superficial wound, an amorphous hydrogel also works well. ALH features are important for the open wound: 1) acidic pH, which decreases bacterial colonization and improves oxygen diffusion; 2) hyperosmolarity, which facilitates autolytic debridement by increasing lymph flow and decreases bacterial proliferation; 3) the ability to decrease pro-inflammatory modulators and proteases, and 4) antimicrobial properties via hydrogen peroxide and methylglyoxal production. These characteristics facilitate extracellular matrix deposition by promoting fibroblast migration, proliferation, and organization of collagen and angiogenesis while supporting slough minimization.2 

Addressing slough. Slough is common in extravasation wounds; at times, it requires a stronger debriding agent. Collagenase (the only enzymatic debrider approved in United States) is perfectly safe to use in neonates, especially in hard slough. Collagenase hydrolyzes peptide bonds and digests all triple helical collagen; it will not degrade any other proteins lacking a triple helix. Collagenase starts at the lower portion of an eschar, working from the bottom up and softening the area, facilitating autolytic debridement, especially in combination with an eschar cross-hatching. Concentrated surfactant gel is another excellent choice for softer slough. Studies support its wound-stabilizing properties (by inserting zeta potential in cell membrane), potentially minimizing the area of necrosis. Surfactant gel lifts necrotic tissue via the principles of amphiphilicity (ie, it possesses both hydrophilic and lipophilic properties) and micelle formation. 

Debridement. Most wounds do not need sharp debridement, but mechanical debridement can be helpful. I like using a monofilament debrider pad or lolly; these are single-use debriding devices composed of monofilament polyester fibers.3 This debrider should be generously moistened with normal saline before use to minimize pain and facilitate necrotic tissue removal. It is well-tolerated, even by children, and works fast. 

Bioengineered skin products. Most wounds heal well with topical honey, gel, atraumatic dressings, and gentle care. Recalcitrant wounds require more advanced dressings. Acellular matrices incorporating collagen have produced good results, acting as a scaffold for new cells and a deterrent for wound proteases while contributing to native collagen to improve extracellular matrix generation.4

A variety of amniotic membrane-based dressings are available and include dehydrated, cryopreserved, amnion-only, and amnion/chorion-based products.5 I have had good experience with dehydrated amniotic membrane allografts; soft, malleable, and easy to work with, these dressings are excellent for neonatal wounds. For bigger, deeper wounds, a cryopreserved version (often combined with umbilical cord-based products) can be considered. Amniotic membrane grafts offer a scaffold, provide anti-inflammatory mediators, promote cellular differentiation and adhesion, suppress infection suppression, support neovascularization, and exert a potentially scar minimizing effect. 

Not much literature exists on the use of epidermal, dermal, or composite allografts, but several case reports describe their efficacy in deep extravasation wounds. The general principal of replacing like tissue with like tissue makes sense in deeper, more advanced wounds. 

Negative pressure. All the above-mentioned products can be supported by using negative pressure wound therapy (NPWT). I often use single-use, portable negative pressure devices — they do not require foam, are easy to operate, facilitate discharge, and employ evaporation along with negative pressure as a work mechanism. Many NPWT systems use traditional, foam- and/or canister-based units. The innate healing potential of neonatal skin responds beautifully to the supportive structure these products offer. 

Case Report

An 18-day-old, 29-week-gestation boy required PIV placement secondary to abdominal distension, gastric residuals, apnea, and respiratory distress. His oral feeds were stopped, antibiotics were started, and a work-up for necrotizing enterocolitis was initiated. Two (2) days later, an extravasation was noted. PIV was used to administer TPN, vancomycin, and piperacillin/tazobactam (see Figure 1).

The blister was left intact and was debrided after 2 days. Honey-based gel was used, covered by a silicone-based dressing. After a few days, hard slough was noted (see Figure 2). Collagenase and cross-hatching were used to soften the eschar. The wound was debrided with a curette. A dehydrated amniotic allograft, supported by portable NPWT, was used to facilitate closure. Once the wound was partially filled with granulation tissue, we continued ALH gel and silicone dressings. A monofilament debrider was used once to prepare wound (Figure 3 shows loose slough that was removed successfully with a lolly). The baby healed with minimal soft scarring and no range of motion limitation (see Figure 4).

Scarless healing with full preservation of function is the ultimate goal in neonatal wound extravasation management.

Affiliations

Dr. Boyar is Director of Neonatal Wound Services,  Cohen Children’s Medical Center of New York, New Hyde Park; and an Assistant Professor of Pediatrics, Zucker School of Medicine, Hofstra/Northwell, Hempstead, NY.