Nonoperative Management of Extravasation Injuries Associated With Neonatal Parenteral Nutrition Using Multiple Punctures and a Hydrocolloid Dressing

Extravasation is the accidental leakage of intravenously infused medications into extravascular tissue. It is a frequent concern in neonatal intensive care units (NICUs), as parenteral injections are commonly administered through peripheral veins to supply nutrition and drugs to neonates. As neonatal vessels are small and fragile, extravasation injuries often occur despite preventive measures. In addition, the inability of neonates to communicate clearly may also contribute to the aggravation of extravasation injuries.¹

Extravasation injuries in NICUs are most commonly caused by high-concentration parenteral nutrition or high concentrations of ions such as calcium, potassium, and bicarbonate. As they are all potentially noxious to living tissue when extravasation occurs, significant scarring and contractures may result.

To prevent such serious complications, early detection and adequate management are mandatory. Although a standard protocol for the management of extravasation injuries associated with parenteral nutrition is lacking, many treatment modalities such as hyaluronidase injection,² the multiple perforation method,³ enzymatic debridement,⁴ saline flushing and liposuction,^5,6 and DuoDERM Hydroactive Gel (ConvaTec Inc, Princeton, NJ) dressing⁷ have been used with variable results. However, it is not easy to select an adequate treatment modality at an early stage due to difficulties in determining the depth and extent of skin injury. Although some authors have recommended early surgical debridement and skin grafting,⁸ a conservative approach with or without delayed surgical repair is more appropriate in neonates due to the uncertain extent of the damage.^1,9

Using a new method that combines multiple punctures and a hydrocolloid dressing (DuoDERM Extra Thin, ConvaTec Inc, Princeton, NJ), the authors managed neonatal extravasation injuries associated with parenteral nutrition conservatively without surgical repair to treat them. Applying this new methodology, the authors achieved favorable results with minimal scarring and little functional deficits. This presents an easy and useful nonoperative modality to treat neonatal extravasation injuries associated with peripheral parenteral nutrition.

Between November 2010 and June 2014, the authors managed 12 neonatal extravasation injuries with this treatment modality using multiple punctures and a hydrocolloid dressing. The study population consisted of 6 males and 6 females, ranging in gestational ages of 30⁺³ weeks to 39⁺¹ weeks. Nine of the 12 neonates were born preterm. Details pertaining to the 12 patients analyzed are presented in Table 1. Birth weights ranged between 1570 g and 4030 g. Five extravasation injuries developed in the wrist, 5 in the ankle, and 1 each in the dorsum of the hand and the antecubital area. 

All injuries were caused by leakage of peripheral parenteral nutrition, which consisted mostly of 10% dextrose, 50% dextrose, 6% amino acid solution, 20% lipid emulsion, and electrolytes. Treatments were started in 11 neonates within 24 hours after occurrence. Only 1 neonate was managed 2 days after the occurrence of an extravasation injury. The initial lesions manifested as skin discoloration, blebs, marked swelling, and necrosis. Nine of the 12 lesions eventually progressed to full thickness open wounds.

On referral, multiple punctures using a No.11 scalpel blade tip were made on the extravasated wound (Figure 1A) prior to the application of the hydrocolloid dressing (Figure 1B). The dressing was changed every 6 hours on the first day, and then less frequently according to the amount of exudate. When devitalized tissue began to be demarcated and autolyzed, surgical debridement was performed gradually to preserve normal tissue to the greatest extent possible. The procedure was performed at the bedside using a No. 15 scalpel without anaesthesia because the removal of dead tissue is not painful. After wound healing, application of Dermatix Silicone Gel (Meda Pharmaceuticals Ltd., Bishop’s Stortford, UK) to the scar was recommended for the first 3 months to prevent hypertrophic scars. 

The follow-up period ranged from 2 to 18 months (mean follow-up, 8 months). The average duration of treatment for wound healing in the 12 neonates was 25 days. Complications such as secondary infections or nerve and tendon injuries did not develop in any patient. Scars remained inconspicuous; however, regular follow-up was recommended to observe the possible sequelae of minimal contracture in 1 neonate with an extravasation injury to his wrist. All 12 patients showed favorable results without functional deficits and conspicuous scars (Figures 2, 3, 4 and 5). Additionally, parents of the neonates in the study were satisfied with the final results.

Leakage of infused solutions through the peripheral veins in NICUs is common. One UK-based study¹⁰ found that 38 of 1000 neonates undergoing neonatal intensive care suffered an extravasation injury severe enough to result in skin necrosis.¹⁰

There are 2 main categories of medications, irritants and vesicants, that provoke local consequences following their extravasation. Irritants primarily cause local inflammatory reactions at the infusion site but no permanent damage, while vesicants such as high-concentration parenteral nutrition or high concentrations of ions such as calcium, potassium, bicarbonate, and cytotoxic anticancer drugs have the potential to cause severe or irreversible tissue injury and necrosis. However, most extravasation injuries occurring in NICUs are associated with peripheral parenteral nutrition. Although the etiology of thrombophlebitis in peripheral parenteral nutrition is often multifactorial, the osmolarity of the parenteral nutrition may be an important variable. Hyperosmolar forms of parenteral nutrition are all potentially noxious to living tissue when extravasated and can result in significant scarring and contractures.

Numerous treatment protocols have been published regarding the management of extravasation injuries. For example, Laurie et al² demonstrated that the injection of hyaluronidase was beneficial in extravasation injury and postulated that the presumed mechanism of its effect was the spreading of the toxic agent over a larger area, thus reducing its local concentration and perhaps even increasing the rate of its absorption. Conversely, this spreading mechanism also has the potential for provoking harmful effects when large doses of toxic agents are involved. In addition, delayed treatment with hyaluronidase by more than 1 hour did not show significantly different effects as compared with its immediate use in their study. Furthermore, the British National Formulary recommends using hyaluronidase with caution in infants due to possible side effects. A simple multiple puncture method was proposed to remove the infiltrate and prevent skin sloughs from hypertonic solutions in 1986 by Chandavasu et al.³ The method seemed to produce helpful results if performed in early stages, however, substantial effects might not be expected otherwise. Falcone et al⁴ introduced a nonoperative management option for the treatment of full-thickness intravenous extravasation injuries in premature neonates using enzymatic debridement. Lehr et al⁷ managed infiltration injuries effectively in neonates using a gel to facilitate autodebridement of the wound and induce healing by second intention. This method would have promoted wound healing by providing the lesion with a moist environment. Heckler¹¹ reported on the successful management of clysis using a mixture of hyaluronidase and saline. In 1993, Gault⁵ described 2 techniques involving liposuction and saline flush-out to remove or dilute the extravasated material. These techniques have since been reported to be successful in treating neonatal extravasation injuries.^6,12,13 In an animal study, a saline flush-out technique was reported to be effective, particularly if treatment was initiated within 1 hour of injury.¹⁴ It should be noted that hyaluronidase is often used in conjunction with the multiple puncture and saline wash-out techniques; however, it is unclear whether it provides any clinical benefits over the use of saline alone.

There are 2 strategies for treating neonatal extravasation injuries. One of the strategies involves removing offending infiltrates as soon as possible. The second calls for the induction of rapid wound healing to reduce unnecessary hospitalization and undesirable sequelae. The new method described in the present study seems to meet the goals of both strategies. Early multiple punctures using a No. 11 scalpel blade tip provide an easy means of removing infiltrates, and the hydrocolloid dressing facilitates their removal through its well-known absorption capacity. Hydrocolloids are a type of dressing containing gel-forming agents, such as gelatin, pectin, and carboxymethylcellulose. When the dressing comes into contact with wound exudate, hydrocolloids absorb liquid and form a gel. The moist conditions produced under the dressing are intended to promote wound healing by rapid epithelialization, increased fibroblast proliferation, and collagen synthesis.^15-17

Once the devitalized tissue is demarcated, its removal is of paramount importance for wound healing. However, radical excision of tissue of uncertain vitality is not recommended, as demarcation between vital and non-vital tissues is unclear in the early stages of extravasation injuries. Therefore, gradual debridement is helpful in preserving normal tissue. The hydrocolloid dressing was chosen as a dressing material in the present study because it initially aids in the draining of infiltrates through the puncture wounds, facilitates autolytic debridement, and induces rapid second intention healing by providing a moist environment for the open wound. Although existing treatment modalities are mostly intended to achieve 1 of the 2 treatment strategies, this method fulfils both.

Unfortunately, it is not easy to recognize the exact onset of extravasation, as infiltration may not become apparent until the tissue is discolored and significantly damaged. Like the other treatment modalities, the earlier the methodology described in this present study is applied, the better the results. Puncture should not be done too largely or too deeply to avoid injury to vital tissue and the sequelae of scarring. Lancets used for blood glucose tests would seem to be very convenient for multiple punctures; however, their tip sizes are too small to facilitate drainage of extravasated infiltrates. Even though Gault techniques have been shown to be very effective in removing causative infiltrates,⁵ they are too invasive to apply to neonates and may carry some morbidity. The goals of treatment described in the present study are to remove offending infiltrates and promote wound healing by inducing autolytic debridement and providing a moist environment.

Despite growing interest and experimentation in this area, there appears to be little consensus between units and countries on how extravasation injury should be prevented and treated, as much of the available evidence is derived from case reports and clinical reviews.¹⁸ Restieaux et al¹ reported that NICUs in Australia and New Zealand have protocols for the prevention and management of extravasation injury. As previously noted, however, considerable diversity exists between units regarding practice in the UK.

The degree of cellular injury is determined by the volume of the infiltration solution and its physicochemical characteristics such as pH, osmolarity, and degree of dissociability.¹⁹ The initial lesions can appear as blistering, discoloration, or marked swelling. In spite of the initial skin manifestation, most lesions become aggravated and progress to skin necrosis. In the present study, 9 of 12 lesions showed skin necrosis, and their skin manifestations did not always indicate the severity of the oncoming damage. Regardless of the initial skin manifestation, adequate management is required to prevent the progression of skin damage.

The authors suggest that surgical repair is usually not necessary as wound healing in neonates is accomplished more rapidly due to their stronger regenerative abilities in comparison to adults. They also suggest that in spite of large skin defects, neonatal wounds result in low levels of functional deficits attributable to tissue loss as neonates have the capacity to compensate for skin loss during their rapid growth phase. However, further controlled prospective studies would be necessary to confirm these findings.

The authors suggest that their new method using multiple punctures and a hydrocolloid dressing is an easy, effective, and minimally invasive treatment for neonatal extravasation injuries associated with peripheral parenteral nutrition, and it can be used as an alternative treatment option.

From the Department of Plastic and Reconstructive Surgery, School of Medicine, Kangwon National University, Chuncheon, Korea

Address correspondence to:
Sang-Yeul Lee, MD, PhD
Department of Plastic and Reconstructive Surgery, Kangwon National University Hospital,
Baekryeong-ro 156, Chuncheon 200-722, Korea
serafin5@unitel.co.kr

Disclosure: This study was funded by a 2015 Kangwon National University research grant