Primary mechanism of injury | Drug | Other mechanism(s) | Toxicity | Compresses* | Potential antidote(s) for peripheral catheter extravasation |
Acidic | Amiodarone | NI | Necrosis | Cold or warm | None |
Gentamicin | NI | Necrosis | Cold | None | |
Metronidazole | NI | Necrosis, gangrene | Cold | None | |
Nicardipine | NI | Necrosis | Cold | None | |
Promethazine | NI | Necrosis | Cold or warm | None | |
Vancomycin | NI | Necrosis | Warm if hyaluronidase used; cold may be used if hyaluronidase is not used | Hyaluronidase may be considered based on mechanism of injury¶ | |
Alkaline | Acyclovir | NI | Necrosis | Cold | None |
Aminophylline | Hyperosmotic | Ischemia | Cold | None | |
Furosemide | NI | Necrosis | Cold | None | |
Ganciclovir | NI | Necrosis | Cold | None | |
Phenobarbital | NI | Necrosis | Cold | None | |
Phenytoin | Hyperosmotic, precipitation | Necrosis, purple glove syndrome | Warm | Hyaluronidase¶ or topical nitroglycerinΔ may be considered based on mechanism of injury | |
Chemical | Amphotericin | NI | Phlebitis | Cold | None |
Digoxin | NI | Inflammation, apoptosis | Cold | None | |
Foscarnet | NI | Phlebitis, arteritis | Cold | None | |
Propofol | NI | Necrosis | Cold | None | |
Hyperosmotic (osmolarity >290 mOsm/L) tissue damage may resemble compartment syndrome | Contrast media, radiographic | Pressure effect of large volume | Pressure necrosis | Cold or as per radiologist | None |
Calcium solutions | Vasoconstriction, calcinosis | Necrosis, calcinosis | Warm if hyaluronidase used; cold may be used if hyaluronidase is not used | Hyaluronidase¶ Severe forms of cutaneous calcinosis have been treated with sodium thiosulfate infusions, eg, once weekly for 3 weeks | |
Dextrose ≥10% | NI | Necrosis | Warm if hyaluronidase used; cold may be used if hyaluronidase is not used | ||
Magnesium sulfate | NI | Necrosis | Warm if hyaluronidase used; cold may be used if hyaluronidase is not used | None | |
Mannitol >5% | NI | Necrosis | Warm if hyaluronidase used; cold may be used if hyaluronidase is not used | Hyaluronidase¶ | |
Nafcillin | NI | Necrosis | Warm if hyaluronidase used; cold may be used if hyaluronidase is not used | Hyaluronidase¶ | |
Parenteral nutrition/amino acids solutions | Acidic | Necrosis | Warm if hyaluronidase used; cold may be used if hyaluronidase is not used | Hyaluronidase¶ | |
Potassium chloride >40 mEq/L | NI | Necrosis | Warm if hyaluronidase used; cold may be used if hyaluronidase is not used | Hyaluronidase¶ | |
Sodium bicarbonate | NI | Necrosis | Warm if hyaluronidase used; cold may be used if hyaluronidase is not used | Hyaluronidase¶ | |
Sodium chloride >1% | NI | Necrosis | Warm if hyaluronidase used; cold may be used if hyaluronidase is not used | None | |
Valproate sodium | NI | Necrosis | Warm if hyaluronidase used; cold may be used if hyaluronidase is not used | None | |
Vasoconstriction (causing local ischemia) | Dobutamine | NI | Necrosis | Warm | 2% topical nitroglycerin ointmentΔ and/or terbutaline administered subcutaneously may be considered |
Dopamine | Acidic | Necrosis | Warm | Preferred: Phentolamine◊ Alternative: 2% topical nitroglycerin ointmentΔ Terbutaline administered subcutaneously has been used if phentolamine is unavailable | |
Epinephrine | Acidic | Necrosis | Warm | ||
Methylene blue | NI | Cellular toxicity | Warm | ||
Norepinephrine | Acidic | Necrosis | Warm | ||
Phenylephrine | Acidic | Necrosis | Warm | ||
Vasopressin | Acidic | Necrosis | Warm | None documented; 2% topical nitroglycerin ointmentΔ followed by phentolamine◊ may be considered based on mechanism of injury |
NI: none identified.
* Dry cold or warm compresses should be applied to affected area for 20 minutes once every 4 to 6 hours for 1 to 2 days after removal of the catheter/needle and limb elevation. Cold compresses reduce pain, inflammation, and localize the vesicant potentially facilitating administration of an antidote. Application of warmth causes vasodilation and may facilitate dispersion and absorption.
¶ Hyaluronidase, administered as multiple subcutaneous injections around affected area, enhances dispersion and absorption of extravasated medications. Ideally, administer within 1 hour of extravasation; some benefit may be derived within 12 hours. If hyaluronidase is used, avoid cold compresses as they oppose its action; warm compresses are preferred.
Δ Alternative, if phentolamine is unavailable, is topical nitroglycerin 2%, applied as 1 inch (2.5 cm) strip over affected area, should be applied within 1 hour of extravasation. Avoid use of warm compresses if topical nitroglycerin is used. Local injection of terbutaline has also been tried as an antidote for vasopressors if phentolamine is unavailable.
◊ Phentolamine, administered as multiple subcutaneous injections around affected area, antagonizes alpha-adrenergic receptors stimulated by catecholamine extravasation. Ideally administer as soon as possible; some benefit may be derived within 12 hours.Adapted from: Valentin D, Christou N, Etienne P, et al. Extravasation of Noncytotoxic Drugs. Ann Pharmacother 2020; 54:804.
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