Sir,

Extravasation is defined as the accidental instillation or leakage of a solution during its infusion into the perivascular or subcutaneous space [1]. With wide variations, this complication has been reported in 0.1–6.5% of infusions [2]. Its damage depends on the toxicity and quantity of the product [3]. Currently, there are no recommendations for the management of these lesions, which may lead to a wrong choice or delay in possible treatments.

Herein, we describe three adult patients with localized and similar reactions at the injection site, the first after an amiodarone infusion, the second after aciclovir, and the third after a contrast infusion for radiological examination.

The first patient was a 54-year-old male with treated ischemic heart disease admitted to the intensive care unit for impaired consciousness, for which he had received an 800 mg amiodarone infusion.

The second patient was a 46-year-old female hospitalized at the dermatology department for herpes zoster and treated with aciclovir injection at a dose of 560 mg/8 h.

The third patient hospitalized at the thoracic department for pneumopathy received an infusion of contrast medium for a thoracic scan.

The upper limb was the exclusive site of extravasation of their administered products. The evolution was marked by the rapid development of a painful, edematous, erythematous placard opposite to the injection site. The urgent course of action was to stop the infusion, to aspirate the extravasated liquid, and to apply alcohol dressings. The evolution was marked, within an average of three days, by the installation of a painless, necrotic plaque based on a significant infiltration of the underlying soft tissues (Figs. 1a and 1b). Two patients were admitted to the operating room and underwent an excision of the necrosis by the surgeon (Fig. 2), while the woman underwent local trimming with close scar support. The post-operative follow-up was marked by a bacterial superinfection treated with a course of antibiotics with good improvement.

	Figure 1: (a) Skin necrosis secondary to contrast extravasation. (b) Skin necrosis secondary to amiodarone extravasation.
	Figure 2: Surgical excision of the necrosis.

Extravasation consists of the leakage of an intravenously administered agent outside the blood vessel, causing the infiltration of the surrounding tissue. It may present with different clinical pictures, ranging from a simple erythema and minor, sensitivity made of pain or a burning sensation, to a post-bullous erosion, or even an ulceration with a necrotic surface [4]. The severity of tissue damage may vary depending on the type of agent administered and its quantity [5]. The main drugs involved are anticancer drugs, contrast agents, immunoglobulins, and radiopharmaceutical drugs [6].

Special attention should be paid to patients of extreme age. Similarly, patients with vascular disorders, diabetes, or trophic disorders are at increased risk. When the injection is to be performed at a site of low subcutaneous tissue (back of the hand, wrist, ankle) or when using a needle rather than a catheter enhanced monitoring will be required [7].

When this is identified, management must be immediate. General measures are implemented: stop the injection, aspirate as much extravasated fluid as possible, delimit the extravasated area. Specific measures will be taken depending on the type of product and associated risk factors [5].

The management and monitoring of the consequences of extravasation require a good knowledge of tissue damage by soft tissue ultrasound or angiography to more fully assess blood flow [5].

There are recommendations for prevention: focus on the upper limb, begin with the most distal veins, check venous return, apply a transparent dressing, and check for pain or extravasation at the time of placement [7].

In light of our discussed cases, the implementation of a multidisciplinary thinking, including dermatologists, surgeons, radio-pharmacists, and nurses, is essential in order to identify potential risk factors for patients and focus on early detection and adequate management to mitigate possible consequences.

REFERENCES

1. Pluschnig U, Haslik W, Bartsch R, Mader RM. Extravasation emergencies:State-of-the-art management and progress in clinical research. Memo. 2016;9:226-30.

2. Nogler-Semenitz E, Mader I, Fürst-Weger P, Terkola R, Wassertheurer S, Giovanoli P, et al. [Extravasation of cytotoxic agents]. Wien Klin Wochenschr. 2004;116:289-95.

3. HaslikW, PluschnigU, Steger GG, Zielinski CC, Schrogendorfer KF, Nedomansky J, et al. La vide?oangiographie au vert d’indocyanine pre?dit l’issue des le?sions par extravasation. PLOSONE. 2014;9(8):103649.

4. Okuda H, Masatsugu A, Sijimaya T, Arai R. Skin necrosis due to the extravasation of irritant anticancer agents. Intern Med. 2018;57:757-60.

5. Pluschnig U, Haslik W, Bartsch R, Mader RM. Extravasation emergencies:State-of-the-art management and progress in clinical research. Memo. 2016;9:226-30.

6. Ly C. [The care of skin lesions caused by extravasation of intravenous fluids in peripheral venous perfusion]. Arch Pediatr. 2017;24:884-93.

7. Mandlik V, Prantl L, Schreyer AG. Contrast media extravasation in CT and MRI:A literature review and strategies for therapy. Rofo. 2019;191:25-32.