Dopamine is just as bad (Ann of Pharmacotherapy 1998;32:545)
Phentolamine is available 5 mg (per 1 ml) vials (Regitine, ; manufactured by Ciba-Novartis Pharmaceuticals). (Ref. 21). For treatment of an extravasation, the contents of the vial should be diluted to 5-10 ml. A dose of 0.1 to 0.2 mg/kg (up to a maximum of 10 mg) should then be injected through the catheter or subcutaneously around the site. As with hyaluronidase, phentolamine should be administered as soon as the extravasation is detected, but may be given up to 12 hours later. For Prevention: 10 mg of phentolamine mesylate is added to each liter of solution containing norepinephrine. The pressor effect of norepinephrine is not affected. For Treatment: 5 to 10 mg of phentolamine mesylate in 10 mL of saline is injected into the area of extravasation within 12 hours.
Extravasation Flush-out Technique
In brief, the treatment can be carried out either under local or general anaesthetic. If the treatment is to be carried out under local anaesthetic this is infused into the subcutaneous space both beneath the zone of extravasation and around it. Then into this zone is directed dilute Hyaluronidase. One vial containing 1500 units is diluted down with 10cc of saline and injected throughout the zone. Once numbness of the area has been established, four small stab incisions around the zone of extravasation injury are made. It is essential to have an infusion cannula which has a sealed or blunt end and side holes to flush out this zone. Such cannulae are widely available for use in rapid infusion prior to liposuction. Through the subcutaneous space beneath the area of extravasation, normal saline is infused. It is planned that the saline go in through one of the stab incisions and exit through the others. At various times throughout the procedure, volumes of saline will collect in the subcutaneous space above and below the treatment zone and this fluid needs milking down to exit through the stab incisions. A thorough flush out of the extravasation space is required. Large volumes of saline, up to 500mls are usually flushed through in 20cc of 30cc aliquots using a syringe and a blunt ended cannula. After the flush out a layer of Jelonet and Betadine soaked gauze is applied to the wound and the limb wrapped in a padded bandage and elevated for twenty-four hours. The stab incisions are never sutured and are allowed to close spontaneously. This flush out technique is now established as the most effective way of removing extravasated material and it is well worth invoking the surgical maxim when in doubt get it out. In seriously debilitated patients, for example those with neutropenia, a short course of prophylactic antibiotics is recommended.
Flush-out technique reproduced by kind permission of Mr David Gault – Mr David Gault FRCS Consultant Plastic Surgeon The Portland Hospital http://www.davidgault.co.uk Hyaluronidase for CaCl Extravastion
150 units with NS added to make 1 cc. inject 0.2 cc of mixture in 5 separate places around the area
elevate with cold packs
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