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Extravascular iatrogenic extravasation corresponds
to the passage of a perfusion product and its tissue distribution at the
injection site; its consequences depend on the nature of the product concerned,
and the risk of progressive and disabling skin necrosis are major. We report
the clinical case of a 45-year-old patient, followed for type 2 diabetes for 3
years and put on insulin, admitted initially for community-acquired pneumonia,
for which she was hospitalized and put under amoxicillin protected by
intravenous peripheral line in the right wrist. Four days later the evolution
was marked by the onset of pain with tumefaction and severe edema at the site
of the perfusion, drug extravasation was suspected which justified the
immediate cessation of the perfusion, but the evolution was quickly marked by
the appearance of extensive necrotic plate extending on the side face of the
distal third of the right forearm and the right hand. We retained the diagnosis
of skin necrosis secondary to extravasation of antibiotic therapy based on
amoxicillin-clavulanic acid. Given the extension of necrosis, treatment
consisted of amputation of the hand and
putting the patient under antibiotics. The extravasation is to be considered as
a serious complication of intravenous treatments and its management as a surgical
emergency is absolute. Whatever the injected product, it is necessary to
respect the recommended route of administration, and after extravasation of a
product it is mandatory to control the injection site.
Keywords: Extravasation of
antibiotics, Skin necrosis, Diabetes
INTRODUCTION
Extravascular iatrogenic extravasation corresponds
to the passage of a perfusion product and its tissue distribution at the
injection site; its consequences depend on the nature of the product concerned,
and the risk of progressive and disabling skin necrosis are major. The causes
of skin necrosis originating from drugs or toxic vary widely. We report a case
report.
OBSERVATION
A forty five-year-old woman (E.F) is followed for type 2 diabetes for 3 years and put on insulin, she is also followed for asthma for 4 years and put under Beta-agonists and she has no other particular medical history. The patient was admitted for community-acquired pneumonia, for which she was hospitalized and put under amoxicillin protected by intravenous peripheral line in the right wrist. Four days later, the evolution was marked by the onset of pain with tumefaction and severe edema at the site of the perfusion, drug extravasation was suspected which justified the immediate cessation of the perfusion, but the evolution was quickly marked by the appearance of extensive necrotic plate extending on the side face of the distal third of the right forearm and the right hand (Figure 1). We retained the diagnosis of skin necrosis secondary to extravasation of antibiotic therapy based on amoxicillin-clavulanic acid. Given the extension of necrosis, treatment consisted of amputation of the hand and puting the patient under antibiotics.
DISCUSSION
Extravasation is the leakage of a liquid from a
blood vessel toward the subcutaneous or perivascular space [1].
The extravasation results
in a reaction ranging from local irritation to severe tissue necrosis of the
skin, subcutaneous tissue, peripheral vascular system, ligaments or tendons
[1]. The most classical medicinal causes of skin necrosis associated with
injections are: Nicolau dermatitis corresponding to intra-arterial emboli of a
medicament normally injected intramuscularly (IM) (but cases after intradermal
mesotherapy are described); subcutaneous (SC) injections of a medicament intended for the IM route;
extravasation of a product of sclerosis of varicose veins or vascular
malformations, the chemotherapy extravasation, of carbonate or calcium
chloride, or potassium; necrosis at the injection sites with heparin; necrosis
at the injection sites of interferon in SC, necrosis due to extravasation of
contrast material [3].
In our knowledge no cases
of secondary cutaneous necrosis by extravasation of amoxicillin-clavulanic acid
has been reported. Is it therefore a direct toxicity of the antibiotic, favored
by a deleterious vascular bed on diabetes ground?
Beyond the functional and
vital risks, it is necessary to take into consideration the psychological
impact of the possible consequences of extravasation on the patient. Treated
according to the usual methods, necrosis leaves room for chronic wounds for
which healing is very long to obtain and requires the use of a secondary
surgical treatment [4].
- De Wit M, Ortner P, Lipp HP, Sehouli J, Untch M, Ruhnke M, et al.
(2013) Management of cytotoxic extravasation - ASORS expert opinion for
diagnosis, prevention and treatment. Onkologie 36: 127-135.
- Le A, Patel S (2014) Extravasation of Noncytotoxic
Drugs: A Review of the Literature. Ann Pharmacother 48: 870-886.
- Perceau G (2015) Les nécroses cutanées
d’origine toxique et médicamenteuse. JMV 40: 89-90.
- Reynolds
PM, MacLaren R, Mueller SW, Fish DN, Kiser TH. Management of extravasation injuries:
a focused evaluation of noncytotoxic medications.
- Pharmacotherapy (2014)
34: 617-632.
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