Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 14  |  Issue : 2  |  Page : 50-54

The effectiveness of saline washout in the management of exytravasation of cytotoxics


1 Department of Surgery, University of Lomé, Sylvanus Olympio Teaching Hospital, Lomé, Togo
2 Department of Plastic Surgery, Hassan II University, Ibn Rochd Teaching Hospital, Casablanca, Morocco

Date of Web Publication28-Nov-2018

Correspondence Address:
Dr. Komla S Amouzou
Department of Surgery, University of Lomé, Sylvanus Olympio Teaching Hospital, Lomé
Togo
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njps.njps_12_18

Rights and Permissions
  Abstract 

Extravasation of cytotoxics is a dreaded complication of the intravenous route medication, especially in chemotherapy. The use of saline washout is insufficiently documented in the literature. Here, we report the excellent results of using saline washout in the management of these injuries. Three patients presenting extravasation of anthracycline, calcium gluconate, and radiologic contrast were treated in our department by saline washout. The technique was a use of saline to flush the extravasation area after liposuction of the body site injured. All patients were treated in an outpatient setting. No case of skin necrosis nor other complications related to the extravasation or to the surgical technique have been reported during the follow-up. Patients with extravasation should be referred to the plastic department at early stage. Saline washout is reliable technique to prevent skin and soft tissue necrosis caused by extravasation of cytotoxics.

Keywords: Cytotoxic, extravasation, liposuction, saline washout, skin necrosis


How to cite this article:
Amouzou KS, Malonga-Loukoula EJ, Haidara TM, Diouri M, Ezzoubi M. The effectiveness of saline washout in the management of exytravasation of cytotoxics. Nigerian J Plast Surg 2018;14:50-4

How to cite this URL:
Amouzou KS, Malonga-Loukoula EJ, Haidara TM, Diouri M, Ezzoubi M. The effectiveness of saline washout in the management of exytravasation of cytotoxics. Nigerian J Plast Surg [serial online] 2018 [cited 2019 Sep 16];14:50-4. Available from: http://www.njps.org/text.asp?2018/14/2/50/246153


  Key message Top


When extravasation of cytotoxics occurs, plastic surgeons are often consulted regarding managing skin necrosis. Nevertheless, the use of saline washout at an earlier stage can prevent the skin damage consecutive to extravasation of cytotoxics products. The results in three patients treated in our department add to those reported in the literature show the reliability and safety of saline washout in the management of extravasation of cytotoxics regarding skin and soft tissue damage.


  Introduction Top


Extravasation is defined as the accidental leakage into the extravascular space of a product given by the intravenous (IV) route.[1],[2] Products of chemotherapy, especially those with a vesicant property, lead to extended skin damage with extension to underneath osseofibrous structures, resulting in severe tissue damage and loss of function in the affected limbs.[2],[3],[4] Other substances such as radiologic contrast given by IV route can cause deep damage to the soft tissue, especially when their volume is high.[5] Although these complications are well known by oncologists and the majority of healthcare providers, most of the guidelines on the management of extravasation, including the dreaded form of anthracyclines, mentioned the opinion of a plastic surgeon lately at the stage of tissue necrosis.[2],[3],[6] These guidelines have ignored the role of saline washout reported as safe and reliable.[1],[2],[5],[7],[8],[9]

In this article, we aimed at reporting the good results of the use of saline washout in three cases of extravasation and to add to the few existing studies in the literature on this topic.


  Case history Top


The technique of saline washout

Patients were assessed for age, medical and social history, current treatments, medication given, the volume of product extravasated, the chief complains (pain, swelling, reduction of mobility), and the timing of presentation.

A clinical assessment was completed for the skin, presence of edema, and mobility after a quick general examination. When the indication was taken, the consent form was signed. The procedure was performed under sedation added to local anesthesia. The site of the extravasation was palpated and marked out [Figure 1]. A solution of 100 ml of normal saline added to 40 ml of 1% xylocaine was used to infiltrate the site of extravasation (2 ml/cm2). A prophylactic intraveinous 1 g of ceftriaxone was given. A small sharp blade 11 stab incision was performed that allowed a cannula of liposuction. We used a Mercedes liposuction 4-mm cannula. A superficial low-grade suction (200 mm Hg) was completed over the marked area. The superficial fat was preserved as much as possible. Other incisions were made on the boundaries of marked area [Figure 1]. A 300 to 500-ml saline equivalent to 5 to 10 ml of sterile saline solution per square cm was flushed out through the skin incisions. At the end of the procedure, the skin appeared tender and no swelling was detected on the site, and the joints were supple. The wounds were left open for a spontaneous healing. The patient was discharged the same day and reviewed in a scheduled 24 to 36 h, 1 week, and 2 weeks postoperative time. The site was inspected for pain, swelling, bruising, skin necrosis, and hematoma.
Figure 1: Delineation of the zone to be treated (A), with the liposuction cannula (B), skin incisions toward the delineated area

Click here to view


Case reports

Cases 1 and 2: A 58-year-old woman and 53-year-old man sustained epirubicin and calcium foliate extravasations, respectively, on the site of a permanent infusion device in the upper chest [Figure 2]. The patients were referred to our plastic and reconstructive department 1 h after the extravasation. There was no precision about the quantity of the product involved in the extravasation. The patients presented with a painful swelling of the right upper anterior trunk. The implantable chambers were removed, and a saline washout was performed. After 2 weeks follow-up, the skin was healthy, and no skin necrosis was observed [Figure 2]. The chemotherapy was continued by a catheter in another site without any delay.
Figure 2: Injured zones on the upper right chest (A and B), result after 4 days and 2 weeks (C and D)

Click here to view


Case 3: A young 13-year-old girl was referred from the Department of Radiology 2 h after the extravasation of radiologic contrast on the left cubital fossa during a computerized tomography (CT) scan procedure. The extravasation had been documented by upper limb radiography [Figure 3]. The quantity of product was estimated at 30 ml. She presented a swelling and painful upper forearm, elbow, and lower left arm with restriction in elbow flexion. She was treated by saline washout. The swelling subsided and the elbow flexion was normal postoperatively. The girl presented with a normal skin, and no complication occurred within 2-week follow-up.
Figure 3: Swelling over elbow and forearm postextravasation of contrast media (A), X-ray of the injured zone (B), presentation of the forearm and elbow at H24 (C), postoperative X-ray (D)

Click here to view



  Discussion Top


Many extravasation management protocols have been described according to the property of the product (vesicant vs. nonvesicant), volume, and site of the injury. Conservative measures include ice application, topical corticosteroids, and the use of specific antidotes. A time frame of 6 h is reported to result in success. Nevertheless, the clinical effectiveness remains to be documented in the use of many of these conservative measures.[2],[3],[5],[6] Only a few publications have mentioned the use of saline washout as an early treatment of extravasations.[5],[8],[9] In fact, chemotherapy drugs, especially anthracyclines that have a vesicant property, and many other drugs with a cytotoxic characteristic cause a skin necrosis that extends to the subcutaneous tissues including osseofibrous structures underneath the extravasation site. The result is a severe damage to these structures leading to complex deformities and disabilities.[4],[8] Even when the product has no cytotoxic property, the volume and site of the injury could be the cause of unfavorable outcome. Therefore, extravasation of radiologic contrast agents is seen as benign, especially when iodinated products are used, thus reducing the need for a plastic surgery consultation.[10] Nevertheless, Vinod et al.[10] reported a case of compartment syndrome and skin necrosis of the hand after the extravasation of an iodinated product. In our case, as reported by other authors, the saline washout performed in a time frame of 24 h yielded good results. In addition, Dionyssiou et al.[8] presented a series of 48 patients treated with saline washout for extravasation of anthracyclines and reported that 19 patients treated between the third day and the second week postextravasation achieved excellent results. In the washout procedure, the saline solution is believed to dilute the product in the site of extravasation, thus decreasing the vesicant effect. Then superficial liposuction in the wet environment, followed by a washout, removes the product from the site of extravasation consequently, avoiding further skin complications.[7],[9] In our practice, the first infiltration of saline is added to xylocaine that provide anesthesia for the rest of the procedure. Possible early complications include hematoma, bruising, and skin necrosis.[5],[9] The latter is due to insufficient treatment or an aggressive liposuction. In the late postoperative course, skin retraction and adherence due to aspiration of the superficial fat can be seen. By following a rigorous procedure, avoiding total superficial fat suction, and washing the site of extravasation abundantly, any of the complications mentioned above has occurred in the patients of this study.

In summary, saline washout is an effective procedure that every plastic surgeon needs in his armamentarium. The equipment should be kept ready to treat the patients without delay. Staff, especially in oncologic centers, should be educated on referring patients after extravasation to a plastic surgery department before the onset of soft tissue necrosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


  Acknowledgment Top


The authors are grateful to INASP, that provided a voucher for a free language editing in the American Journal of Experts.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Khan MS, Holmes JD. Reducing the morbidity from extravasation injuries. Ann Plast Surg 2002;48:628–32.  Back to cited text no. 1
    
2.
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.  Back to cited text no. 2
    
3.
Kreidieh FY, Moukadem HA, El Saghir NS. Overview, prevention and management of chemotherapy extravasation. World J Clin Oncol 2016;7:87–97.  Back to cited text no. 3
    
4.
Amouzou KS, Berny N, Haidara TM, Chlihi A, Ezzoubi M. Surgical management of a hand extravasation of anthracycline at late presentation. J Surg Dermatol 2017;2:83–5.  Back to cited text no. 4
    
5.
Giunta R. Early subcutaneous wash-out in acute extravasations. Ann Oncol 2004;15:1146–6.  Back to cited text no. 5
    
6.
Harrold K, Gould D, Drey N. The management of cytotoxic chemotherapy extravasation: A systematic review of the literature to evaluate the evidence underpinning contemporary practice. Eur J Cancer Care (Engl) 2015;24:771–800.  Back to cited text no. 6
    
7.
Harrold K, Gould D, Drey N. The efficacy of saline washout technique in the management of exfoliant and vesicant chemotherapy extravasation: A historical case series report. Eur J Cancer Care (Engl) 2013;22:169–78.  Back to cited text no. 7
    
8.
Dionyssiou D, Chantes A, Gravvanis A, Demiri E. The wash-out technique in the management of delayed presentations of extravasation injuries. J Hand Surg Eur Vol 2011;36:66–9.  Back to cited text no. 8
    
9.
Martin PH, Carver N, Petros AJ. Use of liposuction and saline washout for the treatment of extensive subcutaneous extravasation of corrosive drugs. Br J Anaesth 1994;72:702–4.  Back to cited text no. 9
    
10.
Vinod KV, Shravan R, Shrivarthan R, Radhakrishna P, Dutta TK. Acute compartment syndrome of hand resulting from radiographic contrast iohexol extravasation. J Pharmacol Pharmacother 2016;7:44–7.  Back to cited text no. 10
[PUBMED]  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Key message
Introduction
Case history
Discussion
Acknowledgment
References
Article Figures

 Article Access Statistics
    Viewed568    
    Printed88    
    Emailed0    
    PDF Downloaded7    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]