Characterizing Risk Factors and Outcomes of Peripheral IV Extravasation Injuries in Neonates
Marten N Basta, MD; Jonathan L Bass, MD, MS; Reena A Bhatt, MD
Brown University & Rhode Island Hospital, Providence, RI
Introduction Peripheral intravenous (IV) extravasation is not uncommon in the neonatal period, with published incidences between 30-50%. While severe tissue damage occurs less frequently, there is little margin of error in treating this patient population. Current management protocols are highly inconsistent and lack clinical validation. The purpose of this study was to characterize outcomes of IV extravasation injuries in neonates and determine if there are predisposing or protective clinical factors.
Materials & Methods An institutional review was conducted of all patients 1 year or younger experiencing IV infiltration or extravasation requiring hand specialist evaluation between 1/2012-4/2017. The primary outcome of interest was IV extravasation resulting in severe tissue injury, defined as Millam grade III/IV. Descriptive statistics, univariate tests of association, and regression analyses were used to investigate factors influencing outcome.
Results 108 patients experienced IV extravasation and were included for quantitative analysis. 75% were in the first week of life at the time of consultation. 49% of infiltrations occurred in the upper extremity, 41% were lower extremity, and 10% the scalp. 2 patients had infiltration with phenobarbital and propofol, respectively, the remainder were crystalloid or TPN solutions. Overall, 35% of patients received hyaluronidase.
11 patients (10%) had wounds classified Grade III/IV upon initial evaluation. Upper extremity extravasations were less likely to be high-grade (3.8% vs. 16.4% all others, p=0.05), while scalp infiltration was significantly more likely to result in high-grade wounds (36.4% vs. 7.2% all others, p=0.01). Hyaluronidase administration demonstrated slightly lower incidence of Grade III/IV wounds (5.3% vs. 12.9%) but this was not statistically significant. Delay in consultation by 1 or more days was associated with a 44% incidence of high grade wounds vs. 7% (p=0.006). Ultimately, no patients with Grade III/IV wounds required operative intervention and healed with local wound care; however, 1 patient with an ankle infiltrate experienced a 4th toe thromboembolism, which could not be salvaged. Independent predictors of high-grade wounds in logistic regression included extravasation site (OR=2.7, p=0.05) and delay in consultation (OR=7.0, p=0.03), respectively, with a highly predictive and discriminatory C-statistic=0.76.
Conclusions Although extravasation injuries rarely progress to require surgery, consequences can be devastating in neonates. This study indicates that low-grade wounds may not require specialist referral, but grade III-IV wounds prompt consultation and consideration of anatomic location to avoid significant morbidity. Furthermore, predictive risk modeling represents an evidence-based, accurate, and reliable means of anticipating clinical course in order to prevent further complications in this vulnerable patient population.
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