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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 3  |  Page : 172-175

Skin necrosis after extravasation of intravenous vancomycin in a 1-month-old infant: A case report and description of treatment options


1 Department of Nursing, School of Nursing and Midwifery, Qom University of Medical Sciences, Qom, Iran
2 Department of Epidemiology and Biostatistics, Research Center for Environmental Pollutants, Qom University of Medical Sciences, Qom, Iran

Date of Web Publication6-Aug-2019

Correspondence Address:
Dr. Abolfazl Mohammadbeigi
Department of Epidemiology and Biostatistics, Research Center for Environmental Pollutants, Qom University of Medical Sciences, Qom
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.JCN_108_18

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  Abstract 


In this case report, we describe a patient with extravasation injury with vancomycin given through a peripheral catheter. Extravasation occurs more in children and old people. A 1-month-old girl came to the hospital complaining of lethargy, poor feeding, fever, dyspnea, coughing, and cyanosis and was admitted in the neonatal department. The patient was diagnosed with pneumonia after blood tests and chest radiography. On the 2nd day of treatment, the nurse noticed extravasation of vancomycin with severe painful blistering surrounding the infusion site on the patient's left leg. Necrotic ulcer at the vancomycin leakage site was visible. Moreover, according to the surgeon, necrotic ulcer needed debride. However, modern dressing with collagen besides the combination dressing of Aquasel Ag+, foam Aquasel, and ColActive collagen was used for treatment. The patient's wound was improved with modern dressing and was recovered after 31 days. She was discharged from the hospital without a certain problem.

Keywords: Collagen dressing, extravasation, hydrocolloid dressing, necrosis, new dressing, vancomycin


How to cite this article:
Ahmadli R, Farshadpour N, Kaffash Z, Mohammadbeigi A. Skin necrosis after extravasation of intravenous vancomycin in a 1-month-old infant: A case report and description of treatment options. J Clin Neonatol 2019;8:172-5

How to cite this URL:
Ahmadli R, Farshadpour N, Kaffash Z, Mohammadbeigi A. Skin necrosis after extravasation of intravenous vancomycin in a 1-month-old infant: A case report and description of treatment options. J Clin Neonatol [serial online] 2019 [cited 2019 Aug 21];8:172-5. Available from: http://www.jcnonweb.com/text.asp?2019/8/3/172/264031




  Introduction Top


Extravasation is the accidental injection or leakage of fluid into the subcutaneous or perivascular tissues.[1] The extravasation occurs more in children whose blood vessels are small and cannot express their pain, and in the elderly whose blood vessels and skin are fragile. In addition to commonly used fluid such as normal saline and dextrose water, electrolytes, calcium, anticancer drugs, and some other medications also cause drug leakage injuries.[2] Recognition of extravasation injury can be difficult but is important because skin necrosis can be prevented with immediate treatment in some cases.[3] Vancomycin is related with some complications such as Red-man syndrome, hypersensitivity, reversible neutropenia, thrombocytopenia and agranulocytosis, ototoxicity, and nephrotoxicity, urticaria, exfoliative dermatitis, macular rashes, eosinophilia, vasculitis, transient anaphylaxis, vascular collapse, Stevens–Johnsons syndrome, and toxic epidermal necrolysis.[4],[5] We report a case of the skin necrosis after the intravenous (IV) vancomycin extravasation in a 1-month-old infant and describe of treatment options.


  Case Report Top


A 1-month-old girl came to the hospital complaining of lethargy, poor feeding, fever, dyspnea, coughing, and cyanosis and was admitted in the neonatal department. The patient was diagnosed with pneumonia after blood tests and chest radiography. Dextrose serum with ampicillin, cefotaxime, and vancomycin was started as doctor's order. The 1st day of antibiotics was successfully administered without any incident. On the 2nd day of treatment, the nurse noticed extravasation of vancomycin with severe painful blistering surrounding the infusion site on the patient's left leg [Figure 1]. Severe pain with edema and inflammation around the injection site at the left side of the patient were seen. Necrotic ulcer at the vancomycin leakage site was visible. We removed the catheter immediately after the extravasation of vancomycin [Figure 2] and applied a cold pack. The site of the damage was elevated. The patient was advised for plastic surgery. Moreover, according to the surgeon, necrotic ulcer needed debride, which was treated with modern dressing. DuoDerm gel and dressing hydrocolloid had been used for cleaning and otolithic debride. After three sessions, the skin necrosis was debrided. From the fourth session, for complete cleaning used alginate and hydrocolloid dressing [Figure 3]. During the seventh session, due to excessive wound secretion for two sessions, hydro-fiber dressing (Aquacel Ag) was used [Figure 4]. Then, the wound was improved using the collagen dressing after two sessions [Figure 5]. The patients wound was improved with a modern dressing after 31 days.
Figure 1: The lesion after vancomycin extravasation

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Figure 2: Cleaning the necrosis with DuoDerm gel and hydrocolloid dressing

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Figure 3: Complete cleansing of necrotic alginate and hydrocolloid dressing

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Figure 4: Use of hydrofiber dressing (Aquacel Ag)

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Figure 5: Restoration of the skin after using ColActive collagen

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  Discussion Top


Extravasation refers to the process by which one substance (e.g., fluid, drug) leaks into the surrounding tissue and includes the injury which occurs the following extravasation. The degree of injury can range from a very mild skin reaction to severe necrosis.[6] Tissue injuries due to the extravasation of IV drugs have a variety of features, from edema and redness to infection and necrosis. When fluids such as normal saline or dextrose water extravasate and cause edema or redness, almost all lesions improve to normal conditions after conservative management.[2] Risk factors for drug extravasation included neonates and small children; small fragile veins; chronic diseases; cancer; peripheral vascular disease; those who are unable to communicate, for example, sedated, unconscious, confused; and those who have undergone repeated IV cannulation and IV placement across areas of flexion (wrist and antecubital fossa).[7] Vancomycin is acidic (pH 2.5–4.0) and hyperosmolar (328 mOsm/L), which may make it a vesicant when administered through a peripheral line. Bohm and Wong describe bullous dermatitis as a result of vancomycin extravasation.[8] Extravasation guidelines specifically cite vancomycin as a potential cause, recommending the use of cold compress in the event of extravasation. In this case, we used a cold compress for the first 24 h to reduce congestion, and we used a new dressing for wound healing. In this study, hydrocolloidal dressing was used for wound debridement. Dissemond et al. showed that a moist wound milieu promoted wound healing. In addition to necrotic areas, fibrin, crusts, or dressing remnants must also be removed.[9] Siddique et al. stated that hydrocolloid dressings are impermeable dressings that provide an optimal environment for wound healing.[10]

Then, alligat and hydrocolloid dressing were used to clean the wound. Alginate products consist of a loose dressing structure made up of fibers which are composed of red or brown algae. After contact with sodium salts present in the blood or in wound secretions, the alginate fibers absorb the secretions to form a moist hydrophilic gel; bacteria are enclosed in the gel structure. The speed and amount of gel formation depend on the amount of exudate absorbed, and the fiber weave alginates are capable of absorbing up to 20 times their own weight. Alginates are used for deep, jagged, or heavily exuding wounds, either for wound cleansing or to promote granulation for clinically infected wounds, the dressing should be changed daily. For all other wounds, a new dressing should be placed every 2–5 days, depending on the amount of exudate.[9]

The hydrophobic dressing (Aquacel Ag) was used for two sessions of wound healing due to large amount of exudate. Hydrofibers or aquafibers are composed of sodium carboxyl cellulose. Fluid absorption occurs vertically only. Hydrofiber products may be used for wounds with a large amount of exudate to promote granulation and for wound cleansing. The hydrofiber dressing is placed on the wound and may extend over the wound margin. The wound should be covered with a secondary dressing. The dressing should be changed after 1–3 days.[11]

Finally, the wound was improved using the collagen dressing after two sessions. Collagen is a biomaterial that encourages wound healing through deposition and organization of freshly formed fibers in the wound bed, thus creating a good environment for wound healing.[12] Biological dressings like collagen are impermeable to bacteria and create the most physiological interface between the wound surface and the environment. Collagen dressings have other advantages over conventional dressings in terms of ease of application and being natural, nonimmunogenic, hypoallergenic, and pain free. Collagen may be used for the promotion of granulation and epithelization, especially in previously stagnant wound healing. Due to their hemostatic properties, they are also used after surgical debridement. Collagen sheets, when applied to a wound, not only promote angiogenesis but also enhance body's repair mechanisms. The role of collagen dressing in better pain control and superior wound healing is found in the literature.[9],[13]

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

We would like to thank the staff of the Pediatric Intensive Care Unit, Hazrat Masoumeh Hospital, for providing in nursing care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lake C, Beecroft CL. Extravasation injuries and accidental intra-arterial injection. Contin Educ Anaesth Crit Care Pain 2010;10:109-13.  Back to cited text no. 1
    
2.
Kim YH, Kim YD. A case of skin necrosis after extravasation of intravenous immunoglobulin. Pediatr Ther 2012;2:2161-665.  Back to cited text no. 2
    
3.
van der Wal G, Janssen JC, Spronk PE. Extravasation injury by norepinephrine: A case report and description of treatment options. Cancidase 2007;33:9.  Back to cited text no. 3
    
4.
Vincent P, Sasson E. Vancomycin extravasation: Evaluation, treatment, and avoidance of this adverse drug event. Case Rep Intern Med 2016;3:40.  Back to cited text no. 4
    
5.
Hoelen DW, Tjan DH, van Vugt R, van der Meer YG, van Zanten AR. Severe local vancomycin induced skin necrosis. Br J Clin Pharmacol 2007;64:553-4.  Back to cited text no. 5
    
6.
Nurse C, Anderson W, Williamson S, Jones G, Rushbrooke S. Guidelines for the Management of Extravasation. 2016. Available from: http://www.northerncanceralliance.nhs.uk/wp-content/uploads/2018/11/NECN-Guidelines-for-Management-of-Extravasation-v5.5-Nov-2016.pdf. [Last accessed on 2019 May 30].  Back to cited text no. 6
    
7.
Martin SM. Extravasation management of nonchemotherapeutic medications. J Infus Nurs 2013;36:392-6.  Back to cited text no. 7
    
8.
Bohm NM, Wong JG. Bullous dermatosis associated with vancomycin extravasation. Am J Med Sci 2012;343:177-9.  Back to cited text no. 8
    
9.
Dissemond J, Augustin M, Eming SA, Goerge T, Horn T, Karrer S, et al. Modern wound care-practical aspects of non-interventional topical treatment of patients with chronic wounds. J Dtsch Dermatol Ges 2014;12:541-54.  Back to cited text no. 9
    
10.
Siddique K, Mirza S, Housden P. Effectiveness of hydrocolloid dressing in postoperative hip and knee surgery: Literature review and our experience. J Perioper Pract 2011;21:275-8.  Back to cited text no. 10
    
11.
Barnea Y, Weiss J, Gur E. A review of the applications of the hydrofiber dressing with silver (Aquacel Ag) in wound care. Ther Clin Risk Manag 2010;6:21-7.  Back to cited text no. 11
    
12.
Ramesh BA, Jayalakshmi BK, Mohan J. A comparative study of collagen dressing versus petrolatum gauze dressing in reducing pain at the donor area. J Cutan Aesthet Surg 2017;10:18-21.  Back to cited text no. 12
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13.
Singh O, Gupta SS, Soni M, Moses S, Shukla S, Mathur RK, et al. Collagen dressing versus conventional dressings in burn and chronic wounds: A retrospective study. J Cutan Aesthet Surg 2011;4:12-6.  Back to cited text no. 13
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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