Table 28.1 Staging of Extravasation Injury (10)

Stage Characteristics

1 Pain at site—crying when IV cannula is flushed

IV cannula flushes with difficulty

No redness or swelling

2 Pain

Redness and slight swelling at site

Brisk capillary refill

3 Pain

Moderate swelling

Blanching of area

Skin cool to touch

Brisk capillary refill below site

Good pulse below site

4 Pain

Severe swelling around site

Blanching of area

Skin cool to touch

Area of skin necrosis or blistering

Prolonged capillary refill time (>4 s)

Decreased or absent pulse

Fig. 28.1. A: Stage IV extravasation injury with blistering of skin. B: Same area 2 weeks later, with eschar

formation.

154 Section V ■ Vascular Access

may be repeated every 8 hours if perfusion has

not improved (17)

Precautions: Absorption through the skin may

lead to hypotension.

Phentolamine (6,18)

i. Effective in treating extravasations of vasopressors such as dopamine and epinephrine, which

cause tissue damage by intense vasoconstriction

and ischemia

ii. Mechanism of action: Competitive alpha-adrenergic blockade, leading to smooth muscle relaxation and hyperemia

iii. Effect should be seen almost immediately; most

effective within 1 hour but may be used up to 12

hours. The biologic half-life of subcutaneous

phentolamine is <20 minutes.

iv. Doses have not been established for newborn

infants. The exact dose is dependent on the size

of the lesion and the size of the infant.

v. Recommended doses range from 0.01 mg/kg

per dose to 5 mL of 1-mg/mL solution.

vi. Administration: 0.5 to 1 mg/mL of solution

injected subcutaneously into infiltrated area,

after removal of IV catheter

vii. Precautions: Hypotension, tachycardia, and dysrhythmias may occur; use with extreme caution

in preterm infants; consider using repeated

small doses.

e. Wound management

(1) Goal: The goal of wound management in neonates who have partial- or full-thickness skin loss is

to achieve primary or secondary healing while avoiding scarring, contractures, and operative intervention. There are several purposes for dressing wounds.

(1) Maintain a moist pH-balanced environment to

promote re- epithelialization.

(2) Manage exudates.

(3) Decrease disruption of healing tissue.

(4) Provide an antimicrobial barrier to prevent local

and systemic infection.

(5) Decrease pain.

(2) Wound care: Wound care regimens differ among

experts and institutions (1,3,7,13,19). Consultation

with a wound ostomy care nurse is often helpful.

(1) Evaluate the wound: Size, depth, edges, wound

bed, presence of exudate, necrotic tissue, eschar,

undermining of margins, evaluation of skin

around the wound for signs of inflammation or

for maceration (13).

(2) Evaluate wound healing every day. Time to heal

ranges from 7 days to 3 months.

(3) Dressing changes can be painful. Consider

using comfort measures, sucrose, and analgesics, as needed.