Case Report

Extravasation Injury of the Upper Limb by

Intravenous Clindamycin
Dahal P,* Shrestha JM**
*Consultant surgeon, Associate Proffesor, TUTH

ABSTRACT
Intravenous drug administration is a common practice in all hospitals. It can cause minor complications
like thrombophlebitis to severe complications like local skin necrosis, and severe soft tissue necrosis. It
can also cause severe disability. Attention and caution is necessary in the intravenous administration
of irritant drugs.

INTRODUCTION

I ntravenous fluids and drugs administration is a routine

procedure for nurses. Extravasation or infiltration
occurs when fluids or medications administered by
factor.In this article, a patient with extravasation of
intravenous Clindamycin is described with literature
review.
the intravenous route penetrates the perivascular or
subcutaneous space. All intravenous fluids can cause CASE REPORT
tissue injury following extravasation. However, certain
A 14 years boy was admitted to the hospital for the
substances such as cytotoxic or vasoactive drugs and
treatment of empyema thoracic with sepsis. He had
hyperosmolar agents are associated with a greater
the history of seizure disorders in the past and he was
risk of tissue injury. The complications may range from
regularly taking phenytoin orally. At the time of hospital
minor (ecchymosis, hematoma and phlebitis) to severe
admission peripheral intravenous line was open and
form (extravasation causing tissue necrosis).
intravenous Clindamycin(Dalacin) and Amikacin was
The reported incidence of complications of administered. He developed painful swelling in the
extravasation is very difficult to obtain in the literatures. right forearm immediately after administration of drug.
Some studies have reported the extravasation of When the swelling and pain increased this intravenous
vesicant chemotherapy in children by 11% and in line was removed. Central venous pressure line was
adults by 22%.1But there are different case reports placed, thoracotomy was done but the swelling of
on extravasation of different cytotoxic agents in the forearm increased gradually and extended up to the
literatures but no literature was found about the tissue lower part of arm. The skin became black(Figure: 1) on
injury due to extravasation of intravenous clindamycin. the seventh day.Then hewas referred to plastic surgery
unit with wrist drop on the 15th day after thoracotomy.
Extravasation induces prolonged hospital stay
of patient, unnecessary diagnostic procedures,
treatment, disability and stress in the life of the
patients andto their relatives. The economic loss and
medico legal complications areanother important

Correspondence :
Dr Peeyush Dahal
Figure 1.
Burn& Plastic Surgery Unit
National Academy of Medical Sciences The wound was debrided immediately. Common
Bir Hospital, Kathmandu extensor muscles were necrosed at their proximal part
Email: [email protected] and were necrosed partially at the distal part. Upper

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PMJN
Postgraduate Medical
Journal of NAMS
 Extravasation Injury of the Upper Limb by Intravenous Clindamycin

part of theradius was exposed and the elbow joint DISCUSSION

space was opened (figure: 2).
Extravasation is defined either as the escape of
a chemotherapeutic agent from a vessel into
the surrounding tissues by leakage or as an
involuntary injection of a drug into the tissues2. The
chemotherapeutic agents may be vesicants or the
irritants and extreme ph causes decrease vein tolerance
and rupture leading to extravasation. Author could
Figure 2.
not find a single literature regarding extravasation of
The raw area was covered with thick split thickness skin intravenous clindamycin.
graft and the bone was covered with fasciocutaneous
Irritants are drugs that can cause an inflammatory
abdominal flap(Figure 3&4).
reaction, aching, swelling, pain or phlebitis at the
injection site or along the vein. Generally symptoms
are self-limiting and usually there are no long-term
sequelae. But Symptoms may arise immediately
orseveral days or weeks after extravasation of vesicant
drugs. The severity of tissue injury is dependent on
the type, concentration and quantities of the injected
chemotherapeutic agent. It may cause severe and
lasting tissue injury and necrosis and sometimes
leading to disability.

Review of the literature has revealed case reports of

devastating tissue injuries(skin with or without muscle
necrosis following cysplatin3, Mitomycin4 phenytoin5
Figure 3. extravasation. It is also found that the antibiotic,
diuretics, dextrose extravasation has induced severe
tissue injuries requiring reconstructive surgery.6

There different modalities of the treatment of the

acute stage of this complication which include general
measures like elevation of the involved extremity
and application of coldcompresses to minimize the
inflammatory reactions7, 8. The use hyaluronidase,
phentolamineinjections and glyceryl trinitrate patches
Figure 4.
topromote drug absorption are also found9, 10, 11, 12.
Flap was detached after four weeks (Figure 5) and Saline flush-outhas been used to dilute the drug. Some
he was discharged by planning for tendontransfer to authorsadvocate specific antidotes as the mainstay
correct the wrist drop. of treatment8.Early surgical debridement and skin
grafting have also beenrecommended13.

The systemic approach with some guide lines help for

prompt and effective management. For this purpose
Millam’s Classification (Table no.1)6 would be useful.
Millam proposed conservative treatment for Stages
I and II, and intervention for Stages III and IV. Stages
III and IV infiltrates require prompt and aggressive
intervention. Some exit stab incisions under local or
Figure 5. general anesthesiaare made around the periphery

52 Volume 11│Number 2│Jul-Dec 2011

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Postgraduate Medical
Journal of NAMS
 Extravasation Injury of the Upper Limb by Intravenous Clindamycin

of the area of extravasation and saline isinjected for REFERENCES

flushing.Hyaluronidase, glyceryltrinitrate are other 1. L. Hadaway, Infiltration and extravasation, preventing a
agents to reduce the ongoing tissue injury. There are complication of IV catheterization. AJN, 2007, 107 (8):
specific antidotes for specific agents like anthracyclines, 64-72,
mitomycin C and mustine14. 2. D. L.Schrijvers Extravasation: a dreaded complication of
chemotherapy. Annals of Oncology 14 (Supplement 3):
Table 1. Staging of intravenous (IV) infiltrates 26–30, 2003.
Stage Features 3. O. Bairey, M. Shakali, J. Bashara. Severe tissue necrosis
I Painful IV site after Cysplatin Extravavasation at Low Concerntration:
No erythema possible “Immediate Recall Phenomenon”.J Natl Cancer
No swelling Inst 1997, 89 (16): 1233-1234.
II Painful IV site 4. E. U. Avdal, N. Aydinoğlu. Extravasations of Vesicant /
Slight swelling (0%–20%) Non- Vesicant Drugs andEvidence – Based Management:
No blanching Int J Caring Sciences 2012, 5(2): 192-202.
Good pulse below infiltration site 5. J. J. Edwards, V Bosek. Extravasation Injury of the Upper
Brisk capillary refill below infiltration site Extremity by intravenous phenytoinAnesthAnalg 2002,
III Painful IV site 94; 672-3.
Marked swelling (30%-50%) 6. REC Rose, R Felix, A Crawford-Sykes, R Venugopal, G
Blanching Wharfe, G Arscott; Extravasation Injuries; West Indian
Med J 2008; 57 (1): 40-47
Skin cool to touch
Good pulse below infiltration site 7. DLLarson. What is the appropriate management of tissue
extravasationby antitumor agents? Plast Reconstr Surg
Brisk capillary refill below infiltration site
1985; 75: 397–405.
IV Painful IV site
8. D. Casanova, J Bardot, GMagalon. Emergency treatment
Very marked swelling (75%)
of accidentalinfusion leakage in the newborn: report of
Blanching 14 cases. Br J Plast Surg2001; 54: 396–9
Skin cool to touch
9. DCasanova, J Bardot, G Magalon. Emergency treatment
Decreased or absent pulse* of accidentalinfusion leakage in the newborn: report of
Capillary refill > four seconds* 14 cases. Br J Plast Surg2001; 54: 396–9.
Skin breakdown or necrosis 10. R.G. Dufresne. Skin necrosis from intravenously infused
* The presence of any one of these characteristics materials.Cutis 1987; 39: 197–8
constitutes a Stage IV infiltrate. 11. L. Flemmer, JSL Chan. A pediatric protocol for
management of extravasation injuries. Pediatr Nrusing
CONCLUSION 1993; 19: 355–8, 424.
Intravenous extravasations of clindamycin may cause 12. 24. O’Reilly C, McKay FMA, Duffy P, Lloyd DJ.
Glyceryl trinitrate in skinnecrosis caused by extravasation
devastating complication as other chemotherapeutic
of parenteral nutrition. Lancet 1988;2: 565–6.
agents. Safe Medication practices, precaution,
13. Linder RM, Upton J, Osteen R. Management
awareness and intravenous drug administration
of extensive doxorubicinhydrochloride extravasation
guideline should be established to minimize injuries. J Hand Surg 1983; 8: 32–8.
extravasations. Prompt recognition and intervention
14. Bertelli G. Prevention, management of extravasation of
also reduce the incidence of tissue necrosis leading to cytotoxicdrugs. Drug Saf 1995; 12: 245–55.
disability.

Volume 11│Number 2│Jul-Dec 2011 53

PMJN
Postgraduate Medical
Journal of NAMS