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Phentolamine is available 5 mg (per 1 ml) vials (Regitine, ; manufactured by
Ciba-Novartis Pharmaceuticals). (Ref. 21). For treatment of an extravasation,
the contents of the vial should be diluted to 5-10 ml. A dose of 0.1 to 0.2
mg/kg (up to a maximum of 10 mg) should then be injected through the catheter or
subcutaneously around the site. As with hyaluronidase, phentolamine should be
administered as soon as the extravasation is detected, but may be given up to 12
hours later.
For Prevention: 10 mg of phentolamine mesylate is added to each liter of
solution containing norepinephrine. The pressor effect of norepinephrine is not
affected.
For Treatment: 5 to 10 mg of phentolamine mesylate in 10 mL of saline is
injected into the area of extravasation within 12 hours.
In brief, the treatment can be carried out either under local or general
anaesthetic.
If the treatment is to be carried out under local anaesthetic this is infused
into the subcutaneous space both beneath the zone of extravasation and around
it. Then into this zone is directed dilute Hyaluronidase. One vial containing
1500 units is diluted down with 10cc of saline and injected throughout the zone.
Once numbness of the area has been established, four small stab incisions around
the zone of extravasation injury are made. It is essential to have an infusion
cannula which has a sealed or blunt end and side holes to flush out this zone.
Such cannulae are widely available for use in rapid infusion prior to
liposuction.
Through the subcutaneous space beneath the area of extravasation, normal saline
is infused. It is planned that the saline go in through one of the stab
incisions and exit through the others. At various times throughout the
procedure, volumes of saline will collect in the subcutaneous space above and
below the treatment zone and this fluid needs milking down to exit through the
stab incisions. A thorough flush out of the extravasation space is required.
Large volumes of saline, up to 500mls are usually flushed through in 20cc of
30cc aliquots using a syringe and a blunt ended cannula.
After the flush out a layer of Jelonet and Betadine soaked gauze is applied to
the wound and the limb wrapped in a padded bandage and elevated for twenty-four
hours. The stab incisions are never sutured and are allowed to close
spontaneously. This flush out technique is now established as the most effective
way of removing extravasated material and it is well worth invoking the surgical
maxim “when in doubt get it out”.
In seriously debilitated patients, for example those with neutropenia, a short
course of prophylactic antibiotics is recommended.
Flush-out technique reproduced by kind permission of Mr David Gault -
Mr David Gault FRCS
Consultant Plastic Surgeon
The Portland Hospital
http://www.davidgault.co.uk
Hyaluronidase for CaCl Extravastion
150 units with NS added to make 1 cc. inject 0.2 cc of mixture in 5 separate places around the area
elevate with cold packs
http://www.extravasation.org.uk/home.html
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