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Novel management of methylene blue extravasation: A case report and review of literature.

Khokhar RS, Aqil M, Al-Zahrani T, Gelidan A, Al Khayal K - Saudi J Anaesth (2015 Apr-Jun)

Bottom Line: Methylene blue is a highly irritant drug and has been used intraoperatively.Its accidental extravasation can lead to tissue necrosis.In this report, a unique management is described, and the patient recovered without any morbidity.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesia, College of Medicine, King Saud University, Riyadh, Saudi Arabia.

ABSTRACT
Methylene blue is a highly irritant drug and has been used intraoperatively. Its accidental extravasation can lead to tissue necrosis. In this report, a unique management is described, and the patient recovered without any morbidity.

No MeSH data available.


Related in: MedlinePlus

Methylene blue extravasation
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Figure 1: Methylene blue extravasation

Mentions: A 79-year-old female, 72 kg, American Society of Anesthesiologists physical status 2, belonging to black race (Fitzpatrick class 5), was diagnosed of having ascending colon carcinoma, along with subcutaneous chest and abdominal nodules. She was scheduled for laparoscopic right hemi-colectomy under general anesthesia (GA). On the day of surgery, the patient reported to the operating room having a 20G cannula on the right hand. She received GA with endotracheal intubation. After induction of GA, an additional 18G intravenous (IV) cannula was inserted on the dorsum of the right hand (close to the wrist joint) after multiple attempts and was attached to an infusion pump delivering Lactated Ringer's (LR) solution at 400 ml/h. It was a difficult IV cannulation as she was an old lady with dark skin color in addition to having fragile, tortuous veins, most of which were previously pricked due to a couple days’ worth of preoperative IV infusions. For surgery, the surgical team positioned the patient, tucked both of her upper limbs alongside the body and started the operation. Surgical dissection was difficult due to multiple adhesions and a suspicion of tumor invasion into the right kidney. Totally, 2 h into the operation, the surgeon suspected a right ureteric injury and requested to administer IV MB for localization. 1% w/v sterile MB injection, 1 mg/kg (diluted in 20 ml of LR solution) infused manually over 10 min through 18G IV cannula on the left hand dorsum (which was continuously infusing IV fluids through an infusion pump) without any significant resistance. After the administration of the MB, the previous infusion was started again at the same rate through the infusion pump. After about 30 min of the MB injection, the surgeon decided to convert the procedure to open exploratory laparotomy due to surgical difficulties. The position of the patient was changed again for the open procedure, and both upper limbs were abducted and kept on the side arm supports of the operating table. At this moment, we noted blue discoloration and swelling on the dorsum of the left hand along with blisters, which were extending upward beyond the wrist and measured about 10 cm × 10 cm [Figure 1]. There was minimal swelling of the digits also. The capillary circulation of the digits was well preserved, and capillary refill time was <2 s. The surgeon was notified about the incident. We attempted removal of the extravasated fluid through the cannula by aspiration with a syringe, but only 2-3 ml fluid could be retrieved and therefore the IV cannula was removed. Urgent consultation with a plastic surgeon was sought, who planned immediate liposuction of the swelling. Liposuction without infiltration of tumicen fluid was carried out straightaway, and about 50 ml of the blue colored fluid was retrieved from the swelling and the hand was dressed and immobilized by a splint. Surgical procedure (hemicolectomy) went uneventful, and the patient was shifted to a high dependency unit after the operation. On 1st postoperative day, the hand swelling had reduced significantly (with no vascular impairment), and there was only the loss of superficial skin (epidermis). Patient stayed in the hospital for 10 days and during this period, the plastic surgeons reviewed her on a daily basis. On subsequent visits to the clinic, it was found that she had complete healing of the skin damage with no need for skin grafting and had no neurological dysfunction of the hand.


Novel management of methylene blue extravasation: A case report and review of literature.

Khokhar RS, Aqil M, Al-Zahrani T, Gelidan A, Al Khayal K - Saudi J Anaesth (2015 Apr-Jun)

Methylene blue extravasation
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4374232&req=5

Figure 1: Methylene blue extravasation
Mentions: A 79-year-old female, 72 kg, American Society of Anesthesiologists physical status 2, belonging to black race (Fitzpatrick class 5), was diagnosed of having ascending colon carcinoma, along with subcutaneous chest and abdominal nodules. She was scheduled for laparoscopic right hemi-colectomy under general anesthesia (GA). On the day of surgery, the patient reported to the operating room having a 20G cannula on the right hand. She received GA with endotracheal intubation. After induction of GA, an additional 18G intravenous (IV) cannula was inserted on the dorsum of the right hand (close to the wrist joint) after multiple attempts and was attached to an infusion pump delivering Lactated Ringer's (LR) solution at 400 ml/h. It was a difficult IV cannulation as she was an old lady with dark skin color in addition to having fragile, tortuous veins, most of which were previously pricked due to a couple days’ worth of preoperative IV infusions. For surgery, the surgical team positioned the patient, tucked both of her upper limbs alongside the body and started the operation. Surgical dissection was difficult due to multiple adhesions and a suspicion of tumor invasion into the right kidney. Totally, 2 h into the operation, the surgeon suspected a right ureteric injury and requested to administer IV MB for localization. 1% w/v sterile MB injection, 1 mg/kg (diluted in 20 ml of LR solution) infused manually over 10 min through 18G IV cannula on the left hand dorsum (which was continuously infusing IV fluids through an infusion pump) without any significant resistance. After the administration of the MB, the previous infusion was started again at the same rate through the infusion pump. After about 30 min of the MB injection, the surgeon decided to convert the procedure to open exploratory laparotomy due to surgical difficulties. The position of the patient was changed again for the open procedure, and both upper limbs were abducted and kept on the side arm supports of the operating table. At this moment, we noted blue discoloration and swelling on the dorsum of the left hand along with blisters, which were extending upward beyond the wrist and measured about 10 cm × 10 cm [Figure 1]. There was minimal swelling of the digits also. The capillary circulation of the digits was well preserved, and capillary refill time was <2 s. The surgeon was notified about the incident. We attempted removal of the extravasated fluid through the cannula by aspiration with a syringe, but only 2-3 ml fluid could be retrieved and therefore the IV cannula was removed. Urgent consultation with a plastic surgeon was sought, who planned immediate liposuction of the swelling. Liposuction without infiltration of tumicen fluid was carried out straightaway, and about 50 ml of the blue colored fluid was retrieved from the swelling and the hand was dressed and immobilized by a splint. Surgical procedure (hemicolectomy) went uneventful, and the patient was shifted to a high dependency unit after the operation. On 1st postoperative day, the hand swelling had reduced significantly (with no vascular impairment), and there was only the loss of superficial skin (epidermis). Patient stayed in the hospital for 10 days and during this period, the plastic surgeons reviewed her on a daily basis. On subsequent visits to the clinic, it was found that she had complete healing of the skin damage with no need for skin grafting and had no neurological dysfunction of the hand.

Bottom Line: Methylene blue is a highly irritant drug and has been used intraoperatively.Its accidental extravasation can lead to tissue necrosis.In this report, a unique management is described, and the patient recovered without any morbidity.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesia, College of Medicine, King Saud University, Riyadh, Saudi Arabia.

ABSTRACT
Methylene blue is a highly irritant drug and has been used intraoperatively. Its accidental extravasation can lead to tissue necrosis. In this report, a unique management is described, and the patient recovered without any morbidity.

No MeSH data available.


Related in: MedlinePlus