An infant with hand dorsal compartment syndrome due to intravenous infiltration of glucose-acetate Ringer's solution

doi:10.21203/rs.3.rs-2730714/v1

Introduction: Compartment syndrome caused by infusion pump in children has not been sufficiently reported.

Case presentation: A five-month-old boy was admitted to the hospital and underwent decompression of a dorsal hand compartment while receiving only glucose-acetate Ringer's solution.

Conclusion: Infiltration, a commonly seen complication with intravenous fluids and their administration, can cause compartment syndrome due to a variety of factors and should be treated promptly when infiltration or extravasation is detected. Guidelines and recommendations for the management of such cases have not been sufficiently described, and specific guidelines to prevent and detect fluid leakage early in infants are necessary.

Compartment syndrome

Intravenous infiltration

Glucose-acetate Ringer's solution

Compartment syndrome of the extremities is a condition in which there is a sudden increase in pressure within a muscle compartment.¹ It can be caused by a variety of factors, including fracture, burn, delivery trauma, and reperfusion, but infusion pump-induced compartment syndrome has not been sufficiently reported, especially in pediatric cases.²

We herein report the youngest case yet of right-hand dorsal compartment syndrome that developed during infusion of glucose-acetate Ringer's solution and was treated with reduction tension incision.

A five-month-old boy born to healthy Japanese parents was admitted to the hospital for a close examination and treatment because of the appearance of black stool since the day before admission.

At admission, he was conscious and clear. His temperature was 37.9 °C, and he had no respiratory disturbance or tachycardia. There were no abnormalities in his physical examination. After admission, he was started on fasting glucose-acetate Ringer's solution (Na⁺ 130 mEq/L, K^-4 mEq/L, Cl^- 109 mEq/L, Ca²⁺ 3 mEq/L, acetate 28 mEq/L, glucose 5.0 g/dL) at 35 ml/h as replacement fluid. At 6:00 on the fourth day of hospitalization, the right dorsal hand, which was the puncture site of the peripheral venous system that had been checked every three hours, was swollen, so the needle was removed and re-secured at a different site. The patient was in a good mood, and the capillary refilling time was less than two seconds, but the right radial artery was not palpable, and there was blister formation.

The patient's decompression and swelling improved (Figure 1). The wound was opened and washed daily. The wound was sutured closed on the sixth day of hospitalization because of its shrinking trend. The wound was debrided on the 15th day of admission due to some necrotic tissue. Thereafter, epithelialization improved with washing, trafermin spray, topical antimicrobial application, and gauze protection. The patient's general condition was confirmed to be good, and he was discharged on the 24th day of admission. Thereafter, however, there was no functional impairment in the right hand.

Compartment syndrome of the forearm in children is generally caused by fracture, but compartment syndrome caused by infusion or intravenous administration has been reported in a few cases.²The term “infiltration” is defined as the accidental leakage of a non-necrotic agent into surrounding tissues, while extravasation is defined as the accidental leakage of a necrotic agent into surrounding tissues.³As fluid passes from the intravenous tubing into the narrow-gauge intravenous catheter, the rate of fluid movement increases exponentially. The high-velocity fluid exiting the tip of the catheter results in high pressure, damaging the venous wall and causing leakage of the drug into the perivascular area.⁴ In addition, infiltration or extravasation of fluids or intravenous administration causes the surrounding tissue pressure to exceed the intracompartmental pressure. This increases venous pressure, which in turn further increases the intracompartmental pressure due to increased tissue pressure from the stasis of blood flow. ⁵

In the present study, we reported a child who presented with forearm compartment syndrome caused by infiltration or extravasation, and similar cases were reviewed in the academic article database PubMed and the Japanese article database I-Chu-Shi, under the headings of “infiltration and compartment syndrome” (Table1). The median age of the 10 previous cases was 6 months (4 months to 9 years). Nine of the 10 cases occurred at the forearm or dorsum of the hand; this high prevalence may be due to the fact that the dorsum of the hand is the most common insertion site for venous catheters in children.

The delay in detection of compartment syndrome due to infiltration or extravasation can be attributed to four factors: first, the use of pressurization devices may play a role. In adults, there have been scattered reports of forearm compartment syndrome due to intraoperative infusion of large volumes of fluid under pressure, ^{6, 7}but in the present case, there was no rapid intravenous administration or infusion of fluids, nor was any extravasation-prone drug administered. However, a pressurization device was used in four of the ten previous cases reviewed. Because children are often infused or intravenously administered agents under positive pressure with a pressurization device rather than spontaneous titration, infiltration or extravasation occurs, and infusion continues even when tissue pressure is elevated.⁵ Second, glucose-acetate Ringer's solution is a hypertonic solution. Although glucose-acetate Ringer's solution is a commonly used preparation in infusion therapy, it has an osmotic pressure ratio of approximately 1.7% to 0.9% saline. As the osmotic ratio increases, the cytotoxicity increases; therefore, an osmotic ratio of 3 and a sugar concentration of 10%-12% are considered acceptable for administration through a peripheral vein. ⁸Third, immobilization is necessary because children can easily dislodge the venous tract with body movement. Fourth, symptoms and physical examination findings are unreliable. The five “Ps” (paresthesia, pain, pallor, paralysis, and loss of pulse) are considered symptoms of compartment syndrome, but only pain is reliable, while paralysis and paresthesia are findings after progression, and pulsatility does not disappear unless the compartment pressure exceeds the arterial pressure. ⁹ Furthermore, all ten previous cases were infants, and it is difficult to infer pain or discomfort due to infiltration or extravasation from symptoms because infants are unable to express pain or discomfort well.⁹

In the present case, there were no findings suggesting pain, such as grumpiness, making the diagnosis of compartment syndrome difficult. If the clinical findings are inconclusive, intramuscular pressure measurement can also be useful.¹⁰ Although an invasive test, it can cause irreversible dysfunction if left untreated. Swelling at the site of peripheral venous tract puncture during infiltration should also be considered as a possible indicator of compartment syndrome, and if suspected, intramuscular pressure measurement should be considered after consultation with a specialist.

It should also be understood that although infiltration is a relatively common complication of infusion therapy,¹¹ even commonly used infusion products can cause compartment syndrome, as in the present case. In order to prevent a situation such as the one described in the present case, prompt action is needed to (1) stop administration of intravenous fluids immediately; (2) disconnect the intravenous tubing from the device; (3) attempt aspiration of the residual drug from the IV device; (4) administer nursing interventions, as indicated; and (5) notify the physician or advanced practice nurse.³

One of the causes of infiltration or extravasation in children is the difficulty in observing the area around the puncture site due to immobilization of the joint, but transparent bandages and tapes have been developed,¹¹ and if these are put into practical use, early detection of infiltration or extravasation will be possible. Although previous reports have described how to respond after extravascular leakage, there are few reports or statements that take into account the characteristics of fixation in children, and furthermore, there are no reports that suggest how to detect extravascular leakage immediately. Specific guidelines for the prevention and early detection of fluid leakage in infants are necessary. For example, we propose a new method of immobilizing peripheral venous catheters using a transparent bandage and tape to detect infiltration or extravasation at an early stage, or periodically checking for spontaneous dripping of the infusion tube even while using an infusion pump.

We herein report an infant who required fasciotomy due to a dorsal hand compartment while receiving glucose-acetate Ringer's solution alone. Since glucose-acetate Ringer's solution is hypertonic with an osmotic ratio of approximately 1.7, the possibility of infiltration is high, and if infiltration or extravasation is detected, immediate action should be taken, such as discontinuation of drug administration, removal of the intravenous line, and aspiration of the drug at the time of removal. The possibility of compartment syndrome should also be considered when a drug is administered under pressure with a continuous infusion pump. Peripheral venous catheter fixation, in which the fixation site as well as the puncture site is easily visible, may allow for the early detection of infiltration or extravasation and prevent progression to compartment syndrome.

• Ethics approval and consent to participate: Ethics approval and consent for this case were waived.

• Consent for publication: Written informed consent was obtained from the patient parents or legal guardian.

• Availability of data and materials: All relevant data are within the manuscript.

• Competing interests:

• Funding: The authors declare no conflict of interest.

• Authors' contributions: ST managed the case and redaction and correction of the manuscript. SK, TM, YU and KM assisted with redaction, correction, and reconstruction of the manuscript.

• Acknowledgements: Not applicable

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Talbot SG, Rogers GF. Pediatric compartment syndrome caused by intravenous infiltration. Ann Plast Surg 2011; 67: 531-3.
Yamaguchi M, Ojima Y, Ono S, Matsumura H. Two cases of forearm compartment syndrome caused by infusion pump or syringe pump. Surgery 2022; 84: 395-8.
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Table1: Compartment syndrome by intravenous infusion

Patient	Age	Sex	Reason for Admission to Hospital	Contents of infusion	Infusion pump or syringe driver	Location	Sequelae
this case	5m	M	Meckel diverticulum	Glucose acetated Ringers	use	Right dorsum manus	None
^{Ouellette , 1996[13]}	6m	F	Meningitis	Dopamine	unknown	Dorsum manus and forearm	None
	9	F	Cerebral aneurysm	Dilantin	unknown	Dorsum manus and forearm
	5m	F	Meningitis	Dilantin	unknown	Forearm	Below-the-elbow amputation
	1	M	Pneumonia	Aminophylline	unknown	Dorsum manus and forearm	None
^Stahl,2000 ^[14]	10	F	Left femoral subtrochanteric fracture	20% mannitol	unknown	Left dorsum manus and forearm	None
^{Spenny,2004[15]}	3	F	RSV bronchiolitis	Methylprednisolone Normal saline 5% dextrose in half saline CTRX	unknown	Left dorsum manus	None
^{Altan ,2013[16]}	23d	M	pulmonary disease	Iohexol	use	Right dorsum manus and forearm	None
^{Chen,2010[17]}	4d	M	Hypocalcemia	10% calcium gluconate	use	Right medial malleolus	None
^Yamaguchi, ^2022[5]	1	F	endoscope	Glucose acetated Ringers	use	Left dorsum manus and forearm	None

No competing interests reported.

An infant with hand dorsal compartment syndrome due to intravenous infiltration of glucose-acetate Ringer's solution

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Abstract

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Introduction

Case Presentation

Discussion

Conclusion

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Table

Additional Declarations

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