Indian Journal of Dermatology
  Publication of IADVL, WB
  Official organ of AADV
Indexed with Science Citation Index (E) , Web of Science and PubMed
 
Users online: 542  
Home About  Editorial Board  Current Issue Archives Online Early Coming Soon Guidelines Subscriptions  e-Alerts    Login  
    Small font sizeDefault font sizeIncrease font size Print this page Email this page


 
Table of Contents 
CORRESPONDENCE
Year : 2012  |  Volume : 57  |  Issue : 1  |  Page : 78-79
Propofol extravasation and tissue necrosis


Department of Medicine, Sound Shore Medical Center and New York Medical College, NewRochelle, New York, USA

Date of Web Publication10-Mar-2012

Correspondence Address:
Prasanta Basak
Department of Medicine, Sound Shore Medical Center and New York Medical College, NewRochelle, New York
USA
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.92692

Rights and Permissions



How to cite this article:
Basak P, Poste J, Jesmajian S. Propofol extravasation and tissue necrosis. Indian J Dermatol 2012;57:78-9

How to cite this URL:
Basak P, Poste J, Jesmajian S. Propofol extravasation and tissue necrosis. Indian J Dermatol [serial online] 2012 [cited 2019 Dec 7];57:78-9. Available from: http://www.e-ijd.org/text.asp?2012/57/1/78/92692


Sir,

Propofol injectable emulsion is an intravenous sedative-hypnotic agent for use in the induction and maintenance of anesthesia or sedation. Propofol is one of the most commonly used IV anesthetics. [1] It has many advantages such as a rapid onset of action, rapid recovery after long periods of anesthesia, and minimal occurrence of post procedural vomiting. Extravasation is an unintentional injection or leakage of fluid in the perivascular or subcutaneous space. Extravasation injury results from a combination of factors, including solution cytotoxicity, osmolality, vasoconstrictor properties, infusion pressure, regional anatomical peculiarities, and other patient factors. [2] Propofol extravasation does not usually lead to tissue necrosis due to the favorable chemical properties, including a neutral pH and isotonicity. [1] We report a patient who had propofol-induced necrosis of the skin.

A 27-year-old female was treated for status asthmaticus. She was intubated and mechanically ventilated. Propofol was infused through an IV cannula in the left antecubital fossa. No other medications were delivered through that IV access. The bronchoconstriction got better, propofol drip discontinued, and she was successfully extubated the following day. She then reported a progressive intense burning pain in her left upper extremity. The left upper extremity was red, swollen, and warm, extending from the wrist up to the left axilla. The whole arm was extremely tender to palpation. Sensations were intact and strong radial pulses were palpated. A blister was noted on the left cubital fossa at the site of insertion of the cannula. The left arm was elevated and morphine given for pain. A Doppler ultrasound of the left upper extremity excluded venous thrombosis. The next day, the blister ruptured, exposing the underlying necrotic tissue. The arm was kept elevated, the wound dressed, and a sequential compression device applied to the left arm as recommended by the surgical consult team. Healthy granulation tissue appeared in a week [Figure 1], and the patient fully recovered without any residual sign of tissue damage.
Figure 1: Healthy granulation tissue at the site of propofol extravasation

Click here to view


The induction of pain caused by propofol extravasation is probably due to activation of the kallikrein-kinin system. [3] The lipid solvent in the formulation activates the kallikrein-kinin system, and the bradykinins increase the permeability and dilatation of the veins. This increases the contact between propofol and free nerve endings in the skin, resulting in intense pain. [3] It is recommended to stop propofol infusion immediately when extravasation is suspected. A plastic surgery consult can be considered as a graft may be necessary if widespread tissue necrosis occurs. Our case had minimal tissue necrosis which resolved with supportive therapy. Although clinical reports and animal studies have shown propofol extravasation does not cause serious clinical consequences, [4],[5],[6] isolated case reports have documented extensive tissue necrosis after use of propofol. [7],[8] Till date, six case reports of propofol-induced tissue necrosis have been reported in adults, and one in a newborn. A wound at the site of infusion should arouse suspicion of extravasation injury. Our case highlights the need to closely monitor the propofol infusion site for any sign of inflammation, and the need for an expedited surgical consult if extravasation does occur.

 
   References Top

1.Schummer W, Schummer C, Bayer O, Müller A, Bredle D, Karzai W. Extravasation injury in the perioperative setting.Anesth Analg 2005;100:722-7.  Back to cited text no. 1
    
2.Dolin SJ. Drugs and pharmacology.In:Padfield NL, editor. Total Intravenous Anesthesia. Oxford:Butterworth Heinemann; 2000.p. 13-35.  Back to cited text no. 2
    
3.Huijbers EJ, Baars JW, Schutte PF, Schellens JH, Beijnen JH. Propofol extravasation in a breast cancer patient. Br J Anasth 1999;83:397-404.  Back to cited text no. 3
    
4.Tokumine J, Sugahara K, Tomori T, Nagasawa Y, Takaesu Y, Hokama A. Tissue necrosis caused by extravasated propofol. J Anesth 2002;16:358-9.  Back to cited text no. 4
    
5.Stark RD, Binks SM, Dutka VN, O'Connor KM, Arnstein MJ, Glen JB. A review of the safety and tolerance of propofol ("Diprivan"). Postgrad Med J1985;61:152-6.  Back to cited text no. 5
    
6.Huijbers EJ, Baars JW, Schutte PF, Schellens JH, Beijnen JH. Propofol extravasation in a breast cancer patient. J Oncol Pharm Pract 2008;14:195-8.   Back to cited text no. 6
    
7.Mahajan R, Gupta R, Sharma A. Extravasation injury caused by propofol. Anesth Analg 2006;102:648.  Back to cited text no. 7
    
8.Roth W, Eschertzhuber S, Gardetto A, Keller C. Extravasation of propofol is associated with tissue necrosis in small children.Paediatr Anaesth 2006;16:887-9.  Back to cited text no. 8
    


    Figures

  [Figure 1]

This article has been cited by
1 Propofol up2date - Teil 2: Patientengruppen, unerwŁnschte Wirkungen und die Nachfolgesubstanz Fospropofol | [Propofol up2date. Part 2: Patient groups, unwanted effects and the metabolite fospropofol]
Bushuven, S., Heise, D.
Source of the Document Anasthesiologie Intensivmedizin Notfallmedizin Schmerztherapie. 2013;
[Pubmed]



 

Top
Print this article  Email this article
 
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Article in PDF (902 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    References
    Article Figures

 Article Access Statistics
    Viewed4550    
    Printed94    
    Emailed1    
    PDF Downloaded40    
    Comments [Add]    
    Cited by others 1    

Recommend this journal