In reply

Letters to the Editor Extravasation Injuries of the Limbs in Neonates and Children Development of a Treatment Algorithm by Dr. med. Roslind K. Hackenberg, PD Dr. med. Koroush Kabir, Prof. Dr. med. Andreas Müller, Dr. med. Andreas Heydweiller, Prof. Dr. med. Christof Burger, and Dr. med. Kristian Welle in issue 33–34/2021

We thank Dr. Mader for his comments on our article (1). Although the WHO three-step analgesic ladder was originally developed to treat tumor pain, it is nowadays in use for all forms of pain, and acute pain therapy—independently of the application mode—follows the scheme (2). Furthermore, further development of the analgesic ladder added a fourth step to the original three steps—step 4 includes invasive measures, including regional anesthetic procedures (3), and should therefore be part of the standard repertoire of pain therapy. Owing to space restrictions, our review article focused on the description of the diagnosis and emergency treatment of extravasation injuries, with the primary objective of preventing severe complications, such as necroses. We were therefore not able to discuss the individual analgesic procedures in detail. For this reason we mentioned in general the pain therapeutic principles according to the WHO analgesic ladder.

Isotonic, balanced full electrolyte solutions should be used analogous to the recommendations of the S1 guideline for perioperative infusion therapy in children (4). We cannot make a recommendation, however, for using full electrolyte solutions for surgical irrigation after extravasation injuries. Thus far, irrigation has been described only for saline fluids, primarily 0.9% saline solution (5, 6), and further studies are needed before a recommendation can be made for using isotonic, balanced full electrolyte solutions for irrigation.

For reasons of legal liability, it should also be borne in mind that for the intravenous administration of medications as well as for the application of hyaluronidase after extravasation, these have to be prepared in accordance with the manufacturers’ instructions—when using hyaluronidase, typically by using physiological saline solution. Where possible and sensible, however, full electrolyte solutions should be used in preference, and we support our correspondent’s objection.

DOI: 10.3238/arztebl.m2022.0045

On behalf of the authors
Dr. med. Roslind K. Hackenberg
Dr. med. Kristian Welle
Klinik und Poliklinik für Orthopädie und Unfallchirurgie
Universitätsklinikum Bonn

Conflict of interest statement
The authors of all contributions declare that no conflict of interest exists.

References

1. Hackenberg RK, Kabir K, Müller A, Heydweiller A, Burger C, Welle K: Extravasation injuries of the limbs in neonates and children—development of a treatment algorithm. Dtsch Arztebl Int 2021; 118: 547–54

2. Freys SM: Akutschmerztherapie. In: Schwenk W, Freys S, Kalff J (eds.): Perioperative Medizin. Stuttgart: Thieme 2017; 248–65.

3. Günther U, Bantel C: Analgesie und Sedierung. In: Weigand M, Hecker A, Mayer K, Michalski D (eds.): Intensivmedizin compact. Stuttgart: Thieme 2021; 95–106.

4. Sümpelmann R, Röher K, Becke-Jakob K, et al.: AWMF 001–032 S1 Perioperative-Infusionstherapie-Kinder 2021–07, www.awmf.org/uploads/tx_szleitlinien/001-032l_S1_S1_Perioperative-Infusionstherapie-Kinder_2021-07.pdf (last accessed on 3 October 2021).

5. Gault DT: Extravasation injuries. Br J Plast Surg 1993; 46: 91–6

6. Ghanem AM, Mansour A, Exton R, et al.: Childhood extravasation injuries: improved outcome following the introduction of hospital-wide guidelines. J Plast Reconstr Aesthet Surg 2015; 68: 505–18