Anesthesia Patient Safety Podcast
The official podcast of the Anesthesia Patient Safety Foundation (APSF) is hosted by Alli Bechtel, MD, featuring the latest information and news in perioperative and anesthesia patient safety. The APSF podcast is intended for anesthesiologists, anesthetists, clinicians and other professionals with an interest in anesthesiology, and patient safety advocates around the world.
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Anesthesia Patient Safety Podcast
#268 Beyond the Vein: The Dangers of Infiltrated Muscle Relaxants
Ever wondered what happens when neuromuscular blocking agents infiltrate into surrounding tissue instead of flowing smoothly through an IV? The consequences can be serious and potentially life-threatening for patients recovering from anesthesia.
We dive deep into a complication that affects nearly 14% of the 150 million peripheral IV catheter insertions performed annually in the United States. While most healthcare providers have experienced IV infiltrations, few understand the unique dangers posed when paralytics like rocuronium leak into surrounding tissues. This scenario creates unpredictable pharmacokinetics with delayed absorption that can lead to secondary recurarization – muscle weakness and respiratory compromise that may occur hours after a patient appears to have fully recovered.
Experts Dr. Andrea Vannucci and Dr. Karolina Brook share their insights and clinical experience on this important patient safety topic. They outline a comprehensive management approach including immediate interventions (attempting medication aspiration, establishing alternative IV access), treating the infiltration site (with nitroglycerin paste and hyaluronidase), and preventing recurarization through careful medication dosing and extended monitoring. Most critically, they recommend monitoring extubated patients for a minimum of four hours following infiltration of neuromuscular blocking agents – a practice not universally followed but essential for patient safety.
Whether you're an anesthesiologist, CRNA, resident, or any perioperative clinician, this episode provides crucial information to help you recognize, manage, and prevent complications from this common but potentially dangerous event. Subscribe to the Anesthesia Patient Safety Podcast for more evidence-based strategies to protect your patients from harm.
For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/268-beyond-the-vein-the-dangers-of-infiltrated-muscle-relaxants/
© 2025, The Anesthesia Patient Safety Foundation
You're listening to the Anesthesia Patient Safety Podcast, the official podcast of the Anesthesia Patient Safety Foundation. We're bringing you the very best from the APSF newsletter and website, as well as the latest information in perioperative patient safety. Thanks for joining us.
Speaker 2:Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Allie Bechtel and I'm your host. Thank you for joining us for another show. We will be talking about how to keep patients safe following IV infiltration of neuromuscular blocking agents and we'll be hearing from the team responsible for this latest APSF article. Team responsible for this latest APSF article. Before we dive further into the episode today, we'd like to recognize Preferred Physicians Medical. A major corporate supporter of APSF, ppm, has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, ppm. We wouldn't be able to do all that we do without you. Our featured article today is Treatment and Complications of IV Infiltration of Neuromuscular Blocking Agents by Rangrass and Colleagues. To follow along with us, head over to APSForg and click on the newsletter heading. The first one down is the current newsletter. Then scroll down until you get to our featured article today. I will include the link in the show notes as well.
Speaker 2:There are over 150 million peripheral intravenous catheter insertions placed in the United States every year. How many have you placed today or this week? It is the most common invasive procedure performed in hospitals. There are several important complications of this procedure, including nerve injury, vascular injury and infiltration. Iv infiltration is the unintended administration of any medication or fluids into tissues surrounding the catheter. Did you know that infiltration occurs in almost 14% of peripheral IV catheter insertions? This is a big threat to anesthesia patient safety. Risk factors may be related to the equipment and care-related factors. Many IV infiltration events can be managed conservatively, but severe cases can result in severe consequences, including tissue injury requiring surgical intervention, specialized wound care, persistent pain or loss of limb function.
Speaker 2:When an IV infiltrates in the operating room, there are additional important complications to consider, including intraoperative awareness, failed resuscitation or compartment syndrome. What about when the IV infiltrates following neuromuscular blocking agent administration? This can have additional consequences. Infiltration of non-depolarizing neuromuscular blocking agents puts patients at risk for subsequent resorption and recurrization, leading to muscle weakness, respiratory insufficiency and postoperative pulmonary complications. Patients with decreased liver and kidney function may be at even higher risk following neuromuscular blocking agent infiltration. For this complication, we don't have guidelines for the management and it can be difficult to figure out how to keep patients safe, especially during same-day surgery and with higher risk patients. Now, before we go further into the article, let's hear from one of the authors.
Speaker 3:Hi, my name is Andrea Vannucci and I am a clinical professor of anesthesia and vice chair for quality and safety at the Carver College of Medicine at the University of Iowa in Iowa City, Iowa.
Speaker 2:I asked Vannucci what got him interested in this topic. Here is his response.
Speaker 3:Perioperative intravenous infiltration is a common complication that can pose significant patient safety risks. The severity of these risks depends on several factors, including the physicochemical properties of the infiltrated substance, the time elapsed before recognition and intervention and the pharmacologic actions of the drug involved. A particularly concerning scenario involves the extravasation of neuromuscular blocking agents. These agents may be reabsorbed unpredictably, potentially leading to delayed or recurrent neuromuscular blockade. These can impair critical functions such as swallowing and respiratory muscle activity, posing a risk of airway and ventilation compromise after extubation. Currently, there are no formal guidelines for the management of neuromuscular blocking agents' extravasation. In response to this gap, our team sought to develop a clinical approach grounded in general medical principle and informed by the best available evidence from the anesthesia literature.
Speaker 2:I also asked Venucci what's next for your research and projects? Let's take a listen now.
Speaker 3:I am interested in developing and communicating strategies that can help clinicians and organizations identify and manage high-risk situations. My current projects include enhancing event reporting systems, developing EMR-integrated perioperative end-of-tools and evaluating video laryngoscopes to guide device selection for specific clinical scenarios.
Speaker 2:Those are some very exciting projects and we will have to stay tuned for the results. Let's return to the article now. There is a study from 30 years ago that evaluated subcutaneous administration of succinylcholine and found that patients receiving equal doses of subcutaneous succinylcholine had incomplete maximum depressed twitch height, prolonged onset time for paralysis and shorter recovery from paralysis time. Looking at inadvertent subcutaneous non-depolarizing neuromuscular blocking agent administration, there can be prolonged onset and duration of paralysis with significant variability. This is due to the unpredictable movement of this drug from the subcutaneous tissue into the central circulation. There is an increased risk for recurarization after rocuronium administration into subcutaneous tissue following IV administration of reversal agents. This is what the scenario of secondary recurarization looks like. Patients were administered additional intubating doses of rocuronium 0.6 to 1.2 milligrams per kg ideal body weight after an initial infiltrated administration combined with suboptimal dosing of the reversal agents.
Speaker 2:While Sugamidex may be used to successfully reverse neuromuscular blockade following infiltrated rocuronium administration, there is a risk for recurarization due to the short half-life of Sugamidex only about two hours and the molar one-to-one binding ratio. For patients with mild renal insufficiency, the half-life of Sugamidex is longer, at about four hours and up to about 19 hours in severe renal failure. So this may, in theory, be a benefit to patients following infiltration of rocuronium, as long as the binding capacity is not full. Before we get to the management of neuromuscular blocking agent infiltration, let's hear from another one of the APSF authors.
Speaker 4:Hi, my name is Carolina Brooke. I am an anesthesiologist and director of quality and safety at Boston Medical Center in Boston, Massachusetts. I'm also the ASA Committee for Patient Safety and Education vice chair.
Speaker 2:I also asked Brooke what got her interested in this topic. This is what she had to say.
Speaker 4:In my department we collect data on what we call unanticipated events. This includes adverse events as well as near misses, but also far more expansive events, and one example of this is actually IV infiltrations. Now, for example, iv infiltrations that result in, say, compartment syndrome would be a recognized adverse event. Syndrome would be a recognized adverse event. However, just a plain IV infiltration that doesn't necessarily result in negative sequelae would not be considered an adverse event. This is the type of unanticipated events that we are capturing.
Speaker 4:So we actually started capturing data on IV infiltrations in our department and in the last year we saw a huge rate of increase in IV infiltrations in our department. And in the last year we saw a huge rate of increase in IV infiltrations in a variety of our patients and we started looking into those patients to see what was the cause of IV infiltrations. Was it something related to pre-op nursing? Who were traditionally placing these IVs? Were these IVs coming from the floor? And so we did a little bit of analysis to try to reduce the number of IV infiltrations, because it obviously results in unpleasant consequences for the patient having to have another IV placed, delays in starting the OR case while the surgeon's waiting for you to place another IV, potentially having to do an inhalation induction which you may not have planned on, et cetera. So we did some interventions and we actually were able to reduce the number of IV infiltrations.
Speaker 4:But all of this got me interested in actually what do we do about the IV infiltrations themselves. Are we supposed to treat them? For the majority of them, do we just leave them alone? Do we compress them? And so this article is really interesting for me, because one of the common medications that we do push is rocuronium and, in large part, most of us were doing absolutely nothing to manage these IVF infiltrations, and so it was really interesting to me, when I was doing research for this paper, to learn about what is recommended management for these kinds of complications.
Speaker 2:This is a great lead-in for when we start to discuss the management options for IV infiltration. I also asked Brooke what's next for her research and projects. Let's take a listen to what she had to say.
Speaker 4:So I'm really interested in collecting data. For me, if you do not know what the problems are, you can't fix them, and so we are collecting vast amounts of data on unanticipated events, which is a type of anesthesia event that we have published on previously, and looking into what potential interventions we can do to further improve anesthesia care beyond the typical retrospective analysis of adverse events or near misses that we have traditionally been doing, and so my feeling is that this will move the needle on anesthesia care and help us improve patient safety going forward in the future patient safety going forward in the future.
Speaker 2:We are really excited to see where this project takes you and the impact on anesthesia patient safety. We have more to talk about when it comes to IV infiltration of neuromuscular blocking drugs. Plus, we have more exclusive author content, but you will need to tune in next week for the exciting conclusion. For a quick spoiler, we are going to review figure one in the article, which describes the author's proposed algorithm to manage this complication. The first step is identification of paralytic infiltration, followed by the immediate actions of attempt medication aspiration place and utilize an alternative IV access. Demarcate the infiltration site and document the type, dose and time of medication administered. Next, treat the infiltration injury with considerations for the following infiltration injury with considerations for the following Apply nitroglycerin 2% paste. Inject hyaluronidase through the infiltrated IV and or around the infiltration site and apply warm, dry, compress and elevate the affected extremity. Decrease the risk for reurrization with the following steps Avoid or reduce the next dose of non-depolarizing neuromuscular blocking agent or use a depolarizing agent. Monitor interoperative neuromuscular block depth with a quantitative monitor if available, and the preferred reversal agent for rocuronium or becuronium in this setting is Sugaminex. Finally, postoperative care involves monitoring extubated patients in the PACU for secondary recurarization for a minimum of four hours, with serial exams on the infiltrated site. Don't worry, we will go through the management in more detail next week, so mark your calendars.
Speaker 2:If you have any questions or comments from today's show, please email us at podcast at apsforg. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSForg for detailed information and check out the show notes for links to all the topics we discussed today. Have you checked out the Lookalike Drug Vials resource recently? This resource includes alerts and photos that show how lookalike drug vials and packaging can contribute to medication errors and impact patient safety. In May there were examples of carboprostromethamine injection stored in the spinal marcane compartment or on Danzotron 4mg and 2mL next to Ephedrine 50 mg per mL, both with green caps stocked next to each other in the medication drawer, and more. We hope that you will check it out and consider contributing if you see look-alike drug vials at your institution. There is more work to be done to keep patients safe from lookalike drug vials and medication errors. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.