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.
The Anesthesia Patient Safety Podcast delivers the best of the APSF Newsletter and website directly to you, so you can listen on the go! This includes some of the most important COVID-19 information on airway management, ventilators, personal protective equipment (PPE), drug information, and elective surgery recommendations.
Don't forget to check out APSF.org for the show notes that accompany each episode, and email us at podcast@APSF.org with your suggestions for future episodes. Visit us at APSF.org/podcast and at @APSForg on Twitter, Facebook, and Instagram.
Anesthesia Patient Safety Podcast
#269 Infiltrated IV Crisis: Managing Complications and Keeping Patients Safe
Every anesthesia professional has encountered IV infiltration—but when neuromuscular blocking agents are involved, this common complication becomes a complex patient safety challenge with no established guidelines.
This episode delves into the critical management of infiltrated paralytics, a complication affecting 14% of peripheral IV catheterizations that can lead to delayed induction, compromised emergence, and potentially serious tissue injury. We're joined by Dr. Govind Rangrass, Professor of Anesthesiology and Critical Care, who shares why this overlooked issue deserves urgent attention: "When a paralytic is involved, the complexity skyrockets and there's almost no literature to guide us."
We break down a comprehensive management algorithm, from the counterintuitive first step of leaving the infiltrated catheter in place to attempt medication aspiration, through systemic absorption enhancement techniques using hyaluronidase and nitroglycerin paste. The episode covers detailed reversal strategies based on monitoring capabilities, explaining how to prevent recurarization and safely manage these patients postoperatively.
Beyond immediate management, we look toward a future where infiltration detection technologies and standardized guidelines are integrated into residency training and crisis checklists. This episode provides the missing guidance that anesthesia professionals need to navigate this surprisingly common complication with confidence.
Have you experienced neuromuscular blocker infiltration in your practice? What strategies have worked for you? Share your thoughts or questions at podcast@APSF.org and join us in building a safer future where no one is harmed by anesthesia care.
For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/269-infiltrated-iv-crisis-managing-complications-and-keeping-patients-safe/
© 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 are back for part two of our series, all about how to keep patients safe following IV infiltration of neuromuscular blocking agents. Plus, we have more exclusive content from one of the authors. Plus, we have more exclusive content from one of the authors. Before we dive further into the episode today, we'd like to recognize Merck, a major corporate supporter of APSF. Merck has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, merck. We wouldn't be able to do all that we do without you.
Speaker 2:Our featured article once again 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, and I will include a link in the show notes as well. Have you placed any peripheral intravenous catheters this week? Did any of these infiltrate intravenous catheters this week? Did any of these infiltrate Peripheral IV cannulation is the most common invasive procedure performed in hospitals. Anesthesia professionals need to stay vigilant for complications, which may include nerve injury, vascular injury and infiltration IV. Infiltration is the unintended administration of any medications or fluids into the tissues surrounding the catheter and this occurs in about 14% of peripheral IV catheter insertions. We talked about this threat to anesthesia patient safety last week on the show and we are going to continue the conversation today. To help kick off the show today, we are going to hear from one of the authors. I will let him introduce himself now.
Speaker 3:Hello, my name is Govind Rangras and I'm a professor of anesthesiology and critical care at SSM Health St Louis University Hospital, where I also serve as the director of patient safety and quality.
Speaker 2:I asked Rangras why he wrote this article. Let's take a listen to what he had to say.
Speaker 3:We wrote this article because IV infiltration is a surprisingly common complication in perioperative care, but there is very little guidance on how to manage it, especially when it involves the infiltration of neuromuscular blocking agents. We believe the stakes are high if a paralytic is administered into compromised IV access. It can lead to delayed or even failed induction and complicate safe emergence from anesthesia. Our goal by writing this article was to highlight this overlooked issue and offer an algorithmic approach that anesthesiologists can use immediately. We also hope that it serves as a call to action for further research and consensus building within the field.
Speaker 3:I personally am passionate about this topic because it combines a very practical clinical challenge with patient safety implications that are often under-recognized. Iv infiltration is something that we've all seen, but when a paralytic is involved, the complexity skyrockets and there's almost no literature to guide us. It's really deeply unsatisfying from a clinical and academic standpoint. To tell a colleague, there's no clear answer here, and I think our colleagues deserve better, and so do our patients. So that's really what primarily drove us to dive deeper and help create something actionable for the anesthesia community.
Speaker 2:Thank you so much to Rangrass for helping to kick off the show today. It's time to talk about the management of neuromuscular blocking agent infiltration. Here we go, oh no, the peripheral IV catheter infiltrated on induction of anesthesia. The first step is to leave the infiltrated catheter in place and attempt to aspirate the medication. Next, review the medications that were administered into the infiltrated catheter. If a non-depolarizing neuromuscular blocking agent was used, then once you have a new peripheral IV catheter, it is important to consider using a reduced dose or avoid any redosing of any further non-depolarizing neuromuscular blockers, or consider changing to succinylcholine During the surgery. There are a few steps that you can take to help keep patients safe as well, including the following Elevate the extremity with the infiltration. Apply a warm compress with dry heat to aid in systemic uptake of the drugs. Demarcate the area of the infiltration. Area of the infiltration. Consider administration of hyaluronidase through the infiltrated catheter and intradermally around the leading edge of the infiltration site. Conduct serial exams of the area and consult surgery if there are any concerns for tissue injury or compartment syndrome. Check out figure 1 in the article for the author's proposed algorithm to help manage paralytic medication infiltration. You can use this as an important resource to guide management of this event and help prevent harm from this complication. I will include the figure in the show notes as well. Now let's talk about some of these steps in a little more detail. The onset and duration of action of infiltrated rocuronium depends on local circulation and systemic absorption. Improving the systemic absorption of the infiltrated rocuronium enables reversal in the immediate interoperative period.
Speaker 2:There are two medications that have been used to help increase systemic absorption of many infiltrated medications hyaluronidase and nitroglycerin paste. Hyaluronidase is an enzyme that hydrolyzes hyaluronic acid to help with the absorption and dispersal of injected medications. It is often used to treat severe infiltration events with pH-related and hyperosmolar vesicants. Hyaluronidase comes in a 1 ml vial with 150 units per ml. It should be administered with a tuberculin syringe and a 25-gauge or smaller needle. Time is of the essence, since administration of this medication should occur within one hour of the infiltration event and you may begin to see improvements in swelling within 15 to 30 minutes of enzyme delivery along the tissue plane. Here are the steps for one of the recommended administration methods. Step one dilute hyaluronidase to 15 units per ml. Step two perform five 0.2 ml injections for a total of one ml around the leading edge of the infiltration site and, finally, prior to removal of the infiltrated catheter. 15 units may be administered through the catheter and repeated every 30 to 60 minutes until the infiltration site resolves. Another option is to take advantage of the vasodilating effects of nitroglycerin 2% paste to improve systemic drug absorption. You can apply this to one inch square areas of infiltration, but you will need to avoid any areas of skin breakdown.
Speaker 2:Once you get to the end of the surgery, it's time for neuromuscular blockade reversal. There is not a lot in the literature to guide us, since there are only 12 case reports and one prospective study that addresses the pharmacokinetics and pharmacodynamics of subcutaneously administered steroidal neuromuscular blocking agents. Looking at the case reports, there were only about 30 patients and the medications used were pancuronium, vacuronium and rocuronium. There are no infiltration reports from cases where benzalicylquinoline alkaloids were used, and this may be due to their spontaneous degradation at tissue pH, which helps to prevent against complications related to resorption.
Speaker 2:For reversal following an infiltration event, it is important to consider monitoring the depth of blockade, as well as the patient's hepatic and renal function. Sugamidex is the preferred agent for reversal of rocuronium and becuronium, and here are several options, depending on resource availability, For patients who continue to have deep levels of blockade or if Sugamidex is not available, they may need to remain intubated postoperatively until intact neuromuscular function has been restored. If only qualitative monitoring is available or there is concern for residual neuromuscular blocking agent at the infiltration site and the depth of blockade is mild to moderate, then administer standard reversal doses and monitor the patient for recurrization in the PACU. If quantitative train of four ratio monitoring is used and the infiltration site has visibly improved, reversal can be guided by the train of four ratio data and patients can be monitored clinically for residual paralysis, and patients can be monitored clinically for residual paralysis. Consider reducing the stimulation current to below 40 mA using electromyography-based quantitative train of four ratio monitor, if needed, in the PACU for patient comfort.
Speaker 2:Once extubated, patients without hepatic and renal dysfunction should be monitored in the PACU for at least four hours, and the patient and nursing teams will need to be informed about the signs and symptoms of residual blockade, with a plan to guide escalation of care if needed. Authors leave us with a call to action for anesthesia professionals to remain vigilant for infiltration events and be prepared to manage patient injuries and prevent secondary recurrization when neuromuscular blocking agents are involved, to help keep patients safe from harm following this complication? Before we wrap up for today, we are going to hear from Rangrass again. I also asked him what do you envision for the future with regards to this area of anesthesia care? Here is his response.
Speaker 3:Looking ahead, I envision a future where we have standardized guidelines for managing IV infiltration in the OR, especially when paralytics are involved. For managing IV infiltration in the OR, especially when paralytics are involved. Ideally, this will be a topic that's integrated into residency training and crisis checklists, just like anaphylaxis or local anesthetic systemic toxicity. I'd also love to see greater integration of safety technologies that can detect infiltration early. But, most of all, I just hope that our work sparks further discussion, data collection and consensus building so that this very real clinical problem is no longer treated as a footnote.
Speaker 2:Thank you so much to Rangrass for contributing to the show today. We are looking forward to a future with readily available checklists for managing IV infiltration and tools to help detect and even prevent this complication going forward. 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 APSF dot org for detailed information and check out the show notes for links to all the topics we discussed today.
Speaker 2:The 2025 APSF Stolting Conference is right around the corner, on September 3rd through 4th. The focus for this year's conference is transforming maternal care innovations and collaborations to reduce morbidity and mortality. Conference objectives include innovative strategies to reduce severe maternal morbidity. Actions that anesthesia clinicians can take to advance birth equity. The role of anesthesia professionals to reduce preventable causes of maternal mortality. And identifying opportunities for collaboration across role groups to overcome current maternal care challenges. Across role groups to overcome current maternal care challenges. This is a high-yield conference for anyone interested in keeping patients safe during maternal anesthesia care. You can register for the live stream. Check out the conference link in the show notes for more information. Plus, we'll be featuring highlights from the conference on upcoming podcast episodes, so you don't miss a thing. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.