Extravasation

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Extravasation refers to the leakage of a fluid out of its container. In the case of inflammation, it refers to the movement of white blood cells from the capillaries to the tissues surrounding them. In the case of malignant cancer metastasis it refers to cancer cells exiting the capillaries and entering organs. It is frequently used in medical contexts, either referring to urine, or to blood. In some languages (e.g. German), extravasation is called "paravasation".

More specifically, it can refer to:

• Extravasation of irrigation fluid
• Extravasation (intravenous)
• Leukocyte extravasation
• Extravasation of urine
• Extravasation of infusates

Extravasation of Irrigation Fluid

Extravasation of irrigation fluid is the unintended migration of irrigation fluid (e.g. saline) introduced into a human body. This may occur in a number of types of endoscopic surgery, such as minimally-invasive orthopedic surgery, i.e. arthroscopy, TURP's (trans-urethral resection of the prostate) and TCRE (trans-cervical resection of the endometrium).

In arthroscopy fluid under pressure is used to inflate and distend a joint and make a working surgical space. Arthroscopy is typically performed on shoulder and knee joints, however, hip arthroscopy is becoming more popular. Arthroscopy is done by making surgical portals or puncture wounds into the joint. A surgical instrument called an arthroscope is used to introduce irrigation fluid under pressure to distend, or expand the joint. The arthroscope includes a small diameter (typically 4mm) rod optic scope to view the joint. Other portals or puncture wounds are made to introduce surgical instruments to perform cutting or repair procedures.

If the joint is surrounded by soft tissue, as in the shoulder and hip, fluid under pressure may leak out of the joint space through the surgical portals and collect in the patient's soft tissue. A typical arthroscopy can result in from 1-3 liters of irrigation fluid beig absobed into the patient's interstitial tissue. This buildup of irrigation fluid in the soft tissue may cause swelling, known as edema. This swelling can interfere with the arthroscopic procedure by collapsing the surgical space, or migrating into the patient's neck and causing airway blockage. In hip arthroscopy, a feared complication is abdominal flooding where the irrigation fluid leaks from the hip joint capsule and drains into the abdominal cavity. Risk factors for fluid extravasaton include procedure length (>90-120 min), obesity, and age (>45-50) with accompanying lack of muscle tone.

Shoulder arthroscopy is typically limited to about 90-120 minutes before the swelling from fluid extravasation interferes with the procedure, and presents a potential risk to the patient. Typically, fluid extravasation is managed by controlling fluid pressure, or hastening the procedure.

Arthroscopic instrumentation such as the newer Extravastat devices to drain extravasated fluid from the soft tissue during shoulder and hip arthroscopy has been reported to be beneficial in reducing fluid extravasation and swelling.

References:

Complications in Orthopaedics: Shoulder Arthroscopy, chapter "Severe Edema During Shoulder Arthroscopy" pp 9-16 Xavier A. Duralde, MD, Editor

Immediate postoperative fluid retention and weight gain after shoulder arthroscopy. LoIK, Burkhart SS. Arthroscopy. 2005 May;21(5):605-10.

Life Threatening Airway Edema Resuling From Prolonged Shoulder Arthroscopy

Steven L. Orebaugh, M.D. Anesthesiology, V 99, No. 6, Dec. 2003.

Severe Airway Obstruction During Arthroscopic Shoulder Surgery

Stephan Blumenthal, M.D., Marco Nadig, M.D., Christian Gerber, M.D., Alain Borgeat, M.D. Anesthesiology, V 99, No. 6, Dec. 2003.

Complete Airway Obstruction During Shoulder Arthroscopy

Hynson JM, Tung A, Guevara JE et al. Anesthesiology Analg, 76 : 875-878, 1993.

Complications of hip arthroscopy.

Sampson TG. Clin Sports Med. 2001 Oct;20(4):831-5.

[1]Wikipedia article on Arthroscopy

[2] Monograph on Complications in Shoulder Arthroscopy published by the American Association of Orthopedic Surgeons (AAOS)

Extravasation of Infusates

Extravasation may also refer to the leakage of infused substances into the vasculature into the subcutaneous tissue. The leakage of high osmolarity solutions or chemotherapy agents can result in significant tissue destruction, and significant complications.

[3]British National Health Service page on complications from extravasation of infusates