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In this section, we will go over:

• Medication Extravasation

• Drug Reactions

• Dermatologic Emergencies

Medication Extravasation

The inadvertent extravasation of medication is a concerning issue that demands swift and coordinated action. This occurs when a medication intended for intravenous administration leaks into the surrounding tissue instead of entering the bloodstream, potentially causing tissue damage and severe complications. Medication extravasation can occur for various reasons, including improper administration technique, inappropriate choice of IV site, high infusion pressure, and patient-related factors such as fragile veins or poor circulation. It is important for healthcare providers in the ICU to have a thorough understanding of medication extravasation in order to prevent, recognize, and manage this complication effectively.

When a medication extravasation occurs, the type and concentration of the medication, as well as the volume and rate of infusion, play a significant role in determining the severity of tissue damage. Immediate steps are taken to stop the infusion. Vesicant medications, which have the potential to cause tissue injury, include chemotherapy drugs, vasopressors (commonly seen in our practrice), certain antibiotics, and contrast agents. Non-vesicant medications, on the other hand, are less likely to cause tissue damage.

The signs and symptoms of medication extravasation can vary depending on the medication involved and the extent of tissue damage. Early signs may include pain, swelling, and erythema at the infusion site. As the condition progresses, blisters, ulceration, and tissue necrosis may develop. In severe cases, compartment syndrome, infection, and impaired wound healing can occur.

In general, when you have a medication extravasation occur, you should always do the following:

• Stop the infusion

• Place a RL report regarding the incident (can be done by the nursing staff)

• Give an antidote if applicable (we have an Extravasation Orderset you can use thanks to Brittany Bowman)

• Place an order for neurovascular checks of area; often, you will also see it marked with a sharpie

• Consult wound care if applicable

Drug Reactions

In our ICU patients are often exposed to a wide range of medications to manage their critical conditions. While these medications are essential for their treatment, they can also lead to various drug reactions. Drug reactions in ICU patients can range from mild skin irritations to severe allergic reactions. It is crucial for healthcare providers in the ICU to be aware of these common drug reactions and take appropriate measures to manage and prevent them.

Some common drug reactions we see:

1. Skin Rash: One of the most common drug reactions seen in ICU patients is a skin rash. These rashes can vary in appearance, ranging from mild redness and itching to more severe blistering and peeling. Drug-induced rashes can be caused by a variety of medications, including antibiotics, anticonvulsants, and nonsteroidal anti-inflammatory drugs (NSAIDs).

2. Hypersensitivity Reactions: Hypersensitivity reactions are immune-mediated responses to medications. These reactions can manifest as skin rashes, hives, swelling, or even life-threatening conditions such as anaphylaxis. Antibiotics, particularly penicillins and cephalosporins, are common culprits for hypersensitivity reactions in the ICU.

3. Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN): SJS and TEN are severe and potentially life-threatening drug reactions that cause widespread skin detachment. These conditions often start with flu-like symptoms and progress to painful blisters and skin sloughing. Medications commonly associated with SJS and TEN include antiepileptic drugs, allopurinol, and sulfonamides.

4. Drug-induced Photosensitivity: Some medications can make the skin more sensitive to sunlight, leading to an exaggerated sunburn-like reaction. This reaction typically occurs on sun-exposed areas of the skin and can be caused by medications such as diuretics, antibiotics, and nonsteroidal anti-inflammatory drugs (NSAIDs).

5. Drug-induced Pigmentation: Certain medications can cause changes in skin pigmentation, resulting in either darkening or lightening of the skin. This can be seen with medications like amiodarone, antimalarials, and chemotherapeutic agents.

Prompt recognition and appropriate management of drug reactions are crucial in the ICU setting. The following steps should be taken:

1. Discontinuation of the Offending Medication: The first step in managing a drug reaction is to identify and discontinue the medication responsible for the reaction. This may involve consulting with a pharmacist or specialist to determine suitable alternative medications.

2. Symptomatic Relief: Depending on the severity of the reaction, symptomatic relief measures may be necessary. This can include the use of topical corticosteroids or antihistamines to alleviate itching and inflammation.

3. Monitoring and Supportive Care: Close monitoring of the patient's vital signs and organ function is essential, especially in severe drug reactions. Supportive care measures, such as intravenous fluids and respiratory support, may be required.

4. Consultation with Dermatology or Allergy Specialist: In cases of severe or complex drug reactions, consultation with a dermatology or allergy specialist may be necessary to guide further management. If you call carelink, you can usually see if someone is on. It can be difficult to find a dermatologist so looping in your attending is always a good idea.

dermatologic Emergencies

While very uncommon, dermatologic emergencies can arise and require immediate attention and management. These emergencies can range from severe drug reactions to life-threatening skin conditions. Prompt recognition and appropriate intervention are crucial to prevent further complications and ensure the well-being of ICU patients.

Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)

Stevens-Johnson Syndrome (SJS) and its more severe big sister, Toxic Epidermal Necrolysis (TEN), are rare but potentially life-threatening dermatologic emergencies. These conditions are characterized by widespread skin detachment and mucosal involvement. SJS and TEN are often triggered by medications, such as antibiotics, anticonvulsants, and nonsteroidal anti-inflammatory drugs (NSAIDs).

The initial symptoms of SJS/TEN may include fever, malaise, and a flu-like illness. Within a few days, patients develop painful, blistering skin lesions that rapidly progress to widespread skin detachment. Mucosal involvement can lead to severe complications, including respiratory compromise, ocular damage, and gastrointestinal complications.

The management of SJS/TEN in the ICU involves immediate discontinuation of the offending medication and supportive care. Patients should be transferred to a specialized burn unit or dermatology center for further management. Supportive measures include fluid and electrolyte management, pain control, wound care, and prevention of infection. In severe cases, immunomodulatory therapies, such as intravenous immunoglobulin (IVIG) or systemic corticosteroids, may be considered.

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), also known as Drug-induced Hypersensitivity Syndrome (DIHS), is a severe drug reaction that can occur in the ICU. DRESS is characterized by a widespread rash, fever, lymphadenopathy, and multiorgan involvement. It typically occurs 2-8 weeks after exposure to the offending medication.

The skin manifestations of DRESS include a morbilliform rash (measles-like rash) that can progress to exfoliative dermatitis. Other organs commonly affected include the liver, kidneys, lungs, and heart. Prompt recognition and withdrawal of the causative medication are essential in managing DRESS.

Some hallmarks of treatment include supportive care, including fluid and electrolyte management, monitoring of organ function, and treatment of complications. Systemic corticosteroids are often used to suppress the immune response and reduce inflammation. Close monitoring of vital signs, laboratory parameters, and organ function is crucial in the management of DRESS.

Acute Generalized Exanthematous Pustulosis (AGEP)

Acute Generalized Exanthematous Pustulosis (AGEP) is a rare but severe cutaneous reaction that can occur in the ICU. AGEP is characterized by the rapid onset of numerous sterile pustules on an erythematous base. It is often triggered by medications, such as antibiotics, antifungals, and antiepileptics.

Patients with AGEP may present with fever, malaise, and a generalized rash with pustules. The pustules can be accompanied by itching and burning sensations. Systemic involvement, such as liver or kidney dysfunction, can occur in severe cases.

The management of AGEP involves discontinuation of the offending medication and supportive care. Supportive measures include wound care, pain control, and prevention of infection. Systemic corticosteroids may be considered in severe cases or when systemic involvement is present. Most patients with AGEP recover within a few weeks with appropriate management.

Bullous Pemphigoid

Bullous Pemphigoid is a chronic autoimmune blistering disorder that can occasionally present as a dermatologic emergency in the ICU. It primarily affects the elderly population and is characterized by the formation of large, tense blisters on the skin and mucous membranes.

In the ICU, bullous pemphigoid can be complicated by secondary infection, fluid and electrolyte imbalances, and impaired wound healing. Prompt recognition and management are essential to prevent further complications.

The management of bullous pemphigoid in the ICU involves wound care, prevention of infection, and systemic immunosuppressive therapy. Systemic corticosteroids are the mainstay of treatment, and additional immunosuppressive agents may be used in refractory cases.

Other Dermatologic Emergencies

Other dermatologic emergencies that may be encountered in the ICU include acute urticaria, angioedema (see our HEENT section), and severe cutaneous adverse reactions (SCARs) like Drug-induced Bullous Pemphigoid, Acute Febrile Neutrophilic Dermatosis (Sweet Syndrome), and Erythema Multiforme. Each of these conditions requires prompt recognition, appropriate management, and, in some cases, consultation with dermatologists.