Hospital Pharmacy - September 2017 - 560

560

Hospital Pharmacy 52(8)

Figure 1. Intravenous medications administered during emergency department encounter.

involving metronidazole infiltration available at this time,
we report a case which contrasts the limited but seemingly
concerning profile of this medication.

Case Presentation
The patient, a 38-year-old Caucasian female (weight approximately 63 kg), presented from an outside facility with left
upper quadrant pain and concern for pancreatitis versus
bowel perforation. The patient had a history significant for a
perforated gastrointestinal ulcer, peptic ulcer disease, and a
partial colectomy and cholecystectomy in 2014. She reported
10 out of 10 left-sided abdominal pain for the past three or
four days with worsening pain today including radiation to
her chest. She also reported bright green emesis 10 times
since earlier that morning. Review of systems was positive
for fever, chills, activity change, and appetite change. She
had leukocytosis (white blood cell: 18.7 K/µL), computed
tomography denoting edema near the duodenum, and a small
amount of pneumoperitoneum. Therefore, she was initiated
on intra-abdominal antimicrobial therapy consisting of intravenous metronidazole and levofloxacin.
The emergency department registered nurse caring for
the patient called the clinical pharmacist in the emergency
department at 21:36 pm regarding infiltration of intravenous
metronidazole injection (500 mg in 100-mL sodium chloride). This product was initiated at 21:28 open to gravity,
and thereby faster than the standard 60-minute infusion
time, through an 18-gauge peripheral catheter in the left
brachial vein. Based upon product remaining, 50 mL was
estimated as a conservative volume of medication which
had infiltrated (estimated administration rate ~375 mL/h).
Levofloxacin 750 mg in 150-mL dextrose 5% water was
administered successfully open to gravity via this same
access site prior to metronidazole starting at 21:00 and
ending at an estimated time of 21:20 (estimated rate of
~450 mL/h). The intravenous catheter was confirmed to be
patent during and after administration of levofloxacin by
the registered nurse. Other therapies administered via this

Figure 2. Metronidazole infiltration site (L brachial vein) at 22:00.

intravenous catheter during the emergency department
stay are denoted in Figure 1.
Based upon bedside examination at approximately 22:00, the
site was found to be slightly edematous and erythemic (Figures 2
and 3). The involved site measured approximately 5.5 × 6.6 cm.
There were no observed blanching, blister formation, induration,
skin discoloration, or diminished capillary refill. The patient
reported some pain at the catheter site, but no coolness, burning,
numbness, or warmth. The Infiltration/Extravasation Scale was
utilized to stratify the patient's event and was found to be a 2 out
of 4.1,12 Interventions performed included catheter discontinuation, cleansing of the catheter site with alcohol, marking of the
infiltration site with a patient skin marker, and patient education
on alarm symptoms of infiltration such as extension of edema,
erythema, decreased range of motion, and diminished sensation.
The decision was made to not treat the site with hyaluronidase
due to an estimated osmolarity of ~310 mOsm/L and a pH of 5.8
(pH range: 4.5-7).13 The recommendation provided to the treatment team consisted of monitoring the left brachial infiltration
site at least every two hours for the next 24 hours. No specific
recommendations were made with regard to thermal compresses
or extremity elevation. Replacement intravenous catheter access
was obtained via the right internal jugular vein in the emergency
department.

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