Extravasation injuries represent a significant concern in pediatric patients receiving intravenous therapy. Our study, spanning 13 years, provides valuable insights into the epidemiology, management, and outcomes of severe extravasation injuries in a tertiary pediatric hospital. The results highlight crucial areas requiring improvement, including early detection, standardized management protocols, and prevention strategies.

In our cohort, a notable male predominance was observed (71%), consistent with several prior studies [1,2]. However, other investigations have reported a more balanced gender distribution [3]. No definitive biological rationale explains a gender-based difference in extravasation risk, and discrepancies across studies may reflect sampling variability rather than true epidemiologic trends.

The most affected age group in our study was children aged between 2 to 6 years (43%), differing from previous reports that identified neonates as the most vulnerable population [4,5]. Neonates have inherently fragile veins, low tissue resilience, and limited ability to communicate discomfort, placing them at heightened risk [6]. Our different age distribution could be attributed to the specific patient flow and selection bias in surgical referrals at our center, where more severe lesions necessitating surgery were prevalent among older infants and toddlers.

Anatomically, the dorsal hand emerged as the most frequent extravasation site (72%), a finding that mirrors observations in large pediatric cohorts [7,8]. The vulnerability of the dorsal hand relates to the thinness of subcutaneous tissues, frequent movement, and superficial vein positioning, all contributing to catheter instability [9]. The dorsal foot and scalp were also implicated, although to a lesser extent. Understanding the anatomical predilection for extravasation is vital in guiding the choice of vascular access sites and securement techniques.

The type of infused product significantly influenced the severity of extravasation injuries. In our series, hypertonic glucose solutions were responsible for 72% of cases, followed by chemotherapeutic agents (21%) and antibiotics (7%). Similar findings have been reported globally, with hyperosmolar fluids frequently implicated in severe injuries [10,11]. Hypertonic glucose's high osmolarity leads to cellular dehydration, protein denaturation, and subsequent tissue necrosis [12]. Chemotherapeutic agents, particularly anthracyclines, are known vesicants, and their extravasation can result in devastating soft tissue loss if not managed promptly [13].

Timely intervention is paramount in mitigating extravasation-related morbidity. Our study found that only one patient (7%) received intervention within 48 hours, whereas the majority experienced significant delays. Early detection and management are associated with improved outcomes, as demonstrated by several pediatric studies [14,15]. Delay in recognition leads to progression from infiltration to tissue necrosis, ultimately necessitating more aggressive surgical interventions, including debridement, grafting, and, in extreme cases, amputation.

Surgical intervention played a major role in our management strategy, particularly for Grade IV injuries. Directed healing after debridement was performed in 36% of cases, while skin grafting was required in 36% (full-thickness or split-thickness). Amputation was necessary in two patients (14%) who presented with extensive necrosis and vascular compromise. Our findings align with existing reports emphasizing the critical role of surgical management in advanced extravasation injuries [16,17].

The absence of antidotal therapies in our series represents a notable gap. Agents such as hyaluronidase, dexrazoxane, and dimethyl sulfoxide (DMSO) have been proven effective in limiting tissue damage in specific types of extravasations [18,19]. Hyaluronidase facilitates the dispersion of extravasated solutions and is particularly useful in cases involving non-cytotoxic hyperosmolar agents [20]. Dexrazoxane, an FDA-approved agent, is highly effective against anthracycline-induced tissue injury if administered promptly [21]. Future improvements in our center’s extravasation management could benefit from the incorporation of such pharmacological interventions.

Preventive strategies must be emphasized to reduce the incidence of extravasation. Recommended measures include careful selection of vascular access sites, using securement devices, limiting osmolarity and irritant concentrations in peripheral infusions, and frequent site monitoring [10,22]. Educational programs for nursing and medical staff are critical to improve vigilance and early recognition of signs of infiltration.

Overall, our study reaffirms the serious nature of extravasation injuries in pediatric populations and underscores the importance of early recognition, multidisciplinary management, and robust preventive strategies. Strengthening healthcare provider training, establishing standardized protocols, and ensuring access to antidotal therapies are pivotal steps toward reducing extravasation-related morbidity.

Despite these valuable findings, our study has limitations.It is limited by its retrospective design, which introduces potential selection and information biases. The small sample size and single-center setting limit generalizability. Moreover, only surgically managed cases were included, excluding milder injuries, which may distort the perceived severity profile. Future prospective, multicenter studies with larger cohorts are needed to better define risk factors and develop standardized prevention and management protocols.