1043-3155 Pediatr Neurol Briefs pedneurbriefs Pediatr Neurol Briefs Pediatric Neurology Briefs Pediatr Neurol Briefs 2166-6482 1043-3155 2166-3155 Pediatric Neurology Briefs Publishers Chicago, IL, USA PNB-8-95-b 10.15844/pedneurbriefs-8-12-12 Antiepileptic Drugs Neurology Pediatrics Nervous System Diseases Child Development Brain Diseases Neurosurgery Child Infant IV Phenytoin and Soft Tissue Reaction in a Neonate http://orcid.org/0000-0002-0173-7931 Millichap J. Gordon MD 1 2 * Division of Neurology, Children's Memorial Hospital, Chicago, IL Departments of Pediatrics and Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL Correspondence: Dr. J. Gordon Millichap, E-mail: jgmillichap@northwestern.edu 12 1994 01 06 2016 8 12 95 96 Copyright: © 1994 The Author(s) 1994 This work is licensed under the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Soft tissue injury associated with intravenous phenytoin in a neonate

A blue discoloration in the hand following an iv infusion of phenytoin in a term baby with neonatal convulsions is reported from Basildon Hospital, Essex, UK.

 Phenytoin Cannula Vasospasm

A blue discoloration in the hand following an iv infusion of phenytoin in a term baby with neonatal convulsions is reported from Basildon Hospital, Essex, UK. A dose of 10 mg/kg was inadvertently diluted with sterile water rather than the recommended saline. The phenytoin infusion via a cannula was aborted after 2 ml/10 min when an intense blue discoloration appeared round the iv site at the dorsum of the hand. Capillary return and radial pulse were normal. On removal of the cannula, blood oozed freely, and the discoloration spread to the rest of the hand. Improvement occurred after 20 hrs and a blister appeared at the iv site. The lesion resolved within one week. A second iv phenytoin, diluted in saline, and given via a cannula in the foot was aborted when a similar reaction occurred. No systemic side effects were noted. Two possible factors are postulated for the injury: 1) precipitation of phenytoin with alteration in pH on contact with blood or infusing fluid and direct vascular injury and vasospasm; or 2) infiltration of drug with tissue reaction from alkaline solution. [1]

COMMENT. The authors refer to similar reports in the literature occurring in adults but none in infants and children. This type of tissue reaction to phenytoin in neonates appears to be a rare occurrence. Although slow iv injection of undiluted phenytoin parenteral solution (1-3 mg/kg/min) is recommended by some, most neonatologists and neurologists advocate dilution with normal saline prior to iv injection, infusion at a rate of no more than 0.75 mg/kg/min [2], and followed by a normal saline flush. Avoidance of the hand and an in-line filter are additional precautions cited in the literature. Phenytoin should not be mixed in glucose solutions since the drug precipitates out in microcrystals.(Ramsay RE, 1993). Intramuscular injection of PHT should be avoided because of local discomfort, muscle necrosis, and slow and erratic absorption.

 Sharief N Goonasekera C Soft tissue injury associated with intravenous phenytoin in a neonate Acta Paediatr 1994 Nov 83 11 1218 1219 10.1111/j.1651-2227.1994.tb18288.x 7841742 Ramsay SE Treatment of status epilepticus Epilepsia 1993 34 Suppl 1 S71 S81 10.1111/j.1528-1157.1993.tb05922.x 8462493