P028 Localized nonuraemic calciphylaxis following extravasation of peripheral intravenous metaraminol and glucose

Abstract We report a rare case of a localized nonuraemic calciphylaxis following extravasation of metaraminol and glucose infusion in a critically ill patient. A 61-year-old woman with a history of alcohol excess was admitted to intensive care with respiratory failure due to Klebsiella pneumonia, requiring mechanical ventilation and vasopressor support. She had a peripheral cannula inserted onto the dorsum of the left foot, and after extravasation of metaraminol and 10% glucose, developed a painful area of ulceration with eschar, surrounded by retiform purpura. Yellow–white mineralized material was visible on the surface and within the skin. Plain radiograph showed diffuse soft tissue. Skin biopsy demonstrated stromal and vascular calcification in the dermis. Serum biochemistry showed normal renal function and mild nonparathyroid hypercalcaemia. The clinicopathological diagnosis was a localized nonuraemic calciphylaxis. Clinical improvement was achieved with bedside debridement and wound care. Nonuraemic calciphylaxis is associated with hyperparathyroidism, malignancy, autoimmune disorders, alcoholic liver disease and drugs (warfarin, glucocorticoids). Localized calciphylaxis due to extravasation injuries has been reported to be exceedingly rarely. In our case, the extravasation of metaraminol, with its low pH and high osmolarity, combined with hypertonic glucose (both of which should ordinarily be given into a large peripheral vein), likely caused localized vascular injury in a patient with underlying risk factors (sepsis, hypercalcaemia, alcoholism), contributing to the development of calciphylaxis. This highlights the need to avoid intravenous administration of locally irritant drugs into small peripheral veins, particularly in critically ill patients with risk factors for tissue injury and calcification.