The research progress in external application of physic liquor exosmosis in mannitol intravenous infusion

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(1. School of Nursing; 3. School of Medicine, Yangzhou University, Yangzhou, Jiangsu, 225009;2. Nagano College of Nursing, Nagano, Japan, 399-4117)

ABSTRACT: Mannitol is the first choice of clinical dehydrating agent, which can alleviate brain edema and reduce intracranial pressure. As a hypertonic solution, it has strong vascular irritation. Moreover, fast infusion speed is required, which can be related to pain, physic liquor exomosis and some other side effects. Regarding of the physic liquor exosmosis in mannitol intravenous infusion, this paper reviewed the research progress of different external application treatment, and provided references for clinical treatment of physic liquor exosmosis in mannitol intravenous infusion.

KEY WORDS: mannitol; intravenous infusion; physic liquor exosmosis; external application

Intravenous infusion is one of the most effective treatment methods available for the treatment of multiple diseases. According to domestic and foreign statistics, more than 90% of hospitalized patients need intravenous infusion[1-2]. However, there are some complications during intravenous. The most common complication is physic liquor exosmosis. After the physic liquor exosmosis of some hypertonic solution (such as 20% mannitol, potassium chloride, calcium glucose, fat emulsion, etc.), if not be treated in time and properly, local skin tissue canker or even necrosis may be caused[3-4]. As a macromolecular hypertonic solution, when mannitol is infused with high concentration and rapid speed, plasma osmotic pressure increases rapidly, which leads to the dehydration of vascular endothelial cells and aggregation of local platelet, followed by releasing the prostaglandin E1 and E2. At that time, the permeability of the venous wall is enhanced and the infiltration of white corpuscles induces an inflammatory response. At the same time, histamine is released, which makes the vein shrink and then harden, leading to the occurrence of phlebitis and even the occurrence of osteofascial compartment syndrome[5-6]. At present, there have been various studies on the external application treatment to physic liquor exosmosis during mannitol intravenous infusion. This paper reviewed the research progress of external application of different medicine, which aimed to provide references for the treatment and nursing of physic liquor exosmosis during mannitol intravenous infusion.

1 Hirudoid cream

Hirudoid cream, known as mucopolysaccharide polysulfate cream, is a kind of polysaccharide heparin extracted from animal liver. It can reduce inflammation, stimulate the regeneration of damaged endothelial cells, promote blood circulation in local tissues, promote hematoma absorption, and inhibit thrombosis. It is also effective in relieving pressure and pain, absorbing fluids, reducing swelling and promoting the recovery of connective tissue[7-8]. DONG Y et al.[9]found that in the case of physic liquor exosmosis of mannitol, hirudoid cream can be applied on the skin of the exosmosis site evenly. The medicine can fully penetrate into the skin if you massage gently with spiral manipulation along the direction of blood vessels for 2-3 minutes. There is a favorable effect on the treatment of physic liquor exosmosis of 20% mannitol when intravenous infusion is performed. Neither adverse stimulation nor side effect was observed. What is more, it is reported that patients can tolerate it and feel comfortable with it, so that they are willing to accept it. It is important to pay attention that when applying it, people should avoid applying it to the ulceration and pinpricks of the skin. On the other hand, the application area should be 1-2 cm larger than the exosmosis area and it should be covered with a layer of sterile gauze and fixed with adhesive tape. The dressing should be changed once a day and the warmth of the limbs should be paid attention to.

2 50% magnesium sulfate

Several studies have shown that 50% magnesium sulfate can treat the physic liquor exosmosis of mannitol effectively when intravenous infusion is performed. Magnesium ions and sulfate ions in magnesium sulfate are strong polar substances for its strong penetrability, it can penetrate into the subcutaneous tissue and blood vessels through the skin tissue, and make the local tissue edema subside through the expansion of blood vessels, so as to alleviate the edema of damaged local tissue[10]. However, different external application methods of magnesium sulfate have different effects on mannitol exosmosis. LAN Y L et al.[11]divided the patients with mannitol extravasation into two groups. Patients in the observation group were treated with cold and wet application of magnesium sulfate within 24h after the occurrence of mannitol extravasation, then hot and wet application of magnesium sulfate within 24-48 h after the extravasation. Patients in the control group were treated with nothing in the first 24h after mannitol exosmosis, and then were treated with hot and wet application of magnesium sulfate during 24-48 h after the physic liquor exosmosis. It was found in the study that the duration of local skin heat, swelling and pain of mannitol extravasation in the observation group was significantly shorter than that in the control group, which could significantly shorten the local recovery time of patients with mannitol intravenous and reduce local lesions and pain effectively. In a word, the therapeutic effect was better than that in the control group. The purpose of applying 50% cold and wet magnesium sulfate during the first 24h after exosmosis is to make local blood vessels constrict and slow down the blood flow, and then reduce cell activities and metabolism to control the spread of inflammation. In addition, it is a favorable way to reduce skin temperature and inhibit cell activities, then slow down nerve impulse conduction and reduce the sensitivity of nerve ends to reduce pain. The purpose of applying 50% hot and wet magnesium sulfate during the second 24h after exosmosis is to dilate local blood vessels, promote inflammation and dissipate inflammation and swelling.

3 Plants

Many researchers have used external application of plants to study the prevention and treatment of the physic liquor exosmosis of mannitol during intravenous infusion, such as potato ships, kelps, mulberry leafs, aloes and so on. They all achieved effective results but the mechanisms are different. For example, potato contains a large amount of starch and solanine. Starch is hypertonic and it can relieve pain and swelling by external application. Solanine can stimulate smooth muscle and strengthen blood circulation, so as to reduce swelling effectively when applied to skin. In addition, a lectin can be extracted from potato, which can hinder the growth of gram bacillus. Bactericidal and antifungal effects were also found in lectin. Although many studies have proved that it has a favorable effect on the treatment of mannitol exosmosis, it is apt to result in nurse-patient disputes due to the long time of local treatment and slow speed of pain relief. The slow duration may due to that both the potato and the mannitol in swelling tissue are hypertonic substances, and the concentrations of the two are close to each other. When the potato is applied to the swollen skin, the osmotic gradient difference is small, and the water molecules move relatively slowly, affecting the speed of pain relief and swelling reduction. WEI Z M et al.[12]found that the effect is better if 1-2 cotton pads were soaked with water for injection and applied to the swelling skin, then potato slips are applied after 30 minutes. The mechanism related to the gradient principle of osmotic pressure. Water for injection is easy to be moved as a pure solvent. The skin is able to secret, absorb, and maintain water and salt balance. The water molecules in the water for injection move to the swollen tissue and then dilute mannitol, which reduces the stimulation and damage of mannitol to the tissue and alleviates pain. After 30 minutes, potato slices were applied to the swelling area. It also uses the gradient principle of osmotic pressure. As the starch percentage of potato is 15%-23%, it has the effect of hyperosmosis, which can move the water molecules in the swelling tissue to the outside of the skin so as to achieve the purpose of rapid pain relief and swelling reduction.

4 Comfeel hydrocolloid dressing

HE F et al.[13]found that if the patient who received 20% mannitol intravenous infusion were applied by Comfeel hydrocolloid transparent dressing on the indwelling needle were more likely to avoid the incidence of phlebitis as well as the friction with the vascular wall. The study showed that the Comfeel hydrocolloid transparent dressing could effectively absorb the effusion, keep the needle mouth dry so as to reduce the incidence of phlebitis. In addition, it can firmly fix the indwelling needle and effectively reduce the friction with the vascular wall caused by indwelling needle loose. It can reduce the damage of vascular intima caused by the friction and then reduce the occurrence of mechanical phlebitis. Apart from this, it can prolong the using time of the indwelling needle and reduce the workload of nursing. Comfeel hydrocolloid dressing is elastic and can adapt to the slight movement of the skin. Patients will feel comfortable so that it can improve patients' satisfaction with the nursing work effectively. Comfeel hydrocolloid dressing also has a strong ability of autolysis and clearance, which can effectively absorb fluid and maintain local dryness. The closed dressing can form hypoxic tension, and then stimulate and release interleukin and macrophages. It can accelerate inflammation regression and reduce colony growth. In addition, as a new type of polymer material, Comfeel hydrocolloid dressing is not apt to bring allergic reactions of the skin in patients.

5 Alcohol

A number of studies have shown that the gauze with 75% or 95% alcohol could be applied to the upper part of the puncture vein for 30min after mannitol intravenous infusion, which can relieve pain and inhibit inflammation of local skin. In addition, clingfilm can be covered on gauze during infusion, and then fixed with adhesive tape to keep the gauze wet. Alcohol has the effect of local anesthesia and analgesia, which can dilate local blood vessels of patients and then improve local blood circulation and function of vascular endothelial cells. When alcohol volatilizes, it can take away body heat, and enhance the ability of vascular endothelial cells to resist injury with a low temperature, which can effectively relieve pain of patients and inhibit the occurrence and development of local inflammation[14].

6 Yunnan Baiyao

WU Y et al.[15]found that when a proper amount of Yunnan Baiyao mixed with 75% alcohol into a paste was applied to the swelling skin, with a thickness of about 0.2-0.4cm and wrapped with plastic wrap, its clinical efficacy was observed after the dressing was removed 20min later. They analyzed the difference before and after the treatment of patients with Visual Analogue Scale/Score (VAS). The study confirmed that the total effective rate of the treatment was higher and the VAS score was significantly reduced. As a Traditional Chinese Medicine preparation, Yunnan Baiyao is commonly used in clinic, which has the effects of analgesic, anti-inflammatory, detumescence, anticoagulation, antithrombosis, reducing capillary permeability, inhibiting the exudation of inflammatory factors and so forth. Alcohol can disinfect, relieve pain, dilate blood vessels, improve blood circulation, reduce local skin temperature and enhance the resistance of vascular endothelial cells and the like. Therefore, Yunnan Baiyao mixed with 75% alcohol into a paste applied to the skin, which could effectively treat the physic liquor exosmosis of mannitol after intravenous infusion.

In addition, scald ointment, Jinhuang San , cooling gel sheet, Snyrene, Phytocare toothpaste, external application of traditional Chinese medicine (such as phellodendri 20 g, isatidis folium 30 g, portulacae herba 60 g, after decocting, warm and wet topical application, 3-4 times a day), natrii sulfas, alum ice liquid, compound Sanqi powder, Jiawei gold Fugao, wounds grass ointment, Honghua alcohol and some other medicines all have been validated by scholars for the treatment of external treatment of mannitol during intravenous infusion[16-18].

In recent years, many scholars have achieved remarkable results in the external application treatment of the physic liquor exosmosis of mannitol intravenous infusion by combining different medicine, mainly including: potato combined with dexamethasone injection; potato combined with iodophor; potato combined with magnesium; potato combined with Yunnan Baiyao aerosol; potato combined with alcohol; alcohol combined with Houfeng San; alcohol combined with 654-2; alcohol combined with vitamin B12; vitamin B12 combined with hypertonic sugar and dexamethasone, dexamethasone combined with lidocaine, dexamethasone combined with Yunnan Baiyao lidocaine combined with vitamin C and so on[19-21].

Physic liquor exosmosis is a common manifestation of iatrogenic injury, which significantly affects the prognosis, treatment costs and hospital stay[22].Although the phenomenon of physic liquor exosmosis during mannitol intravenous infusion is relatively common, domestic and foreign scholars have reached a lot about its external application in recent years. Clinically, corresponding prevention and treatment methods can be selected according to the actual situation of patients in order to reduce the incidence of physic liquor exosmosis and reduce the adverse consequences caused by physic liquor exosmosis so as to improve the comfort level of patients in the end.