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BRIEF COMMUNICATIONS: Terence J. O’Brien, Frances M. Meara, Helen Matthews, and Frank J. Vajda Prospective study of local cutaneous reactions in patients receiving IV phenytoin Neurology 2001; 57: 1508-1510 [Abstract] [Full text] [PDF]

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Reply to Letter to the Editor

Terence J O'Brien, Frank J Vajda   (14 November 2001)

Prospective study of local cutaneous reactions in patients receiving IV phenytoin

Jorge G Burneo, Gregory L Barkley   (14 November 2001)

Reply to Letter to the Editor 14 November 2001
Terence J O'Brien St. Vincent's Hospital Melbourne Fitzroy Victoria Australia, Frank J Vajda Send Correspondence to journal: Re: Reply to Letter to the Editor sandi_moriarity{at}urmc.rochester.edu Terence J O'Brien, et al.	We thank Drs. Burneo and Barkley for their interest in our article. [1] We note that they found an incidence of the purple glove syndrome (PGS) of three (not two) of 179 exposures in their recently published prospective study. [2]. We agree that local practices are likely to influence the rate of reactions following IV phenytoin administration, particularly as they relate to the risk of extravasation of the highly irritant solution. The slow rate of infusion (20 mg/min) dictated at their hospital may well have contributed to the low rate of the PGS that they found. In contrast, at our hospital the infusions could be administered up to 50 mg/min, and the actual rate of administration was rarely recorded. Differences in the patient populations may have also been a contributing factor, with our patients being older (median age 65 years vs 57 years) and therefore potentially more vulnerable to developing IV extravasations. [4] We also agree that differences in terminology and definition may also be important. The site of the edema, discoloration and pain complicating IV phenytoin infusions is dependant on the site its administration, and in many cases will be prominent proximally in the forearm or arm rather than distally in the hand, as in the classic PGS. For this reason we preferred the site independent term “LCR”, rather that attempting to rather arbitrarily classify reactions as being the “PGS” according to their site. Burneo et al. [2] classified reactions as being the “PGS” only when they occurred “distal to the IV site”. Of interest, their incidence per exposure (1.7%) was similar to that of our previous retrospective study from the Mayo Clinic (9/6/77, 1.3%), where a more strict definition of the “PGS” was used. [3]. However, we dispute that the LCR reported in our current study represented non-specific reactions related to direct trauma, uncomplicated fluid extravasation, infection or age related changes. To be classified as a LCR the reactions needed to have discoloration as well as edema, to be present within 24 hours of the infusion and to have progressed after the commencement of the infusion, all features that would not be expected with any of the above alternate explanations. Furthermore, as a comparison group we prospectively examined the limbs of 16 general ward patients who were given IV benzodiazepines during the last four months of our study (mean age 53 years vs. 65 years for the phenytoin patients, p=0.27, Student t-test), with no cases fulfilling the criteria for a phenytoin LCR being detected. References: 1. O’Brien TJ, Meara FM, Matthews H, Vajda FJ. Prospective study of local cutaneous reactions in patients receiving IV phenytoin. Neurology 2001;57:1508-1510. 2. Burneo JG, Ananda JV, Barkley GL. A prospective study of the incidence of the purple glove syndrome. Epilepsia 2001;42:1156-1159. 3. O'Brien TJ, Cascino GD, So EL, Hanna DR. Incidence and Clinical Consequences of the Purple-Glove Syndrome in Patients Receiving Intravenous Phenytoin. Neurology 1998;51:1034-1039. 4. MacCara ME. Extravasation: A hazard of intravenous therapy. Drug Intell Clin Pharm 1983;17:713-717.
Prospective study of local cutaneous reactions in patients receiving IV phenytoin 14 November 2001
Jorge G Burneo University of Alabama at Birmingham Birmingham Al, Gregory L Barkley Send Correspondence to journal: Re: Prospective study of local cutaneous reactions in patients receiving IV phenytoin sandi_moriarity{at}urmc.rochester.edu Jorge G Burneo, et al.	We read with interest the work by O’Brien et al. [1] since we have recently published a prospective study of the purple glove síndrome (PGS). [2] The differences in rate of localized cutaneous reactions (LCR) in their series and ours may be due to several factors. The high incidence of LCR in their series (25.2%) may be related to the rate of infusión of phenytoin on different hospital services. At Henry Ford Hospital, the rate of administration is dictated by the Department of Pharmacy and is set at no more than 20 mg/min throughout the hospital , including the Department of Emergency Medicine. [2] The reported rates of cutaneous reactions in this report do not directly compare to our series where we reported only the rate of PGS. The authors of this study have combined the rates of PGS with other cutaneous reactions. They do not differentiate between PGS and local inflammation as a result of direct trauma of the vein due to a catheter insertion, intravenous fluid extravasation, and local cutaneous infection. In our series, only two exposures out of 179 developed PGS. This small incidence makes us reluctant to say that the rate of PGS is elevated in the elderly. We suspect that the increased incidence of cutaneous findings in the elderly in this report is a non-specific phenomenon of aging due to the known changes in the skin that occur with increasing age rather than a specific cutaneous reaction to phenytoin. We would be interested to see the PGS rates separated from other cutaneous skin findings. In addition, we wonder if O’Brien et al. have any data on the rates of these other non-specific skin reactions in an age-matched control group in their hospital. References: 1. O’Brien TJ, Meara FM, Matthews H, Vajda FJ. Prospective study of local cutaneous reactions in patients receiving IV phenytoin. Neurology 2001; 57: 1508-1510. 2. Burneo JG, Ananda JV, Barkley GL. A prospective study of the incidence of the purple glove syndrome. Epilepsia 2001; 42 (9): 1156-1159.