Phenytoin (Aleviatin®) 被用於治療兒童癲癇重積狀態，紫色手套綜合症 (purple glove syndrome, PGS) 是phenytoin 靜脈輸注的罕見併發症，通常在注射部位出現疼痛、水腫和變色，並擴散到遠端肢體。PGS 風險因素包括年齡、劑量、輸注時間 ( 輸注越久，外滲風險可能越高 )、輸注速度和導管粗細等與PGS 的「發生」有關；然而，病因仍然未知。過去大多數PGS 病例報導都是成人，且女性和老年患者PGS 風險會增加，本個案描述一名3 歲的女孩在phenytoin (Aleviatin®) 靜脈輸注給藥後發生PGS，醫師立即停用針劑更改為口服藥治療並給予支持性療法，後續追蹤已痊癒。藉由文獻回顧，探討此案例給予phenytoin 靜脈輸注，引起PGS 之成因及可能性。
目前針對藥液外滲發生於新生兒及早產兒探討個案及文獻非常少，因此當意外發生時能即時有效提供醫療處置文獻不多，本院藉由此個案討論訂定兒科加護病房之小兒外滲高警訊品項清單，並明確規範給藥途徑、給藥最大劑量、稀釋濃度及給藥速率等，提供醫療人員執業上之參考，確保病人的治療安全，降低風險發生。
Phenytoin (Aleviatin®) is used for pediatric status epilepticus treatment. Purple glove syndrome (PGS) is a rare adverse event associated with intravenous phenytoin injection. PGS presents with pain, edema, and discoloration at the injection site and then spreads to the distal limb. There are several risk factors including age, dose, and infusion time (the longer the infusion time, the higher the risk of extravasation), the infusion rate, and the thickness of the catheter related to the development of PGS; however, the etiology remains unknown. In recent decades, most PGS cases have been reported as adults and the risk of PGS has increased in both female and elderly patients. This case described a three-year-old girl who developed PGS after an intravenous administration of phenytoin (Aleviatin®).
The physician immediately stopped injecting and changed to oral medication and supportive therapy. This case was investigated through a literature review to understand the risk of PGS during phenytoin intravenous infusion. At present, there have been very few cases and literature on the occurrence of drug extravasation among neonates and premature babies, so there is not much literature on the immediate and effective provision of medical treatment when such accidents occur. The hospital used this case to discuss the pediatric intensive care unit, the list of children’s extravasation high-alert items, and clearly define the route of administration, maximum dose, concentration of dilution, drug delivery rate, etc. to ensure patient safety and reduce risk.
