Extravasation

Extravasation refers to the leakage of medication, administered intravenously, from a vein into the surrounding tissue. Certain medications can cause severe tissue damage if extravasation occurs. The best prevention is the correct administration technique to avoid such incidents. Nonetheless, should extravasation happen, the provided guidelines outline the immediate steps to manage and minimize potential tissue damage.

Irritant agents are those medications that cause pain and inflammation without necrosis at the site of the injection.

Vesicant agents are those medications that cause blistering, which is associated with subsequent cell death and extensive tissue necrosis.

The optimal treatment of drug extravasations is unknown. Very little objective clinical evidence is available to support wide-spread recommendations, especially in paediatrics. These guidelines represent potential treatment options.

Identifying Extravasation

1. Signs of extravasation include the patient reporting sensations of burning, stinging, or pain, or noting any sudden changes at the site of injection.
2. Other indications are the presence of hardness, redness, swelling at the injection site, a cool sensation upon touch, or the whitening of the area. Regular inspection of IV sites is crucial, particularly for patients unable to communicate discomfort, including those in comas or infants.
3. A lack of blood return when attempting to draw from the site also indicates extravasation.

Risk factors

• Venipuncture technique (e.g., multiple punctures or probing)
• Obscuring site with tape
• Selection of site (antecubital fossa is difficult to assess for extravasation)
• Peripheral versus central line administration
• Use of metal-tipped needles
• Type and concentration of vesicant or irritant infused
• Infusion characteristics (e.g., rapid rate, long durations of infusion or large infusion volume)
• Small, sclerosed, or fragile veins
• Site with little fat such as dorsum of hand
• Lymphedema (e.g., radiation, mastectomy, etc.) or altered circulation (e.g., superior vena cava syndrome, severe edema, etc.)
• Peripheral neuropathy (e.g., diabetes or previous vinca therapy)
• Inability to communicate with the nursing staff (e.g., patient using CNS depressants like opioids or benzodiazepines, infants, comatose patients, dementia, etc.)

Prevention

• Place I.V. lines for administration of drugs with potential for extravasation injury in a large, intact vessel with good blood flow.
• Select the most appropriate vein site (avoid the hand, antecubital area, scalp veins, and joint areas); a central line may have already been placed.
• Verify blood return and assess patency of vein routinely.
• Assess infusion site for evidence of infiltration/extravasation (sluggish/slowed/no blood return, edema, pain or burning, or leakage around needle).
• Instruct patient to report any pain or burning with the infusion.

Treatment – General Recommendations

1. Stop the infusion immediately, leaving needle or I.V. catheter in place.
2. If possible, withdraw 3 to 5 mL of blood to remove some of the drug.
3. Immediately inform the physician. Request order for antidote if applicable (see Tables 1 and 3).
4. Do NOT flush the line. Flushing may distribute the vesicant over a wider area.
5. Do not use this site for I.V. access until instructed otherwise.
6. Avoid pressure or friction. Do not rub area.
7. Apply Cold or heat if applicable (see Tables 1 and 3).
8. If applicable and ordered by physician, administer antidote.
9. Elevate the extremity for 72 hours. Elevate above the level of the heart using pillows or a sling. Avoid any pressure or friction to the skin that may aggravate the injury.
10. Delineate the infiltrated area on the patient’s skin with a felt-tip marker.
11. Document the occurrence of the extravasation in the medical record by noting the date, time, needle size and type, site, medications(s) administered, sequence of medications administered, approximate amount of agent extravasated, subjective symptoms reported by patient, nursing assessment of site, nursing interventions, notification of MD and interventions, instructions given to patient, and follow-up measures. Photograph if possible.
12. Complete event report
13. Observe site every 4 hours for pain, erythema, induration, and necrosis.
14. Observe the wound closely for the next several days for signs of increased erythema, pain or skin necrosis. If increased pain, erythema, or necrosis occurs, the attending physician should consider a surgery consult.
15. After 72 hours, encourage the patient to use the extremity normally to promote full recovery of the area.

Treatment of Extravasation Due to Antineoplastic (Known Vesicants or Irritants)

Extravasation Antidote

Treatment of Extravasation Due to Non-antineoplastic (Known Vesicants or Irritants): Not an all-inclusive list

Extravasation Antidote

References

• Cancer Chemotherapy manual. St Louis, MO: Wolters Kluwer Health, Inc; 2005: 23-34.
• Martin SA, Cooper TY, and Sterling J. Guide to Extravasation Management in Adult Patients [wall chart]. Hospital Pharmacy. December 2005.
• Management of Drug Extravasations. Lexi-Comp Online. Accessed January 12, 2009.