CLINICIAN-RELATED RISKSInadequate nursing knowledge pertaining to: F Peripheral IV InsertionF Identification of vesicant vs. non-vesicant agents

Poor assessment skillsF Hourly assessments recommended

• Geriatrics, Pediatrics and infusion of vesicantsF Assessments every 4 hours recommended

• Patients receiving infusion of non-vesicant/irritantsNegligence in overall nursing care planning, intervention and follow-up care

Source: (Sauerland, C., Engelking, C., Wickham, R., & Corbi, D., 2006)

RECOGNIZING INFILTRATION IN OUR PATIENTSInfiltrationF Swelling F RednessF EdemaF Pain

INS Infiltration ScaleF Grade 0: No symptomsF Grade 1: Skin blanched; edema <1” in any direction;

cool to touch; may have painF Grade 2: (same as Grade 1) to include edema 1-6”

in any directionF Grade 3: Skin blanched; translucent; gross edema

>6” in any direction; cool to touch; mild to moderate pain; possible numbness

F Grade 4: Typically considered extravasation; skin discolored, bruised, swollen; circulatory impairment; moderate to severe pain;

BEST EVIDENCE-BASED PRACTICES FORTREATMENT OF IV INFILTRATION F Remove cannula immediatelyF Assess siteF Evaluate ROM and sensation in affected limbF Assess for sensory deficit F Measure area of infiltrationF Cautious use of warm or cold compressesSources: (Dougherty, L., 2008); (Schulmeister, L., 2009); (Sauerland, C., Engelking, C., Wickham, R., & Corbi, D., 2006); (Schummer, W., et. al., 2005)

RECOGNIZING EXTRAVASATION IN OUR PATIENTSF Typically classified as Grade 4 on INS Infiltration ScaleF Degree of injury is proportionate to:

• Amount of drug infused• Location of peripheral IV site• Concentration of the drug

F All of which can lead to:• Ulceration within days or weeks• Severe, continuous pain • Tissue damage and possible

impairment of affected limbSource: (Dougherty, L., 2008); (Sauerland, C., Engelking, C., Wickham, R., & Cordi, D., 2006)

BEST EVIDENCE-BASED PRACTICES FORTREATMENT OF EXTRAVASATIONFactors to consider prior to treatment: F The individualF Type of vesicant used F Institution’s protocol for treatment

Systematic ApproachF Stop infusion immediatelyF Determine substance and amount usedF Consider location of peripheral catheterF Length of contact with the substanceF Cold or hot compresses?

Use of Hot or Cold compresses?F Cold

• Used to treat DNA-binding vesicant infiltration- Results in vasoconstriction, localizing extravasation- Apply 15-20 mins 3-4 x daily for up to three days, or as

indicated by the physicianF Hot

• Used to treat Non-DNA binding vesicant infiltration- Results in vasodilation

• Reduces local drug concentration • Decreases pain• Helps with reabsorption of local swelling

- Apply via electric heating pad or covered hot water bottle for up to 24 hours, or as prescribed by the physician

Elevation of affected limbAntidotesF Steroid Cream

• Reduces local trauma and irritation HyaluronidaseF An enzyme that helps to reduce tissuedamageF Promotes drug absorptionF Usually injected around the

extravasation siteF Itching and redness may occur

Dimethyl Sulfoxide (DMSO)F Topical solution F Antidote to cytotoxic drugs such

as anthracyclinesF Itching and redness may occur

DextrazoxoneF Reduces the size and duration

of the woundF Must be administered within 6

hours of extravasation F Only used with anthracycline cytotoxic drugs

Surgical InterventionF Surgical Incision

• Effective if lesion is of a certain size or there is residual pain or minimal healing

F Flush-Out Technique• Infiltration of the area with a local anesthetic• Making a number of small stab incisions• Tissue is flushed out using normal saline • Effective if performed immediately after extravasation

• Usually performed by a plastic surgeonSource: (Dougherty, L., 2008); (Schulmeister, L., 2009); (Sauerland, C., Engelking, C., Wickham, R., & Corbi, D., 2006)

PREVENTING EXTRAVASATIONF Hourly assessmentsF Cover site with

transparent dressingF Stabilize equipmentF Proper site selectionF Use smallest gauge

plastic cannula possibleF Prepare and organize

material prior to insertion F Vesicant education for

all nurses F Pharmacy

involvementF Interdisciplinary

approachF IVT (Intravenous

Therapy) Teams• The Journal

of Clinical Innovations suggests IVT Teams reduce the occurrences of complications associated with peripheral IV’s.

• Evidence is limited pertaining to the Cost effectiveness of implementing such teams.

• Based on the academic review and appraisalof a multitude of articles, case studies and random clinical trials, it is our suggestion that hospitals conduct an independent study to determine the effectiveness of IVT Teams in relation to cost.

POLICY CHANGES

• Blanched skin • Possible numbness• Circulatory impairment• Skin tight and leaking

BEST EVIDENCE-BASED PRACTICES TO TREAT INTRAVENOUS INFILTRATION

OVERVIEWThe purpose of our research is to identify the best practice for IV infiltration management. Although IV infiltration is a common occurrence, extensive research on the subject is limited. We exploredseveral medical journals,reviewed case studies andweb-based articles in aneffort to compile effectivepractices to improve patient outcomes.

WHAT IS IV INFILTRATION? Displacement of “non-vesicant, or irritant” medications or fluids into surrounding tissuesF Aldesleukin (interleukin-2)F IfosfamideF Bleomycin

Displacement of “vesicant” medications into surrounding tissues is known as extravasationF Antibiotics F Lactated RingersF Dilantin F Cytotoxic (chemotherapy drugs), and non-cytotoxic

drugs (Digoxin, Diazepam, TPN)F DNA binding (Anthryacycline Antibiotics)F Non-DNA binding (Alkylators, antitumor antibiotics)

DEVICE-RELATED RISKSMetal needles, large-gauge cathetersF Smaller is better!

Inadequately secured IV needle or catheterF Use a transparent dressing!F Crisscross tape after the transparent dressing

is appliedUndesirable IV site location F Avoid areas of flexionF Avoid hard, cordlike veins F Avoid veins of the hand F Avoid the antecubital fossa F Veins of the forearm are preferred

PATIENT-RELATED RISKSAgeF PediatricsF Geriatrics

• Communication barrier

• Fragile veinsSource: (Sauerland, C., Engelking, C., Wickham, R., & Corbi, D., 2006)

Pre-existing medical conditions F Chemotherapy patientsF DiabeticsF Hypovolemia

Cultural groupsF Asian Culture

STANDARD OF PRACTICE

STANDARD NUMBER: 1624,320

STANDARD TITLE: Peripheral Intravenous Therapy

REGULATORY STANDARD:

EFFECTIVE DATE: 05/06

REVISION DATE: 11/2008, 6/2010, 08/2010, 9,2011

STATEMENT: Peripheral intravenous (IV) therapy will be provided based on physician order in a safe,aseptic manner for short-term vascular access and fluid administration.

SCOPE:All patients with peripheral IV sites

RESPONSIBILITY:RN, IV Credentialed LPN

GUIDELINES:

1. Observe proper hand-hygiene procedures either by washing hands with conventional antiseptic-containing soap and water or with waterless alcohol- based gels or foams. Observe hand hygiene before and after palpating catheter Insertion sites, as well as before and after inserting, replacing, accessing, repairing or dressing an intravascular catheter. Palpation of the insertion site should not be performed after the application of antiseptic, unless aseptic technique is maintained. Use of gloves does not obviate the need for hand hygiene.2. The drip rate safety feature on the IV pump will be utilized for all IV Heparin, Insulin, Vasoactive and Antiarrhythmic drugs. a. In emergency situations, continuous vasoactive drugs and propofol, if started peripherally, should be changed to central line access as soon as practical.

12. Infiltration/Extravasation • Remove catheter. • Warm/Cool compresses: a. Warm compresses: i. All chemotherapy agents

ii. Dopamine b. Cool compresses i. All hypertonic solutions and antibiotics c. For drug specific detail, refer to 1624.140 Extravasation Management policy• Complete an Adverse Drug Event form• Detail charting to include: a. Site of infiltration b. Assessment of surrounding area• Complete infiltration scale in HED.• Document further skin assessment in HED.• Notify physician if the infiltration is Stage 3 or greater and for all extravasations. (refer to policy 1624.140 Extravasation Management)• Do not start IV in the same extremity.