Extravasation of Intravenous Non-Chemotherapeutic Agents Lisa
Sheehan, RN, BSN UPMC Shadyside
Slide 2
What is Extravasation? Cannula puncturing the wall of the vein
Fluid leaking from vein at insertion site Extravasation happens
when a vesicant medication escapes into the surrounding tissue by:
Signs / Symptoms: pain, redness, burning, pallor, no blood return,
edema, decreased IV flow or flush
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Who is at an increased risk for extravasation? Patients with
chronic conditions causing arterial insufficiency Patients with
compromised venous or lymph drainage Patients on meds that can
cause the skin and veins to become more fragile: corticosteroids,
anticoagulants, chemotherapy Elderly, children, and sedated
patients
Slide 4
Prevention, Prevention, Prevention Early detection and prompt
action are required to prevent tissue necrosis and functional loss
in this medical emergency First step after extravasation is noticed
or suspected STOP THE INFUSION STOP
Slide 5
Calcium Chloride extravasation that resulted in hand
amputation
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Post-Extravasation Steps Leave catheter in place without any
pressure to the site and explain procedure to patient Estimate
amount of medication that entered surrounding tissue Perform hand
hygiene Aspirate medication with 3ml syringe directly attached to
the colored hub and withdraw catheter while aspirating
Slide 7
Post-Extravasation Steps Clean area with alcohol and let dry
Trace leading edge of extravasated area and / or photograph to
monitor improvement or worsening of area (This step is often
missed) Elevate extremity above level of heart for 48 hours to help
reduce edema DO NOT use this site, sites distal to, or entire
extremity if possible for IV access until resolved Re-establish IV
access
Slide 8
Consider MD consultation Severe extravasation symptoms exist
Severe pain Skin discolored around area Inflammation larger than a
quarter Drugs used include amiodarone, epinephrine, norepinephrine,
phenylephrine, dopamine, ephedrine, vasopressin, calcium chloride,
or vancomycin
Slide 9
When to Consult Plastic Surgery Extravasation involves calcium
chloride Surrounding tissues are discolored, tense, blistering
Patient reports severe pain Decreased peripheral pulse or slow cap
refill Greater than 25ml medication escaped into tissue
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Compresses Warm Compress Promote vasodilation Increased drug
absorption Decreased local drug concentration Can cause maceration
and necrosis if MOIST HEAT used Cold Compress Promote
vasoconstriction Localizes the extravasation Allows vasculature and
lymph system to drain the medication from the area Procedure: Apply
compress for 5 minutes then check site. If red, macerated,
blistering, or patient feels pain with compress remove compress!!
Apply for 15-20 minutes at least 4 times / day for 24 hours or
until discomfort resolved.
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Antidotes All antidotes must be ordered by MD or advanced
practice provider MD must assess patient prior to giving antidote
Use for severe extravasations where patients are showing severe
symptoms or severe pain Time is of the essence to be
effective!
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Phentolamine Primarily used for Pressor extravasation Should be
used within 12 hours of incident May use more than one dose if
needed to encircle affected area Max dose 50 mg During drug
shortages nitroglycerin topical ointment or transdermal patch may
be used if patient is stable with SBP > 90.
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Hyaluronidase Primarily for non-pressor extravasations Most
effective if used within 60 minutes of incident, but can be
beneficial up to 12 hours after the incident.
Slide 14
Antidote Administration Multiple subcutaneous injections are
given using a 25g or 26g needle in a pin-cushion fashion along the
periphery of the affected site. Change the needle with each new
injection
Slide 15
Assessment To be performed and charted each shift or patient
handoff until any symptoms are resolved or patient is discharged
Affected Area Redness / necrosis Edema Drainage Pain, burning,
itching Changes in temperature of area Affected Extremity Sensation
of fingertips / toes Movement Pulses
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Documentation Complete an incident report Document severity
according to Infiltration Rating Scale Include: Measurements,
location, catheter size Subjective description Estimated fluid
volume of medication MD notification Management of extravasation
provided Photograph if taken Patient education and follow-up
instructions Consults if needed
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INS Infiltration and Extravasation Scale
Slide 18
Case Study #1 Radiology called IV Team for restart of an IV but
the patient was in transit. IV Team advised them to have floor call
when patient settled. 30 minutes later, floor RN calls with
infiltrate of Potassium and possibly Zosyn into a swollen hand /
wrist area IV RN arrives within 15 minutes to find IV removed and
patient reporting, This is the worst pain I have ever felt in my
life. IV Team suggested antidote Hyaluronidase was needed, so call
MD. IV Team notes swelling approximately to mid forearm, cool to
touch and leaking from IV site and advises plastic surgery consult
if antidote does not relieve pain. All pulses WNL
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Case Study #1 contd MD arrives and unsure of what to order or
how to treat. IV RN suggests antidote and hands hospital policy to
RN for MD reference. IV RN had to leave unit for urgent blood
restart. IV Team arrives back to unit to find antidote was never
given and the plastic surgeon was angry at being told he needed to
be there within 60 minutes to address this situation. Patient arm
was elevated with cool compress. Plastics did see patient and
advised current treatment and that antidote no longer needed by the
time he arrived (2-3 hours after call) and no risk for necrosis was
evident.
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Case Study #1 Questions What could have been done better? What
was done well? How could it have been prevented?
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Case Study #2 IV Team called to ICU for extravasation of
epinephrine from a chest port. IV Team arrived within 10 minutes.
Advised immediate MD consult to order antidote. MD arrived within
10 minutes and ordered antidote. ICU RN administered antidote with
IV Team as a resource. Plastics consulted with treatments advised
for tissue sloughing, but no surgical intervention needed.
Slide 22
Case Study #2 Questions What could have been done better? What
was done well? How could it have been prevented?
