Extravasation is the leakage of intravenously (IV) administered fluid or medications into the extravascular tissue surrounding the site of infusion. This leakage may occur due to fragile veins in elderly individuals, prior venipuncture access, or incorrect positioning of venous access devices. When the leaked substance doesn't result in harm, it is termed infiltration. The extravasation of medication during intravenous therapy constitutes an adverse event linked to the treatment. Depending on factors such as the specific medication, exposure duration, and location, it has the potential to cause severe injuries and permanent damage, including tissue necrosis. Less severe consequences involve irritation, characterized by pain and inflammation, accompanied by clinical signs such as warmth, erythema, or tenderness.
Signs and Symptoms
- Changes in sensation or pain, burning or tingling
- Reduction in infusion speed, increased resistance or pump pressure
- Swelling at the cannulation site or along the vein pathway
- Induration
- Erythema
- Venous discoloration/blanching
- Absence of capillary return
- Increased resistance when administering IV drugs
- Inflammation or blistering
- Local flare reaction
- Red blotching along the vein
Severity
Grade 1
- Painful IV site
- Difficulty running infusion
- Minimal amount of swelling
Grade 2
- Slightly more painful IV site
- Medication flowing more slowly through the cannula
- Erythema
- Mild swelling
- No skin blanching
- Normal peripheral pulses and capillary refill at site
Grade 3
- Very painful IV site
- Blocked cannula
- Skin blanching
- Marked swelling
- Cool to touch
- Skin look pale or more gray than usual, but without nearby discoloration
- Normal peripheral pulses and capillary refill at site
Grade 4
- Intense pain around the IV site
- Skin blanching
- Pronounced swelling
- Cool to touch
- Capillary refill >4 seconds at site
- Decreased or absent pulse
- Patches of paler skin with nearby discoloration
- Skin breakdown or necrosis
Prevention
General guidelines
Most extravasations can be prevented with the systematic implementation of careful, standardized, and evidence-based administration techniques. The staff involved in the infusion and management of cytotoxic drugs must be trained to implement several preventive protocols for the minimization of the risk of extravasation. It is important to remember that the degree of damage is dependent on the type of the drug, the drug concentration, the localization of the extravasation, and the length of time for which the drug develops its potential for damage.[Source]
- Be familiar with the extravasation management standard guidelines and prepare the extravasation kit.
- Regularly check the extravasation kit and refill any used medications. Extravasation kit includes the following: 25G needle, 10-cc syringe, and 1-mL syringe; disinfection swabs, sterile gauze, and adhesive bandage; saline solution (1 ampule); sterile distilled water (1 ampule); dimethyl sulfoxide 99% solution; hyaluronidase 1,500 U/mL (refrigerated); hydrocortisone cream 1%; sodium thiosulfate 25% solution; and warm pack and an ice pack (frozen).
- Assess patient’s sensory changes, tingling or burning, and always pay attention to the words of patients.
Preventive strategies: peripheral venous access device extravasation
- Do not insert the cannula in the joints because it is difficult to secure, and neural damage and tendon injury can be caused if extravasation occurs due to vesicant drugs.
- Do not insert the cannula in the antecubital fossa area, where it is extremely difficult to detect extravasation.
- Veins on the back of the hand can be used, and in some cases, observation is easier. But it must be done carefully because this area can suffer a more severe injury due to extravasation.
- For observation, do not cover the cannula area with opaque gauze.
- Secure the cannula during the administration of the drug.
- Even if there is an existing IV route, secure a new route when administering vesicant drugs.
- If in doubt, re-insert the cannula and administer the drug.
- Watch for edema, inflammation, and pain around the cannula during administration.
- Check for blood backflow before/during administration, and always rinse the catheter with a saline solution in between administrations.
- Dilute stimulant drugs as much as possible and inject them at a proper rate.
- Once the needle is removed, apply pressure to the puncture site for about five minutes and elevate the limb.
Preventive strategies: central venous access device extravasation
- Check for blood backflow before injection to ensure that the catheter is positioned in the vein.
- Check if there is any local discomfort or swelling by running a saline solution through the catheter, and then inject the drug.
- After the injection, make sure to run a saline solution through the catheter.
IV Infiltration
IV infiltration occurs when the liquid that is supposed to be delivered to the vein through the IV leaks into the surrounding tissue instead. It can be caused by an IV that has pierced a vein, a catheter that is the wrong size, or a dislodged or improperly placed IV.
Movement can also cause IV infiltration, which is why patients need to be monitored closely: Getting in and out of a bed or flexing a joint too close to the IV site can cause the catheter to slip out.
Additional preventive measures
Only qualified, chemotherapy-certified nurses who have been trained in venipuncture and administration of medications with vesicant and irritant potential should be allowed to administer vesicants.
Choose a large, intact vein with good blood flow for the venipuncture and placement of the cannula. Do not choose inadvertently "dislodgeable" veins (e.g. dorsum of hand or vicinity of joints) if an alternative vein is available.
The digits, hands, and wrists should be avoided as intravenous sites for vesicant administration because of the close network of tendons and nerves that would be destroyed if an extravasation occurred.
Place the smallest gauge and shortest length catheter to accommodate the infusion.
Monitor the venipuncture site closely for evidence of infiltration and instructing patients to report any pain, discomfort, or tightness at the site.
The IV infusion should be freely flowing. The arm with the infusion should not begin to swell (edema), "get red" (erythema), "get hot" (local temperature increase), and the patient should not notice any irritation or pain on the arm. If this occurs, extravasation management should be initiated.
The infusion should consist of a suitable carrier solution with an appropriately diluted medicinal/chemotherapy drug inside.
After the IV infusion has finished, flush the cannula with the appropriate fluid.
Depending on clinical circumstances, central line access may be most appropriate for patients who require repeated administrations of vesicants and irritants.
Nursing Interventions
Nursing interventions for extravasation of intravenous (IV) fluids and medications include the following:
- Stop the infusion immediately. This is the most important step to prevent further damage to the surrounding tissue.
- Disconnect the IV tubing from the cannula. This will prevent any more fluid or medication from leaking into the tissue.
- Aspirate any remaining fluid or medication from the cannula. This will help to reduce the amount of extravasated fluid or medication.
- Administer a drug-specific antidote, if available. There are specific antidotes available for some vesicant medications, such as hyaluronidase for vinca alkaloids and extravasation kits for anthracyclines.
- Notify the physician. The physician will assess the severity of the extravasation and determine the need for further treatment.
In addition to these immediate interventions, the nurse should also:
- Elevate the affected extremity. This will help to reduce swelling and promote drainage of the extravasated fluid or medication.
- Apply a warm or cold compress to the site, depending on the type of medication extravasated. Warm compresses may help to promote vasodilation and absorption of the extravasated fluid or medication, while cold compresses may help to reduce pain and inflammation.
- Monitor the site closely for signs and symptoms of infection, tissue damage, or other complications. These may include swelling, redness, warmth, pain, tenderness, and blistering.
- Document the occurrence of the extravasation and the interventions taken in the patient's medical record. This information will be helpful for the physician in assessing the patient's progress and determining the need for further treatment.
Treatment
The best treatment of extravasation is prevention. Depending on the medication that has extravasated, there are potential management options and treatments that aim to minimize damage, although the effectiveness of many of these treatments has not been well studied. In cases of tissue necrosis, surgical debridement and reconstruction may be necessary. The following steps are typically involved in managing extravasation:
- Stop infusion immediately. Put on sterile gloves.
- Replace infusion lead with a disposable syringe. While doing this, do not exert pressure on the extravasation area.
- Slowly aspirate back blood back from the arm, preferably with as much of the infusion solution as possible.
- Remove the original cannula or other IV access carefully from the arm (removal of the original cannula is not advised by all healthcare institutions, as access to the original cannula by surgeons can be used to help clean extravasated tissue).
- Elevate arm and rest in elevated position. If there are blisters on the arm, aspirate content of blisters with a new thin needle. Warm compresses should be placed initially on the site to help diffuse the contrast medium, and cold compresses are used later to help reduce the swelling.
- For the extravasated medication, if substance-specific measures apply, carry them out (e.g. topical cooling, DMSO, hyaluronidase or dexrazoxane may be appropriate).
- Recent clinical trials have shown that Totect (USA) or Savene (Europe) (dexrazoxane for extravasation) is effective in preventing the progression of anthracycline extravasation into progressive tissue necrosis. In two open-label, single arm, phase II multicenter clinical trials, necrosis was prevented in 98% of the patients. Dexrazoxane for extravasation is the only registered antidote for extravasation of anthracyclines (daunorubicin, doxorubicin, epirubicin, idarubicin, etc.).[Source]
- Treatment for vasopressor extravasation is phentolamine.
Complications
Complications from IV infiltration can range from mild discomfort to serious injuries:
- Skin damage such as scars, blisters, ulcers, or sores
- Serious infections
- Permanent nerve damage
- Vein ruptures
- Necrosis
- Diminished use or amputation of the affected extremity