By Taiquita Ardan, Raúl Cardona, Clara Dalton, and Julie Teegarden Extravasation By Taiquita Ardan, Raúl Cardona, Clara Dalton, and Julie Teegarden

Introduction Extravasation: The inadvertent administration of a vesicant solution or medication into surrounding tissue. Learner Goals: Identification, treatment, and prevention of extravasation of medications. Extravasation: The inadvertent administration of a vesicant solution or medication into surrounding tissue. Vesicant: a drug or solution that can cause tissue necrosis or blistering when it accidentally infuses into tissue outside of a vein. A common misconception among nurses is that extravasation comes only from cytotoxic drugs (Doughtery, 2010). The goal of this presentation is to educate about the identification, treatment, and prevention of extravasation of medications. The picture on the left is immediately after extravasation occurred and the picture on the right is two weeks later. Image retrieved from: http://www.medicaljournals.se/acta/content/files/web/2792-web-images/2792fig1_opt.jpeg

Objectives Identify medications that can cause extravasation. Identify predisposing factors to extravasation. Identify signs and symptoms of extravasation. Understand the treatment and management of extravasation. Recognize ways to prevention extravasation. OBJECTIVES By the end of the teaching session… The class will identify 5 medications likely to cause extravasation The class will be able to identify 5 factors that predisposes patients to extravasation The class will be able to recognize 3 signs and symptoms of extravasation 95% will know how to manage extravasation 95% of the class will be able to list 4 ways to prevent extravasation

Significance of Topic to Critical Care Patients in critical care units are extremely unstable and any complication can have major consequences. Critical care patients have many of the risk factors associated with extravasation. Many of the medications used in critical care can cause extravasation injuries. Critical care patients typically have many IV lines. Patients in critical care units are extremely unstable and any complication can have major consequences. Extravasation may not cause too much trouble for a normally healthy patient, but in a critically ill patient it could have deadly effects because they already have so much going on Examples of how extravasation can complicate matters for a CC patient include: increasing pain and discomfort (which is already hard enough to manage as it is), increasing swelling (which could alter their delicate fluid and electrolyte balance), and causing tissue necrosis (which increases stress on the body by increasing the need for wound healing as increasing the risk for infection) Critical care patients have many of the risk factors associated with extravasation: Age (elderly); although people of many ages end up on the ICU, a large percentage of ICU patients are elderly Hard or sclerosed veins, small veins, fragile veins; this would apply especially to patients in the Vascular ICU Impaired communication or altered sensory perception; this would apply especially to patients in the Neuro ICU Sedation/somnolence, impaired cognition/altered mental status, unconscious/use of general anesthetics/comatose; this would apply generally to pt’s in the ICU Patient movement (vomiting, coughing, stretching seizures); ICU pt’s can be agitated from certain sedative medications or mental states, causing them to be fidget Many of the medications used in critical care can cause extravasation injuries. Anti-infectives like Vancomycin; it is common for CC pt’s to be on some kind of anti-infective Electrolyte substitutes such as KCl, NaCl, and parenteral nutrition are common with CC pt’s Vasopressors such as Dobutamine and Epinephrine; these are commonly given in high-stress emergency situations, creating a greater risk of wrong technique and, consequently, extravasation Misc: Digoxin, Mannitol, and Phenytoin Critical care patients typically have many IV lines. (Martin, 2013) It is like a maze sometimes trying to figure out what IV lines go to what med and which connection on the patient

Medications Implicated in Extravasation Cytotoxic medications Electrolyte solutions Calcium chloride, Calcium gluconate, Parenteral nutrition, Potassium chloride, Sodium bicarbonate, Sodium chloride > 0.9%. Vasopressors Dobutamine, Dopamine, Epinephrine, Norepinephrine. Anti-infectives Vancomycin. Miscellaneous Contrast media, Diazepam, Digoxin, Mannitol, Phenytoin. Anti-infectives: Acyclovir, Amikacin, Amphotericin B, Dicloxacillin, Nafcillin, Oxacillin, Vancomycin Electrolyte solutions: Calcium chloride, Calcium gluconate, Parenteral nutrition, Potassium chloride, Sodium bicarbonate, Sodium chloride > 0.9% Vasopressors: Dobutamine, Dopamine, Epinephrine, Norepinephrine Cytotoxic: Vincristine, Vinorelbine, Doxorubicin, Epirubicin, Paclitaxel Miscellaneous: Aminophylline, Chlordiazepoxide, Contrast media, Dextrose ≥ 10%, Diazepam, Digoxin, Doxapram, Intralipids, Mannitol, Phenytoin, Promethazine, Urea Image retrieved from: http://one2onecmo.com/drugdeliverysystems.aspx

Factors Associated with Extravasation Catheter-Specific Factors. Physiologic Factors. Pharmacologic Factors. Patient-Specific Risk Factors. Nurse-Specific Factors. Catheter-Specific Factors Larger catheter size relative to vein size Insertion into site that is likely to be affected by movement (e.g. areas of joint flexion, dominant hand) Unstable catheter Poor securing of implanted port access needle Multiple venipuncture sites (e.g. a second puncture above the first) Use of an infusion pump or power injector during the infiltration or extravasation event Catheter port separation or catheter fracture Physiologic Factors Clot formation above the cannulation site Thrombus or fibrin sheath at the catheter tip Lymphedema Pharmacologic Factors Solutions with very high or very low pH Solutions with very high or very low osmolarity Vasoconstrictive potential Cytotoxicity Patient-Specific Factors Small size and poor condition of veins (fragile or thrombosed veins) Patient activity Age (elderly and pediatric patients are at increased risk) Obesity Underlying chronic medical disease (diabetes, peripheral vascular disease, cancer) History of multiple IV cannulations or venipunctures Impaired communication or altered sensory perception Nurse-Specific Factors Inexperience or lack of skill of the person inserting the catheter Probing during IV insertion Interruptions/distractions during administration Image retrieved from: http://blogs.wsj.com/health/2008/04/14/end-of-life-care-count-the-ivs/

Signs and Symptoms of Extravasation Pain. Redness. Swelling. Blood Return. Ulceration. Others. Recognition of Extravasation Assessment parameters: Pain Immediate manifestations (during drug administration): Severe stinging or burning pain (not always present). This can last from minutes to hours and will eventually subside. Pain occurs during drug administration at the device site and surrounding areas. Delayed manifestations (24 hours after extravasation): Can continue following extravasation or may start within 48 hours. Pain may intensify over time. Redness Not always present immediately. Blanching of the skin may be observed. As the area becomes inflamed, redness will appear around the device site. Later occurrence. Swelling May occur immediately, but is not always easily identifiable. Usually occurs within 48 hours. Blood Return Inability to obtain blood return (peripheral or central), but blood return may be present throughout. Only occurs immediately. Ulceration Unlikely. Can occur within 48-96 hours, but may take three to four weeks to develop. Others Change in quality of the infusion or pressure/resistance on the syringe barrel during injection, leaking around the cannula or port needle site. Local tingling and sensory deficits. Dougherty, L. (2010). Extravasation: prevention, recognition and management. Nursing Standard, 24(52), 48-55. Image retrieved from: http://garyolson.net/extravasation-injury-26.jpg Image retrieved from: http://jkms.org/ArticleImage/0063JKMS/jkms-22-588-g001-l.jpg Image retrieved from: http://openi.nlm.nih.gov/imgs/512/94/2740528/2740528_IJPS-41-145-g001.png

Treatment of Extravasation Stop the injection or infusion Remove the IV Notify the medical staff Elevate the extremity for 48 hours Depending on medication Apply warm or cold pack Administer hyaluronidase or phentolamine Document Monitor Stop the injection or infusion - withdraw as much of the drug as possible (injection only). Remove the IV Notify the medical staff Elevate the extremity for 48 hours Depending on medication Apply warm or cold pack Administer hyaluronidase or phentolamine For antibiotics, aminophylline, contrast media, dextrose, glucose, electrolytes, mannitol, phenytoin, parental nutrition - Inject 1,500 units hyaluronidase subcutaneously around the site. For dobutamine, dopamine, epinephrine, metaraminol, norepinephrine, phenylephrine, vasopressin – Inject phentolamine subcutaneously around the area after catheter removal. Warm packs aid absorption of hyaluronidase and phentolamine/vasodilation - should remain in place for two to four hours For amphotericin, acyclovir, cefotaxime, diazepam, ganciclovir, thiopental amsacrine, carmustine, actinomycin D, decarbazine daunorubicin, doxorubicin, epirubicin, idarubicin, mitomycin C, streptozocin, trabectedine - Apply cold pack to cause vasoconstriction – 15-20 minutes three to four times daily. For unknown medications/non-vesicant – use cold pack Document  Date and time the extravasation occurred.  Type and size of vascular access device.  Length and gauge of needle (ports only).  Location of device.  Details of how patency was established before and during administration (description and quality of blood return).  Number and location of all cannulation attempts.  Vesicant administration method, for example bolus or infusion.  Estimated amount of extravasated drug.  Symptoms reported by the patient.  Description of device site, for example swelling.  Assessment of the limb (where applicable) for range of movement.  Immediate nursing interventions.  Follow-up interventions.  Patient information.  Photographs of extravasation site. Monitor for tissue sloughing, necrosis, or blistering – if this occurs, needs to be treated as a chemical burn – silver sulfadiazine, antibiotics, surgical evaluation Best treatment is prevention: Adherence to correct medication administration procedure, early recognition, awareness of factors associated with extravasation, knowledge of medications implicated in extravasation, staff and patient education

Nursing Research Errors in high-risk intravenous injections administered by nurses: The causes according to healthcare professionals (Kim & Seomun, 2014). Aim: To identify the causes and problems of errors in the administration of IV meds. Methods: Qualitative study involving 13 participants divided into three focus groups. Interviews were transcribed, analyzed, and organized in topics and subtopics. (Kim & Seomun, 2014) high risk meds include KCl, NaCl, and heparin -13 participants were divided into 3 focus groups (7 nurses, 3 doctors, and 3 pharmacists) -the fact that information was collected from three different groups of people allowed researchers to analyze the differences in their perspectives -focus group approach was chosen because it allowed researchers to collect varied information, and participants could speak freely and were allowed the opportunity to share their thoughts and experiences -focus groups were conducted June-Nov 2011, and lasted between 80-100 mins -focus groups discussions were led by two field workers -focus groups began with broad questions and became more specific as the interview went on -researchers focused on both verbal and non-verbal elements of communication

Nursing Research Results: 3 categories emerged from the data concerning causes of IV administration errors: human-related factors injection procedure-related environmental factors One of the main things needed to avoid extravasation is simple awareness. This is even more important in the critical care setting where serious complications are more likely to result. -participants had at least 48 months of experience in their current position, except for three of the doctors -human-related factors: -lack of knowledge and understanding of drugs; the number of drugs we are required to know about is getting bigger and bigger; inattention and lack of awareness were an issue, and pharmacists emphasized the importance of using a systematic approach to drug administration -lack of responses to fast inflows of new drugs -inaccurate drip speed control of drugs; -force of habit on drugs used frequently -changing the patient’s posture -occlusion of aqueous solution -problem of patency -injection procedure-related -hasty injection or negligence of confirmation -when many aqueous solutions are connected simultaneously -when not closely checked -environmental factors -lack of new nurse monitoring -lack of safety devices -inexperienced operation of device -pharmacists pointed out that sometimes nurses administer IV meds without regard for the drugs characteristics -simple awareness: knowing which drugs place pt’s at greatest risk for harm if they are extravasated, and the s/s of extravasation

Nursing Research Increasing nurse competence in peripheral intravenous therapy (Woody & Davis, 2013). Aim: To identify complications associated with extravasation and evaluate the impact of incidents on a medical/surgical unit. Methods: Determine methods of documentation. Reviewing how nursing competency is assessed. Creation of a pretest and post-test, and educational module Collecting info from pretest and post-test

Nursing Research Number of reported cases before education were compared with number of cases after. 35 participants. Results: Pretest scores had a mean of 12.77, post-test had a mean of 13.29 (no significant difference). The number of incidents over a three month period pre-intervention was compared with three-month period post-intervention, and indicated a 50% decrease in rates of extravasation. Significance is that it shows the importance of reeducation of core competencies.

Conclusion Discussed medications that can cause extravasation. Identified factors that predispose patients to extravasation. Discussed how to identify signs and symptoms of extravasation. Described the treatment and management extravasation. Discussed how to prevent extravasation.

Evaluation of Objectives: Post Test Which one of these medications does not cause extravasation? A. Potassium chloride B. Calcium gluconate C. Epinephrine D. Vancomycin E. Lasix

Evaluation of Objectives: Post Test True or False Patient’s risk factors include… Age Obesity Underlying chronic disease (diabetes) Condition of veins Impairment in communication History of multiple venipunctures

Evaluation of Objectives: Post Test Which sign or symptoms are not classified as delayed manifestations of extravasation? Select all that apply. A. Swelling B. Inability to obtain blood return C. Ulceration D. Severe stinging or burning pain E. Local tingling and sensory deficits

Evaluation of Objectives: Post Test You suspect your patient has extravasation, which action do you perform first. A. Call the physician B. Administer 1,500 units hyaluronidase C. Stop intravenous infusion D. Apply hot or cold pack

References Coyle, C. E., Griffie, J., & Czaplewski, L. M. (2014). Eliminating Extravasation Events: A Multidisciplinary Approach. Journal of Infusion Nursing, 37(3), 157-164. Doellman, D., Hadaway, L., Bowe-Geddes, L. A., Franklin, M., LeDonne, J., Papke-O'Donnell, L. ... & Stranz, M. (2009). Infiltration and extravasation: update on prevention and management. Journal of Infusion Nursing, 32(4), 203-211. Dougherty, L. (2010). Extravasation: prevention, recognition and management. Nursing Standard, 24(52), 48-55. Dychter, S. S., Gold, D. A., Carson, D., & Haller, M. (2012). Intravenous therapy: A review of complications and economic considerations of peripheral access. Journal of Infusion Nursing, 35(2), 84-91.

References Groll, D., Davies, B., Mac Donald, J., Nelson, S., & Virani, T. (2010). Evaluation of the psychometric properties of the phlebitis and infiltration scales for the assessment of complications of peripheral vascular access devices. Journal of Infusion Nursing, 33(6), 385-390. Kim, M., & Seomun, G. (2014). Errors in high-risk intravenous injections administered by nurses: The causes according to healthcare professionals. Health Science Journal, 8(2), 249-261. Martin, S. M. (2013). Extravasation Management of Non-chemotherapeutic Medications. Journal Of Infusion Nursing, 36(6), 392-396. doi:10.1097/NAN.0000000000000010 Woody, G., & Davis, B. A. (2013). Increasing Nurse Competence in Peripheral Intravenous Therapy. Journal Of Infusion Nursing, 36(6), 413-419. doi:10.1097/NAN.0000000000000013