1. Extravasation of Intravenous Non-Chemotherapeutic Agents
Lisa Sheehan, RN, BSN
UPMC Shadyside

2. What is Extravasation?
Extravasation happens when a vesicant medication escapes into the surrounding tissue by:
Cannula puncturing the
wall of the vein
Fluid leaking from vein at
insertion site
Signs / Symptoms: pain, redness, burning, pallor, no blood return, edema, decreased IV flow or flush

3. 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

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

5. Calcium Chloride extravasation that resulted in hand amputation

6. 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

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

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

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

10. Compresses Warm Compress Cold Compress Promote vasodilation
Increased drug absorption
Decreased local drug concentration
Can cause maceration and necrosis if MOIST HEAT used
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 minutes at least 4 times / day for 24 hours or until discomfort resolved.

11. 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!

12. 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.

13. 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.

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

15. Assessment To be performed and charted each shift or patient handoff until any symptoms are resolved or patient is discharged
Affected Area
Affected Extremity
Redness / necrosis
Edema
Drainage
Pain, burning, itching
Changes in temperature of area
Sensation of fingertips / toes
Movement
Pulses

16. 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

17. INS Infiltration and Extravasation Scale

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

19. Case Study #1 cont’d…
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.

20. Case Study #1 Questions What could have been done better?
What was done well?
How could it have been prevented?

21. 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.

22. Case Study #2 Questions What could have been done better?
What was done well?
How could it have been prevented?