How to manage extravasation

This topic shows how to manage the extravasation, step by step.
Abdelwahab Ward, BS Pharm, PharmD
This article was written by: Alaa Khalid Said, BS Pharm, PharmD.
  • Senior oncology pharmacist,
    Clinical Pharmacy Department, Tanta Oncology Center.

OVERVIEW ã…¡ IV infiltration is a common complication of intravenous (IV) therapy. According to current medical reports, about 50% of IVs fail, with over 20% of those failures due to infiltration or extravasation, for further information, see note on, "Overview on extravasation". An IV site assessment should be conducted every hour when there are fluids or medications running through the line. If nothing is being infused, the site should be assessed before accessing the line and at least every eight hours. There are 4 grades of extravasation symptoms (see Table 1).

Table (1). Grades of extravasation symptoms
Grade 1 Grade 2 Grade 3 Grade 4
Pain at infusion site

Difficulty flushing cannula

Minimal swelling

Nil redness		 Pain at infusion site

Difficulty flushing cannula

Mild swelling

No skin blanching

Minimal redness

Normal capillary refill time

Normal perfusion		 Pain at infusion site

Difficulty/inability to flush cannula

Swelling

Skin blanching +/- redness at the site

Sluggish capillary refill time

Normal/decreased perfusion		 Pain at infusion site

Marked swelling

Skin blanching

Cool blanched area

Reduced capillary refill time

Decreased perfusion

+/- Arterial occlusion

+/- Blister

COMPLICATIONS

COMPLICATIONS OF UNTREATED EXTRAVASATION ã…¡ Extravasation can involve serious complications that include...
    • Compartment syndrome. Compartment syndrome is a painful and dangerous condition caused by pressure buildup from internal bleeding or swelling of tissues. Muscles in the patient’s hand, forearm, or lower leg are surrounded by tissue. These tissue bands create “compartments”. After infiltration, when too much fluid leaks into the tissue, a patient may experience compartment syndrome. Compartment syndrome may cause nerve, tissue or muscle damage. The condition often requires emergency surgery to decompress the affected area.
    • Skin burns, necrosis and amputation. Serious burns may require a skin graft – a surgeon removes unburned skin on the patient and places it over the affected area. Wounds with necrotic, or dead, tissue cannot heal and must be removed to allow healthy tissue to grow in its place. While amputating the area may create a much larger wound, it is sometimes the only way to treat the complication.
    • Permanent nerve damage. Nerve damage from IV insertion is relatively rare. It can be caused by puncturing the nerve with the needle when an IV is started, or from compartment syndrome. While this is a less common complication, it can cause numbness, tingling, and even loss of function in the limb.

  • Note..
    Injuries and complications can usually be minimized or completely eliminated when patients and healthcare providers carefully monitor and care for the IV site.

MANAGEMENT

NURSING INTERVENTION ã…¡ At the first sign of extravasation, the following steps are recommended stop administration of IV fluids immediately, disconnect the IV tube from the cannula, aspirate any residual drug from the cannula, administer a drug-specific antidote and notify the physician (see figure 1: Steps of extravasation management). Elevation of the limb may help in reabsorption of the infiltrate or extravasated vesicant by decreasing capillary hydrostatic pressure. Take medical photographs and consult the department of cosmetic surgery if necessary.

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Figure (1)
Steps of extravasation management.

THERAMAL APPLICATION ã…¡ Local thermal treatments are used to decrease the site reaction and absorption of the infiltrate. Local cooling (ice packs) aids in vasoconstriction, theoretically limiting the drug dispersion. Cold application is recommended for extravasation of DNA-binding vesicants except for mechlorethamine (nitrogen mustard), contrast media, and hyperosmolar fluids. Cold application done for 15-20 mins. up to 6 time per day. The use of local warming therapy (dry heat) is based on the theory that it enhances vasodilation, thus enhancing the dispersion of the vesicant agent and decreasing drug accumulation in the local tissue. The use of local warming is recommended for the extravasation of non–DNA-binding vesicants. Although clear benefit has not been demonstrated with thermal applications, it remains a standard supportive care, and the recommended application schedule for both warm and cold applications is 15 to 20 minutes, every 4 hours, for 24 to 48 hours.

REFERENCES

Abdelwahab Ward, BS Pharm, PharmD