Overview on extravasation

This article provides readers with an overview of extravasation, including risk factors and management strategies.
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.

INTRODUCTION ã…¡ Being a clinical pharmacist and an expert in all matters of medications, you must clarify all matters related to the drugs, especially the correct way to administer it to the patient with the nurses. Identify any patients in your clinical area who are receiving intravenous fluids or medications and who may be at increased risk of extravasation. List any interventions you could perform to reduce any risks. Nurses are not always aware of the vesicant nature of the every day medications they administer, often falsely believing that it is only cytotoxic drugs that are of concern in relation to extravasation and its effects 

DEFINITION ã…¡ Extravasation refers to leakage of IV injected drug from blood vessels to the surrounding tissues causing damage. The common symptoms of tissue damage include pain, burning sensation, edema around IV injection site. In sever cases, extravasation may lead to tissue dysfunction or physical defect. Examples of vesicant drugs are cytotoxic drugs that include vincristine, vinorelbine, doxorubicin, epirubicin and paclitaxel AND non-cytotoxic drugs such as potassium chloride (concentrated), glucose 50%, mannitol, etc.

CLASSIFICATION

In cancer, extravasation is classified based on drug nature into vesicant, non-vesicant and irritant. Vesicant drugs are divided into 2 groups: (1) DNA binding drug and (2) Non-DNA binding drug. The incidence of extravasation reported in adults is between 0.1% to 6%.

RISK FACTORS

The risk factors of extravasation can be classified under patient-related, product-related and procedure-related. Patient-related risk factors are small and fragile veins specially in infant, child or elderly patient. Harden and thickened vessels in cancer patient frequent venipuncture. Patient with vessels moves easily during venipuncture attempts and obese patients. Procedure-related risk factors are untrained staff, high flow pressure and multiple attempt at cannulation. Product-related risk factors are inadequate choice of equipment, inadequate dressing and poor cannula fixation.

    SIGNS AND SYMPTOMS

    There are a number of signs and symptoms that indicate a vesicant drug may be leaking into the surrounding tissues. These may be divided into immediate and delayed manifestations (see Table 1).

    Table (1). Recognition of extravasation
    Assessment Parameter Immediate manifestations
    (during drug administration)    		 Delayed manifestations parameter
    (24 hours after extravasation)
    Pain Severe stinging or burning (not always present). This can last from minutes to hours and will eventually intensify over time subside. Pain occurs during drug administration at the device site and surrounding areas. 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

    PREVENTION AND MANAGEMENT

    GENERAL GUIDELINE ã…¡ 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 to minimize the risk of extravasation. Assess patient’s sensory changes, tingling or burning. 

         For peripheral venous access device extravasation, don’t insert the cannula in the joints because it is difficult to secure. Neural damage and tendon injury can be caused if extravasation occurs due to vesicant drugs. Don’t 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. 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. Watch for edema, inflammation, and pain around the cannula during administration. Check for blood back flow before/during administration, and always rinse the catheter with a saline solution in between administrations. Once the needle is removed, apply pressure to the puncture site for about five minutes and elevate the limb 

         For central venous access device extravasation, check for blood back flow 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 

    MANAGEMENT ã…¡ See, "Algorithm (1). Steps to be taken of the extravasation". For further information, see note on, "How to manage extravasation".

    CONCLUSION ã…¡ Extravasation is a serious problem in patient care. Although there are many other types of drug administration (e.g., micro-patch, micro-injection), but some drugs can only be taken by IV injection or central vain injection, so extravasation can’t totally be avoided.

    REFERENCES

    Abdelwahab Ward, BS Pharm, PharmD