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Peripheral Extravasation Injuries: Initial management and washout procedure

  • See also

    Acute pain management

    Key Points

    1. Early identification and appropriate management of extravasation is crucial in order to prevent serious adverse outcomes
    2. Under NO circumstances should the device be flushed
    3. If the extravasated drug or fluid is a vesicant then a washout procedure is required

    Background

    • Extravasation is the leaking of a fluid or medication into extravascular tissue from an intravenous device
    • Large volumes can cause nerve compression and compartment syndrome
    • Extravasation injury results from a vesicant leaking into the extravascular space, where the medication or fluid itself causes damage to the tissues. The damage increases the longer the vesicant is within the tissues. It can cause blistering, tissue necrosis and loss of parts
    • Risk factors for extravasation injuries include: neonates, using small or fragile veins, insertion across joints, sedation and poorly secured cannulae
    • Extravasation can occur in peripheral and central lines
    • Prompt recognition and management can prevent the need for surgical intervention, permanent scarring, loss of function or loss of parts
    • Appropriate management can vary depending on volume, pH, osmolarity and pharmacological action of the vesicant

    Assessment

    • Particular vigilance is required in children who are anaesthetised, sedated, are unable to communicate due to age or disability, and in if the IV cannula is sited in an area with a peripheral neuropathy
    • Symptom onset may occur many hours after extravasation occurs

    Signs of extravasation

    • 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 discolouration/blanching
    • Absence of capillary return
    • Increased resistance when administering IV drugs
    • Inflammation or blistering
    • Assess volume and type of extravasation
    • Attempt to distinguish extravasation from:
      • venous irritation, where the infusion is still running intravenously and diluting or slowing infusion may assist symptoms
      • local flare reaction, with itch and red blotching along the vein

    Assessment of severity

    Grade 1

    • Painful IV site
    • Difficulty running infusion

    Grade 2

    • Painful IV site
    • Erythema
    • Slight swelling
    • No skin blanching
    • Normal peripheral pulses and cap refill at site

    Grade 3

    • Painful IV site
    • Skin blanching
    • Marked swelling
    • Cool to touch
    • Normal peripheral pulses and cap refill at site

    Grade 4

    • Painful IV site
    • Skin blanching
    • Very marked swelling
    • Cool to touch
    • Cap refill > 4 seconds at site
    • Decreased or absent pulse
    • Skin breakdown or necrosis

    Management

    Investigations

    No investigations are required

    Treatment

    Compromise to the neurovascular status of the limb or suspected compartment syndrome is a surgical emergency and should be immediately referred to Plastic Surgery

    Initial Management
    • Immediately stop the infusion/injection. Do not remove the needle or cannula at this stage
    • Aspirate as much of the residual drug as possible
    • Under NO circumstances should the device be flushed
    • Disconnect administration set or syringe containing drug but retain it to determine amount of drug extravasated/infiltrated
    • Mark and photograph the whole area of extravasation injury
    • Assess the grade of injury
    • Agree on a plan with senior staff and bedside nurse and inform family

    Is the drug a vesicant?

    • If so prepare to perform a washout

    Grade 1 and 2

    • Remove IV cannula
    • Elevate limb for 48 hours
    • Remove any constricting bands/clothing
    • If a vesicant undertake washout
    • Regular review of site

    Grade 3 and 4

    • Leave cannula in-situ until review by senior doctor
    • Elevate limb
    • Remove constricting tapes/clothing
    • Undertake washout
    • Consider specific treatments (below)
    • Inform consultant and plastic surgery

    Additional specific treatment

    Extravasation Washout procedure 
    Non-physiological pH agents

    • No specific antidote, attempts to neutralise pH may worsen the injury

    Vasopressors

    • Consider phentolamine (reverses alpha mediated vasoconstriction)

    Extravasation Washout Procedure

    Indications:

    Grade 3 or 4 extravasation injury
    AND any grade if the drug is a vesicant

    Staff:
    Doctor

    Equipment:
    • Sterile Saline
    • 25G needle
    • 23G needle
    • 10 mL syringe (s)

    Monitoring:

    • Record limb observations including colour, capillary refill, pulse and limb warmth
    • Photograph taken and stored in patient’s notes or electronic medical record

    Procedure:

    • Ensure adequate analgesia
      • IV/oral plus 1% lignocaine (max 4mg/kg) subcutaneously around zone of extravasation or local nerve block
    • Use an aseptic technique and clean with antiseptic
    • Using 25G needle make multiple vertical punctures 1cm apart around and over the affected area
    • Using 23G needle horizontal to skin, infuse normal saline 0.9% into the subcutaneous tissue from different angles around the site (360˚). Infuse at least 2-3 times the extravasated volume
    • Infused saline should appear out of the vertical punctures made prior (Fig. 1). Flushing can be aided by gentle milking of the saline out of exit points
    • Infuse additional antidote after normal saline if indicated by class of vesicant
    • Cover the wound with a sterile non-stick dressing, review at least six-hourly in the first 24 hours
    • Keep limb warm and elevated for 24 hours

    Peripheral Extravasation Injuries

    Fig 1. Illustration of saline washout procedure

    Post-procedure care and discharge instructions

    • Agree a plan with bedside nurse about informing parents
    • Consider ongoing analgesia requirements
    • Inform plastic surgery registrar on call. All Grades 3 and 4 injuries should be reviewed by plastic surgery within 24 hours to assess the degree of tissue damage and outcome of the irrigation procedure if performed
    • Grade 1 and 2 injuries should be reviewed daily by medical staff
    • Document details in medical record and lodge an incident report via the appropriate system for all extravasation injuries
    • If the line was placed by a consulting team inform them of the event

    Consider consultation with local paediatric team when:

    • Monitoring or management exceeds local abilities
    • Consult local plastic surgery team for allGrades 3 and 4 injuries, for review within 24 hours

    Consider transfer when:

    • Grade 3 or 4 injury
    • Injury requiring plastic surgical intervention if not available locally
    • Any concern for compartment syndrome

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

    Additional notes

    Classification of Vesicants

    Hyperosmolar Solutions

    Non-physiological pH

    Vasopressors

    Cytotoxic Drugs

    Fluids

    • 10 – 50% glucose
    • 3% saline
    • Parenteral nutrition (TPN)
    • Potassium chloride > 40mmol/L
    • Mannitol

    Medications

    • Calcium solutions
    • Diazepam
    • Digoxin
    • Lorazepam
    • Magnesium sulphate 20 or 50%
    • Nitroglycerin
    • Phenobarbitone
    • Phenytoin 
    • Potassium phosphate
    • Radiographic contrast
    • Sodium Bicarbonate

    Acidic

    • Amiodarone
    • Amphotericin
    • Caffeine
    • Cefotaxime
    • Co-trimoxazole
    • Doxycycline
    • Gentamicin
    • Metronidazole
    • Pentamidine
    • Promethazine
    • Vancomycin

    Alkaline

    • Aciclovir
    • Ampicillin
    • Aminophylline
    • Erythromycin
    • Foscarnet sodium
    • Ganciclovir
    • Phenytoin
    • Thiopentone

     

    • Adrenaline
    • Noradrenaline
    • Dopamine
    • Dobutamine
    • Vasopressin
    • Phenylephrine
    • Prostaglandins

     

    • Actinomycin  D
    • Amrubicin
    • Azothiaprine
    • Carmustine
    • Dacarbazine
    • Daunorubicin
    • Docetexal
    • Doxorubicin
    • Epirubicin
    • Flucloxacillin
    • Mitomycin C
    • Paclitexel
    • Streptomycin
    • Treosulfan
    • Trabectedin
    • Vinblastine
    • Vincristine
    • Vindesine

    Last updated March 2020

  • Reference List

    1. Clinical Nurse Specialist 2016, IV Extravasation Management Practice Guideline, Sydney Children’s Hospitals Network, viewed 1 April 2020 < http://www.schn.health.nsw.gov.au/_policies/pdf/2016-9057.pdf>
    2. McSharry B 2016, Extravasation and Infiltration Injuries Management in PICU, Starship Hospital Auckland, viewed 1 April 2020 <https://www.starship.org.nz/guidelines/extravasation-and-infiltration-injuries-management-in-picu/>
    3. Murphy AD et al 2019, Extravasation injury in a paediatric population, ANZ Journal of Surgery 89(4):E122-E126