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Peripheral extravasation injuries: Initial management and washout procedure

  • See also

    Procedural sedation
    Intravenous access - Peripheral
    Peripheral intravenous (IV) device management

    Key points

    1. Early identification and appropriate management of extravasation is crucial in order to prevent serious adverse outcomes
    2. Do not flush the intravenous device following extravasation
    3. Neurovascular compromise second to extravasation is a surgical emergency and requires prompt recognition and management

    Background

    • Extravasation refers to the leaking of a fluid or medication into extravascular tissue from a peripheral intravenous (IV) cannula or central venous access device (CVAD) with potential to cause short or long term tissue damage
    • Risk factors for extravasation injuries include:
      • neonates
      • using small or fragile veins
      • insertion of IV lines across joints
      • poorly secured IV lines
      • patient sedation, paralysis or inactivity
      • paraesthesia or neuropathy
      • impaired neurocognition or communication
    • Severity of extravasation injury depends on the volume infused into the tissue and the drug properties (pH, osmolarity and pharmacological action of the drug)
    • Some drugs cause significant local tissue damage (erythema, blistering, ulceration or necrosis) when they enter the extravascular space
    • Large volumes can cause nerve compression and compartment syndrome
    • Prompt recognition and management can prevent the need for surgical intervention, permanent scarring or loss of function

    Assessment

    • Assessment of a peripheral IV cannula should occur at the time of infusing a drug, or frequently if there is an ongoing infusion
    • Assessment of extravasation severity is not limited to a single point in time. Intervention should be made whenever the threshold defined below is met
    • Onset of signs and symptoms may occur many hours after extravasation occurs
    • All extravasation injuries should be photographed, and images saved to the child’s medical record
    • Ask about pain, burning or stinging, or complete a pain assessment if child is non-verbal  
    • Peripheral IV line site assessment should involve visualising, palpating and comparing the site with the opposite limb/other side of the body

    Examination

    Signs and symptoms of extravasation may include:

    • Sudden change in infusion pressure or speed when infusing a drug
    • Leakage of fluid from insertion site
    • Changes in sensation surrounding or distal to the site eg pain, burning, or tingling. Use a pain scale where appropriate
    • Swelling at the IV line site, along the vein pathway or down the limb
    • Skin changes including erythema, induration, blistering, pallor or blanching
    • Absence or decrease of capillary return
    • Attempt to distinguish extravasation from venous irritation (symptoms often coincide with start of infusion) or local flare reaction (itch and red blotching along the vein)
      • Diluting or slowing infusion may assist symptoms of venous irritation or local flare reaction

    Assessment of severity

    • Volume of fluid infused
    • Type of drugs and/or fluids delivered in past 2 hours or since the last site assessment (whichever is longer)
    • Size of swelling: see below for estimation of percentage of swelling
    • Signs of neurovascular compromise
      • capillary refill at the site of the extravasation
      • capillary refill time distal to the extravasation
      • presence of distal pulses
    • Signs of compartment syndrome: severe pain especially with passive flexion of affected muscle compartment, tightness, pallor, paraesthesia, weakness or paralysis
    • Signs of impending tissue ischaemia: blanched skin, an area with central grey/black discolouration, numbness, prolonged capillary refill time

    STEP 1: Assess degree of swelling

    Estimate volume infused into the tissues

    Assess degree of swelling


    STEP 2: Stratify drug and fluid risk

    List of medications based on risk profile:

    Green
    Low risk

    Yellow
    Intermediate risk

    Red
    High risk

    Aminophylline
    Amphotericin B liposomal
    Ampicillin
    Benzylpenicillin
    Cefazolin
    Cefotaxime
    Ceftazidime
    Ceftriaxone
    Cefuroxime
    Clindamycin
    Glucose <10%
    Fentanyl
    Fosphenytoin
    Furosemide
    Gentamicin
    Heparin
    Imipenem/Cilastatin
    Iron infusion
    IVIG
    Lactated ringers
    Magnesium sulfate
    Meropenem
    Methylprednisolone
    Sodium chloride 0.9%
    Sodium chloride 0.45%
    Pentamidine
    Piperacillin/Tazobactam
    Tobramycin

    Acetazolamide
    Alteplase
    Amikacin
    Arginine
    Ciprofloxacin
    Glucose 10 to ≤12.5%
    Dantrolene
    Diazepam
    Digoxin
    Etomidate
    Erythromycin
    Flucloxacillin
    Ganciclovir
    Lorazepam
    Midazolam
    Morphine
    Mycophenolate
    Nitroglycerine
    Ondansetron
    Phenobarbital
    Phenytoin
    Propofol
    Radiographic contrasts
    Sulfamethoxazole/
    Trimethoprim
    Thiopental sodium
    Any medication containing propylene glycol

    Aciclovir
    Alprostadil
    Amiodarone
    Caffeine citrate
    Calcium (all salt forms)
    Cytotoxic medications
    Glucose >12.5%
    Doxycycline
    Epoprostenol
    Esmolol
    Foscarnet
    Mannitol
    Nitroprusside
    Promethazine
    Potassium chloride >40 mmol/L
    Sodium bicarbonate ≥3%
    Sodium chloride ≥3%
    Total parental nutrition (TPN)
    Vasoactive medication (eg adrenaline, dobutamine, dopamine, milrinone, noradrenaline, phenylephrine, prostaglandins, vasopressin)

    Note: This list is not exhaustive. If a medication does not appear on this list, contact local pharmacist for advice. Extravasation of any medication may cause serious harm, ischaemia or compartment syndrome.

    Management

    Investigations

    No investigations are required

    Treatment

    • Stop infusion
    • Do not remove IV line
    • Elevate affected limb if possible. Do not apply pressure
    • Do not flush the line
    • Attempt aspiration of remaining drug from IV line with a small syringe
    • Administer pain relief if required
    • Assess extent of swelling and type of drug/fluid (above), and use table below to guide management
    • A warm compress may be used to disperse the drug over a larger area eg extravasated glucose, antibiotics, TPN, concentrated glucose solutions and electrolytes
    • A cold compress may be used to limit distribution of the drug eg extravasated IV contrast. Do not use for extravasation of vasoactive medications as this causes further vasoconstriction and ischaemia
    • Mark and photograph the whole area of extravasation injury

    Note: compromise to the neurovascular status of the limb or suspected compartment syndrome is a surgical emergency and requires immediate referral to plastic/relevant surgical team

    Management

    % Swelling and infusate

    Action

    Any extravasation of
    Vasoactive medication
    from the Red infusate list

     adrenaline, dopamine, noradrenaline and related medication

    Review immediately
    Prepare for treatment with Phentolamine (below)
    Do not use ice/cold compress as this will cause further vasoconstriction

    Extravasation ≥30%
    AND
    Red list infusate

    Review within 30 minutes
    Prepare for washout procedure (below)
    Washout procedure should be performed as soon as possible and within 12 hours
    Notify plastic/local surgery team if the washout procedure may need to be performed in the operating theatre
    Consider treatment with Hyaluronidase (see dose below)

    Extravasation <30%
    AND
    Red list infusate

    Review within 30 minutes
    Hourly observation and reassessment of the injury for 48 hours
    Notify plastic/relevant surgical team in hours
    Washout procedure only required if progressing towards 30% swelling or evidence of impending tissue ischaemia (above)
    Consider treatment with Hyaluronidase (see dose below)

    Extravasation ≥30%
    AND
    Yellow or Green list infusate

    Review within 30 minutes
    Hourly observation and reassessment of the injury for 48 hours
    Treatment not usually required
    A washout procedure is required if there is impending tissue ischaemia or if swelling >60%
    Discuss with a plastic/relevant surgical team if worsening, to determine whether treatment is needed
    Consider treatment with Hyaluronidase (see dose below)

    Extravasation <30%
    AND
    Yellow or Green list infusate

    Non-urgent review
    4 hourly observation and reassessment of the injury for 24 hours
    Treatment not usually required but may be indicated if swelling increasing or evidence of impending tissue ischaemia
    A washout procedure is indicated if there is impending tissue ischaemia

    Note:  Local guidelines may differ, please see local policy where appropriate

    Antidotes

    Phentolamine

    • alpha-adrenergic receptor antagonist
    • Can be used to counter the effects of vasoconstriction and ischaemia in the event of vasopressor extravasation
    • Preparation:
      • 5 mg made up to 10 mL with 0.9% sodium chloride
        (1 mL = 0.5 mg Phentolamine)
    • Instructions:
      • Inject in 4-5 small aliquots intradermally across the site of injury
      • Dose 0.1-0.2 mg/kg to a maximum dose of 5 mg
      • Ideally injection is administered as soon as possible, but may be used up to 12 hours following injury


    Hyaluronidase

    • Hydrolyses hyaluronic acid and allows dispersion of extravasated fluid
    • May be used to reduce necrosis in severe extravasation
    • Preparation:
      • add 1 mL hyaluronidase (150 unit/mL) with 9 mL of 0.9% sodium chloride to make up 10 mL (concentration = 15 units/mL)
    • Instructions:
      • inject 0.2 mL in 5 sites around edge of extravasation site ie total dose 1mL = 15 units
      • administer in conjunction with saline wash out (above)

    Washout procedure

    Planning for the procedure is critical to ensure success
    Consider analgesia and sedation requirements, or the need for general anaesthesia.
    The procedure should be performed as soon as practical and within 12 hours of the injury meeting treatment requirements (see “Management based on severity” table above)

    To perform a washout procedure:

    • Ensure adequate analgesia and sedation, eg
      • 1% lignocaine (max 4 mg/kg) subcutaneously around zone of extravasation or local nerve block. Avoid local anaesthetic with adrenaline
      • Intranasal fentanyl or ketamine
      • Inhaled nitrous oxide
      • IV/IM ketamine
      • General anaesthesia
    • Use an aseptic technique and clean site with appropriate antiseptic
    • Use 25G needle to make multiple vertical punctures 1 cm apart around and over the affected area (see figure below)
    • Us 23G needle horizontal to skin, infuse 0.9% sodium chloride into the subcutaneous tissue from different angles around the site (360˚°). Infuse at least 2-3 times the estimated extravasated volume
    • Infused saline should appear out of the vertical punctures made prior, flushing can be aided by gentle milking of the saline out of these exit points
    • Cover the wound with a sterile non-stick dressing, review at least 6 hourly for at least the first 24 hours
    • Keep limb warm and elevated for at least 24 hours

    Washout procedure

    Post-procedure care and discharge instructions

    • Consider ongoing analgesia requirements
    • Daily review by medical staff
    • If the line was placed by a consulting team, inform them of the event
    • Report to local incident management system

    Consider consultation with local paediatric team

    • For all children with an extravasation injury

    Consider consultation with plastic or relevant surgical team for

    • All children with compromise to neurovascular status of the limb or if any concern for compartment syndrome
    • All extravasation of medications on the “red infusate” list
    • All extravasation injuries with swelling ≥30%

    Consider transfer when

    • Child requiring care above the level of comfort of the local hospital
    • Injury requiring surgical intervention, if not available locally

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

    Parent information

    Kids Health Information Wound care resource

    Last updated December 2023

  • Reference List

    • Arangoa Miller, MV, Frazier-Warmack and Castelo et al. Standardized Venous Access Assessment and Safe Chemotherapy Administration to Reduce Adverse Venous Events. 2023. Clin J Oncol Nurs 27(3): 305-309.
    • Ben Abdelaziz, RH et al. Peripheral venous catheter complications in children: predisposing factors in a multicenter prospective cohort study. BMC Pediatr. 2017. 7(1): 208.
    • Children's Hospital at Richmond. 2021. Peripheral IV Extravasation/Infiltration (PIVIE) Treatment; https://emi.vcuhealth.org/media/file/VCU-CHOR_clincial_pathway_PIVIE.pdf
    • Cincinatti Children's Hospital. 2019. Venous Infusion Extravasation Risk; https://www.cincinnatichildrens.org/service/v/vascular-access/hcp
    • Corbett, MD et al.Treatment of extravasation injuries in infants and young children: a scoping review and survey. Health Technol Assess. 2018. 22(46), p1-112.
    • Corbett, MD et al. Treating extravasation injuries in infants and young children: a scoping review and survey of UK NHS practice.  BMC Pediatr. 2019. 19(1), p6.
    • Gault, DT. Extravasation injuries. Br J Plast Surg Mar. 1993. 46(2), p91-6.
    • Johnson, N. Preventing Intravenous Extravasation Injuries to the Children’s Hospital. 2013. https://www.cincinnatichildrens.org/service/v/vascular-access/hcp
    • Larsen, EN et al. Intravenous antimicrobial administration through peripheral venous catheters - establishing risk profiles from an analysis of 5252 devices. Int J Antimicrob Agents. 2022. 59(4), p106552.
    • Sydney Children's Hospital Network. Intravenous extravasation - Management Practice guideline. 2023. https://www.schn.health.nsw.gov.au/_policies/pdf/2016-9057.pdf