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Clinical Guidelines (Nursing)

Extravasation injury management

  • Introduction

    Extravasation may occur due to either the cannula piercing the vessel wall or from increased venous pressure that causes leakage around the original venepuncture site. Literature suggests up to 11% of paediatric patients and up to 70% of neonates receiving intravenous therapy will experience extravasation of an intravenous infusion. 
    Although the risk of extravasation is higher with peripheral intravenous catheters, extravasation injuries can occur from central venous access devices as well. A small proportion of these may develop long-term cosmetic or functional compromise as a result of the injury.
    Intravenous pumps do not always alert staff to an extravasation injury in progress. Limiting the pump cycle to one hour may minimise the extent of tissue damage from extravasation by triggering a reminder to inspect the insertion site and limb for signs of extravasation. Nursing vigilance along with prompt recognition and management is the key to avoiding or minimising injury.

    Aim

    • To define the grading and management of extravasation injuries
    • Intended for use in paediatric and neonatal patients
    • This guideline does not address the extravasation of chemotherapeutic agents. 
    • Refer to Extravasation of Chemotherapy Agents Clinical Guideline 

    Definition of terms

    • Extravasation: the unintentional leakage of vesicant fluids or medications from the vein into the surrounding tissue
    • Vesicant: agents capable of causing blistering, tissue sloughing or necrosis
    • Hyaluronidase: an enzyme which temporarily (over 24-48 hours) breaks down the hyaluronic acid of tissue and promotes more rapid reabsorption of extravasated fluid

    Risk factors

    • Increased skin and vein fragility (eg. neonates, multiple cannulations, flexible subcutaneous tissue, chemotherapy)
    • Inability to report pain
    • Inability to visualise insertion sites 
    • Limbs with central venous access devices or peripheral intravenous cannulas being covered or unable to be visualised
    • Prolonged intravenous therapy 
    • Volume, pH (outside of blood pH, arterially 7.35-7.45), osmolarity and chemical composition of the fluid or drug being infused

    Assessment

    Initial Acute assessment 

    A 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. 

    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
     


    Note: In the event of a grade 3 or 4 injury in a community setting, notify the medical team immediately. The patient is required to return to RCH for a medical review as soon as possible and ensure treatment if needed, is commenced within 1 - 2 hours for the best results. 
    Follow acute management instructions below until the patient has been reviewed by medical staff.

    Ongoing Assessment

    Continue to observe affected area post extravasation injury for 24 hours to ensure no signs of infection or further complications. 
    If there are signs of infection/complications, the site should continue to be observed until the signs and symptoms resolve. 
    Any signs of infection must be reported to the treating medical team to determine the need for antibiotic treatment.

    Management

    Acute management

    • Stop infusion immediately
    • Medical staff of the treating team should be informed immediately of any extravasation injury
    • Most extravasation injuries are Grades 1 & 2 and do not require extensive intervention to prevent long-term skin and soft tissue damage
    • Grade 3 & 4 injuries have a greater potential for skin necrosis, compartment syndrome and the potential need for plastic surgery involvement, depending on the type and volume of solution extravasated. Once the treating team is informed the decision can be made to refer to the Plastics team for further input and/or management. 

    Grade 1 Grade 2 Grade 3 Grade 4
    • Stop infusion
    • Remove cannula and tapes
    • Elevate limb
    • Stop infusion
    • Remove cannula and tapes
    • Elevate Limb
    • Stop infusion
    •  Remove constricting tapes
    • Leave cannula insitu until reviewed by a doctor (treating team)
    • Photograph injury if this will not delay treatment
    • Doctor to commence irrigation procedure within 1 hour of extravasation by irrigating affected area using hylauronidase and saline 0.9% or saline 0.9% irrigation alone
      Give appropriate pain relief prior to beginning procedure*
    • Apply non occlusive dressing as advised by treating medical team or plastics
    • Elevate limb
    • +/- Refer to plastics team
    • Stop infusion
    • Remove constricting tape
    • Leave cannula insitu until reviewed by a doctor (treating team)
    • Photograph injury if this will not delay treatment
    • Doctor to commence irrigation procedure within 1 hour of extravasation by irrigating affected area using hylauronidase and saline 0.9% or saline 0.9% irrigation alone
      Give appropriate pain relief prior to beginning procedure*
    • Apply non occlusive dressing as advised by treating medical team or plastics
    • Elevate limb
    • Refer to plastics team

    * Minimum Paracetamol and sucrose (for infants) +/- Morphine 

    • Evidence suggests hyaluronidase irrigation for parenteral nutrition and calcium chloride extravasation is beneficial. Irrigation of major grades of extravasation has been used to prevent extensive skin loss and need for plastic surgery. However, the evidence for the use of irrigation in preventing long-term injury is limited to case reports
    • Hylauronidase should be used within 1-2 hours of extravasation for the best results
    • Hyaluronidase should NOT be used for extravasation of vasoconstrictive agents (dopamine, adrenaline, noradrenaline etc.)
    • The decision to treat or not to treat with Hyaluronidase is the decision of the medical staff from the treating team and should be documented in the patient’s medical record
    • Compromise to the neurovascular status of the limb or suspected compartment syndrome is a surgical emergency

    Irrigation Procedure

    1. Administer analgesia and wait 10 minutes before commending procedure
    2. Do not rupture formed blisters during the procedure
    3. Clean the affected limb with antiseptic solution
    4. Infiltrate the affected area in four quadrants with subcutaneous 1% lignocaine (max 0.15mL/kg)
    5. Hyaluronidase irrigation (followed by Saline 0.9% irrigation): Inject around and through the extravasation injury a total of 5 lots of 0.2mL aliquots of hyaluronidase 1000units/mL (available on imprest stock on Butterfly ward and Theatre)
    6. Saline Irrigation: Irrigate the area using the four puncture marks already made from the hyaluronidase using 0.9% saline in 10-20mL aliquots
    7. If the cannula is still insitu, infiltrate 3-5mL 0.9% saline and then remove the cannula
    8. Massage out any oedema that develops in the direction of the puncture marks 
    9. If the extravasation fluid includes lipid, irrigate the area until the effluent runs clear
    10. Large areas of extravasation may require additional infiltration of local anaesthetic during the procedure
    11. Once complete Apply a non-occlusive dressing to the area as advised by the treating medical team or plastics team
    12. Elevate the affected limb
    13. Do not apply hot or cold packs to the affected limb
    14. Administer antibiotics if signs of infection occur
    15. Nursing staff to continue to observe the site hourly for the first 24 hours to monitor for adverse effects 
    16. Medical staff should review the site 1-2 hours post irrigation procedure to assess effectiveness. This should then be reviewed again in 24hours by medical staff

    Ongoing Management

    • Document the site, extent and management of the injury in the patient's medical recor
    • Create an extravasation LDA in the patients EMR for grade 3 and 4 extravasations to monitor the injury, hourly for the first 24hours and then once a shift unless indicated otherwise
    • Keep limb elevated until swelling reduces
    • Administer pain relief as appropriate for grade 3 and 4 injurie
    • If, at any time, the wound appears infected, a wound swab, full blood count, CRP and blood cultures should be taken and the patient commenced on appropriate antibiotics 

    Follow-up and review

    • Grades 1 and 2 should be reviewed within 24 hours by the treating team
    • Medical staff should review all Grades 3, as soon as possible to assess the degree of tissue damage and determine if referral to plastics is needed
    • Grades 4 should be reviewed by medical staff as soon as possible and referred to plastic surgery to assess degree of tissue damage 
    • A VHIMS is to be completed for all extravasation injuries
    • If the line was placed by a consulting team (e.g. anaesthetics or surgery) this team should be informed

    Special considerations

    • Use standard precautions including hand hygiene and aseptic technique 
    • Patient Safety Alert – an VHIMS report should be completed for grade 3 & 4 extravasations
    • Potential adverse events; burns, compartment syndrome, tissue necrosis

    Evidence Table 

    The evidence table for this guideline can be viewed here. 

    Companion documents

    References

    • Ainsworth S, McGuire W. Percutaneous central venous catheters versus peripheral cannulae for delivery of parenteral nutrition in neonates. Cochrane Database of Systematic Reviews 2015, Issue 10. Art. No.: CD004219. DOI: 10.1002/14651858.CD004219.pub4.
    • Al-Benna, S., O'Boyle, C., & Holley, J. (2013). Extravasation injuries in adults. ISRN dermatology, 2013, 856541. doi:10.1155/2013/856541
    • Amjad, I., Murphy, T., Nylander-Housholder, L. and Ranft, A. (2011) A New Approach to Management of Intravenous Infiltration in Pediatric Patients: Pathophysiology, Classification, and Treatment. Journal of Infusion Nursing, 34(4), pp. 242-249.
    • Beall, V., Hall, B., Mulholland, J. T. and Gephart, S. M. (2013) Neonatal Extravasation: An Overview and Algorithm for Evidence-based Treatment. Newborn and Infant Nursing Reviews, 13(4), pp. 189-195.
    • Casanova D, Bardot J, Magalon G. (2001).  Emergency treatment of accidental infusion leakage in the newborn: report of 14 cases. British Journal of Plastic Surgery. 54(5):396-39
    • Ching, D. L. H., Wong, K. Y. and Milroy, C. (2014) Paediatric extravasation injuries: A review of 69 consecutive patients. International Journal of Surgery, 12(10), pp. 1036-1037.
    • Corbett, M., Marshall, D., Harden, M., Oddie, S., Phillips, R. and McGuire, W. (2019) Treating extravasation injuries in infants and young children: a scoping review and survey of UK NHS practice. BMC Pediatr, 19(1), pp. 6.
    • Davies J, Gault D, Buchdahl R. (1994).  Preventing the scars of neonatal intensive care. Archives of disease in childhood. 70(1):F50-F5
    • Gault DT. (1993). Extravasation injuries. British Journal of Plastic Surgery. 46(2):91-9
    • Gopalakrishnan PN, Goel N, Banerjee S. Saline irrigation for the management of skin extravasation injury in neonates. Cochrane Database of Systematic Reviews 2017, Issue 7. Art. No.: CD008404. DOI: 10.1002/14651858.CD008404.pub3
    • Hadaway, L. C. (2010) Preventing Extravasation. Oncology Times, 32(8), pp. 5-6.
    • Keogh S, Mathew S. Peripheral intravenous catheters: A review of guidelines and research. Sydney: ACSQHC; 2019
    • Lim, E. Y. P., Wong, C. Y. W., Kek, L. K., Suhairi, S. S. B. M. and Yip, W. K. (2018) Improving the Visibility of Intravenous (IV) Site in Pediatric Patients to Reduce IV Site Related Complications – An Evidence-based Utilization Project. Journal of Pediatric Nursing, 41, pp. e39-e45
    • Maly, C., Fan, K. L., Rogers, G. F., Mitchell, B., Amling, J., Johnson, K., Welch, L., Oh, A. K. and Chao, J. W. (2018) A Primer on the Acute Management of Intravenous Extravasation Injuries for the Plastic Surgeon. Plastic and reconstructive surgery. Global open, 6(4), pp. e1743 doi:10.1097/GOX.0000000000001743
    • Murphy, A., Gilmour, R. and Coombs, C. (2017) Extravasation injury in a paediatric population: Extravasation injury. ANZ Journal of Surgery, 89
    • Odom, B., Lowe, L. and Yates, C. (2018) Peripheral Infiltration and Extravasation Injury Methodology: A Retrospective Study. Journal of Infusion Nursing, 41(4), pp. 247-252.
    • Park, H. J., Kim, K. H., Lee, H. J., Jeong, E. C., Kim, K. W., & Suh, D. I. (2015). Compartment syndrome due to extravasation of peripheral parenteral nutrition: extravasation injury of parenteral nutrition. Korean journal of pediatrics, 58(11), 454–458. doi:10.3345/kjp.2015.58.11.454
    • Paquette, V., McGloin, R., Northway, T., Dezorzi, P., Singh, A., & Carr, R. (2011). Describing Intravenous Extravasation in Children (DIVE Study). The Canadian journal of hospital pharmacy, 64(5), 340–345. doi:10.4212/cjhp.v64i5.1069
    • Phelps SJ, Tolley EA, Cochran EB. (1990).  Inability of inline pressure monitoring to predict or detect infiltration of peripheral intravenous catheters in infants. Clinical Pharmacy. 9(4):286-29


    Please remember to read the disclaimer.


    The development of this nursing guideline was coordinated by Aaliya Fanham, Registered Nurse, Butterfly, and approved by the Nursing Clinical Effectiveness Committee. Updated January 2020.