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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.
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.
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.
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.
* Minimum Paracetamol and sucrose (for infants) +/- Morphine
The evidence table for this guideline can be viewed here.
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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.