Clinical Guidelines (Nursing)

Extravasation Injury Management

  • Introduction

    Extravasation may occur due to either the cannula piercing the vessel wall or from distal venous occlusion causing backpressure within the vessel. Literature suggests up to 11% of infants and children admitted to hospital will experience extravasation of an intravenous infusion. A small but significant proportion of these may develop long-term cosmetic or functional compromise as a result of the injury.

    Peripheral and central venous catheters are both capable of causing extravasation. A Cochrane review comparing catheter types in neonates receiving TPN showed that centrally placed catheters may provide better nutritional input but did not significantly decrease the incidence of extravasation when compared with peripherally placed catheters.

    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 providing the entry site is observed concurrently. Nursing vigilance is the key to avoiding or minimising injury.

    Aims

    • 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

    Definition of terms

    • Extravasation: the leakage of intravenous medicinal fluid from the vein into the surrounding tissue
    • Hyaluronidase: an enzyme which temporarily (over 24-48 hours) breaks down the hyaluronic acid of tissue cement and promotes the reabsorption of extravasated fluid

    Risk factors

    • Skin/vessel fragility
    • Low muscle to subcutaneous tissue mass
    • Inability to report pain
    • Multiple previous venepunctures especially moving distally along a vein
    • The degree of tissue damage due to extravasation is dependent upon: the volume of the infusate, its pH & osmolarity, the dissociation constant and pharmacological action of any drug(s) being infused

    Examples of commonly used solutions with the potential to cause skin necrosis

    • Note: blood products have varying pH’s and may cause extravasation injuries

    Extravasation example alkali solution

    Assessment

    Extravasation Assessment

    Management

    Acute management

    • Medical staff should be informed immediately of any extravasation injury
    • Most extravasation injuries are of 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 need for future plastic surgery, depending on the type of solution extravasated
    • Evidence suggests hyaluronidase irrigation for parenteral nutrition and calcium chloride extravasation is beneficial
    • 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 Consultant or Fellow and should be documented in the patient’s medical record
    • Use hyaluronidase within 1 hour of extravasation for best results
    • Compromise to the neurovascular status of the limb or suspected compartment syndrome is a surgical emergency
      Extravasation Acute Management2

    Further assessment and management

    • Documentation of the site, extent and management of the injury should be completed in the patient's progress notes
    • Following irrigation treatment, all injuries should be reviewed within 24 hours of the extravasation occurring
    • Irrigation of major grades of extravasation has been used to prevent extensive skin loss and need for plastic surgery and skin grafting. However, the evidence for the use of irrigation in preventing long-term injury is limited to case reports
    • If, at any time, the wound appears infected, a wound swab, full blood count, CRP and blood culture should be taken and the patient commenced on appropriate antibiotics 

    Follow-up and review

    • Determined by the grade of extravasation
    • Minor grades should be reviewed after 24 hours by neonatal medical staf
    • All Grades 3 and 4 should be reviewed by neonatal and plastic surgery staff within 24 hours to assess the degree of tissue damage and outcome of the irrigation procedure if performe
    • A VIHMS form 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

    Family-centred care

    The patient's parents should be informed of an extravasation injury and management plan.

    Special considerations

    • Infection control – standard infection control procedures should be observed
    • Patient Safety Alert – an incident report should be completed for grade 3 & 4 extravasations

    Companion document

    Procedure for the irrigation of neonatal extravasation injuries
    This should be completed by the Doctor performing the irrigation procedure, printed and scanned into the patient's EMR. 

    References

    1. Ainsworth SB, Mcguire W. (2015). Percutaneous central venous catheters versus peripheral cannulae for delivery of parenteral nutrition in neonates. Cochrane Database of Systematic Reviews. Issue 10. Art.No.: CD004219.DOI:10.10002/14651858. CD004219.pub4
    2. 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
    3. Davies J, Gault D, Buchdahl R. (1994).  Preventing the scars of neonatal intensive care. Archives of disease in childhood. 70(1):F50-F5
    4. Flemmer L, Chan JS. (1993). A pediatric protocol for management of extravasation injuries. Pediatr Nurs. 19(4):355-35
    5. Fullilove S, Fixen J. (1997).  Major limb deformities as complications if vascular access in neonates. Pediatric Anaesthesia. 7:247-250
    6. Gault DT. (1993). Extravasation injuries. British Journal of Plastic Surgery. 46(2):91-9
    7. Goutus I, Cogswell LK, Giele H. (2014). Extravasation injuries: a review. The Journal of Hand Surgery (European Volume). 39E(8):808-81
    8. Laurie SW, Wilson KL, Kernahan DA, Bauer BS, Vistnes LM. (1984).  Intravenous extravasation injuries: the effectiveness of hyaluronidase in their treatment. Ann Plastic Surg. 13(3):191-4
    9. Montgomery LA, Hanrahan K, Kottman K, Otto A, Barrett T, Hermison B.(1999). Guideline for i.v. infiltrations in pediatric patients. Pediatr Nurs.25(2):167-9, 173-8
    10. Phelps SJ, Tolley EA, Cochran EB. (1990).  Inability of inline pressure monitoring to predict or detect infiltration of peripheral intravenous catheters in infants. Clin Pharm. 9(4):286-29
    11. Ramasethu J. (2004). Pharmacology review: Prevention and management of extravasation injuries in neonates. Neoreviews. e491-49
    12. Raszka WV Jr, Kueser TK, Smith FR, Bass JW. (1990).The use of Hyaluronidase in the treatment of intravenous extravasation injuries. Journal of Perinatology.10(2):146-14
    13. Scott DA, Fox JA, Philip BK, Lind LJ, Cnaan A, Palleiko MA, Stelling JM, Philip JH. (1996).  Detection of intravenous fluid extravasation using resistance measurements. J Clin Monit. 12(4):325-33
    14. Siu SLY, Kwong KL, Poon SST, So KT. (2007).  The use of hyaluronidase for treatment of extravasations in a premature infant. Hong Kong Journal of Paediatrics. 12:130-13
    15. Sokol D, Dahlmann A, Dunn D. (1998). Hyaluronidase treatment for intravenous phenytoin extravasation. Journal of Child Neurology. 13(5):24
    16. Wilkins CE, Emmerson AJ. (2004). Extravasation injuries on regional neonatal units. Archives of Disease in Childhood, Fetal & neonatal edition. 89(3):F274-27
    17. Hyaluronidase product information leaflet. Sanofi-Aventis, Macquarie Park, NSW 2113, Australi
    18. Hyaluronidase. Neonatal medication protocols. Women and Newborn Health Service. King Edward Memorial Hospital and Princess Margaret Hospital, Perth. Sept 2013
    19. Burd DAR, Santis G, Milward TM. (1985) severe extravasation injury: an avoidable iatrogenic disaster?. British Medical Journal. 290:1579-1580

    Evidence table

    The evidence table for this guideline can be found here

    Please remember to read the disclaimer.


    The development of this nursing guideline was coordinated by Trudy Holton, Clinical Nurse Educator, Butterfly, and approved by the Nursing Clinical Effectiveness Committee. Updated May 2016.