This guideline covers the recognition, management and prevention of infiltration and extravasation injury.
Note: While this guideline refers to the 'child' throughout, all activities are applicable to young people.
Infiltration is the inadvertent leakage of a non-vesicant solution from its intended vascular pathway (vein) into the surrounding tissue ( Infusion Nurses Society (INS) 2011; European Oncology Nursing Society (EONS) 2007; Dougherty and Lister 2008; Doellman et al 2009; Royal College of Nursing (RCN) 2010).
Infiltration is increasingly seen as a benign event as it generally does not lead to tissue necrosis; however a large volume of infiltrate can cause compression of nerves and acute limb compartment syndrome (ALCS) resulting in long-term disability ( Hadaway 2007).
If this is the case then surgical intervention eg fasciotomy may be required to prevent nerve compression and compromise of arterial circulation.
A plastic surgeon referral should be sought immediately where large volumes of infiltrate have accumulated.
Extravasation is the inadvertent leakage of a vesicant solution from its intended vascular pathway (vein) into the surrounding tissue ( INS 2006; EONS 2011; Dougherty and Lister 2008; Doellman et al 2009; RCN 2010).
A vesicant refers to any medicine or fluid with the potential to cause blisters, severe tissue injury (skin/tendons/muscle) or necrosis if it escapes from the intended venous pathway ( Sauerland et al 2006 (EONS); Hadaway 2007; Doellman et al 2009).
Concentration of vesicant; the amount extravasated; and the type of vesicant are all factors which will influence the severity of the extravasation ( Wengstrom & Marguiles, 2008).
The degree of injury ranges from mild skin reaction to severe necrosis ( EONS 2007). Other possible consequences include: infection; complex regional pain syndrome; and loss of function ( Hadaway, 2009).
In severe cases extravasation injury may lead to amputation ( Roth 2006; Hadaway 2007; Doellman et al 2009).
There has been little research into extravasation due to ethical considerations limiting controlled research; most evidence is based on small, uncontrolled trials or case reports ( Hadaway 2007; Doellman et al 2009).
Vesicant drugs and solutions reported to cause extravasation injury
Commonly used IV medications
- Aciclovir, Gancicolvir
- Mycophenolate Mofetil
- Epinephrine (adrenaline)
- Norepinephrine (noradrenaline)
Concentrated electrolyte solutions
- Calcium chloride
- Calcium gluconate 10%
- Potassium chloride 7.45%
- Sodium bicarbonate 4.2% & 8.4%
- Sodium chloride 10%
- Total parenteral nutrition
- >10% dextrose
- Mannitol 15%
- Radiographic contrast media
- Promethazine (phenergan)
This is not an exhaustive list.
Risk factors for infiltration and extravasation
Risk factors include device-related, drug-related, patient-related and clinician-related factors ( Sauerland et al 2006).
- metal/steel needles (butterfly)
- large gauge cannula relative to vein size
- inadequately secured cannula
- undesirable cannula site location (eg antecubital fossa, dorsum of hand or wrist rather than forearm, areas of joint flexion and use of dominant hand)
- clot formation above cannula site
Central venous access device (CVAD):
- CVAD surgically placed in an area prone to movement; difficult to secure
- inadequately secured needle in implanted port
- inadequately secured catheter
- inappropriate needle length for Implanted Intravenous Access Port (IVAP) (ie too short to reach back of reservoir)
- development of fibrin sheath/thrombus at catheter tip
- IVAP (port)/catheter separation, catheter fracture or catheter dislodgement
- flushing with a small gauge syringe
- vesicant potential
- volume of drug/fluid infiltrated
- concentration of vesicant drug/fluid
- repeated use of the same vein for vesicant administration
- pH of drug/fluid (extremes of pH ie acid or alkaline - pH < 5 or >9)
- osmolarity of drug/fluid (osmolarity >375 can influence the degree of tissue damage eg hypertonic drugs/solutions eg 10% Dextrose and parenteral nutrition solutions)
- vasoconstrictive potential (extravasation of vasoconstrictive substances eg dobutamine, dopamine, epinephrine, norepinephrine and vasopressin can cause ischaemic necrosis)
- cytotoxicity (drugs that bind to DNA can cause greater damage and may remain in the tissues causing further damage)
- age (very young or old)
- patients with small, fragile or thrombosed veins
- impaired communication - unable to communicate due to young age or confusion, sedation, inability to speak or language issues
- compromised circulation
- altered sensory perception
- poor understanding of risk related to anxiety or fear, cultural barriers or medicines
- active patient
- lack of knowledge
- lack of intravenous therapy skills
- unfamiliarity with CVAD use and management
- interruptions or distractions during drug administration
Recognition of infiltration/extravasation
It is important for the nurse to be able to recognise the early signs and symptoms of infiltration and extravasation ( Dougherty 2008, Schulmeister, 2011; Coyle et al, 2014).
Signs and symptoms of infiltration:
- coolness or blanching at the cannula insertion site
- taut or stretched skin
- leakage of fluid at the insertion site
- inability to obtain blood return (not always present)
- change in quality and flow of the infusion or injection
- numbness, tingling or 'pins and needles'
Signs and symptoms of extravasation are as for infiltration plus:
- burning, stinging pain
- redness may occur followed by blistering, tissue necrosis and ulceration
Signs and symptoms of infiltration and extravasation from CVADs (Wickham et al 2006)
|Event||Can occur with||Etiology||Potential objective manifestations||Potential subjective manifestations|
|Needle dislodgement||IVAP||Needle not in port, needle not stable/secured, incorrect needle length||Sudden swelling about port pocket or chest area; no or loss of blood return; palpable subcutaneous tissue; fluid leaking around needle||Pain, stinging, burning at port pocket or chest area|
|CVC damage||IVAP, tunneled CVC||Separation of port from catheter; nicked catheter at insertion||Swelling and erythema in port pocket or catheter tunnel with infusion; no or loss of blood return||Pain or burning around port or CVC tunnel with infusion|
|CVC pinch off||IVAP, tunneled CVC||Subclavian insertion medial to midclavicular line||Loss of blood return; swelling and erythema in clavicular area with infusion||Clavicular pain or burning with infusion|
|CVC tip displacement through SVC||IVAP, tunneled CVC, PICC||Early: difficult insertion; Late: unknown; thrombosis of SVC or great veins may increase risk||Intractable cough with infusion, pleural effusions, abnormal CXR/CT||Substernal chest pain, dyspnea, fatigue|
|CVC tip displacement from SVC||IVAP, tunneled CVC, PICC||Unknown, possible increased risk with severe coughing||Loss of blood return, erythema in neck (if CVC in IJV)||Discomfort in chest about CVC or tip with infusion of irritants or vesicants|
|Fibrin sleeve and back-tracking||IVAP, tunneled CVC, PICC||Fibrin sleeves are nearly universal; thrombosis is uncommon||Erythema at venous insertion site during infusion; backtracking can be confirmed by linogram||Discomfort at CVC insertion site|
IVAP-implanted venous access port; CVC-central venous catheter; PICC-peripherally inserted central catheter; SVC-superior vena cava: IJV-internal jugular vein; CXR-chest x-ray ( Wickham et al, 2006).
Distinguishing extravasation from other local reactions
Making the distinction between extravasation and other local reactions can be difficult. There are several conditions that resemble extravasation:
- flare reaction
- vessel irritation
- venous shock
The principle differences between extravasation and the above conditions relates to the nature and timing of the patient's complaints, type and extent of erythema, and the location and presence of swelling ( EONS 2007) (see table below).
When a nurse cannot differentiate between extravasation and a local reaction, the nurse should err on the side of caution and manage the patient as if an extravasation has occurred ( Wickham et al 2006).
Distinguishing extravasation from other conditions (EONS, 2007)
|Characteristic||Flare reaction||Vessel irritation||Venous shock||Extravasation|
|Presenting symptoms||Itchy blotches or hives; pain/burning uncommon||Aching & tightness||Muscular wall of blood vessel in shock (can be caused by very cold drugs or by rapid administration)||Pain/burning common at injection site; stinging may occur during infusion|
|Colouration||Raised red streak, blotches or hive like erythema along the vessel; diffuse or irregular pattern||Erythema or dark discolouration along vessel||n/a||Erythema around needle/venepuncture site|
|Timing||Usually appears suddenly and dissipates within 30-90 minutes||Usually appears within minutes after injection. Colouration may only appear later in the process.||Usually appears right after the injection.||Symptoms start to appear right after injection, symptoms endure|
|Swelling||Unlikely||Unlikely||n/a||Occurs often; does not dissipate for several days|
|Blood return||Usually, but not always intact||Usually, but not always intact||Often absent||Usually absent or sluggish|
( EONS 2007)
Management of infiltration and extravasation
Early intervention and identification of the first signs and symptoms of infiltration and extravasation is crucial, in order to prevent serious adverse outcomes ( Doellman, 2009; Schulmeister, 2011).
Compliance with guidelines is essential to minimise the complications associated with extravasation or infiltration ( Roth 2006; Coyle et al, 2014).
This is a medical emergency any time of the day or night.
The recommended immediate management is:
- Immediately stop the infusion/injection ( Doellman et al 2009).
- Explain the procedure to the child and family. Give child and family extravasation information leaflet.
- Aspirate as much of the residual drug as possible to minimise the injury caused by the residue of the drug ( Schulmeister, 2011).
Under no circumstances should the device be flushed.
- Leave the cannula/port needle in situ (in case plastic surgeon wants to use to facilitate treatment and administration of any antidote(s)).
- Disconnect administration set or syringe containing drug but retain it to determine amount of drug extravasated/infiltrated.
- Mark and measure the extravasated area ( Wengstrom et al, 2008).
Urgently, during the day, a nurse or the child’s SpR should contact the hospital switchboard for the on-call plastic surgeon’s mobile. The CSP should be contacted initially overnight, giving the following details:
- time of injury
- distal circulation
- area and site of injury
- local examination
- details of the drug/fluid
Further management as indicated:
- The SpR should prescribe pain relief as required.
- Administer analgesia as required/prescribed.
- If a limb is affected it should be elevated.
- Obtain the extravasation kit (available from Lion Ward and Safari Daycare, PICU, VCB theatres, Ocean theatres and Eagle Ward for use by medical team at GOSH ( Wengstrom et al, 2008)).
- Document the incident and actions taken in the child’s health care records and complete an incident form.
- Inform child and family of the following:
- that an extravasation is suspected/has occurred
- the possible cause of the extravasation
- what action/treatment will be required
- any follow-up arrangements
- that an incident form will be completed
- allow time for any questions and/or queries
- Continue monitoring the site, as signs such as erythema/ulceration can be delayed for 48 hours post-extravasation ( Hadaway, 2009). This should be done at least eight hourly and documented in the child's health care record ( Wengstrom et al, 2008).
Documentation of an extravasation/infiltration injury
- date and time of event
- patient’s comments
- clinician’s comments
- insertion site (precisely located by detailed anatomical descriptors or marking an anatomical drawing)
- photographs of the involved site
- catheter gauge and length
- non-coring needle gauge and length (IVAPs)
- type and volume of diluent
- administration by IV bolus, piggyback, gravity or pump (if a pump include infusion rate)
- appearance of the infusion site
- type and estimated volume of the extravasated drug
- techniques used to manage the extravasation
- use of antidotes or treatments
- description of wound care
- grade extent of injury
- notification of doctor, including time, information discussed and advice received
- outcome of surgical consultation when applicable
- description of follow up measures
- patient education
- signatures and credentials of all personnel involved
- complete incident form
Documentation of the process is essential if litigation were to occur ( Masoorli 2003; Roth 2006, Fidalgo et al, 2012). This documentation will be done by nurses and doctors.
In accordance with the NMC (2009), record-keeping is an integral part of nursing and is essential to the provision of safe and effective care. It is also part of the hospital incident reporting policy.
Treatment will be determined by the plastic surgeon but may include:
- Monitoring – the site will be observed, elevated and monitored to determine whether further treatment is required.
- Conservative management – this may involve the usage of hot or cold compresses or antidotes (if possible).
- Surgical management – this involves a saline washout, a procedure that dilutes the extravasated drug in the tissue ( Wickham et al 2006).
Extravasation kits should be available to the plastic surgeon, these can be obtained from:
- Lion Ward and Safari Daycare
- VCB Theatres (main cupboard)
- Ocean Theatres (main cupboard)
- Eagle Ward
Good results have been achieved with this technique when used at an early stage with adults and children.
The age of the child and the extent of the injury will determine if a local or general anaesthetic will be required.
Antibiotic prophylaxis maybe recommended in some patients depending on the severity.
In a saline washout the injured area is ( Gault 1993):
- Injected with the enzyme hyaluronidase.
- Peripheral incisions are made around the "clock face" of the injury.
- Using an atraumatic cannula the area is perfused with 0.9% sodium chloride.
- The washout efflux may be tested for decreasing concentrations of toxin.
- Dressing applied post-operatively and the limb elevated for 24 hours.
If the plastic surgery team have been involved follow their management plan, if not, follow the plan from the child’s medical team.
Further surgical intervention may be required.
The child may need their injury to be reviewed as an outpatient.
If no action is required, observe the extravasation site for:
- fluid leakage from cannula/device site
This should be done as often as required by the condition of the child, or at least eight hourly, until the site regains its normal appearance and any changes documented ( Wengstrom et al, 2008).
If limb involvement, elevate it (if appropriate, monitor the limb mobility of the child).
If the extravasation site deteriorates or its condition does not improve another referral must be made to the Plastic Surgery team.
Prevention of infiltration/extravasation
Peripheral IV access:
- Place cannula in forearm when possible.
- Use the smallest gauge plastic cannula feasible.
- Avoid joints (eg wrist, antecubital) and limbs with impaired arterial, venous or lymphatic circulation or any neurological impairment ( Wengstrom et al, 2008).
- Stabilise and secure the cannula in place using dressing that does not obscure the site (ie transparent).
- Confirm blood return prior to vesicant administration.
Central IV access:
- Preferred route of administration.
- Confirm blood return prior to vesicant administration.
- IVAP: ascertain correct needle placement in septum.
- IVAP: stabilise and secure the needle in place using dressing that does not obscure the site (ie transparent).
- If catheter tip is questionable, assess prior to vesicant administration (ie through a chest x-ray).
- Instruct the patient and family about the risks of vesicant administration.
- Instruct the patient and family to notify a health care professional if the child experiences any pain/burning/change in sensation at the cannula or port site; this includes non verbal assessment also.
- Instruct the patient and family not to disturb or dislodge the cannula or port needle and to take care when mobilising.
- The patient and family should be able to understand these points.
Nursing responsibilities when administering intravenous medicines
Intravenous therapy is now an integral part of the majority of nurses' professional practice ( RCN 2010). Any nurse involved in the administration of intravenous therapies must be competent to undertake the procedure and act in accordance with the Nursing and Midwifery Council (NMC) Code and maintain knowledge and skills ( NMC 2008a).
The nurse has a duty of care to the patient to monitor the patient and their response throughout the duration of intravenous medication administration ( RCN 2010; NMC 2008b).
The GOSH Trust medicines administration policy must be adhered to when administering intravenous medications and fluids. Refer to the medicines administration policy in the GOSH document library.
Any member of nursing staff deemed competent in IV therapy may administer a vesicant infusion via peripheral and central venous access devices. However, the nurse must undertake all safety precautions and assessments and close monitoring must be continued throughout the infusion.
The administration of peripheral vesicant cytotoxic drugs as a bolus via a peripheral cannula is covered by the following policies on the GOSH intranet site in medicines and pharmacy:
- Cytotoxic and cytostatic medication CPG - safe handling and administration (2013).
- Policy for the safe handling of hazardous medicines including cytotoxic chemotherapy (2014).
- Pan London guidelines for the safe prescribing, handling and administration of systemic anti-cancer treatment drugs v1.0 (2011).
Monitoring of the infusion
The access device should be well secured ( Sauerland et al 2006; Dougherty 2008)
The pressure of the infusion pump must be monitored and documented at least hourly, along with the signature of the person doing so, on the child’s fluid chart.
The infusion site must be inspected every 30-60 minutes and documented when in use and if extravasation or infiltration is suspected ( Masoorli 2003). Observe for any erythema or oedema ( Hadaway, 2009).
The port needle entry site should be observed before administering vesicants or irritant solutions ( Sauerland 2006).
The suggested maximum pressure alarm setting for an infusion pump is 15–25mmHg for vesicant drugs.
More frequent checks may be necessary in some instances depending on the patient, infusate, vascular integrity and the vascular access device being used (15–30 minutes).
The pressure alarm limit must be set when a vesicant infusion is commenced and rechecked at the beginning of each shift, if still running.
Record pump pressures and site monitoring on the fluid balance charts as per hospital policy.
A rise in pressure must be investigated.
The pressure reading should not be the sole indicator for an extravasation ( Sauerland et al 2006).
Bandages are not recommended for use when administering bolus vesicant therapy and should be used with caution for infusions. Never cover the insertion site as this compromises effective monitoring ( Roth 2006; EONS 2007).
Patient and family queries about pain, discomfort or swelling must be investigated; they should also have been informed of signs and symptoms ( Sauerland et al 2006; Fidalgo et al, 2012; Coyle et al, 2014).
Administration of vesicants
The patency of the vein and catheter must be assessed prior to administering vesicant drugs/fluids. The line should be flushed to determine if any resistance is felt and there should be a brisk, free flowing blood return into an empty syringe; slow or inadequate blood return could indicate a problem ( Hadaway 2007; Dougherty 2008).
A flashback of blood into a saline syringe is not an adequate assessment of any venous access device when administering vesicant drugs ( Sauerland et al 2006).
Further investigation must take place if:
- blood cannot be aspirated
- the device cannot be flushed
- pain is experienced on flushing
- swelling is observed on flushing
Do not continue with the vesicant if any of the above are present.
Vesicant drugs/fluids must be administered in concentrations recommended by the manufacturers.
Vesicants should be administered first in a sequence of medications as vascular integrity decreases over time and also the vein is less irritated initially ( Dougherty 2008).
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