What is the optimal approach to infiltration and extravasation of nonchemotherapy medications?

IMPORTANT DISTINCTIONS: TERMINOLOGY

An review of terminology is helpful when discussing leakage of IV fluids.

A vesicant is an agent capable of causing tissue damage when escaped from the intended vascular pathway into surrounding tissue.

An irritant or nonvesicant is an agent that causes discomfort including, aching, tightness, and phlebitis with or without inflammation, but does not typically cause tissue necrosis.

Infiltration is leakage of a nonvesicant solution into the surrounding tissue. It is a relatively common occurrence and can cause redness, swelling, and pain or discomfort but does not cause tissue necrosis.

Extravasation is leakage of vesicant fluid out of a blood vessel into surrounding tissue. It can cause more damage than infiltration of nonvesicant solutions and can lead to blistering, tissue ischemia, and necrosis. In extreme cases, surgical debridement, skin-grafting, or even amputation may be required.

In this article, we will use the terms extravasation and extravasated for any IV infusion-related leakage.

THE PROBLEM

The frequency of extravasation in adults is between 0.1% and 6%.² Some suggest the incidence is decreasing thanks to improved infusion procedure, early recognition of drug leakage, and training.²

The consequences of fluid leakage from a vessel into surrounding tissue vary depending on the agent being dispensed. Awareness of these agents and their potential consequences will enhance the likelihood of prompt recognition and treatment.

IMMEDIATE INTERVENTIONS

The following immediate interventions are recommended to prevent complications:

• Stop administration of fluid

• Disconnect the IV tubing, but leave the catheter or needle in place to facilitate aspiration of fluid from the extravasation site and, if indicated, administration of an antidote

• Do not flush the line

• Remove the catheter or needle if an antidote will not be administered into the extravasation site

• If an antidote is indicated, inject it through the catheter to ensure delivery to the extravasation site, then remove the catheter

• Elevate the site and apply warm or cold compresses.

GAUGING THE SEVERITY, SELECTING AN ANTIDOTE

Many patients with extravasation experience erythema, edema, ulceration, stinging, burning, pain, tissue-sloughing, and even necrosis. A severity of grade 3 or greater, which requires an antidote, is characterized by pain, swelling, sluggish capillary refill time, normal or decreased perfusion, and other symptoms (Table 1).^1,4–6

Treatment differs depending on the extravasated medication, and the selection process may be complex. In general, hyaluronidase is the antidote of choice for nonvesicant agents. Other antidotes include topical nitroglycerin, phentolamine, terbutaline, and sodium thiosulfate. Their vasodilating effects clear the drug from the affected area and neutralize harmful irritants that cause discomfort (aching, tightness, and phlebitis with or without inflammation) but typically not tissue necrosis. The treatment varies depending on the medication involved and the grade of severity (Tables 2 and 3).^1–8

CONTRAST MEDIA EXTRAVASATION

Extravasation of IV-administered iodine-based and gadolinium-based contrast media can cause serious tissue damage, including necrosis. While the incidence of contrast media extravasation is relatively low (between 0.1% and 0.9%),^9–11 factors associated with increased risk of contrast extravasation include use of iodine-based contrast (as opposed to gadolinium contrast), use of automatic power injectors, high injection rates, patient-related factors (older age, female sex, cachexia, IV drug use, inpatient status), venous access site (dorsum of hand), and small-gauge needles (less than 22-gauge).^9,12 Use of high-osmolar and high-viscosity contrast media increases the risk of extravasation. Prewarming the contrast agent to 37°C (98.6°F) lowers the viscosity and, in turn, the probability of extravasation.⁹

The clinical presentation of contrast extravasation resembles that of other vesicant drug extravasations and can include local pain, tenderness, swelling, redness, itching, and skin tightness. In more severe cases or with large-volume, high-osmolarity contrast extravasation, skin-blistering, soft-tissue necrosis, or compartment syndrome can occur.

Treatment requires immediate discontinuation of the infusion, aspiration of contrast if possible, conservative measures such as limb elevation and cooling compresses, and injection of hyaluronic acid. There is no set threshold of extravasate volume at which surgical consultation is warranted. However, it has been suggested that plastic surgery consultation be requested when extravasation volume is greater than 100 to 150 mL.^9,13 Severe symptoms such as ulceration or necrosis may warrant surgical consultation regardless of extravasate volume.

PREVENTION

Focusing on preventive measures will lower the risk of extravasation, promote patient trust, and increase patient satisfaction.² Patient engagement is key to prevention. When infusing a vesicant, counsel the patient to immediately report changes in skin color, integrity or firmness, temperature, mobility, sensation, or pain.² The vein used for infusion should be a large, intact vessel with good blood flow, specifically a basilic, cephalic, or antebrachial vein. Avoid veins in the hands, dorsum of the foot, any joint space, or antecubital fossa area.² Always check for blood back-flow to ensure correct catheter positioning.² When possible, use of a central venous catheter helps limit drug extravasation.¹⁴

DISCLOSURES

The authors report no relevant financial relationships which, in the context of their contributions, could be perceived as a potential conflict of interest.