Grading the severity of extravasation damage
| Grade | Presentation | Treatment |
|---|---|---|
| 1 | Minimal swelling, pain at infusion site | Stop infusion Remove cannula and tapes Elevate |
| 2 | Pain at infusion site, mild swelling, no skin-blanching, minimal redness, normal capillary refill time | Stop infusion Remove cannula and tapes Elevate |
| 3 | Pain at infusion site, swelling, skin-blanching with or without redness at the infusion site, sluggish capillary refill time, normal or decreased perfusion, hard to flush cannula | Stop infusion Leave cannula until reviewed by a doctor Photograph injury if this will not delay treatment Provider to commence irrigation procedure within 1 hour of extravasation by irrigating affected area using saline or appropriate antidote Apply nonocclusive dressing as advised Elevate limb Consider plastic surgery team consult Nursing staff to continue to observe the site hourly for the first 24 hours to monitor for adverse effects Provider should review the site 1–2 hours after antidote to assess effectiveness, and reviewed again in 24 hours |
| 4 | Pain at infusion site, marked swelling, skin-blanching, coolness, reduced capillary refill time, decreased perfusion, with or without arterial occlusion, with or without blistering | Stop infusion Leave cannula until reviewed by clinician Photograph injury if this will not delay treatment Commence irrigation procedure within 1 hour of extravasation by irrigating affected area using saline or appropriate antidote Apply nonocclusive dressing as advised Elevate limb Refer to plastic surgery team Nursing staff to continue to observe the site hourly for the first 24 hours to monitor for adverse effects Review the site 1–2 hours after antidote to assess effectiveness, and review again in 24 hours |
Based on information in references 5 and 6.