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Oncology Times:
doi: 10.1097/01.COT.0000372178.68484.4f
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Preventing Extravasation

Hadaway, Lynn C. MED-RN-BC, CRNI

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Extravasation—the infiltration of a vesicant drug from an IV line into surrounding tissue—can occur with either a peripheral or central venous catheter. This article describes prevention and management of extravasation from a peripheral catheter.

Extravasation occurs when a peripheral catheter erodes through the vessel wall at a second point, when increased venous pressure causes leakage around the original venipuncture site, or when a needle pulls out of the vein. Signs and symptoms of extravasation include edema and changes in the site's appearance and temperature, such as blanching and coolness. The patient may complain of pain or a feeling of tightness around the site.

Vesicant drugs or solutions (such as certain antineoplastic drugs, antibiotics, electrolytes, antiemetics such as promethazine, and vasopressors) cause severe tissue injury or destruction when they extravasate. Possible consequences include necrotic ulcers requiring surgical debridement and skin grafting, infection, disfigurement, complex regional pain syndrome, and loss of function.

Although short and midline peripheral catheters aren't recommended for continuous infusion of vesicants, they may be appropriate for a medication dose given by slow injection. Adhere strictly to proper administration techniques and follow these guidelines:

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* Know your hospital's policy on the use of antidotes for vesicants. For example, is a kit packaged with all needed supplies available or will you need to collect items individually?

* Make sure you know the antidote and other recommended treatment for the vesicant drug you are giving.

* Ensure that the drug has been properly diluted before injection or infusion. Dilution reduces the amount of vesicant that will reach subcutaneous tissue if extravasation occurs. It also helps you detect edema or complaints of pain before the entire dose is administered.

* Select a small-gauge catheter to minimize trauma to the vein and let enough blood flow around the catheter to hemodilute vesicants.

* Select the venipuncture site carefully, using a distal vein so you can perform successive proximal venipunctures if necessary. Don't use the dorsum of the hand, the wrist, fingers, antecubital fossa, or other areas of flexion; previously damaged areas; or areas with compromised circulation.

* Don't probe for a vein. If you don't penetrate it immediately, stop and begin again at another site.

* Don't administer a vesicant at an IV site that is more than 24 hours old; the vein may already be irritated. Perform venipuncture at another site so you can ensure correct needle or catheter placement and vein patency.

* Secure the catheter properly, preferably with a manufactured catheter stabilization device. Cover the venipuncture site with a transparent dressing so you can see the area.

* Immediately before giving each dose of the drug, or every one to two hours for a continuous infusion, assess the site to reconfirm vein and catheter patency. Gently flush the catheter with 5 to 10 mL of 0.9% sodium chloride solution while palpating the site to detect edema. Ask the patient about any pain or tenderness in the area.

* Aspirate from the catheter before injecting a vesicant and look for a brisk blood return. Hold the vesicant and assess catheter placement if you don't see blood return. Lack of blood return does not always indicate extravasation. Blood return may be impeded if the vein is small or the catheter lumen is pressed against the vein wall. Likewise, the presence of blood return does not necessarily mean the catheter is properly placed; the catheter may still be partly eroded through the vein.

* Check for infiltration before starting the vesicant infusion by applying a tourniquet above the catheter to occlude the vein and seeing if the IV solution continues to flow despite the tourniquet. If so, it's infiltrating into tissue.

* Inject or infuse the vesicant medication through the Y-site needleless connector of a free-flowing IV solution such as 0.9% sodium chloride solution. This additional fluid helps dilute the drug and reduces the risk of vein damage.

* If you're giving a hazardous drug that creates a health risk for you, use a closed-system drug transfer device.

* Use an infusion pump to control the rate of drugs such as potassium chloride. (Your facility may have a policy about giving certain drugs via pump.) Assess the site frequently; the pump will continue infusing the drug if extravasation occurs.

* During the infusion, observe the site for erythema or edema. Tell the patient to report pain, burning, stinging, pruritus, or temperature changes.

* After the infusion is complete, use 0.9% sodium chloride solution to flush the tubing and catheter.

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If Extravasation Does Occur

If extravasation does occur, consider extravasation an emergency and follow your facility's protocol, which should include these essential steps:

* Immediately stop the infusion and disconnect the tubing as close to the catheter hub as possible. Attach a syringe to the hub and attempt to aspirate the remaining drug from the catheter.

* Estimate the amount of extravasated solution and notify the health care provider.

* Remove the catheter without placing pressure on the site. Use a 25-gauge needle to inject the antidote into subcutaneous tissue as ordered or per protocol.

* Elevate the affected arm.

* Apply either ice packs or warm compresses to the affected area, depending on the type of vesicant. For most extravasations, apply ice for 20 minutes four to six times a day for 24 to 48 hours. However, treat extravasations from vinca alkaloids, epipodophyllotoxins, and vasoconstricting drugs with heat.

* Photograph the site, if possible.

* Record the date and time of the infusion, when extravasation was noted, the type and size of the catheter, the drug administered, the estimated amount of extravasated solution, and the administration technique used. Also record the patient's signs and symptoms, treatment, and response to treatment. Include the time you notified the patient's health care provider and the provider's name. Continue regularly assessing and documenting the appearance of the site and associated signs and symptoms. Some signs, such as erythema and ulceration, may be delayed for 48 hours or more after the extravasation.

Adapted from Hadaway LC. Preventing and managing peripheral extravasation. Nursing 2009; 39(10):26-27.

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Resources/References

Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing: An Evidence-Based Approach. 3rd ed. St. Louis, MO: Elsevier Saunders; 2009.

Doellman D, Hadaway L, Bowe-Geddes LA, et al. Infiltration and extravasation: update on prevention and management. J Infus Nurs 2009;32(4):203–211.

Hadaway L. Emergency: infiltration and extravasation—preventing a complication of IV catheterization. Am J Nurs 2007; 107(8):64–72.

IV Therapy Made Incredibly Easy! 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006;253.

© 2010 Lippincott Williams & Wilkins, Inc.

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