Extravasation: Does Your Knowledge Match
Your Patient's Needs?
Esther Csapo Rastegari, RN, BSN, EdM

The call light for room 425B blinks on. You answer it, “Yes, Mrs. Henry, how can I help you?”

“My left arm hurts, and my ID band feels tight.”

“I’ll be right in.” You take her chart and head for room 425B.

Your assessment reveals the following:

• You compare Mrs. Henry’s arms and see that the left is edematous, reddened, and warm to the touch.
• You note erythema around the peripheral catheter insertion site.
• Mrs. Henry complains of tenderness at the insertion site and a feeling of tightness in her left arm.
• The infusion rate has slowed. Mrs. Henry’s position does not indicate a mechanical reason for the problem — she has not been lying on her left arm, the securing tapes and dressing materials do not appear constricting, and her gown is not restrictive.
• In reviewing the chart, you see that her current infusion is vancomycin hydrochloride, a known vesicant.

You suspect extravasation and immediately implement your organization’s policy.

Recognizing Extravasation

The Infusion Nurses Society (INS) defines extravasation as “the inadvertent administration of vesicant medication or solution into the surrounding tissue.” Infiltration is defined as the “inadvertent administration of nonvesicant medication or solution into the surrounding tissue.”

Vesicant extravasation can lead to short-term complications, such as blistering, ulceration, infection, impaired venous access, delay in receiving prescribed infusion therapy, tissue necrosis, and eschar formation.

As a result of tissue damage, the patient may need surgical interventions, such as debridement, excision, amputation, and skin grafting. In addition, long-term sequelae, including joint stiffness, neuropathy, deformity, disability, and even death, may result.

The nurse may note extravasation immediately following vesicant infusion with both peripheral and central vascular access devices or may not discover the problem right away. Nurses administering such solutions and medications need to understand vesicant administration and be able to recognize and manage associated complications.

While antineoplastic medications usually top the list of vesicant agents, extravasation is also associated with many nonantineoplastic parenteral medications and solutions, including dopamine, epinephrine, and norepinephrine; high concentrations of potassium chloride and sodium bicarbonate; amphotericin B; phenytoin; dextrose in concentrations of 10% or greater; parenteral nutrition; radiographic media; and calcium and calcium-containing compounds. Solutions with a pH below 5.0 or above 9.0, or an osmolarity greater than 500 mOsm/L also carry an increased risk of extravasation.

Because extravasation is more readily associated with antineoplastics, sometimes an organization’s policies for extravasation management are not readily accessible when a nonantineoplastic agent extra-vasates. This results in an unfortunate and unnecessary delay in intervention.

Managing the Complication

Knowing how best to manage this serious complication and swiftly intervening can significantly lessen the progression of tissue damage. If your organization does not have a policy in place for managing extravasation, volunteer to help create one that includes the following interventions:

• Stop the infusion immediately.
• Assess the affected area for swelling, erythema, warmth, taut skin, or altered sensation like pain, numbness, or tingling. Swelling may not be an accurate assessment tool once extravasation has taken place. The absence of pain or discomfort does not rule out extravasation.
• Do not rely on the presence or absence of a blood return as a determining factor for extravasation due to possible migration of the catheter tip.
• Always rate extravasation as Grade 4 on the Infusion Nursing Standards of Practice Infiltration Scale.
• Notify a physician, and obtain any specific treatment orders.
• Treat the injury according to physician’s orders and manufacturer’s recommendations.
• Apply moist compresses. Use cold, moist compresses for extravasation from all medications or solutions except antineoplastic agents known as vinca alkaloids (vincristine sulfate, vinblastine sulfate, and vinorelbine tartrate). Apply warm, moist compresses for extravasation from vinca alkaloids. Compliance with the manufacturer’s recommendations regarding the use of compresses for extravasated medications is the best policy.
• Evaluate the venous access device (VAD) for possible removal.
• Evaluate the patient for new VAD placement, according to the physician’s orders.

The risk of extravasation increases with vein wall injury, such as through unskilled or multiple venipuncture attempts, accidental VAD dislodgment, inadequate device securement, and excessive catheter manipulation. The following steps can help minimize its occurrence:

• Educate nurses administering vesicant solutions and medications and validate their competency in vesicant infusate administration, venipuncture technique, care and maintenance strategies of VADs, and recognition and management of device- and infusion-related complications.
• Use the smallest gauge and shortest length catheter in the largest appropriate vein.
• Use long-term central VADs when possible, especially if the patient will receive irritant or vesicant therapies for several weeks to months.
• Select the site carefully, and use a meticulous, skilled device insertion technique. Avoid areas of flexion found in the antecubital fossa and wrist, the dorsal veins of the hand, or the lower extremities.
• Locate each venipuncture location proximal to previous sites.
• Request that after two unsuccessful venipuncture attempts, a more experienced clinician assess the patient for adequate peripheral vascular access sites and perform the venipuncture.
• Stabilize and secure catheter, allowing for frequent site inspection.
• Establish and confirm catheter patency; check for positive blood return before, during, and after medication or solution administration.
• Check dressing integrity for compromise, such as evidence of moisture or nonadherence.
• Consider the patient’s physical condition and mental alertness. Patients who have extremities with poor circulation, such as those with lymphedema, postsurgical treatments like mastectomy, or peripheral vascular disease or neuropathy are at greater risk for extravasation. Patients who are unable to indicate early warning signs are also at greater risk of significant injury from extravasation. This includes very young children and patients who are comatose, intubated, undergoing cardiac resuscitation, experiencing violent vomiting or coughing, and those suffering from paralysis, stroke, confusion, or impaired communication ability as a result of sedation from anesthesia or other medications.

When extravasation does occur, it’s imperative to thoroughly document in the patient’s permanent medical record. Documentation should include —

• Date and time of discovery.
• Time of medication or solution administration and estimated time elapsed since onset of extravasation.
• Particulars of the administration: vein location; type, gauge, and size of catheter; medication or solution type and name; sequence and dose, amount infused; route and mode of delivery (e.g., IV push, pump); patient complaints of pain, stinging, or burning with administration.
• Recording of all venipunctures and attempts, as vesicants may seep into the tissue surrounding previous insertion sites, enlarging the area of damage.
• Clinical signs of extravasation: estimated size and extent of extravasation. Photograph the injury for the medical record.
• Primary physician notified, with date, time, and orders received.
• Interventions taken once discovery occurred.
• Follow-up care.
• Patient education.

The greater the nurse’s knowledge of extravasation, the sooner this complication can be discovered and remedial interventions initiated. The extent of the damage may in turn be minimized, and permanent disability for the patient averted.

Esther Csapo Rastegari, RN, BSN, EdM, is a research coordinator for the Infusion Nurses Society.

Bibliography

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