Extravasation: Prevention is the Best Treatment

Infiltration is the inadvertent infusion of non-vesicant solutions or medications into the surrounding tissue. Extravasation is the inadvertent infusion of vesicant solutions into the surrounding tissue. A vesicant is defined as a drug that is capable of causing tissue injury.

Dealing with extravasation

The best treatment for extravasation is prevention. When the extravasation occurs, commonly used antidotes may or may not work. According to the Oncology Nursing Society’s Chemotherapy and Biotherapy Guidelines and Recommendations for Practice, treatments using sodium thiosulfite and DMSO have shown very limited success. In some cases, the manufacturer has specific recommendations for treatment of an extravasation. When doxorubin extravasates, for example, the manufacturer recommends applications of cool packs to the swollen area. When vinca alkaloids extravasate, the recommendation is warm packs to the swollen area. In all cases of suspected or actual extravasation, the physician should be notified immediately and given specific information about the drug and drug concentration, as well as an accurate, detailed description of the appearance of extravasated area.Hospitals may have specific extravasation policies and procedures. It is the nurse’s responsibility to know the hospital’s policy. In some cases, the protocol may include subcutaneous steroid injections and/or application of steroid or Silvadene creams. In most cases, once the infusion has extravasated, the only thing that can be done is to monitor the site until tissue damage demarcation is complete. At this point, the site will be assessed for maximum tissue damage. In many cases, a split or full thickness skin graft may be required. In the worst case scenario, amputation above the injury may be required to remove the dead tissue or to stop the spread of the tissue damage.

Preventing extravasation

To help prevent extravasation, two myths need to be dispelled: The first is that a “new” IV device should be used for each vesicant infusion. A new IV site is not guaranteed to work better than an existing one. The second myth is that a peripheral IV catheter should be checked for a blood return prior to the infusion and during the infusion. According to Infusion Therapy in Clinical Practice, obtaining a blood return on a peripheral IV catheter is an inconclusive assessment tool and should not be relied on to determine if the IV catheter is properly seated within the vein. Obtaining a blood flash or obtaining no blood return from a peripheral IV catheter is not an indication of catheter placement within the vein.

The most reliable tests are flushing the catheter before and during the procedure with copious amounts of saline and observing the site for swelling. A complete assessment of the IV site prior to the infusion is essential. A free flowing bag of normal saline should be infusing for IV push or IV piggyback vesicant injections. The vein should be completely flushed with at least 20 mL to 30 mL of saline after the vesicant infusion is complete to prevent the vesicant from “tracking” when the IV catheter is removed. The site should be continually assessed for swelling, coolness, stinging, or burning. When in doubt, the IV device should be removed. Any patient complaint is an indicator that the catheter may be malfunctioning.