Transcript Extravasation of Intravenous Non

Extravasation of Intravenous
Non-Chemotherapeutic Agents
Lisa Sheehan, RN, BSN
UPMC Shadyside
What is Extravasation?
Extravasation happens when a vesicant medication escapes into the
surrounding tissue by:
Cannula puncturing the
Fluid leaking from vein at
wall of the vein
insertion site
Signs / Symptoms: pain, redness, burning, pallor, no blood return,
edema, decreased IV flow or flush
Who is at an increased risk for extravasation?
• Patients with chronic conditions causing arterial insufficiency
• Patients with compromised venous or lymph drainage
• Patients on meds that can cause the skin and veins to become
more fragile: corticosteroids, anticoagulants, chemotherapy
• Elderly, children, and sedated patients
Prevention, Prevention, Prevention…
Early detection and prompt action are required to prevent tissue
necrosis and functional loss in this medical emergency
First step after extravasation is noticed or suspected…
STOP THE INFUSION
STOP
Calcium Chloride extravasation that resulted
in hand amputation
Post-Extravasation Steps…
• Leave catheter in place without any pressure to the site and
explain procedure to patient
• Estimate amount of medication that entered surrounding tissue
• Perform hand hygiene
• Aspirate medication with 3ml syringe directly attached to the
colored hub and withdraw catheter while aspirating
Post-Extravasation Steps…
• Clean area with alcohol and let dry
• Trace leading edge of extravasated area and / or photograph to
monitor improvement or worsening of area (This step is often
missed)
• Elevate extremity above level of heart for 48 hours to help
reduce edema
• DO NOT use this site, sites distal to, or entire extremity if
possible for IV access until resolved
• Re-establish IV access
Consider MD consultation
• Severe extravasation symptoms exist
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Severe pain
Skin discolored around area
Inflammation larger than a quarter
Drugs used include amiodarone, epinephrine, norepinephrine,
phenylephrine, dopamine, ephedrine, vasopressin, calcium chloride, or
vancomycin
When to Consult Plastic Surgery
• Extravasation involves calcium chloride
• Surrounding tissues are discolored, tense, blistering
• Patient reports severe pain
• Decreased peripheral pulse or slow cap refill
• Greater than 25ml medication escaped into tissue
Compresses
Warm Compress
• Promote vasodilation
• Increased drug absorption
• Decreased local drug
concentration
• Can cause maceration and
necrosis if MOIST HEAT used
Cold Compress
• Promote vasoconstriction
• Localizes the extravasation
• Allows vasculature and lymph
system to drain the medication
from the area
Procedure:
Apply compress for 5 minutes then check site.
If red, macerated, blistering, or patient feels pain with compress remove compress!!
Apply for 15-20 minutes at least 4 times / day for 24 hours or until discomfort resolved.
Antidotes
• All antidotes must be ordered by MD or advanced practice
provider
• MD must assess patient prior to giving antidote
• Use for severe extravasations where patients are showing
severe symptoms or severe pain
• Time is of the essence to be effective!
Phentolamine
• Primarily used for Pressor extravasation
• Should be used within 12 hours of incident
• May use more than one dose if needed to encircle affected area
• Max dose 50 mg
During drug shortages nitroglycerin topical ointment or transdermal
patch may be used if patient is stable with SBP > 90.
Hyaluronidase
• Primarily for non-pressor extravasations
• Most effective if used within 60 minutes of incident, but can be
beneficial up to 12 hours after the incident.
Antidote Administration
• Multiple subcutaneous injections
are given using a 25g or 26g
needle in a pin-cushion fashion
along the periphery of the affected
site.
• Change the needle with each new
injection
Assessment
To be performed and charted each shift or patient handoff
until any symptoms are resolved or patient is discharged
Affected Area
Affected Extremity
• Redness / necrosis
• Edema
• Drainage
• Pain, burning, itching
• Changes in temperature of area
• Sensation of fingertips / toes
• Movement
• Pulses
Documentation
• Complete an incident report
• Document severity according to Infiltration Rating Scale
• Include:
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Measurements, location, catheter size
Subjective description
Estimated fluid volume of medication
MD notification
Management of extravasation provided
Photograph if taken
Patient education and follow-up instructions
Consults if needed
INS
Infiltration and
Extravasation
Scale
Case Study #1
• Radiology called IV Team for restart of an IV but the patient was in
transit. IV Team advised them to have floor call when patient settled.
• 30 minutes later, floor RN calls with infiltrate of Potassium and
possibly Zosyn into a swollen hand / wrist area
• IV RN arrives within 15 minutes to find IV removed and patient
reporting, “This is the worst pain I have ever felt in my life.”
• IV Team suggested antidote Hyaluronidase was needed, so call MD.
• IV Team notes swelling approximately to mid forearm, cool to touch
and leaking from IV site and advises plastic surgery consult if antidote
does not relieve pain. All pulses WNL
Case Study #1 cont’d…
• MD arrives and unsure of what to order or how to treat.
• IV RN suggests antidote and hands hospital policy to RN for
MD reference. IV RN had to leave unit for urgent blood restart.
• IV Team arrives back to unit to find antidote was never given
and the plastic surgeon was angry at being told he needed to
be there within 60 minutes to address this situation.
• Patient arm was elevated with cool compress.
• Plastics did see patient and advised current treatment and that
antidote no longer needed by the time he arrived (2-3 hours
after call) and no risk for necrosis was evident.
Case Study #1 Questions
• What could have been done better?
• What was done well?
• How could it have been prevented?
Case Study #2
• IV Team called to ICU for extravasation of epinephrine from a
chest port. IV Team arrived within 10 minutes.
• Advised immediate MD consult to order antidote.
• MD arrived within 10 minutes and ordered antidote. ICU RN
administered antidote with IV Team as a resource.
• Plastics consulted with treatments advised for tissue sloughing,
but no surgical intervention needed.
Case Study #2 Questions
• What could have been done better?
• What was done well?
• How could it have been prevented?