Jakarta, 29 Apr 2010
Extravasation & Infiltration
Within the context of infusion therapy extravasation literally means the escape of infusion solution from blood vessel into the surrounding tissue. However, more detailed exploration clarifies the following definition:
- Extravasation - The inadvertent administration of a vesicant solution or medication into surrounding tissue.
- Infiltration - The inadvertent administration of a nonvesicant solution/medication into a surrounding tissue.
- Irritant - Agents that have the potential to irritate tissue if extravasation occurs.
- Nonvesicant - A solution/medication, which does not cause blistering when infiltrated.
- Vesicant - A solution or medication that causes a blistering process when inadvertently administered into the surrounding tissue.
The distinction between infiltration and extravasation is important because the management strategy for each situation is different from each other.
Common signs of infiltration are:
- Edema at the insertion site
- Taut or stretched skin
- Blanching or coolness of the skin
- Slowing or stopping of the infusion
- Leaking of I.V. fluid out of the insertion site.
Tissue damage
Vesicants, by definition, have the potential to cause tissue damage upon extravasation from the vein. Like the initial symptoms, the extent of tissue damage can vary greatly between different treatment regimens and patients.
Tissue destruction caused by leakage of vesicants into surrounding tissue may be progressive in nature, and may happen quite slowly with little pain. Induration or ulcer formation is by no means an immediate phenomenon – as it takes time to develop. In general, tissue damage begins with the appearance of inflammation and blisters at or near the site of injection.
Depending on the drug and other factors, this can then progress to ulceration, and then in some cases may progress to necrosis of the local tissue. Necrosis can occasionally be so severe that function in the affected area cannot be recovered and surgery is required.
Vein selection in peripheral administration
The choice of vein for the infusion is an equally important consideration for the prevention of extravasation. Finding the largest, softest and most pliable vein is the best choice to avoid complications. Some general guidelines include:
- Try to use the forearm, not the back of the hand
- Avoid small and fragile veins
- Avoid insertion on limbs with lymphoedema or with neurological weakness
- Avoid veins next to joints, tendons, nerves or arteries
- Avoid the antecubital fossa (area near the elbow)
Early Management of extravasation.
Step 1 Stop the infusion immediately. DO NOT remove the cannula at this point.
Step 2 Disconnect the infusion (not the cannula/needle).
Step 3 Leave the cannula/needle in place and try to aspirate as much of the drug as possible from the cannula with a 10 mL syringe.Avoid applying direct manual pressure to suspected extravasation site.
Step 4 Mark the affected area and take digital images of the site.
Step 5 Remove the cannula/ needle.
Step 6 Collect the extravasation kit (if available), notify the physician on service and seek advice from the chemotherapy team or Senior Medical Staff.
Step 7 Administer pain relief if required. Complete required documentation.
Further Management
If the drug is a non-vesicant, application of a simple cold compress and elevation of the limb may be sufficient to limit the swelling etc. In contrast, the extravasation of a vesicant requires several steps and differs for the various classes of drug. There are two broad approaches to limiting the damage caused by extravasation: localisation and neutralisation; or dispersion and dilution.
Localise and neutralise strategy
- Use cold compresses to limit the spread of infusate. It used to be thought that cold limited spread through vasoconstriction. In animal models, it appears that cold prevents spread by a mechanism other than vasoconstriction suggested to be decreased cellular uptake of drug at lower temperatures
- Consider using antidotes to counteract vesicant actions.
Disperse and dilute strategy
- Appropriate for the extravasation of vinca alkaloids
- Use warm compresses to prompt vasodilation and encourage blood flow in the tissues, thereby spreading the infusate around
- Consider using hyaluronidase to dilute infusate
CONCLUSION
Recognition and differentiation between infiltration and extravasation should be considered as an important aspect in monitoring infusion therapy as well as administration of parenteral drugs. In the event of infiltration the appropriate management is generally “dilute and disperse” whereas in extravasation (of vesicant substances) the”localise and neutralise” strategy should be adopted.
References:
- Wengström Y, Margulies A. European Oncology Nursing Society extravasation guidelines. European Journal of Oncology Nursing (2008) 12, 357–361
- Schulmeister L. Extravasation Management. Seminars in Oncology Nursing, Vol 23, No 3 (August), 2007: pp 184–190
- Wiegand R, Brown J. Hyaluronidase for the management of dextrose extravasation American Journal of Emergency Medicine (2010) 81, 257.e1–257.e2
Iyan Darmawan, MD
Medical Director
iyan@ho.otsuka.co.id
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