Guideline for Infiltration of Intravenous Catheter

Guideline for Infiltration of Intravenous Catheter

I. Definition

? Extravasation of fluids or medications outside of the intravascular space of a cannulated vein due to misplacement/dislodgement of the IV or rupture of the vein. This results in the potential for ischemia, necrosis, destruction of surrounding tissue, thrombophlebitis, compressive neuropathies, hematomas, and compartment syndrome. It tends to be more common in pediatrics and in the elderly. It is also more common in females. The most common sites in order of frequency are forearm, hand, wrist, and antecubital fossa.

II. Signs/Symptoms

? Redness, warmth, swelling, or cessation of IV flow may be noticed. Awake patients may complain of burning, pain, or tightness in the affected area. o If crystalloid solution is infiltrated, the affected area may feel cool to touch, be pale, and appear swollen and full. o If medications with sympathomimetic effects (such as phenylephrine, dopamine, epinephrine, and norepinephrine) are infiltrated, the area will be pale, cool, with tissue ischemia and necrosis of utmost concern. o If vesicant medications (such as chemotherapeutics, electrolyte solutions, and hypertonic solutions like mannitol or 3% NS) are infiltrated, the affected area may be warm, red, and swollen. o If commonly used anesthetic drugs (hypnotics, opioids, benzodiazepines, muscle relaxants, reversal agents) infiltrate, then unpredictable pharmacokinetics (absorption, elimination, redistribution) may be seen.

? The most feared complication is tissue necrosis and compartment syndrome either from direct tissue cytotoxic injury or from tissue hydrostatic pressure exceeding tissue perfusion pressure.

High-Risk Medications for Infiltration

Antibiotics

Immunosuppressants Sympathomimetics

Vancomycin Mycophenolate

Dobutamine

Nafcillin

Dopamine

Gancyclovir

Phenylephrine

Acyclovir

Epinephrine

Cefotaxime

Norepinephrine

Gentamicin

Vasopressin

Amphotericin

Electrolytes Calcium Potassium NaHCO3 Dextrose Magnesium NS LR

Hyperosmolar TPN Mannitol Hypertonic NS

Other Contrast Dye Promethazine Digoxin Metoprolol Esmolol Thiopental

Commonly Used Anesthetic Agents That May Infiltrate

IV Anesthetics

Benzodiazepines

Opioids

Propofol

Midazolam

Fentanyl

Ketamine

Remifentanil

Muscle Relaxants Rocuronium Succinylcholine

Reversal Agents Neostigmine

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III. Preventative Measures

? Always confirm a good functioning IV prior to tucking arms and drapes going up (freely flowing, visible site underneath dressing).

? Larger gauge (smaller catheters) IV's are associated with a higher risk of infiltration in pediatrics. IVs that are too large for the cannulated vein also predispose to infiltration.

? Try to only infuse high-risk medications through the most accessible, visible, and secure IV site. ? Frequently check for signs of infiltration and never place pressure bags on high risk infusions. It is

preferable to run these infusions with a free flowing IV because they will stop flowing if infiltrated. If on pressure bag or pump, they may continue to infuse despite infiltration. ? Avoid placing BP cuff on same side as IV if at all possible.

IV. Treatment

? Immediately stop the infusion. Notify the surgeon. Inspect the IV site. ? Attempt to aspirate as much of the residual solution as possible and mark the outline of the affected area

to monitor spread. ? Monitor for induration, swelling, pain, and necrosis. ? Administer drug specific antidote if appropriate (see below). ? Peripheral incisions can be made around the "clock face" of the injury to allow egress of the infiltrated

agent. Saline can then be injected through one of the incisions to flush out the tissue ? Elevation of the affected limb is controversial as it may promote proximal spread of the offending agent. ? Apply warm compresses for hypertonic saline infiltrations. Application of warm compresses for other

infiltrations may lead to worsening necrosis due to increased tissue metabolism. Application of cold compresses may lead to worsening vasoconstriction and delayed clearance of the infiltration. ? For infiltrations with maintenance fluids like LR or NS the primary concern is tissue edema with decreased perfusion as opposed to direct vesicant effects of the solution unless it is hypertonic saline or mannitol. Monitor closely for compartment syndrome especially in extremities. If compartment syndrome is suspected then emergent fasciotomy may be warranted.

Considerations for Commonly Used Anesthetic Drug Infiltrations

Agent

Local Effect

Time to Peak

Elimination Half-Life

Plasma Conc After After Subcutaneous

Sub-Q Injection

Injection

Propofol

Burning, pain.

Unpredictable

Unpredictable, prolonged

Rare cases of

post-op sedation and resp

necrosis reported

depression may occur

Ketamine

Ischemia/Necrosis No data available No data available

Midazolam

None reported 30 minutes

3.2 hours

Fentanyl

Ischemia/Necrosis 15 minutes

10 hours

Remifentanil None

No data available No data available

Rocuronium None

No data available No data available

Succinylcholine None

No data available No data available

Antidote

Hyaluronidase can be used to hasten absorption and elimination of all these agents. Also saline flush through stab incisions may be effective. No other specific antidotes have been proven effective. See next table for instructions on preparation and injection of hyaluronidase.

Adapted from: Debbie Yen, PharmD (debbie.yen@duke.edu; 970-3003), Duke University, March 2015

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Due to the lack of data and literature regarding infiltration of anesthetic agents, advice from Dr. Richard Moon and Dr. Jerry Levy was sought. Listed below is the consensus of their recommendations:

? Muscle relaxants and narcotics: After infiltration of these agents, if a patient meets extubation criteria and is transported to PACU, they should be observed in Phase 1 but there is not any need for special observation. These patients are NOT candidates for Phase 2. A twitch monitor can be used to monitor the response to infiltrated muscle relaxant.

? Propofol: After infiltration of an induction dose of propofol, patients should be observed for at least 1 hour in PACU.

? A wound care consult should be placed if there is a concerning physical exam.

Specific Antidotes:

Agent

Examples

Sympathomimetic Dobutamine

Agents

Dopamine

Epinephrine

Norepinephrine

Vasopressin

Phenylephrine

Antidote Phentolamine

Instructions Infants < 3 months of age: Reconstitute 5 mg phentolamine with 1 ml NS. Withdraw 0. 1 ml of reconstituted solution into a 1 ml syringe. In a 1 ml syringe, draw up 0.9 ml NS and add 0.1 ml of phentolamine to this syringe. This results in a final diluted concentration of 0.5 mg/ml

Other Blanching should reverse immediately; additional injections may be required if blanching returns. Do not exceed 0.1-0.2 mg/kg or 5 mg.

Infants (> 3 months of age), Children and Adults: Reconstitute 5 mg phentolamine with 1 ml NS. In 10 ml syringe, draw up 9 ml of NS. Add the reconstituted phentolamine solution (1 ml) to the 9 ml of NS. This results in a final phentolamine concentration of 0.5 mg/ml.

NTG Ointment

Apply to overlying skin of affected area

An alternative to Phentolamine. May cause hypotension especially if patient is also taking phosphodiesterase inhibitors for ED

Terbutaline

Dilute 1 mg In 10 mL 0.9% NaCl and give as subcutaneous injections into extravasation site

Stellate Ganglion Block

Sympatholysis of upper extremity to relieve vasoconstriction

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Antibiotics

Vancomycin

Hyperosmolar solutions

TPN, Mannitol, 3% NS

Electrolytes

Ca, K, NaHCO3, Mg, Dextrose, Crystalloid

Chemotherapeutics Vincristine

Immunosuppressants Mycophenolate

Other

Any agent that causes significant tissue necrosis

Contrast Dye Promethazine Digoxin Metoprolol Esmolol Sympathomimetics, Chemotherapeutics

Hyaluronidase Collagenase

Dilute to 15 units/mL; inject 1ml into the tissues through the catheter, if still present, or subcutaneously. At catheter hub, inject quantity of hyaluronidase sufficient to clear the IV catheter then remove the catheter. Inject approximately 0.1 ml of hyaluronidase subcutaneously spaced approximately 0.5 cm apart around the site of the extravasation. May use up to 1ml total. Do not inject directly into the site of infiltration.

Apply to areas of necrosis and cover with moist dressing twice daily

Enzyme that allows infiltrated fluid to diffuse through tissues. Effects last 24 to 48 hours. Most effective within first 2 hours post-infiltration, but can be given up to 12 hours later.

Enzymatic debriding agent that breaks down necrotic tissue to promote healing

V. Pediatric Infiltrations

? IV infiltrations are more common in pediatric patients due to larger gauge IV's (smaller catheters) often used as well as the inherent difficulty in obtaining IV access (multiple sticks, difficulty visualizing veins through subcutaneous layers). Furthermore, there is often more patient movement during induction/emergence increasing the risk of catheter migration. Complicating matters, these IV's are often concealed by Coban. Also, pediatric patients often cannot verbalize symptoms that would alert you to suspect infiltration. For this reason, extra vigilance should be exercised in this population.

VI. References

? Absolute bioavailability of midazolam after subcutaneous administration to healthy volunteers. Br J Clin Pharmacol. 2002 Oct; 54(4):357-362

? Extravasation of Noncytotoxic Drugs: A Review of the Literature. Ann Le, PharmD, BCPS1, and Samit Patel, PharmD, BCOP1

? Guide to Extravasation Management in Adult & Pediatric Patients; Journal of Intravenous Nursing 1998; 21(4):232-239

? Inadvertent subcutaneous infusion by a syringe pump. J Anesth 2000;14(3):169-70 ? Intravenous Catheter Complications in the Hand and Forearm; Kagel, Eric M. MD; Rayan, Ghazi M. MD;

Journal of Trauma-Injury Infection & Critical Care: January 2004 - Volume 56 - Issue 1 - pp 123-127 ? Neonatal extravasation injury: prevention and management in Australia and New Zealand-a survey of

current practice; Matthew Restieaux, Andrew Maw, Roland Broadbent, Pam Jackson, David Barker and Ben Wheeler ? Pharmocokinetics of fentanyl after subcutaneous administration in volunteers. Eur J Anaesthesiol. 2010; Mar; 27(3):241-6) ? The Management of Intravenous Infiltration Injuries in Infants and Children; Ostomy Wound Manage. 2012;58(7):40?44

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Revision History:

Version: 1

Created by:

Version: 2

Reviewed by:

S. Todd Hobgood, MD, Elizabeth Malinzak, MD E. Malinzak, MD

Date: 6/8/2014 Date: 10/2018

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