MOQC
Suspected Extravasation
□ Immediately STOP injection/infusion, leave the needle/catheter in place
□ Disconnect the IV tubing from the IV device (do not remove the IV/device or noncoring port needle)
□ Attempt to Slowly ASPIRATE as much of the remaining drug from IV device/port using small 1-3 cc syringe-
(Do not apply pressure to the area during aspiration)
□ Remove IV access while aspirating per your protocol. Use of this site for further IV access is not recommended
□ Record Drug with dilution, estimated amount infiltrated ,time of event (use flowsheet/documentation template)
□ Assess the Site of suspected extravasation: draw or take a picture with time stamp & document
• Measure size of the affected area, diameter ( ____________ mm/cm)
• Location: __________________________________________________________________________
• Site appearance, e.g. measurement of edema, redness: _______________________
• Type/Size of needle/catheter: ___________________________________________________
• Description and quality of blood return before and during administration:
□ No blood return □ Blood sluggish □ Normal □ Other: ___________________________________________
□ Assess Patient Symptoms (pain, ROM) and documents on flowsheet/ template
□ NOTIFY PHYSICIAN OF SUSPECTED EXTRAVASATION including, Drug concentration & amount, & assessments
□ Obtain TREATMENT PROTOCALS , located: ____________________________________________________________________
□ Obtain EXTRAVASATION KIT /SUPPLIES located: ________________________________________
□ Obtain ANTIDOTES LOCATED AT: Location Stored/ Phone/ pager
← DMSO 50% ___________________________________________
← Hyaluronidase 200 units/ml, 4x 1.2 ml vials ____________________________________(needs refrigeration)
← Hydrocortisone 50mg/ml, 2 cc vial ___________________________________________
← Sodium Thiosulfate (10%), 10 ml vial ___________________________________________
← Dexrazoxane/ Totect® __________________________________________________
← _________________________________________ ___________________________________________
□ Initiate initial TREATMENT ( including topical ) per protocol/ order & determine subsequent treatment plan
□ If transporting to alternative treating location: verify availability of required antidote and time-sensitive treatment/s requirement (Note off hours or other special circumstances)
Post-Treatment Follow Up
□ Provide patient education
□ Document all procedures in the medical record
□ Perform quality review (root cause analysis) and notify risk management or patient safety
□ Contact patient within 24 hours for follow-up
□ Plastics Surgery Contact Information ______________________________________________________________________
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