Word: Intravenous Infiltration And Extravasation ...



Site ApplicabilityManagement of intravenous (IV) drug extravasation injuries occurs within BC Women’s Hospital NICU.Practice Levels/CompetenciesMost responsible provider must be aware when there are drug extravasations requiring treatmentRN are responsible to assess and evaluate extravasation injuries and escalate as requiredPlastic Surgery can be consulted whenever an IV extravasation injury occoursPolicyAdministration of hyaluronidase or phentolamine is a minimum two-person procedure: 1 RN and 1 MD/NP or 1 RN, 1 family member (to provide comfort care), 1 MD/NPIntroductionIntravenous infiltration occurs when the administered fluid escapes the walls of a vein, entering the surrounding tissues. It is termed extravasation when the leaked fluid is toxic to the tissues.1 Both infiltrations and extravasations can cause equally serious tissue damage,2,3 and so for the purpose of this guideline, the terms will be used interchangeably.3 The extent of tissue damage depends on the volume extravasated, the nature of the infusate, and factors related to the patient (age, size, IV site, blood pressure, overall health).4Tissue damage in extravasation injury occurs by several mechanisms:3-5 1. Mechanical compression: Extravasated liquid generates localized pressure on vessels, occluding first lymphatics and veins, and subsequently arteries. This prevents perfusion, causing localized tissue necrosis and potentially limb ischemia.2. Osmotic imbalance: Extravasated liquid with high osmolarity (many particles per litre of solution) causes water to leak out of cells into the interstitial space, resulting in further edema as well as cellular dysfunction, inflammation, and cell death. 3. Direct cellular toxicity: Extravasated liquid may be cytotoxic (such as chemotherapeutic agents), caustic due to non-physiologic pH <5.5 or >8.5, or may induce cellular apoptosis (programmed cell death). Skin necrosis from these types of injuries may have delayed presentation of up to 24-72 hours.1,64. Ischemia: Vasopressors cause peripheral vasoconstriction, and localized vessel irritation may cause vasospasm or thrombosis. This decreases the perfusion locally and regionally resulting in ischemic necrosis.5. Infection: Bacterial colonization of necrotic tissue can result in secondary tissue loss. Proper insertion, securing, and monitoring of intravenous devices is crucial in the prevention of extravasations injuries.1,7 Nursing Procedure for Management of an Interstitial Intravenous Catheter:STEPSRATIONALEIf an IV is interstitial:Immediately stop the infusion and disconnect the line. Note the time. Do not remove the IV cannula.Do not apply warm or cold compressesRisk of thermal injury and skin maceration with compress use and compress use is not well studied in neonatesAttach a sterile syringe to the cannula, and gently aspirate while slowly removing the cannula.Aspirate as much of the vesicant as possible Remove anything that may be constricting the involved extremity and do not place tape on the skin.This optimizes circulation and is a prevention strategy to additional tissue damageElevate the extremity if possible.Maintain elevation for 24-48 hoursEvaluate the child’s pain. If needed, administer appropriate analgesia as ordered.Evaluate the extent of the injury and complete the Event Details and the Initial Evaluation on the IV Extravasation Form.Obtain a photograph of the site and place it on the IV Extravasation Form.Do not use personal cameras to take photos: use hospital cameras available on your unitPhotograph the injury site and the non-affected extremity for comparisonPrint two copies of the photo: place one on the IV extravasation injury form, provide the other to the HCP following up with the PSLS reportIf the Initial Evaluation circles are all in the first column of the chart (in the green box), no further treatment is required at this time. If any of the features are not in the first column (i.e. they are in the yellow or red boxes), notify the appropriate provider of the adverse event, and fill out a Patient Safety and Learning System (PSLS) report.If any of the features are in the red box (4th or 5th columns), notify the appropriate provider and obtain the items in the supply list below and have them at the patient’s bedside.Reevaluate and photograph the site in 1 hour, and complete a subsequent assessment of the IV Extravasation Form.Print two copies of the photo: place one on the IV extravasation injury form, provide the other to the HCP following up with the PSLS reportSupplies:Scissors2x2 sterile gauze (2)2 inch cling3MTM blue Kind Removal Silicone “baby” tapeSterile water (2 mL)Mepitel? One (2”x3”) (not ward stock in NICU)Antibiotic ointment – (physician dependant)Actiflex?Provider Management of an Interstitial Intravenous Catheter: ProcedureSTEPSRATIONALEEvaluate the clinical status of the patient, ensuring that the patient is stable and has sufficient access for ongoing necessary care.IV access may be required to provide analgesia or to maintain physiological stabilityEvaluate the patient for sufficient analgesia.Consider ordering morphine, fentanyl or Acetaminophen for pain managementEvaluate the extravasation site and note any changes from the Initial Evaluation section of the IV Extravasation Form.Consult the Plastic Surgery service if necessary.Always consult if there is skin breakdownInform the patient’s family of the event and the planned interventions.Parents can provide comfort care as requiredConsider administration of: phentolamine as an antidote for extravasation of vasopressors hyaluronidase in severe extravasation injuries See additional details at the beginning of the procedures belowWrite a note in the patient’s chart describing the assessment, interventions performed, and note times.Document in physician’s notesRe-evaluate the patient frequently until stable, and make a plan with the primary RN with indications to call for re-assessmentThe patient may need to be re-evaluated if their pain is not managed, or there is evidence of progressing tissue damage (black toes etc.)Apply dressing when there is skin breakdownAs per Plastic Surgery Antidotes in the Management of an Interstitial Intravenous – PhentolaminePhentolamine is an -adrenergic blocker that improves blood flow by peripheral vasodilation. Use: Phentolamine should be used to treat ischemia from extravasation of vasoactive medications such as epinephrine, norepinephrine, phenylephrine, vasopressin, dobutamine, and dopamine. Adverse effects: Tachycardia and hypotension may theoretically occur, but usually do not.8,9 Extra care should be taken with preterm infants.10Timing: Administer within 12 hours of extravasation injury. Readministration may be warranted if symptoms recur.10Order: Phentolamine as per Neonatal & Pediatric IV Extravasation Injuries Treatment: Order Set Provider Administration of Phentolamine Procedure:STEPSRATIONALEPerform independent double check for medication administrationEvaluate patient’s pain and provide analgesia as requiredMorphine, Fentanyl or AcetaminophenPrepare phentolamine dilution:In NICU the phentolamine is prepared by a pharmacist The phentolamine 1 mL ampoule contains 5 mg (concentration 5 mg/mL) For patients ≤2499 g, prepare a 0.25 mg/mL solution: Add 0.25 mL of 5 mg/mL phentolamine and 4.75 mL preservative free 0.9% NaCl into a 10 mL empty sterile vial to make 0.25 mg/mL For patients 2.5 – 10 kg, prepare a 0.5 mg/mL solution: Add 0.5 mL of 5 mg/mL phentolamine and 4.5 mL preservative free 0.9% NaCl into a 10 mL empty sterile vial to make 0.5 mg/mLLabel vial with ‘medication added’ sticker. Two RNs to perform independent double check and sign the solution preparationDraw up total doses evenly divided into four, 1-3mL syringes with primed 30 or 27 gauge needlesBundle/contain patient and expose effected area.Provide containment and developmental support as this procedure is painful Invite and support parents/caregiver to provide comfort care as availableProvider to perform hand hygiene and don sterile gloves.Cleanse the site. Clean/prepare site with Dexidin solution for 30 seconds using side-to-side motion. Allow to air dry for 60 seconds For infants ≤ 1000 grams remove residual Dexidin solution from skin using sterile NS or sterile water after drying is completeInject phentolamine into the subcutaneous plane, placing the needle at the periphery of the injury with the needle directed towards the centre of the infiltrated site.Point the needle towards the centre of the infiltrated siteDiscard the needles in the sharps container once used10756901714500Repeat until the maximum dose for the patient’s weight is reached.Leave site open to air.Do not apply dressing routinelyLeave site undressed for best visualizationTape can further damage the siteMonitor the patient’s vital signs closely to look for tachycardia and hypotension.Re-evaluate the site every 15 minutes for two hours, then every 4 to 6 hours. Monitor for induration (hardening of skin), swelling, discolouration, blanching and blister formation or recurrent vasoconstrictionRe-evaluate and photograph the site at 24 hours. Print two copies of the photo: place one on the IV extravasation injury form, provide the other to the HCP following up with the PSLS reportDocument.Date and time of eventInsertion siteType and estimated volume of infiltrateAppearance of injury site including colour, perfusion, pulse, range of motionDressing appliedManagement planAntidotes in the Management of an Interstitial Intravenous – HyaluronidaseHyaluronidase is an enzyme that breaks down hyaluronic acid, increasing the permeability of the connective tissue and allowing the infusate to disperse into a larger space, thus improving absorption and decreasing local pressure and skin injury.12 Use: It should be considered in the treatment of extravasation injuries involving high and intermediate risk infusates (see below) and in cases with concern for tissue damage (see IV Extravasation Form, red and yellow boxes). Even low risk infusates, in large volumes, can result in serious tissue injury.3 Note that the evidence for the use of hyaluronidase is limited, inconsistent, and of poor quality.13 Infusate Risk Chart:Adapted from 3Low RiskIntermediate RiskHigh RiskAminophyllineAmphotericin B liposomalAmpicillinAmpicillin/sulbactamCefazolinCefotaximeCeftazidimeCeftriaxoneCefuroximeClindamycinDextrose <10%FentanylFosphenytoinFurosemideGentamicinHeparinIVIGLipidsMagnesium sulfateMeropenemMethylprednisoloneNormal salinePiperacillin/tazobactamTobramycinAllopurinolAmikacinAmphotericin BArginineCiprofloxacinDextrose 10% to 12.5%ErythromycinGanciclovirLorazepamMidazolamMorphineNonionic radiologic contrastPhenobarbitalPhenytoinPotassium 60 mEq/LTPN 950 mOs/LVancomycinAcyclovirCaffeine citrateCalciumDextrose >12.5%Potassium >60 mEq/LSodium bicarbonateSodium chloride 3%TPN >950 mOsm/LChemotherapeutic agentsPacked red blood cellsVasopressors (NOTE: use phentolamine, NOT hyaluronidase, to treat extravasation of vasopressors)Adverse effects: Hyaluronidase has a <1% risk of urticaria and angioedema, and a 0.1% risk of anaphylaxis.14 Although tachycardia, hypotension, dizziness, chills, nausea, and vomiting can be associated with hyaluronidase administration, they are not mentioned in any case or animal studies.14Timing: Administer within 1 hour of extravasation injury,11,14,15 however, hyaluronidase may still be effective up to 12 hours post injury.10Order: Hyaluronidase as per Neonatal & Pediatric IV Extravasation Injuries Treatment: Order Set Provider Administration of Hyaluronidase ProcedureSTEPSRATIONALEPerform independent double check for medication administrationEvaluate patient’s pain and provide analgesia as requiredMorphine or FentanylPrepare hyaluronidase dilution:In NICU hyaluronidase is prepared by a pharmacist Provider orders 1 vial hyaluronidase 1500 units/mL (the vial contains 1500 units of lyophilized powder): dilute to 150 units/mLAdd 1mL of sterile normal saline to hyaluronidase vial, reconstituting to 1500 units/mLAdd 1mL of 1500 unit/mL hyaluronidase and 9mL of sterile normal saline to an empty sterile 10mL vial, reconstituting to 150 units/mLLabel vial with ‘medication added’ sticker. Two RNs to perform independent double check and sign the solution preparationDraw up 0.2mL of 150unit/mL hyaluronidase in to four, 1mL syringes with primed 30 or 27 gauge needlesBundle/contain patient and expose effected areaProvide containment and developmental support as this procedure is painful Invite and support parents/caregiver to provide comfort care as availableProvider to perform hand hygiene and don sterile glovesCleanse the site Clean/prepare site with Dexidin solution for 30 seconds using side-to-side motion. Allow to air dry for 60 seconds For infants ≤ 1000 grams remove residual Dexidin solution from skin using sterile NS or sterile water after drying is completeInject hyaluronidase into the subcutaneous plane, placing the needle at the periphery of the injury with the needle directed towards the centre of the infiltrated site.Point the needle towards the centre of the infiltrated siteDiscard the needles in the sharps container once used10756902222500Repeat until 120 units (0.8mL in four 0.2mL aliquots) is delivered.Apply sterile 2x2 gauze and securePlastic Surgery can provide directions for dressings when skin is broken downGauze will absorb leakageConsider topical antibiotic ointment if there are signs of infectionDo not apply warm or moist compresses: this can lead to maceration and further necrosis of the skinApply additional dressings as per Plastic SurgeryMonitor the patient’s vital signs closely to look for tachycardia and hypotension.Reevaluate the site every 15 minutes for two hours, then every 4 to 6 hours Monitor for induration (hardening of skin), swelling, discolouration, blanching and blister formation or recurrent vasoconstrictionReevaluate and photograph the site 24 hours Print two copies of the photo: place one on the IV extravasation injury form, provide the other to the HCP following up with the PSLS reportDocumentDate and time of eventInsertion siteType and estimated volume of infiltrateAppearance of injury site including colour, perfusion, pulse, range of motionDressing appliedManagement planReferencesAmjad, I., Murphy, T., Nylander-Housholder, L., & Ranft, A. (2011). A New Approach to Management of Intravenous Infiltration in Pediatric Patients. Journal of Infusion Nursing, 34(4), 242–249. , D., & Bodnaryk, K. (2006). Neonatal intravenous extravasation injuries: evaluation of a wound care protocol. Neonatal Network, 25(1), 13–19. , E., Giambra, B. K., Hingl, J., Doellman, D., Tofani, B., & Johnson, N. (2013). Reducing Risk of Harm From Extravasation. Journal of Infusion Nursing, 36(1), 37–45. , R. J., Pegg, S. P., & Kimble, R. M. (2001). Management of extravasation injuries. ANZ Journal of Surgery, 71(5), 285–289. , M. S., & Holmes, J. D. (2002). Reducing the morbidity from extravasation injuries. Annals of Plastic Surgery, 48(6), 628–32. , D. C., Pedreira, M. D. L. G., & de Gutiérrez, M. G. R. (2012). Antineoplastic agents extravasation from peripheral intravenous line in children: A simple strategy for a safer nursing care. European Journal of Oncology Nursing, 16(1), 17–25. , B. F., Rineair, S. A., Gosdin, C. H., Pilcher, P. M., McGee, S., Varadarajan, K. R., & Schoettker, P. J. (2012). Quality Improvement Project to Reduce Infiltration and Extravasation Events in a Pediatric Hospital. Journal of Pediatric Nursing, 27(6), 682–689. , A., & Patel, S. (2014). Extravasation of Noncytotoxic Drugs. Annals of Pharmacotherapy, 48(7), 870–886. , G. (1957). Use of phentolamine to prevent necrosis due to levarterenol. Journal of the American Medical Association, 163(16), 1477–1479. , L. A., & Budreau, G. K. (1996). Implementing a clinical practice guideline to improve pediatric intravenous infiltration outcomes. AACN Clinical Issues, 7(3), 411–424. , J. L. (2007). Peripheral intravenous extravasation: nursing procedure for initial treatment. Neonatal Network, 26(6), 379–384. Laurie, S. W., Wilson, K. L., Kernahan, D. A., Bauer, B. S., & Vistnes, L. M. (1984). Intravenous extravasation injuries: the effectiveness of hyaluronidase in their treatment. Annals of Plastic Surgery, 13(3), 191–194. , F. Y. (2016). Overview, prevention and management of chemotherapy extravasation. World Journal of Clinical Oncology, 7(1), 87. , M. J. (2012). Hyaluronidase for Extravasation Management. Neonatal Network, 31(6), 413–419. Bailey, S. H., Fagien, S., & Rohrich, R. J. (2014). Changing Role of Hyaluronidase in Plastic Surgery. Plastic and Reconstructive Surgery, 133(2), 127e–132e. , M., & Moukhachen, O. (2017). Alternative Pharmacological Management of Vasopressor Extravasation in the Absence of Phentolamine. P & T : a Peer-Reviewed Journal for Formulary Management, 42(9), 581–592.Wong, A. F., McCulloch, L. M., & Sola, A. (1992). Treatment of peripheral tissue ischemia with topical nitroglycerin ointment in neonates. The Journal of Pediatrics, 121(6), 980–983. (05)80356-7Brown A, Hoelzer D, Piercy S. Skin necrosis from extravasation of intravenous fluids in children. Plast Reconstr Surg 1979145- 150. Ramasethu J. Prevention and management of extravasation injuries in neonates. Neoreviews. 2004;5(11):e491-497. Lund, C. H., Kuller, J., Raines, D. A., Eckllund, S., Archambault, M. E. & O'Flaherty, P. (2007). Neonatal skin care: Evidence-based clinical practice guideline (2nd ed.). Washington, D.C.: Association of Women's Health, Obstetric and Neonatal Nurses. Developed ByBCW Neonatal Program – Senior Practice Leader, NeonatologistVersion HistoryDATEDOCUMENT NUMBER and TITLEACTION TAKEN18-May-2021C-06-12-62507 Intravenous Infiltration And Extravasation: Guideline And ProceduresApproved at: Neonatal Leadership CommitteeDisclaimerThis document is intended for use?within?BC Children’s and BC Women’s Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health Services Authority (PHSA) assumes no liability arising from use or reliance on this document.?This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA.? ................
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