Extravasation
Encyclopedia
Extravasation is the accidental administration of intravenously (IV) infused medicinal drugs into the surrounding tissue, either by leakage (e.g., because of brittle veins in very elderly patients), or direct exposure (e.g. because the needle has punctured the vein and the infusion goes directly into the arm tissue). Extravasation of medicinal drugs during intravenous therapy
is a side effect
that can and should be avoided.
In mild cases, extravasation can cause pain, reddening, or irritation on the arm with the infusion needle. Severe damage may include tissue necrosis. In extreme cases, it even can lead to loss of an arm.
.
Occurrence is possible with all IV drugs, but is a large problem with cytotoxic drugs for the treatment of cancer (i.e. during chemotherapy
). The percentage of patients affected by extravasation may be as high as 10%. However, the actual percentage is unknown, since extravasation is often unnoticed and/or undocumented, especially if not severe.
In recent years, healthcare professionals are becoming more aware of this problem.
Intravenous therapy
Intravenous therapy or IV therapy is the infusion of liquid substances directly into a vein. The word intravenous simply means "within a vein". Therapies administered intravenously are often called specialty pharmaceuticals...
is a side effect
Side effect
In medicine, a side effect is an effect, whether therapeutic or adverse, that is secondary to the one intended; although the term is predominantly employed to describe adverse effects, it can also apply to beneficial, but unintended, consequences of the use of a drug.Occasionally, drugs are...
that can and should be avoided.
In mild cases, extravasation can cause pain, reddening, or irritation on the arm with the infusion needle. Severe damage may include tissue necrosis. In extreme cases, it even can lead to loss of an arm.
Medicinal drugs
Medicinal drugs that cause only slight damage on the arm with the infusion needle if extravasated are called irritants, and medicinal drugs that cause severe damage up to tissue necrosis if extravasated are called vesicantsBlister agent
A blister agent, or vesicant, is a chemical compound that causes severe skin, eye and mucosal pain and irritation. They are named for their ability to cause severe chemical burns, resulting in painful water blisters on the bodies of those affected...
.
Occurrence is possible with all IV drugs, but is a large problem with cytotoxic drugs for the treatment of cancer (i.e. during chemotherapy
Chemotherapy
Chemotherapy is the treatment of cancer with an antineoplastic drug or with a combination of such drugs into a standardized treatment regimen....
). The percentage of patients affected by extravasation may be as high as 10%. However, the actual percentage is unknown, since extravasation is often unnoticed and/or undocumented, especially if not severe.
In recent years, healthcare professionals are becoming more aware of this problem.
Treatments and techniques
The best "treatment" of extravasation is prevention. While there is no real treatment per se, there are some techniques that can be applied in case of extravasation, though their efficacy is modest. If there is tissue necrosis, surgical reconstruction may be helpful. The following procedure may also be helpful if extravasation occurs:- Stop infusion immediately. Put on sterile gloves.
- Replace infusion lead with a disposable syringe. While doing this, do not exert pressure on the extravasation area.
- Slowly aspirate back blood back from the arm, preferably with as much of the infusion solution as possible.
- Remove the original cannulaCannulaA cannula or canula is a tube that can be inserted into the body, often for the delivery or removal of fluid or for the gathering of data...
or other IV access carefully from the arm (removal of the original cannula is not advised by all healthcare institutions, as access to the original cannula by surgeons can be used to help clean extravasated tissue). - Elevate arm and rest in elevated position. If there are blisters on the arm, aspirate content of blisters with a new thin needle.
- If, for the extravasated medicinal drug, substance-specific measures apply, carry them out (e.g. topical cooling, DMSO, hyaluronidase or dexrazoxane may be appropriate).
- Recent clinical trials have shown that Totect (USA) or Savene (Europe) (dexrazoxaneDexrazoxaneDexrazoxane hydrochloride is a cardioprotective agent.-Uses:...
for extravasation) is effective in preventing the progression of anthracycline extravasation into progressive tissue necrosis. In two open-label, single arm, phase II multicenter clinical trials, necrosis was prevented in 98% of the patients. Dexrazoxane for extravasation is the only registered antidote for extravasation of anthracyclines (daunorubicin, doxorubicin, epirubicin, idarubicin, etc.).
Pain management and other measures
- Pain management is very important for the patient, as are full documentation and prevention of infectionInfectionAn infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
and superinfectionSuperinfectionIn virology, superinfection is the process by which a cell, that has previously been infected by one virus, gets coinfected with a different strain of the virus, or another virus at a later point in time. Viral superinfections of serious conditions can lead to resistant strains of the virus, which...
. If there is superinfection, get an antibiogramAntibiogramAn antibiogram is the result of a laboratory testing for the sensitivity of an isolated bacterial strain to different antibiotics. It is by definition an in vitro-sensitivity....
and consult with an infectious diseases specialist. Of course, regular controls and aftercare are necessary.
Prevention of extravasation in hospitals
- Only qualified registered nurses who have been trained in venipuncture and drug administration skills and who have knowledge of drugs with vesicant potential should be allowed to administer vesicants.
- Choose a large, intact vein with good blood flow for the venipuncture and placement of the cannula. Do not choose inadvertently "dislodgeable" veins (e.g. dorsum of hand or vicinity of joints) if an alternative vein is available.
- The digits, hands, and wrists should be avoided as intravenous sites for vesicant administration because of the close network of tendons and nerves that would be destroyed if an extravasation occurred.
- Place the smallest gauge and shortest length catheter to accommodate the infusion.
- Monitor the venipuncture site closely for evidence of infiltration and instructing patients to report any pain, discomfort, or tightness at the site.
- The IV infusion should be freely flowing. The arm with the infusion should not begin to swell (oedema), "get red" (erythemaErythemaErythema is redness of the skin, caused by hyperemia of the capillaries in the lower layers of the skin. It occurs with any skin injury, infection, or inflammation...
), "get hot" (local temperature increase), and the patient should not notice any irritation or pain on the arm. If this occurs, stop infusion immediately! - The infusion should consist of a suitable carrier solution with an appropriately diluted medicinal/chemotherapy drug inside.
- After the IV infusion has finished, flush the cannula with the appropriate fluid.
- Finally, an excellently and very cleanly placed central line (= central venous catheterCentral venous catheterIn medicine, a central venous catheter is a catheter placed into a large vein in the neck , chest or groin...
) is a huge advantage while infusing vesicant drugs.
Cytotoxic drugs
- Amsacrine
- Cisplatin (if > 0.4 mg/mL)
- Dactinomycin
- Daunorubicin
- Docetaxel
- Doxorubicin
- Epirubicin
- Idarubicin
- Mechlorethamine
- Mitomycin C
- Mitoxantrone
- Oxaliplatin
- Paclitaxel
- Vinblastine
- Vincristine
- Vindesine
- Vinorelbine
Non-cytotoxic drugs
- AlcoholAlcoholIn chemistry, an alcohol is an organic compound in which the hydroxy functional group is bound to a carbon atom. In particular, this carbon center should be saturated, having single bonds to three other atoms....
- AminophyllineAminophyllineAminophylline is a bronchodilator. It is a compound of the bronchodilator theophylline with ethylenediamine in 2:1 ratio. The ethylenediamine improves solubility, and the aminophylline is usually found as a dihydrate-Properties:...
s - ChlordiazepoxideChlordiazepoxideChlordiazepoxide, is a sedative/hypnotic drug and benzodiazepine. It is marketed under the trade names Angirex, Klopoxid, Librax , Libritabs, Librium, Mesural, Multum, Novapam, Risolid, Silibrin, Sonimen and Tropium.Chlordiazepoxide was the first benzodiazepine to be synthesised and...
- DiazepamDiazepamDiazepam , first marketed as Valium by Hoffmann-La Roche is a benzodiazepine drug. Diazepam is also marketed in Australia as Antenex. It is commonly used for treating anxiety, insomnia, seizures including status epilepticus, muscle spasms , restless legs syndrome, alcohol withdrawal,...
- DigoxinDigoxinDigoxin INN , also known as digitalis, is a purified cardiac glycoside and extracted from the foxglove plant, Digitalis lanata. Its corresponding aglycone is digoxigenin, and its acetyl derivative is acetyldigoxin...
- Nafcillin
- Nitroglycerine
- PhenytoinPhenytoinPhenytoin sodium is a commonly used antiepileptic. Phenytoin acts to suppress the abnormal brain activity seen in seizure by reducing electrical conductance among brain cells by stabilizing the inactive state of voltage-gated sodium channels...
- Propylene glycolPropylene glycolPropylene glycol, also called 1,2-propanediol or propane-1,2-diol, is an organic compound with formula C3H8O2 or HO-CH2-CHOH-CH3...
- Sodium thiopentalSodium thiopentalSodium thiopental, better known as Sodium Pentothal , thiopental, thiopentone sodium, or Trapanal , is a rapid-onset short-acting barbiturate general anaesthetic...
- Tetracyclines
- Total parenteral nutritionTotal parenteral nutritionParenteral nutrition is feeding a person intravenously, bypassing the usual process of eating and digestion. The person receives nutritional formulae that contain nutrients such as glucose, amino acids, lipids and added vitamins and dietary minerals...
External links
- UK National Extravasation Information Service
- Iv-therapy.net — links to useful websites about extravasation
- TopoTarget
- Savene website