Vesicant extravasation

Nursing, Aug 2001 by Hadaway, Lynn C

Action

MARCIA THOMAS, 64, calls you to her room to report extreme pain in her left wrist and hand. Her hand is swollen, and when you remove the dressing over her I.V. site, you see a red streak along the vein pathway and a bluish discoloration around the I.V. puncture site.

What's the situation?

Ms. Thomas had a colon resection for cancer yesterday. To treat her nausea, the physician prescribed promethazine HCl (Phenergan), 25 mg IN. every 4 hours p.r.n. Ms. Thomas has an 18-gauge short peripheral catheter in the cephalic vein of her left wrist, with a continuous infusion of 5% dextrose and 0.45% sodium chloride with 40 mEq of potassium chloride at 125 ml/hour on an electronic infusion pump.

An hour ago, you gave her the first dose of promethazine through this I.V. line. The drug concentration is 25 mg/ml, so you withdrew 1 ml of promethazine into a syringe and injected it over 1 minute. At that time, you didn't see any redness or swelling around the I.V. site; tape supporting the dressing partly blocked your view of the vein pathway. When you started to inject the drug, Ms. Thomas immediately complained of severe burning in her wrist. You stopped the injection and looked for swelling but couldn't see any change in the area, so you gave the remaining drug and resumed the fluid infusion.

What's your assessment?

Based on Ms. Thomas's signs and symptoms and the fact that she's receiving two vesicants-promethazine and potassium chloride-you suspect extravasation, the escape of a vesicant solution into subcutaneous tissue, causing tissue necrosis. Extravasation, which can lead to cosmetic disfigurement, loss of limb function, and amputation, triggers many nursing malpractice lawsuits.

What must you do immediately?

Immediately stop the infusion. If your facility protocol calls for injecting an antidote for extravasation, leave the catheter in place and inject the antidote. Remove the catheter and apply a dressing. Elevate the patient's arm and apply cold compresses. Notify the physician.

Ms. Thomas has a strong radial pulse and +2 capillary refill in her fingers, although the edema is limiting range of motion in her left hand. Insert a 20-gauge catheter in the inner aspect of her right forearm and resume the fluid infusion at 125 ml/hour. Complete an incident report and document your interventions in the medical record.

What should be done later?

Take the following steps to prevent extravasation and to minimize the tissue damage should extravasation occur:

* Dilute drugs given by LV push to minimize the amount of drug that would contact the tissue if extravasation occurs.

* Check the LV site thoroughly. Remove tape if necessary and secure the catheter in a way that makes inspection easy. You can easily miss small amounts of swelling or slight changes in color if you can't see the entire catheter and vein pathway.

* Check for a blood return before giving any drug via I.V. push. Catheter movement could have caused erosion through the vein wall. However, extravasation can occur even when you can obtain a good blood return.

* Stabilize the insertion site. This prevents catheter movement, which can irritate the vein and increase the potential for vein erosion and extravasation. Avoid placing I.V. lines in areas of flexion; in this case, an arm board would have supported the wrist while allowing finger movement.

* Assess for pain, tenderness, and a red streak along the vein pathway. These are signs of phlebitis. Discontinue the infusion immediately.

* Assess for blanching, swelling, and complaints of pain or burning at the insertion area. These are signs of infiltration or extravasation. Discontinue the infusion immediately.

* Don't use pressure dressings, which will spread the extravasated drug into tissue and cause more damage.

Ms. Thomas's swelling, pain, and discoloration lasted several weeks, but she didn't develop tissue necrosis or arterial damage and regained complete use of her hand.

BY LYNN C. HADAWAY, RN.C, CRNI, MED Principal * Hadaway & Associates * Milner, Ga.