Preventing and managing peripheral extravasation

Nursing, May 2004 by Hadaway, Lynn C

EXTRAVASATION-the infiltration of a vesicant drug from an I.V. line into surrounding tissue-can occur with cither a peripheral or a central venous catheter. In this article, I'll describe prevention and management of extravasation from a peripheral catheter. In my next article, I'll address the same issues with a central venous catheter.

Extravasation occurs when a peripheral catheter erodes through the vessel wall at a second point, when increased venous pressure causes leakage around the original venipuncture site, or when a needle pulls out of the vein. Signs and symptoms of extravasation include edema and changes in the site's appearance and temperature, such as swelling, blanching, and coolness. The patient may complain of pain or a feeling of tightness around the site.

Vesicant drugs or solutions (such as certain antineoplastic drugs, antibiotics, electrolytes, anticmetics such as promethazine, and vasopressors) cause severe tissue injury or destruction when they extravasate. Possible consequences include necrotic ulcers, infection, disfigurement, reflex sympathetic dystrophy syndrome, and loss of function.

Preventing extravasation

Although short and midline peripheral catheters aren't recommended for continuous infusion of vesicants, they may be appropriate for single injections. Adhere strictly to proper administration techniques and follow these guidelines:

* Know your hospital's policy about the use of antidotes for vesicants. For example, is a kit packaged with all needed supplies available, or will you need to collect the individual items?

* Make sure you know the antidote and other recommended treatment for the vesicant drug you're giving.

* Ensure that the drug has been properly diluted before injection or infusion. Dilution reduces the amount of vesicant that would reach subcutaneous tissue if extravasation occurs. Dilution also helps you to detect edema or complaints of pain before the entire dose has been administered.

* Select a small-gauge catheter to minimize trauma to the vein and allow enough blood flow around the catheter to hemodilute vesicants.

* Select the venipuncture site carefully, using a distal vein so you can perform successive proximal venipunctures if necessary. Don't use the dorsum of the hand, the wrist, fingers, antecubital fossa, or other areas of flexion; previously damaged areas; and areas with compromised circulation.

* Don't probe for a vein. If you don't penetrate it immediately, stop and begin again at another site.

* Don't administer a vesicant at an I.V. site that's more than 24 hours old; the vein may already be irritated. Perform venipuncture at another site so you can ensure correct needle or catheter placement and vein patency.

* Secure the catheter properly. Cover the venipuncture site with a transparent dressing so you can see the area.

* Immediately before giving each dose of the drug, or every 1 to 2 hours for a continuous infusion, assess the site to reconfirm vein and catheter patency. Gently flush the catheter with 5 to 10 ml of 0.9% sodium chloride solution while palpating the site to detect edema. Ask the patient about any pain or tenderness in the area.

* Aspirate from the catheter before injecting a vesicant and look for a brisk blood return. Hold the vesicant and assess catheter placement if you don't see blood return. Lack of blood return doesn't always indicate an infiltrating catheter: Blood return may be impeded if the vein is small or the catheter lumen is pressed against the vein wall. Also, the presence of blood return doesn't necessarily mean the catheter is properly placed; the catheter could still be partly eroded through the vein.

* Check for infiltration before starting the vesicant infusion by applying a tourniquet above the catheter to occlude the vein and seeing if the I.V. solution continues to flow despite the tourniquet. If so, it's infiltrating into tissue.

* Inject or infuse the vesicant medication through the Y-site injection port of a free-flowing I.V. solution, such as 0.9% sodium chloride solution. This additional fluid helps dilute the drug and reduces the risk of vein damage.

* Use an infusion pump to control the rate of drugs such as potassium chloride. (Your facility may have a policy about giving certain drugs via pump.) Assess the site frequently; the pump will continue infusing the drug if extravasation occurs.

* During the infusion, observe the infusion site for erythema or edema. Tell the patient to report pain, burning, stinging, pruritus, or temperature changes.

* After the infusion is complete, use 0.9% sodium chloride solution to flush the tubing and catheter.

If extravasation occurs...

Consider extravasation an emergency and follow your facility's protocol, which should include these essential steps:

* Immediately stop the infusion and disconnect the tubing as close to the catheter hub as possible. Attach a syringe to the hub and attempt to aspirate the remaining drug from the catheter.

* Leave the catheter in place if an injectable antidote is indicated.