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Management of Extravasation of Non-Chemotherapeutic Agents – Adult/Pediatric – Inpatient/Ambulatory

Management of Extravasation of Non-Chemotherapeutic Agents – Adult/Pediatric – Inpatient/Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Medications


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Guideline for Non-Chemotherapeutic Agents:
Prevention and Treatment of Chemical Phlebitis
and Extravasation of Peripherally Administered
Non-chemotherapeutic Agents – Adult/Pediatric
– Inpatient Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
Table of Contents
EXECUTIVE SUMMARY………………………………………………………………………………...3
SCOPE ....................................................................................................................................... 4
METHODOLOGY ....................................................................................................................... 4
DEFINITIONS ............................................................................................................................. 4
INTRODUCTION ........................................................................................................................ 5
RECOMMENDATIONS ............................................................................................................... 6
UW HEALTH IMPLEMENTATION.............................................................................................. 8
TABLE 1: MEDICATION RISKS AND CONSIDERATIONS…………………………………........10
FIGURE 1: MANAGEMENT OF EXTRAVASATION………………………………………………..19
REFERENCES ............................................................................................................... ...……20
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CPG Contact for Content & Changes:
Name: Philip Trapskin, PharmD, BCPS – Manager, Drug Policy Program
Phone Number: 608-263-1328
Email address: ptrapskin@uwhealth.org
Guideline Author:
Emily Czerwonka, PharmD – Pharmacy
Coordinating Team Members:
Rena Gosser, PharmD, BCPS – Pharmacy, Drug Policy Program
Sara S Shull, PharmD, MBA, BCPS – Pharmacy, Drug Policy Program
Review Individuals/Bodies:
Lori J. Williams, DNP, RN, RNC-NIC, CCRN, NNP- BC – Pediatric Clinical Nurse Specialist
Shelly VanDenBergh, MS, RN, GCNS- BC – Adult Clinical Nurse Specialist
Barbara A. Rider, RN – Nurse Clinician, Clinical Research Center
Dawn Berndt, MS, RN, CRNI – Clinical Nurse Specialist, Nursing Practice Innovation
Committee Approval Dates:
Medication Safety Committee (1/9/2015)
Nursing Practice Council (1/27/2015)
Pharmacy and Therapeutics Committee (4/16/2015)
Release Date: April 2015
Next Review Date: April 2017
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Executive Summary
Guideline Overview
Many medications have the potential to cause tissue damage if extravasation occurs. 9 The
severity of the extravasation and amount of tissue injury is dependent upon the dose of the
medication, concentration, site of administration, and duration of medication exposure. 3
Prevention is the most effective tool in the management of extravasation. In the event that
extravasation occurs, a clear, concise policy is important to ensure prompt management of
extravasation and help minimize the amount of tissue damage that results from extravasation.
The most frequently encountered non-chemotherapeutic extravasation wounds are caused by
hyperosmolar solutions and vasopressor agents. Vasopressors and hyperosmolar drugs both
have an antidote, (phentolamine and hyaluronidase, respectively) that can help prevent tissue
damage due to extravasation, and timely management and administration is important.
Key Practice Recommendations
1. Prevention is the most effective tool in the management of extravasation.
2. Vasopressors and hyperosmolar drugs have antidotes, (phentolamine and hyaluronidase,
respectively) that may help to prevent tissue damage due to extravasation.
3. Timely management and administration of antidotes, if available, is key in the
management of extravasation .
Companion Documents
1. Guidelines for the Management of Extravasation of Antineoplastic Agents
Pertinent UW Health Policies & Procedures
1. 7.08 Management of STAT Medications for Inpatient Units
2. Administrative Policy 8.20 – Adverse Drug Event Documentation
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Scope
This guideline is to be used by nurses for the prevention and treatment of chemical phlebitis
and extravasation of peripherally administered non-chemotherapeutic agents in both adult
and pediatric patients in the inpatient setting. This guideline does not include management of
the extravasation of contrast agents. For management of the extravasation of
chemotherapeutic agents, please refer to the Guidelines for the Management of
Extravasation of Antineoplastic Agents on U-Connect.
Methodology
A modified Grading of Recommendations Assessment, Development and Evaluation
(GRADE) developed by the American Heart Association and American College of Cardiology
( Figure 2) was used to assess the quality and str ength of the evidence.1
P rescribing information w as reviewed and supplemented with recommendations from
Micromedex, Lexicomp, and Facts and Comparisons. Trissel ’s™ 2 Clinical Pharmaceutics
Database (parenteral compatibility) was used for all pH information unless otherwise
specified. Primary literature is cited when tertiary sources did not provide recommendations.
Definitions
1. Extravasation - the unintentional administration of a potentially vesicant medication or
solution into tissue surrounding the intended vascular channel2
1.1. Patients at an increased risk of extravasation include: 3
1.1.1. Geriatric, pediatric and neonatal populations, as they have fragile skin and
vascular structures and may be unable to report pain.
1.1.2. Ventilated, sedated, or confused patients who may not be able to report signs
and symptoms of extravasation.
1.1.3. Individuals with small veins.
1.1.4. Patients with poor circulation or decreased sensation (peripheral neuropathy,
diabetes, peripheral vascular disease, Raynaud’s syndrome).
1.1.5. Patients who have undergone multiple venipuncture attempts.
1.2. Signs and symptoms of extravasation:
1.2.1. Patient complains of burning, stinging, or pain at the injection site.
1.2.2. Increased resistance when administering medications intravenously.
1.2.3. Induration, erythema, or swelling at the injection site. Subsequent symptoms
include blister formation, ulceration, skin necrosis, compartment syndrome an d
complex regional pain syndrome.
1.3. Medication properties associated with an increased risk of soft tissue damage with
extravasation:
1.3.1. High c oncentration
1.3.2. Low or high pH
1.3.3. High osmolarity
1.3.4. Size of vein
1.3.5. Rate of flow
1.3.6. Amount of diluents
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1.3.7. Molecular weight
2. Vesicant - an agent that causes blistering and can result in tissue necrosis. 4
3. Irritant - an agent that causes local sensitivity reactions, resulting in pain and
inflammation at the injection site. Irritants do not cause necrosis. Solutions with a pH of
<5 or >9 commonly exhibit irritant properties. These solutions have a greater propensity
to cause symptoms of phlebitis. 5 Hypertonic solutions with an osmolality >600 mOsm/L
can also cause phlebitis. Infiltration of hypertonic solutions can result in nerve damage or
compartment syndrome.
4. Chemical Phlebitis - a chemical irritation affecting the innermost layer of the vein, called
the tunica intima. Chemical phlebitis can result in cell destruction, infiltration and
inflammation. Damage caused by chemical phlebitis can occur proximally or distally to
the tip of the catheter.
4.1. Medication properties associated with an increased risk of phlebitis
4.1.1. High concentration
4.1.2. Low or high pH
4.1.3. High osmolarity
4.1.4. Size of vein
4.1.5. Rate of flow
4.1.6. Amount of diluents
4.1.7. Molecular weight
5. Hyaluronidase - an antidote used for treating hyperosmolar drug extravasations. 6
5.1. Mechanism of action: Increases the distribution and absorption of injected
substances by modifying the permeability of connective tissue through the hydrolysis
of hyaluronic acid. The increased permeability caused by hyaluronidase is transient
and lasts for only 24-48 hours.
6. Phentolamine - an effective antidote for vasopressor extravasation. 7
6.1. Mechanism of Action: Phentolamine is a nonspecific alpha-adrenergic blocking
agent. It is a competitive antagonist of alpha-adrenergic agonists. By acting on both
arterial and venous sites, vasoconstriction is reversed improving blood circulation. 8
7. Neonate – less than 30 days old
8. Infant – between one and 12 months old
9. Children – greater than one year old
B. Introduction
1. Many medications have the potential to cause tissue damage if extravasation occurs. 9
The severity of the extravasation and amount of tissue injury is dependent upon the
dose of the medication, concentration, site of administration, and duration of medication
exposure. 3 Prevention is the most effective tool in the management of extravasation. In
the event that extravasation occurs, a clear, concise policy is important to ensure prompt
management of extravasation and help minimize the amount of tissue damage that
results from extravasation. The most frequently encountered non-chemotherapeutic
extravasation wounds are caused by hyperosmolar solutions and vasopressor agents.
Vasopressors and hyperosmolar drugs both have an antidote, (phentolamine and
hyaluronidase, respectively) that can help prevent tissue damage due to extravasation,
and timely management and administration is important.
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C. Recommendations
1. Prevention of Extravasation3,9
1.1. Become familiar with medications that are likely to cause soft tissue damage if
extravasation occurs and precautions to take with medications (Table 1) . If unsure of
the risk of an extravasated medication, consult a reputable drug information
reference or pharmacist.
1.2. When administering an IV push medication, use a large peripheral vein with
appropriately diluted medication. Avoid foot veins for irritant or vesicant medications.
Avoid placing the intravenous catheter in areas of flexi on. (Class III, Level C)
1.3. Use the smallest gauge and shortest catheter to accommodate the prescribed
therapy. (Class I, Level C)
1.4. Stabilize the catheter to minimize movement at the insertion site. (Class I, Level C)
1.5. Flush the patient’s line and establish patency before administering medication.
(Class I, Level C)
1.6. Administer medications at appropriate rates and ensure dilution to appropriate
concentrations. (Class I, Level C)
1.7. Continuous administration of vesicant medication should not be given in a peripheral
vein. (Class I, Level C)
1.8. Medications with a high potential for soft tissue damage if extravasation occurs
should be administered in the largest vein possible. (Class I, Level C)
1.9. If therapy with an irritant medication is expected to last longer than six days, the
placement of a central vascular access device line should be considered. (Class I,
Level C)
1.10. Ask patients to report burning, pain or stinging. (Class I, Level C)
1.11. Observe the site during the administration of medications checking for swelling,
discoloration or inflammation. (Class I, Level C)
1.12. Do not rely on alarms from electronic infusion devices to detect infiltration or
extravasation. These same devices are used to administer medications
subcutaneously, and the pump cannot distinguish if it is in the vessel or if the vessel
has been damaged. (Class I, Level C)
1.13. In the event that extravasation occurs and vascular access is needed, use an
alternate extremity or site remote from the extravasation. (Class I, Level C)
2. Prevention of Chemical Phlebitis
2.1. Use large veins to increase hemodilution. (Class I, Level C)
2.2. Consider the use of a 10mL syringe over a 3mL syringe when administering
medications known to cause tissues damage if extravasation occurs. 10 (Class I,
Level C)
2.3. Rotate infusion sites often. (Class I, Level C)
2.4. The first sign of phlebitis is usually pain on palpation; change IV site often to prevent
the progression of phlebitis. (Class I, Level C)
2.5. If therapy will last longer than six days, the need for a central vascular access line
should be discussed with the patient’s physician. (Class I, Level C)
2.6. See Table 1 for considerations regarding specific IV medications.
3. Management of Extravasation11,12
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3.1. See Figure 1 for general measures for the management of extravasation.
3.2. It is not known if application of physical modalities to extravasations is helpful and in
fact may have untoward consequences and worsen the outcome (Class I II, Level C).
Prior to applying physical modalities, and specifically heat, seek knowledgeable
medical and pharmacy advice.
4. Treatment of Extravasation
4.1. See Table 1 for management and antidote information for specific IV medications.
4.2. Medications to treat extravasation should be entered and processed as STAT
medications (see 7.08 Management of STAT Medications for Inpatient Units)
4.3. Phentolamine mesylate (Oraverse®)
4.3.1. Phentolamine mesylate may not be effective if more than 12 hours have
elapsed since the onset of the extravasation event. 7, 13 (Class IIb, Level C)
4.3.2. Phentolamine mesylate (Oraverse®) administration 13,14
4.3.2.1. Remove IV catheter.
4.3.2.2. Clean site with chlorhexidine.
4.3.2.3. Obtain 1.18 mg (5 mL) syringe of phentolamine mesylate
(Ora verse ® ) from Central pharmacy (may request second syringe if
necessary)
4.3.2.4. Using a new needle after each injection, inject 0.5mL intradermally in
a circular pattern around the perimeter of the extravasation.
4.3.3. For neonates, the maximum phentolamine dose is 0.1 mg/kg or 2.5 mg (10.6
mL) total dose 16
4.4. Alternatives to phentolamine (due to shortages):
4.4.1.1. Nitroglycerin topical 2% ointment (Class IIb, Level C):
4.4.1.1.1. Apply 4 mm/kg as a thin ribbon to the affected areas. May repeat
after 8 hours if needed 13
4.4.1.1.2. Alternative- apply a 1-inch strip on the affected site 14
4.4.1.2. Terbutaline (Class IIb, Level C) 15:
4.4.1.2.1. Administer subcutaneously throughout the extravasation area using
a solution of terbutaline 1 mg diluted to 10 mL in normal saline
4.4.1.2.2. For a large extravasation site; administration volume may vary from
3-10 mL, or 1 mg diluted in 1 mL normal saline
4.4.1.2.3. For a small/distal extravasation site; administration volume may vary
from 0.5-1 mL in normal saline
4.5. Hyaluronidase
4.5.1. Hyaluronidase is most effective when given within the first hour after
extravasation, and should not be given after 3 hours. 16 (Class I, Level C)
4.5.2. Hyaluronidase administration 16
4.5.2.1. Clean site with chlorhexidine.
4.5.2.2. Obtain a 1 mL hyaluronidase (150-200 units/mL, depending on
stocked manufacturer) syringe from pharmacy.
4.5 .2.3. Inject 0.2 mL through the IV catheter before removing it from the
extravasation site.
4.5.2.4. Remove IV catheter.
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4.5.2.5. Using sterile technique and a 25 gauge needle, inject 0.2 mL
subcutaneously at the edge of the infiltrate.
4.5.2.6. Using a new needle after each injection, continue making 0.2 mL
injections in a circular pattern around the perimeter of the
extravasation until all hyaluronidase is used.
5. Management and Treatment of Chemical Phlebitis
5.1. Remove peripheral venous catheter.
5.2. It is not known if application of physical modalities to chemical phlebitis is helpful and
in fact may have untoward consequences and worsen the outcome. (Class III, Level
C)
Prior to applying physical modalities, and specifically heat, seek knowledgeable
medical and pharmacy advice.
5.3. Consider treatment with an analgesic or anti-inflammatory medication. (Class I Ib ,
Level C)
6. Documentation of Extravasation and Chemical Phlebitis
6.1. Complete Patient Safety Net Report per UWHC Administrative Policy 8.20 .
6.2. Extravasation events should be reported as adverse drug events within Patient
Safety Net and should be documented within the patient’s permanent medical
record.
6.3. Documentation of the incident within Patient Safety Net and within the patient’s
permanent medical record should include the following information:
6.3.1. Date and time of occurrence.
6.3.2. Site of administration, condition of the vein, and age of the IV site.
6.3.3. Method of administration and equipment used with administration.
6.3.4. Patient dialogue including symptoms, complaints etc.
6.3.5. Suspected agent and any other medications administered or procedures
completed around the same time period.
6.3.6. Treatment interventions.
6.3.7. Plan for follow-up care.
D. UW Health Implementation
Potential Benefits:
This clinical practice guideline provides a standardized approach to the management and
treatment of extravasation of peripherally administered non-chemotherapeutic agents.
A decreased risk of adverse effects secondary to timely management of extravasation is
possible through implementation of this clinical practice guideline.
Potential Harms:
Termination of intravenous medications in the event of extravasation may pose harm to patient.
Phentolamine and hyaluronidase both carry risks for adverse events which may pose a potential
harm to the patient.
Implementation Tools/Plan
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1. Release of the guideline will be advertised in the Clinical Knowledge Management Corner
within the Best Practice newsletter.
2. Pharmacy and nursing will be informed of changes to the guideline.
3. This guideline will be searchable on U-connect using the terms: extravasation, vesicant,
irritant, phentolamine, hyaluronidase, terbutaline
4. Nursing educational services will be provided with the document to ensure adequate staff
education.
5. Ongoing monitoring and assessment of Patient Safety Net reports of extravasation will
occur.
E. Disclaimer
1. This CPG provides an evidence-based approach for treatment of adult and pediatric
extravasation of peripherally administered non-chemotherapeutic agents. It is
understood that occasionally patients will not match the conditions considered in the
guideline.
2. CPGs are described to assist clinicians by providing a framework for the evaluation and
treatment of patients. This Clinical Practice Guideline outlines the preferred approach for
most patients. It is not intended to replace a clinician’s judgment or to establish a
protocol for all patients. It is understood that some patients will not fit the clinical
condition contemplated by a guideline and that a guideline will rarely establish the only
appropriate approach to a problem.
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10
F. Appendix A
Table 1: Medication risks and considerations (Class I, Level C)
Intravenous Medication pH17,18
Potential Soft Tissue
Damage with
Extravasation or Chemical
Phlebitis17,19-21
Considerations
Acetazolamide (Diamox ® ) 9.6 Phlebitis Use large veins
Acyclovir
(Zovirax ® )
10.85 - 11.5 Phlebitis Rotate infusion sites often
Alprostadil (Prostin VR
Pediatric ® )
5.5 Ph lebitis Use large veins
Aminophylline (2:1
complex of theophylline
and ethylenediamine)
8.6 - 9.0 Phlebitis Rotate sites often
Antidote: Hyaluronidase
Amiodarone (Cordarone ® )
3.5 - 4.5
Phlebitis Phlebitis incidence increases with
concentrations above 2.5 mg/mL.
Central vascular administration
preferred
Administration of continuous
infusions using an in-line filter is
recommended to reduce the
incidence of phlebitis
Amphotericin B
Conventional
(Fungizone ® )
5 - 6
Phlebitis The addition of heparin 1,000
units per infusion can decrease
the incidence of phlebitis. The
use of a pediatric scalp-vein
needle may lessen the incidence
of thrombophlebitis. 22
Calcium Chloride 10% 5.5 - 7.5 Severe necrosis and
sloughing may occur if
injected into tissues
Push slowly through a small
needle into a large veins
If extravasation occurs, stop
infusion immediately and
disconnect (leave needle/cannula
in place); gently aspirate
extravasated solution (do NOT
flush the line); initiate
hyaluronidase antidote; remove
needle/cannula; apply dry cold
compresses elevate extremity.
Antidote: Hyaluronidase
Calcium Gluconate 10% 6 - 8.2 Local tissue necrosis occurs
with extravasation
Inject through a small needle into
a large vein to avoid possible
necrosis
Antidote: Hyaluronidase
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Intravenous Medication pH17,18
Potential Soft Tissue
Damage with
Extravasation or Chemical
Phlebitis17,19-21
Considerations
Cefotaxime (Claforan ® ) 5.0 - 7.5 Potential soft tissue damage
with extravasation, phlebitis
Rotate infusion site.
Monitor infusion sites regularly.23
Dextrose ≥10% 3.2 - 6.5 Potential soft tissue damage
with extravasation
Stop infusion immediately and
disconnect (leave needle/cannula
in place); gently aspirate
extravasated solution (do NOT
flush the line); initiate
hyaluronidase antidote; remove
needle/ cannula; apply dry cold
compresses, elevate extremity.
Use large veins and confirm vein
patency. In patients with poor
venous access consider IM
glucagon to treat hypoglycemia.
Antidote: Hyaluronidase
Digoxin (Lanoxin ® ) 6.8 - 7.2 Potential soft tissue damage
with extravasation
If extravasation occurs, stop I.V.
administration immediately and
disconnect (leave cannula/needle
in place); gently aspirate
extravasated solution
(d o NOT flush the line); remove
needle/cannula; elevate
extremity.
Dobutamine (Dobutrex ® ) 2.5 - 5.5 Phlebitis with infiltration Use large veins
Antidote: Phentolamine
Dopamine (Intro pin® ) 2.5 - 5.0 Necrosis with extravasation Requires central vascular
administration.
Extravasation may cause
necrosis and sloughing of
surrounding tissue. Large veins
are preferred.
Continuously monitor infusion
sites for free flow.24
Antidote: Phentolamine
Doxycycline
(Vibramycin ® , Doxy 100 ® )
1.8 - 3.3 Prolonged IV administration
may cause thrombophlebitis
Use of central line is preferred
Cold compress25
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Intravenous Medication pH17,18
Potential Soft Tissue
Damage with
Extravasation or Chemical
Phlebitis17,19-21
Considerations
Epinephrine (Adrenalin ® ) 2.2 - 5 Potential soft tissue damage
with extrava sation
Central line preferred.
If extravasation occurs, stop
infusion immediately and
disconnect (leave cannula/needle
in place); gently aspirate
extravasated solution (do NOT
flush the line); remove
needle/cannula; elevate
extremity.
Apply dry warm compress
Antidote: Phentolamine
Erythromycin lactobionate
(Erythrocin
Lactobionate ® )
6.5 - 7.5 Phlebitis
The severity of venous
irritation may be reduced by
use of in-line filtration.
If phlebitis/pain occurs, consider
diluting further (eg, 1:5) if fluid
status of the patient will tolerate,
or consider administering in larger
available vein
Cold compress
Esmolol (Brevibloc ® ) 4.5 - 5.5 Injection site pain
Thrombophlebitis, necros is,
blistering
Use large veins. Avoid small
veins or butterfly catheters. 26
If local infusion site reaction
develops, use an alternative site.
If extravasation occurs, stop
infusion immediately and
disconnect (leave cannula/needle
in place); gently aspirate
extravasated solution (do not
flush the line); remove
needle/cannula; elevate
extremity.
Central line preferred
Foscarnet (Foscavir ® ) 7.4 Phlebitis Administer only into vein with
adequate blood flow to prevent
phlebitis. 27
Peripherally administered
foscarnet must be diluted to
12mg/mL
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Intravenous Medication pH17,18
Potential Soft Tissue
Damage with
Extravasation or Chemical
Phlebitis17,19-21
Considerations
Fosphenytoin (Cerebyx ® ) 8.6 - 9.0 Thrombophlebitis
Edema, discoloration, and
pain distal to the site of
injection (de scribed as
"purple glove syndrome")
have also been reported
following peripheral
intravenous foshphenytoin
injection. This may or may
not be associated with
extravasation. The
syndrome may not develop
for several days after
injection. 28
Confirm vein patency
Immune Globulin
(GAMMAGARD ® )
4.0 - 7.2 Phlebitis Use large veins. Risk increases
with higher concentration (>10%).
Lorazepam (Ativan ® ) 5.7 Potential soft tissue damage
with extravasation/
phlebitis
IV injecti on should be made
slowly. If a patient complains of
pain during administration, stop
immediately to determine correct
placement.29
Mannitol 4.5 - 7.0 Potential soft tissue damage
with extravasation,
thrombophlebitis, phleb itis
If extravasation occurs, stop
infusion immediately and
disconnect (leave needle/cannula
in place); gently aspirate
extravasated solution (do NOT
flush the line); initiate
hyaluronidase antidote; remove
needle/cannula; apply dry cold;
elevate extremity .
Antidote: Hyaluronidase
Nicardipine hydrochloride
(Cardene ® )
3.7 - 4.7
(premixed
solutions)
Phlebitis
Thrombophlebitis
Do not use small veins, such as
those on the dorsum of the hand
or wrist. Use large peripheral
veins or central veins.
Change peripheral infusion site
every 12 hours to minimize the
risk of venous irritation 30
Nitroprusside
(Nitropress ® )
3.5 - 6.0 Irritation at infusion site
Extravasation
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Intravenous Medication pH17,18
Potential Soft Tissue
Damage with
Extravasation or Chemical
Phlebitis17,19-21
Considerations
Norepinephrine
(Levophed ® )
3.0 - 4.5 Potential soft tissue damage
with extravasation. 31
The infusion site should be
checked frequently for free
flow. Local necrosis might
ensue due to the
vasoconstrictive action of the
drug.
Check infusion site
frequently for free flow,
blanching along infused
vein.
Requires central line
administration
Antidote: Phentolamine
Partial Parente ral
Nutrition (PPN)
N/A Potential soft tissue damage
with extravasation
Use large veins and rotate sites
frequently
Antidote: Hyaluronidase
Pentamidine isethionate
(Pentam ® )
4.3 - 5.4 Phlebitis
Extravasations may cause
ulceration, tissue
necrosis and/or sloughing at
the injection site. 32
If extravasation occurs, the
injection should be
discontinued immediately
and restarted in another
vein.
Use large veins
If extravasation occurs, stop
infusion immediately and
disconnect (leave cannula/needle
in place); gently aspirate
extravasated solution (do NOT
flush the line); remove
needle/cannula; elevate
extremity. Apply dry warm
compresses. 32
Pentobarbital (Nembutal ® ) 9.0 - 10.5 Extravascular injection may
cause local tissue damage
with subsequent necrosis;
consequences of intra -
arterial injection may vary
from transient pain to
gangrene of the limb. Stop
injection if any complaints of
pain.33
Avoid intra-arterial administration.
Release of the tourniquet or
restrictive garments to permit
dilution of injected drug, brachial
plexus block, prevent ion of
thrombosis by early anticoagulant
therapy, and supportive
treatment.
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15
Intravenous Medication pH17,18
Potential Soft Tissue
Damage with
Extravasation or Chemical
Phlebitis17,19-21
Considerations
Phenobarbital sodium
(Luminal ® )
9.2 - 10.2 Potential soft tissue damage
with extravasation,
Phlebitis/thrombophlebitis
Extravascular injection may
cause local tissue
damage with subsequent
necrosis; consequences of
intra-arterial injection may
vary from transient pain to
gangrene of the limb. Any
complaint of pain in the limb
warrants stopping the
injection. 34
Treat with the application of moist
heat on the affected area. 34
Phenylephrine
hydrochloride (Neo -
Synephrine ® )
3.0 - 6.5 Extravasation associated
with tissue slough or
necrosis
Central line preferred
Antidote: Phentolamine
Phenytoin (Dilantin ® ) 12 Potential soft tissue damage
with extravasation and
purple glove syndrome (may
not develop for several days
after the injection) 35
Use large veins (central line
preferred) and confirm vein
patency; Follow administration
with a normal saline flush
Avoid small hand, wrist or foot
veins for administration. If
extravasation occurs, di scontinue
the injection/infusion and elevate
the limb.
May consider hyaluronidase
based on case report of its
successful use in a 14 month
old36
Antidote: Hyaluronidase
Potassium chloride,
potassium acetate
4.0 - 8.0 Phlebitis
Potential soft tissue damage
with extravasation
Confirm vein patency;
extravasation will cause necrosis,
have patient report burning or
stinging
Local infiltration of the affected
area with hyaluronidase may
often reduce venospasm and
dilute the potassium remaining in
the tissues locally. Local
application of heat may also be
helpful. 37
Antidote: Hyaluronidase
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16
Intravenous Medication pH17,18
Potential Soft Tissue
Damage with
Extravasation or Chemical
Phlebitis17,19-21
Considerations
Promethazine
(Phenergan ® )
4.0 - 5.5 Potential soft tissue damage
with extravasation including
burning, pain, erythema,
swelling, sensory loss,
palsies, paralysis, severe
spasm of distal vessels,
thrombophlebitis, venous
thrombosis, phlebitis,
abscesses, tissue necrosis,
and gangrene. In some
cases, surgical intervention,
including fasciotomy, skin
graft, and/or amputation. 38
If a patients complains of pain
during intended intravenous
injection, stop the injection
immediately; suspect inadvertent
intra-arterial injection or
perivascular extravasation
If extravas ation occurs, stop
infusion immediately and
disconnect (leave cannula/needle
in place); gently aspirate
extravasated solution (do NOT
flush the line); remove
needle/cannula; elevate
extremity. Apply dry cold
compresses.
Use large veins and confirm vein
patency. Consider IM
administration in patients with
poor IV access.
Propofol (Diprivan ® ) 7.0 - 8.5 Local pain, swelling,
blisters, and/or tissue
necrosis. 39
Phlebitis
Causes local pain during
injection. Minimize by using
lidocaine prior to injection and
use large veins
Rifampin (Rifadin ® ) 7.8 - 8.8 Potential soft tissue damage
with extravasation
If irritation and inflammation
observed, the infusion should be
discontinued and restarted at
another site. 40
Sodium Bicarbonate 8.4% 7.0 - 8.5 Chemical cellulitis, necrosis,
ulceration and sloughing
have been noted with
extravasations 41
Confirm vein patency; promptly
elevate the body part affected,
provide warmth, and
hyaluronidase. 41
Antidote: Hyaluronidase
Sodium Chloride 3%
(Hypertonic Saline)
4.8 Potential soft ti ssue damage
with extravasation
Causes severe tissue necrosis
with extravasation. Central line
preferred.
Sodium Tetradecyl
Sulfate (Sotradecol ® )
7.9 Potential soft tissue damage
and necrosis with
extravasation 42
Phlebitis/thrombophlebitis
Monitor closely for extravasation
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17
Intravenous Medication pH17,18
Potential Soft Tissue
Damage with
Extravasation or Chemical
Phlebitis17,19-21
Considerations
Sulfamethoxazole/
Trimethoprim (Bactrim ® ,
Septra ® )
~10 Potential soft tissue damage
with extravasation/phlebitis
Use large veins and confirm vein
patency
If extravasat ion occurs,
discontinue the infusion and
restart at another site 43
Total Parenteral Nutrition
(T PN)
N/A Potential soft tissue damage
with extravasation
Use large veins and rotate sites
frequently
Antidote: Hyaluronidase
Tromethamine (Tham ® ) 8.4 - 8.7 Local tissue damage and
sloughing may occur if
extravasation occurs.
Chemical phlebitis and
venospasm also have been
reported.
If extravasation oc curs, stop I.V.
administration immediately and
disconnect (leave cannula/needle
in place); gently aspirate
extravasated solution (do NOT
flush the line); remove
needle/cannula; elevate
extremity.
Hyaluronidase infiltrated into the
affected area dilutes the solution
remaining in the tissues. Consider
local infiltration of phentolamine 44
Antidote: Hyaluronidase
Vancomycin (Vancocin ® ) 2.5 - 4.5
(reconstit uted)
3 - 5 (premix)
Potential soft tissue damage
with extravasation
Phlebitis/thrombophlebitis
Rotate infusion sites; use large
veins, central vascular access
device consult for prolonged
therapy.
Consider further dilution and a
slower infusion rate in patients
with smaller veins.
Vasopressin (Pitressin ® ) 2.5 - 4.5 Potential soft tissue damage
with extravasation
Confirm vein patency.
Central line preferred
If extravasation occurs, stop
infusion immediately and
disconnect (leave cannula/needle
in place); gently aspirate
extravasated solution (do NOT
flush the line); remove
needle/cannula; elevate
extremity. Initiate phentolamine
(or alternative antidote).
Antidote: Phentolamine
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18
Intravenous Medication pH17,18
Potential Soft Tissue
Damage with
Extravasation or Chemical
Phlebitis17,19-21
Considerations
Verteporfin (Visudyne ® ) No information Potential soft tissue damage
and burns with extravasation
Use large veins, confirm vein
patency
If extravasation occurs, the area
must be thoroughly protected
from direct light until the swelling
and discoloration have faded in
order to prevent the occurrence of
a local burn which could be
severe. Treat with cold compress.
If emergency surgery is
necessary within 48 hours after
treatment, as much of the internal
tissue as possible should be
protected from intense light. 45
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19
Figure 1: Management of Extravasation 11,12 (Class I, Level C)
Check Table 1 for antidotes for
certain medications
Administer antidote as
outlined in E.4. and remove
catheter as instructed
Elevate the extremity above the
patient’s heart. Avoid pressure or
friction to the skin. Avoid heat, cold
and other physical modalities
(massage, ultrasound, etc unless
otherwise specified)
Consider the need for consultation
with a plastic surgeon
Document occurrence in pa tient’s
clinical record and within Patient
Safety Net
Observe the wound closely over the
next several days
After 48 hours, encourage the
patient to maintain elevation of the
extremity, but also use the extremity
normally to promote full recovery of
the area
Notify patient’s physician
and obtain order for antidote
Aspirate while removing
IV catheter
Notify patient’s physician
Mark the affected area with a felt -tip
pen
Assess pulses and circulation distal
to the infusion site
Stop infusion immediately
Is an antidote
listed?
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20
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21
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Figure 2: Quality of Ev idence and Strength of Recommendation Grading Matrix
Copyright © 2015 University of Wisconsin Hospitals and Clinics Authority
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