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The Art and Science of Infusion Nursing

Darcy Doellman, BSN, RN, CRNI®; Lynn Hadaway, MEd, RN,BC, CRNI®,
Leigh Ann Bowe-Geddes, BS, RN, CRNI®,
Michelle Franklin, BSN, RN, MBA, CRNI®,
Jack LeDonne, MD; Lorelei Papke-O’Donnell, MSN, RN, CRNI®,
Janet Pettit, MSN, RNC, NNP, CNS,
Lisa Schulmeister, MN, RN, APRN-BC, OCN®, FAAN; Marc Stranz, PharmD

Infiltration and Extravasation

Update on Prevention and Management

I
ABSTRACT nfiltration—the inadvertent leakage of a nonvesi-
Infiltration and extravasation are risks of intra- cant solution into surrounding tissue—and
venous administration therapy involving unintend- extravasation—the inadvertent leakage of a
ed leakage of solution into the surrounding tissue. vesicant solution into surrounding tissue1—are
both known risks of intravenous (IV) therapy.2
Consequences range from local irritation to
While the injury is usually minor and resolves
amputation. While immediate action using appro-
spontaneously,3 some cases result in serious complica-
priate measures (ie, dilution, extraction, antidotes, tions, including full-thickness skin loss and muscle and
and supportive treatments) can decrease the tendon necrosis requiring reconstructive surgery or
need for surgical intervention, many injuries may even amputation, leading to longer hospital stays,
be prevented by following established policy and increased morbidity,4 and increased costs.5,6 However,
procedures. However, timely surgical intervention, management of infiltration and extravasation lacks
when necessary, can prevent more serious evidence-based standardization, and many institutions
adverse outcomes. Clinicians should be prepared do not have adequate policies and procedures in place.
to act promptly when an event occurs. Thorough Furthermore, because infiltration and extravasation
incident documentation helps determine whether occur infrequently and ethical concerns prohibit
infusion care meets the standard of practice and controlled research, most treatments are empirical and
are based on small uncontrolled trials, case reports, or
is a keystone to medicolegal defense.
animal studies.7 Additional barriers to optimal man-
agement include failure to identify the problem in a
Author Affiliations: Vascular Access Specialist and timely fashion; failure to disseminate or update
Neonatal/Pediatric PICC Nurse, Cincinnati Children’s Hospital, management information; inadequate staffing; high
Cincinnati, Ohio (Ms Doellman); President, Lynn Hadaway staff turnover; lack of knowledge about effective
Associates, Inc, Milner, Georgia (Ms Hadaway); Vascular Access
Specialist, University of Louisville Hospital, Louisville, Kentucky treatments due to research limitations, as described
(Ms Bowe-Geddes); CPHQ Director, Clinical Services Group, above; and cost.
Hospital Corporation of America, Nashville, Tennessee To better understand infiltration and extravasation, a
(Ms Franklin); General Surgeon, Greater Baltimore Medical Center,
Baltimore, Maryland (Dr LeDonne); Clinical Nurse Manager, panel of clinicians with expertise in nursing, vascular
Vascular Access Service, University of Michigan Health Systems, access, general surgery, and pharmacy convened in
Ann Arbor (Ms Papke-O’Donnell); Vascular Access Specialist, September 2007 in Phoenix, Arizona. Objectives of the
Neonatal Nurse Practitioner, Doctors Medical Center, Modesto,
California (Ms Pettit); Oncology Consultant, River Ridge, Louisiana advisory roundtable were to present current clinical
(Ms Schulmeister); and Vice President, Operations East, Critical practice, review the pertinent literature, and summarize
Homecare Solutions, Conshohocken, Pennsylvania (Dr Stranz). current management options. The discussion was
Editorial support was provided by Barbara Joan Goldman, RPh, of cochaired by Darcy Doellman, BSN, RN, CRNI®, and
Advogent, and funded by Baxter Healthcare Corporation.
Lynn Hadaway, MEd, RN,BC, CRNI®, and made
Corresponding Author: Darcy Doellman, BSN, RN, CRNI®,
Cincinnati Children’s Hospital, 3333 Burnet Ave, Cincinnati, OH possible by an educational grant from Baxter
45229 ([email protected]). International, Inc. While the panel discussion covered

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4 key areas (prevention, recognition, management, and

documentation), this article focuses primarily on the
most current management options for infiltration and TABLE 1
extravasation.
Factors Contributing
MECHANISMS OF TISSUE to the Risk for
INJURY IN INFILTRATION AND
EXTRAVASATION INJURIES Infiltration and
Infiltration and extravasation can be caused by mechani-
Extravasation
cal, physiologic, or pharmacologic factors (Table 1). Mechanical factors
Mechanical factors, occurring either during initial catheter
insertion or while the catheter is in place,2,8 and physiolog- Small size and poor condition of veins8
ic factors relating to preexisting or emerging vein Larger catheter size relative to vein size2
problems8,11,12 can be contributing factors.9,13 Regardless
of the mechanism, specific management of infiltration and Choice of site (eg, areas of joint flexion, dominant hand)2
extravasation is usually determined by the pharmacologic
Unstable catheter2
characteristics of the offending infusion.
Poor securing of implanted port access needle9
Pharmacologic Factors
Patient activity2
While infiltration of nonvesicant agents generally does Multiple venipuncture sites (eg, a second puncture above
not cause tissue necrosis,8,10 the agents can sometimes the first)2
result in long-term disability due to local inflammatory Use of an infusion pump or power injector during the infiltration
reactions caused by their irritant properties2,8,10,14 or by or extravasation event2
compression of surrounding tissues by a large volume of
Catheter port separation or catheter fracture10
infiltrate, known as acute limb compartment syndrome
(ALCS).15,16 In contrast, vesicant extravasation produces Physiologic factors
progressive tissue damage, the full extent of which may
become evident only days or weeks after exposure.7,10 Clot formation above the cannulation site2
Variables that determine the extent of tissue damage Thrombus or fibrin sheath at the catheter tip8
caused by extravasation are summarized in Table 2.
Lymphedema8
pH and Osmolarity Pharmacologic factors

Solutions that irritate the venous endothelium and pH

vessel wall ultimately raise the risk of venous rupture,
allowing the solutions to escape into the surrounding Osmolarity
tissue.18 To minimize venous irritation, infused solu- Vasoconstrictive potential
tions should be close to physiologic pH (7.35-7.40)19
and osmolarity (281-282 mOsm/L).20,21 Extreme pH Cytotoxicity
(both alkaline and acidic) can reduce peripheral vein
tolerance22 by damaging cell proteins and eventually osmolarity ⬎ 350 mOsm/L) causes a fluid shift from
causing cell death, leading to venous endothelial inside cells to the interstitial space,2 which disrupts cell
damage and making it susceptible to rupture.21 The pH function.18,24 The shift from subcutaneous cells to inter-
of infusion solutions should generally be between stitial tissues leads to swelling and increased local pres-
5 and 9.21 sure, which can cause ALCS and other injuries.18 While
For solutions that escape the vein, osmolarity can hyperosmolar solutions can shrink cells and collapse the
also influence the degree of tissue injury. For example, internal structures, hypoosmolar solutions can swell
extravasation of hypertonic fluids such as 10% dextrose cells and lead to cell rupture.
or parenteral nutrition solutions can cause skin necrosis
and serious tissue damage.18,23 Furthermore, dextrose Vasoconstriction
solutions are rarely administered alone: other products
are often added, which can increase osmolarity even Extravasation of vasoactive substances (eg, dobutamine,
more. Extravasation of hypertonic solutions (eg, dopamine, epinephrine, norepinephrine, and vasopressin)

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function, leading to cell death. The impact appears to

depend on drug concentration and time of exposure.
TABLE 2

Extravasant MANAGEMENT
Characteristics That While it is widely recognized that early identification
Determine the Extent and intervention upon the first signs and symptoms of
infiltration and extravasation are critical to the preven-
of Injury tion of potentially serious adverse outcomes, definitive
treatment has not been established, with the exception
Characteristics Leading Characteristics Leading of dexrazoxane hydrochloride (Totect®, TopoTarget
to Tissue Damage8,10 to Cellular Damage2,10,17 USA, Rockaway, New Jersey), which is a Food and
Drug Administration (FDA)-approved anthracycline
Specific drug and/or fluid extravasation treatment.26 Consequently, current man-
pH
characteristics
agement recommendations are based for the most part
Sequence of drug on anecdotal experience.2,27-29 However, all current
Osmolarity
administration
guidelines recommend the following steps at the first
Concentration and amount sign of infiltration or extravasation: (1) stop administra-
Vasoconstrictive potential
of infiltrate
tion of IV fluids immediately; (2) disconnect the IV tub-
Extravasation site Cytotoxicity of the agent ing from the device; (3) attempt aspiration of the resid-
ual drug from the IV device; (4) administer nursing
Duration of tissue exposure interventions (summarized below), as indicated; and (5)
notify the physician or advanced practice nurse.29-31
Underlying disease state
Beginning with the most conservative approach, the
following sections describe the currently available treat-
can result in ischemic necrosis10,25 because these sub- ment options: supportive care; manual extraction of the
stances reduce blood flow by causing severe constriction extravasated fluid; use of dispersal agents, antidotes,
of smooth muscles around capillaries.4,17 In addition, and treatments; and surgical excision of the extravasa-
solutions with high electrolyte concentrations (eg, calci- tion site.27,28 An extravasation kit containing the items
um chloride 5.5% or sodium chloride 3% or 5%) can needed to assess the IV site and to treat an extravasation
prolong the depolarization and contraction of pre- and injury should be readily accessible. Useful kit items
postcapillary smooth muscle sphincters, which, in turn, include the institution’s extravasation policy, manage-
prolongs exposure to injurious substances and leads to ment algorithm, and documentation form; 3-mL
ischemia and tissue necrosis.4,10,17 syringes; 25-gauge needles; cold and warm compresses;
and paper tape.28 Some institutions’ kits also include
Cytotoxicity specific antidotes, with appropriate diluent and recon-
stitution instructions, and a tape measure to determine
Many antineoplastic agents can cause direct cellular the size of the involved area.
toxicity upon extravasation.10 Such agents can be sepa-
rated into 2 categories on the basis of their mechanisms Nursing Interventions
of cellular damage: nonbinding vesicants (agents that do
not bind to tissue nucleic acids) and DNA-binding vesi- Nursing interventions include elevation and thermal
cants (agents that bind to tissue nucleic acids).11 The application (cold or heat). Elevation of the affected limb
most destructive extravasation injuries are caused by may aid in reabsorption of the infiltrate or extravasated
the DNA-binding agents (eg, anthracyclines, antitumor vesicant by decreasing capillary hydrostatic pressure.3,31,32
antibiotics, and some alkylating agents),8 which cause Although one study of limb elevation (of approximately
immediate tissue injury and—by remaining in the 2-4 in) did not demonstrate alleviation of pain or
tissues—create a more prolonged course.11 In contrast, resolution of infiltrate,33 elevation of the affected limb is
nonbinding vesicant agents (eg, vinca alkaloids and tax- recommended for 24 to 48 hours after infiltration or
anes)8 cause immediate tissue damage, but because they extravasation, whenever possible.29-32
do not bind to DNA, these drugs are more easily metab- Local thermal treatments are used to decrease the site
olized, and tissue repair follows a more normal healing reaction and absorption of the infiltrate.28 Local cooling
process.11 Even agents that are not antineoplastics— (ice packs) aids in vasoconstriction, thus theoretically
such as antibiotics—can cause depletion of intracellular limiting drug dispersion.31 Cold application is recom-
ADP and ATP levels and other enzymes that sustain cell mended for extravasation of DNA-binding vesicants

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(with the exception of mechlorethamine [nitrogen mus- chemotherapy extravasations were treated with several
tard]),30 contrast media,3,34 and hyperosmolar fluids.2,35 incisions within 6 hours of the extravasation, followed
The use of local warming therapy (dry heat) is based on by infiltration with 300 to 500 mL of normal saline via
the theory that it enhances vasodilation, thus enhancing a large catheter.38 All 8 patients experienced normal
dispersion of the vesicant agent and decreasing drug healing without functional impairment. Although these
accumulation in the local tissue.31 The use of local early reports of saline washout were positive, they have
warming is recommended for extravasation of limited clinical utility and have not been incorporated
non–DNA-binding vesicants.30 Although clear benefit into infusion guidelines.30
has not been demonstrated with thermal applica-
tions,17,35,36 it remains standard supportive care, and the Dispersal With Saline
recommended application schedule for both warm and
cold applications is 15 to 20 minutes, every 4 hours, for The theory behind the use of dispersal is that tissue
24 to 48 hours.30 It should be noted that heat and cold injury will be decreased secondary to the dilution of the
applications are not well supported in neonates and vesicant across a larger area of tissue.29 Clysis with
young infants. saline has been described as the simplest method to
dilute the concentration of a vesicant extravasation in
Aspiration and Extraction order to prevent tissue injury.27 In a 1994 report on 40
patients with suspected extravasations of vinca alka-
As soon as infiltration or extravasation has been identi- loids or doxorubicin, conservative treatment with 20 to
fied, the infusion should be stopped, the IV tubing 90 mL of saline solution, injected at the extravasation
should be disconnected (leaving the catheter in place), site 3 to 6 times, was administered over a course of sev-
and then an attempt should be made to aspirate the eral days to all patients except 3 with deep lesions.39
residual drug from the IV device using a small (1- to Pain and erythema were resolved in 4 days or less and
3-mL) syringe.30 superficial ulcerations in 10 to 14 days in all treated
Documented experience with methods of manually patients; surgery was required in the 3 patients with
extracting infiltrated or extravasated agents is lacking, deep ulcers. Variations of the saline wash procedure
so these techniques are not routinely recommended, and include the saline flush-out technique described in the
should be performed only by a physician or other qual- preceding section.
ified personnel. The “squeeze maneuver” was described
in a report of 8 patients with more than 50 mL of Pharmacologic Antidotes
contrast-media extravasation that had resulted in vascu-
lar compromise of the fingers. After stopping the infu- Although a number of pharmacologic antidotes
sion, the IV catheter was removed and an 18-gauge have been investigated for management of vesicant
needle was used to create 5 to 8 holes near the insertion extravasation,12,40 their use remains controversial.2
site (avoiding vessels, tendons, and muscles). The While several antidotes described in this section have
patients’ tissue was then “milked” from the edges of the been shown to limit tissue damage caused by extravasa-
distended area toward the needle holes, squeezing out tion of specific vesicants and are recommended in
the extravasated contrast media until distal circulation empirical guidelines,8,28,29,32,41 the most recent
had been restored.37 The advantages of this procedure Oncology Nursing Society guidelines do not recom-
are that it can be performed immediately and it does not mend antidotes for extravasation of chemotherapeutic
require anesthesia37; however, experience with its use is and biotherapeutic agents, with the exception of sodium
limited. thiosulfate.30 Therefore, the package insert or other
Other reported manual extraction methods include reference material should be consulted before considering
percutaneous needle aspiration, liposuction, and surgi- the use of an antidote for management of extravasation
cal fenestration and irrigation.27 Early washout using of specific agents.7
surgical fenestration and irrigation has been described
as a simple, practical procedure,23,38 which immediately Hyaluronidase
reduces the amount of extravasated agent at the site
with good outcomes. In an early report, 44 pediatric Hyaluronidase enzymatically increases tissue permeabil-
patients with extravasations of calcium, potassium, ity, which facilitates systemic absorption of infiltrated
sodium bicarbonate, or 10% dextrose were treated vesicant agents.29 Hyaluronidase rapidly (within 10 min-
within 24 hours of extravasation injury with stab inci- utes) results in diffusion of extravasated fluid over an
sions and 500 mL of normal saline flush, with drains area 3 to 5 times larger than an area left untreated, and
left in place for 24 hours. In these patients, 86% healed tissue permeability is restored within 24 to 48 hours.42
without soft tissue loss.23 In a later report, 8 patients In both animal studies and human reports, good out-
with suspected vinca alkaloid or anthracycline comes have been observed with hyaluronidase treatment

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of suspected extravasations of DNA-binding drugs (eg, striction and ischemia, which can result in tissue necro-
doxorubicin),43,44 non–DNA-binding drugs (eg, vinca sis and ulceration.58 Phentolamine competitively blocks
alkaloids),45,46 irritant drugs (eg, nafcillin),42 hyperos- ␣-adrenergic receptors, reversing these effects, thereby
molar solutions (eg, dextrose 10%, parenteral nutri- mitigating the tissue injury. As early as 1957, phento-
tion),42 and many other agents. In a recent case report on lamine was reported to reduce skin loss caused by
parenteral nutrition extravasation in a premature infant, extravasation of vasoconstrictor agents in animal mod-
early subcutaneous hyaluronidase followed by saline els and in case studies.59 While one early report
flushing resulted in a dramatic response with almost no described a vasopressor extravasation injury that did
sign of injury after 5 days.47 Hyaluronidase is not recom- not respond to phentolamine administered 48 hours
mended for use with dopamine or ␣-agonist drugs.48 after extravasation,60 a later animal study demonstrated
Clinicians should consider patients with allergies and that early administration of phentolamine was critical
with religious/cultural proscriptions when choosing to its beneficial effects on vasopressor extravasation
between animal-derived forms of hyaluronidase and the injuries.61 Results of these animal studies are supported
new recombinant human form (rHuPH20).48 by the findings of several case reports,62,63 and adminis-
tration of phentolamine no more than 12 hours after
Sodium Thiosulfate extravasation is supported in empirical guidelines for
the management of vasopressor extravasation in both
Sodium thiosulfate has long been recognized as an effec- children32,58 and adults.17
tive antidote to mechlorethamine (nitrogen mustard).40
Furthermore, a study of 63 patients who had injuries Dexrazoxane Hydrochloride (Totect ®)
induced by extravasation of a variety of vesicant agents
(eg, doxorubicin, epirubicin, vinblastine, and mito- Totect® is a new FDA-approved treatment for IV
mycin C) showed that sodium thiosulfate combined anthracycline extravasation.64 The mechanism by which
with conservative treatment significantly improved it reduces tissue damage is unknown.64 Efficacy in treat-
healing time compared with conservative treatment ing anthracycline extravasations has been demonstrated
alone.49 The recommended administration of sodium in animal studies,65-67 case reports,68-71 and 2 multicen-
thiosulfate is through immediate subcutaneous injection ter, prospective clinical trials.72 In the 2 clinical trials, 54
of 2 mL of 0.17M solution.50 patients with biopsy-confirmed doxorubicin and epiru-
bicin extravasations received 3 days of IV dexrazoxane
Dimethyl Sulfoxide (1000, 1000, and 500 mg/m2) treatment beginning no
later than 6 hours after the event.72 Skin and tissue
Dimethyl sulfoxide (DMSO) is a topically applied sol- integrity remained intact in 53 of 54 patients (98.2%
vent that may improve systemic absorption of efficacy); only 1 of the 54 patients (2.8%) required sur-
extravasated vesicants. It also acts as a free radical scav- gical resection of necrosis. Sequelae were reported as
enger, thus preventing DNA damage from oxygen free mild among those not requiring surgery, and 74% of the
radicals that might be produced by cytotoxic agents.40,41 patients were able to continue anthracycline chemother-
Topical administration of DMSO after vesicant drug apy on schedule.
extravasation has been shown to prevent tissue necrosis Totect® is packaged as an emergency treatment kit
in several animal studies51,52; however, in another study, for single patient use and contains a complete course of
DMSO failed to reduce ulceration after anthracycline treatment. The drug is administered for 3 consecutive
extravasation53; and a third study suggested that DMSO days as a 1- to 2-hour IV infusion in a large-caliber vein
might potentiate, rather than inhibit, the toxicity of cyto- in an extremity other than the one affected by extrava-
toxic agents.54 Although good results have been reported sation. The recommended dose is the same as that
in clinical trials in patients with suspected extravasations administered in the clinical trials64: 1000 mg/m2 on day
of cytotoxic agents using 90% to 99% DMSO,55-57 1; 1000 mg/m2 on day 2, and 500 mg/m2 on day 3.
medical-grade DMSO at concentrations higher than
50% is not available in the United States.31 Because of Surgical Intervention
conflicting efficacy data, limited drug availability, and
the advent of new treatments such as Totect®, the use of The majority of suspected extravasation injuries are
DMSO as an antidote is not recommended in the believed to heal without surgical intervention, so a con-
Oncology Nursing Society guidelines.30 servative approach is advisable.3,27,29,73,74 However, it
has been estimated that surgery is required for up to
Phentolamine one-third of cases.29,40,75 Therefore, timely surgical con-
sultation is important to minimize adverse outcomes
Extravasation of vasopressor agents (eg, dopamine, when extravasation of nonanthracycline vesicants
epinephrine, and norepinephrine) causes local vasocon- occurs (anthracycline extravasations are immediately

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treated with Totect®).2,28,39 Continuing pain after vasoconstriction, resulting in decreased capillary
administration of conservative local treatment has been blood pressure and transudation.16 Hyperbaric oxygen
cited as an indication for surgical consultation.11,29,40,76 therapy has been shown to reduce edema and tissue
When surgery is indicated, early debridement of necrot- necrosis in experimental models of ALCS82,83 and
ic tissues and entrapped drug can minimize the risk for promote wound healing in patients with ALCS result-
subsequent damage to deeper tissues; and when healing ing from traumatic injury. In one study, 17 of 18
is delayed, wide excision and skin grafting are the most patients who were given hyperbaric treatment follow-
common procedures.40,76 More aggressive surgery, such ing surgical fasciotomy experienced complete wound
as mastectomy, may be required in cases of extensive healing as compared with 10 of 18 patients who
central venous catheter extravasation injury.9 received fasciotomy alone.84 Hyperbaric therapy is
In contrast, the primary treatment of ALCS is currently recommended as an adjunct to fasciotomy or
decompression with fasciotomy.16 Because outcomes in those cases in which immediate surgical treatment is
are optimal when decompression occurs less than not possible.16
12 hours after the onset of ALCS,77,78 surgical treat-
ment should be initiated as soon as possible to mini- Special Issues in Neonatal and
mize complications.16 Pediatric Patients

Total parenteral nutrition, electrolyte therapy, antibi-

Experimental Treatments otics, vasoactive medications, and other drug thera-
Hyperbaric Oxygen Therapy pies requiring peripheral IV therapy are often needed
in low-birth-weight infants and in children with com-
Hyperbaric oxygen therapy involves intermittent plex illnesses.58 However, their small, fragile veins
inhalation of 100% oxygen in a treatment chamber and inability to verbally communicate their pain and
with pressure greater than 1 atm.79,80 The rationale is discomfort leave them particularly prone to infiltra-
that intermittently increasing tissue oxygen tension tion and extravasation injuries.29,85 Although wound
optimizes fibroblast proliferation and collagen synthe- and skin care is emphasized in newborns and
sis, thereby enhancing the oxidative killing capacity of infants,18 treatment for children, like that for adults,
white blood cells during hyperoxia and stimulating is based on the anecdotal literature.32 The value of hot
angiogenesis during hypoxia.80 Enhancement of healing or cold compresses is debatable; there is little evidence
in selected problem wounds is one of the 13 indications of efficacy and some risk of skin maceration with
approved for hyperbaric oxygen therapy by the moist heat.
Hyperbaric Oxygen Committee of the Underwater and
Hyperbaric Medical Society.81
Studies of hyperbaric oxygen therapy in animal mod- IMPORTANCE OF PREVENTION
els of doxorubicin extravasation have reported mixed AND RECOGNITION
results. In an early study, ulcers in rats treated with
hyperbaric oxygen therapy were significantly larger at In view of the current controversy regarding the indi-
2, 3, and 5 weeks as compared with those in untreated cations for some treatments and the limitations of
animals, suggesting that cytotoxic effects of doxoru- others, prevention has been correctly stated to be
bicin were potentiated by this treatment modality.80 In preferable to cure.86 Careful adherence to proper
contrast, a more recent study using a similar model procedures and timely identification of signs and
reported no difference in lesion size in hyperbaric- symptoms are critical to avoiding potentially life-altering
oxygen-treated animals and in control animals on days complications.2,28 Although the primary responsibility
7 or 14, but a significant reduction in the treated for the prevention and early recognition of injury
animals on days 21 and 28, with complete wound healing due to infiltration and extravasation rests with the
by day 40 in 37% of the treated animals versus no wound nursing staff,2,8 physicians and pharmacists should be
healing in the control group.79 These findings are knowledgeable about the most up-to-date treatment
preliminary, and currently there are no reports of hyper- options and institutional protocols and should be
baric oxygen therapy in humans for the treatment of prepared to act promptly in order to prevent serious
tissue necrosis caused by vesicant extravasation. complications.
Moreover, the use of hyperbaric oxygen therapy is not
discussed in the current guidelines for the practice of
chemotherapy and biotherapy.30 DOCUMENTATION
The theoretical mechanism of hyperbaric oxygen
therapy for the treatment of ALCS is that hyperoxy- Because errors associated with IV administration can
genation increases the supply of oxygen and causes result in fatal or life-threatening outcomes, administration

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of IV fluids and medications can be high-risk, with database, which summarizes data from professional
adverse outcomes potentially leading to malpractice liability carriers, showed that 2.1% of injury claims
claims.5 While nurses are named as defendants in such from 1970 to 2001 were related to peripheral
lawsuits in increasing numbers, physicians also can be catheters.6 Among these claims, 28% were related to
named if it appears that intervention was not proper skin slough or necrosis; 17% were related to swelling,
or timely. For example, the Closed Claims Project inflammation, or infection; 17% were related to nerve
damage (with 22% of these caused by ALCS); 16%
were related to fasciotomy scars resulting from ALCS;
and 3% were related to heat compresses used to treat
IV infiltrations.6 Approximately 54% of peripheral
TABLE 3 catheter claims resulted in successful litigation for the
Content of plaintiffs, with compensation ranging from $275 to
$10,050,000.6
Standardized Event Evidence-based management and complete and
accurate documentation are the keys to an effective
Documentation Form legal defense in the event of a medicolegal claim.5 The
Joint Commission defines a sentinel event as “an unex-
Date and time of the event pected occurrence involving death or serious physical
or psychological injury, or the risk thereof. Serious
Patient’s comments injury specifically includes loss of limb or function.”87
According to the Infusion Nursing Standards of
Clinicians’ comments
Practice, an extravasation injury should be considered
Insertion site, precisely located by detailed anatomical a sentinel event and should be documented.1 Extreme
descriptors or marking an anatomical drawing cases of infiltration and all extravasations require a
sentinel event report, which then triggers a root cause
Photographs of the involved area
analysis. Risk managers should encourage complete
Catheter gauge and length and accurate documentation of all infiltration and
extravasation events and should analyze such events
Noncoring needle gauge and length (implanted ports) for system failure and identify opportunities for
process improvement. The most important documenta-
Type and volume of diluent
tion component is a comprehensive, standardized form
Administration by IV push, piggyback, gravity, or pump to ensure that complete detailed information is gath-
(if a pump, include the infusion rate) ered (Table 3). A photograph of the affected site should
also be considered an important component of the
Appearance of the infusion site
documentation record.8
Type and estimated volume of the extravasated drug

Techniques used to manage the extravasation SUMMARY

Use of antidotes or treatments
Infiltration and extravasation injuries are medical emer-
Description of wound care gencies that have the potential to cause serious disabili-
ty, diminish the patient’s quality of life, and leave clini-
Grade extent of injury (per the Infusion Nursing Standards
of Practice Infiltration Scale [0 ⫽ no symptoms to 4 ⫽ skin
cians vulnerable to the risk of malpractice claims. While
that is blanched, bruised, or leaking; gross edema; deep such injuries may be minimized or prevented through
pitting edema; circulatory impairment; etc]1 or documentation adherence to standards of practice and evidence-based
of similar items or an adapted scoring system for infants treatment, further study is needed to address unresolved
and children
questions and controversies surrounding extravasation
Physician notification, including time notified, information management and ways to broaden clinicians’ awareness
discussed, and orders received of the treatment options.
Outcome of surgical consultation when applicable
REFERENCES
Description of follow-up measures
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Patient education
Infus Nurs. 2006;29(1)(suppl):S1-S92.
Signatures and credentials of all clinicians involved 2. Hadaway L. Infiltration and extravasation: preventing a compli-
cation of IV catheterization. Am J Nurs. 2007;107(8):64-72.

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3. Bellin MF, Jakobsen JA, Tomassin I, et al. Contrast medium 27. Langstein HN, Duman H, Seelig D, Butler CE, Evans GR.
extravasation injury: guidelines for prevention and management. Retrospective study of the management of chemotherapeutic
Eur Radiol. 2002;12(11):2807-2812. extravasation injury. Ann Plast Surg. 2002;49(4):369-374.
4. Upton J, Mulliken JB, Murray JE. Major intravenous extravasa- 28. Wickham R, Engelking C, Sauerland C, Corbi D. Vesicant
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