Extravasation (intravenous)
| Extravasation (intravenous) | |
|---|---|
| Classification and external resources | |
| MeSH | D005119 |
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.
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[edit] 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 vesicants.
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.[1][2][3][4][5]
[edit] 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 cannula 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).[6]
- Recent clinical trials have shown that Totect (USA) or Savene (Europe) (dexrazoxane 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.).[7]
[edit] Pain management and other measures
- Pain management is very important for the patient, as are full documentation and prevention of infection and superinfection. If there is superinfection, get an antibiogram and consult with an infectious diseases specialist. Of course, regular controls and aftercare are necessary.
[edit] 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.[8]
- 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" (erythema), "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 catheter) is a huge advantage while infusing vesicant drugs.
[edit] Examples of vesicant medicinal drugs
[edit] Cytotoxic drugs
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[edit] Non-cytotoxic drugs
[edit] See also
[edit] References
- ^ Sauerland C, Engelking C, Wickham R, Corbi D. Vesicant extravasation part I: Mechanisms, pathogenesis, and nursing care to reduce risk. Oncol Nurs Forum. 2006 Nov 27;33(6):1134-41. Review.
- ^ Wickham R, Engelking C, Sauerland C, Corbi D. Vesicant extravasation part II: Evidence-based management and continuing controversies. Oncol Nurs Forum. 2006 Nov 27;33(6):1143-50. Review.
- ^ Goolsby TV, Lombardo FA. Extravasation of chemotherapeutic agents: prevention and treatment. Semin Oncol. 2006 Feb;33(1):139-43. Review.
- ^ Ener RA, Meglathery SB, Styler M. Extravasation of systemic hemato-oncological therapies. Ann Oncol. 2004 Jun;15(6):858-62. Review. Fulltext
- ^ Schrijvers DL. Extravasation: a dreaded complication of chemotherapy. Ann Oncol. 2003;14 Suppl 3:iii26-30. Review. Fulltext
- ^ For more information on substance-specific measures, see, for example, the textbook "Extravasation of cytotoxic agents" (Authors: I Mader et al., Springer Publishing House)
- ^ Mouridsen HT, Langer SW, Buter J, Eidtmann H, Rosti G, de Wit M, Knoblauch P, Rasmussen A, Dahlstrom K, Jensen PB, Giaccone G. Treatment of anthracycline extravasation with Savene (dexrazoxane): results from two prospective clinical multicentre studies. Ann Oncol. 2007 Mar;18(3):546-50.
- ^ Infusion Nurses Society, Infusion Nursing 3rd ed 2010
[edit] External links
- UK National Extravasation Information Service
- Iv-therapy.net — links to useful websites about extravasation
- TopoTarget
- Savene website
