Infiltration and Extravasation

Submitted by Paula Wallis, IVNNZ Inc. Educator 2003 - 2005. Originally printed in IVNNZ Inc. Newsletter

Infiltration and extravasation – two words that you don’t often hear in the everyday ward setting. However, you have all probably heard the more common term “tissued”.
The definition of infiltration is the inadvertent administration of a non vesicant fluid or medication into the surrounding tissues. Extravasation is the inadvertent administration of a vesicant fluid or solution into the surrounding tissue. Some examples of common vesicant medications and fluids include vancomycin, potassium chloride, calcium gluconate, dopamine, Dilantin, a lot of the antineoplastic drugs, dextrose > 10% and 0.45% sodium chloride.

The signs and symptoms of these two complications often don’t occur and are not always obvious until a few hours after the patients IV device has failed and this usually depends on how rapid the medication or fluid is being infused. In children and especially neonates the rate and amount being infused is of small amounts therefore it could take up to 24 hours for the signs and symptoms to appear.
So what are the signs and symptoms? Usually the nurse or patient will notice oedema at the insertion site and the patient may start to complain of pain – this is usually related to the amount of swelling but a burning sensation usually indicates something more sinister and the patient will need further assessment for tissue necrosis.
Extravasation can also appear as a blotchy redness around the affected site and has been described as being similar to ‘sunburn’.

Both complications usually cause the slowing or stopping of the infusion. Tissue damage can depend on the type of drug or fluid being infused and how long it sits in the tissues before being discovered.
Extravasation is serious in that it can cause a chain reaction of inflammation and tissue damage that can last for weeks or months.

Causes
What causes these complications? Improper site selection – is the peripheral IV device inserted over an area offlexion. Traumatic insertions can cause damage to the internal lining of the vessel thus predisposing the vessel to further damage when an irritating fluid or medications are infused. Inadequate securement of the IV device means the catheter is able to move around and cause the tip to go through the catheter wall. This can also cause the catheter to slip out of the vessel and infuse into the surrounding tissues.
Incorrect device selection for the treatment the patient is receiving puts your patient at risk of these complications. Is your patient requiring long term antibiotics or chemotherapy? Would it be more appropriate to have a PICC or a midline inserted?
Obstructions to blood flow around or through the catheter can also cause infiltration or extravasation. This can occur with central venous catheters when a fibrin sheath forms around the tip of the catheter. This leads to a withdrawal occlusion which eventually can force a vesicant fluid or medication to flow backward toward the puncture site, where it can seep out into the surrounding tissue (Skokal, 2001).

Who is at risk for infiltration and extravasation?

Patients with small schlerosed vessels such as with diabetes or atherosclerosis are at increased risk. The elderly have less elastic veins and children have immature veins therefore this puts both these groups at increase risk. How about the patient who cannot communicate? New Zealand has an increasing population where English is the second language. Also at risk is the patient who has had a CVA and the severely debilitated. These patients have and increased risk because they may be unable to tell the nurse that they are experiencing the above symptoms.

Interventions
Once infiltration or extravasation has occurred the interventions can range from common sense to more complex treatments. Firstly stop the infusion immediately. The sooner this occurs the less likely that further tissue damage will occur. Leave the catheter in place – this is in case an antidote can be administered. Seek medical advice – a referral to a plastic surgeon may be required if tissue necrosis has occurred. There are some medications that require an antidote to prevent further tissue damage. The antidote either neutralises, increases systemic absorption or inactivates the infused medication. Depending on the nature of the extravasation you may inject the antidote either into the IV catheter or into the subcut. tissue (after residual medication or fluid has been aspirated). Antidotes should only be instilled by a qualified and experienced person and depending on the facilities policies (Hadaway 1999).
Elevating the affected limb is a time-honoured nursing intervention, but research shows that this may not be as effective as you think (Hadaway 1999). One study showed that the elevation of an extremity made no difference to the rate of fluid reabsorption. A cold or warm compress depends on the type of IV solution. To limit contact of the infused solution with the subcutaneous tissue a cold compress is recommended for all fluids with the exception of some of the antineoplastic drugs where a warm compress is recommended.
Remember to document your findings and any action taken. Documentation tips for infiltration and extravasation include – type of IV device, site, name of the medication or fluid infused an estimate of how much was infused, status of circulation, assessment of insertion site including swelling, colour, capillary refill, circumference of both limbs, any action taken – contacted medical team, treatment.

As with most complications prevention is always the best measure.
Below are some suggestions in which to prevent these two complications occurring include:

• Anticipate that these complications can occur
• Educate your patient or their family or caregivers on the signs and symptoms of infiltration   and extravasation
• Don’t ignore your patient when they c/o pain at their insertion site
• Monitor IV sites at regular intervals – more frequently when an infusion is running
• Ensure catheter securement is adequate
• Protect the site from excessive movement
• Try to avoid areas of flexion for catheter insertion
• Consider the placement of a PICC or midline Know the medications and fluids or solutions being infused

Hadaway (1999) writes “that no treatment can take the place of good assessment skills and problem prevention and that despite your best efforts infiltration and extravasation can still occur but the nurse should be prepared to act correctly and rapidly to minimise tissue damage”.

References

Hadaway LC. I.V. Infiltration: Not just a peripheral problem. Nursing99, September 1999: 41-47.
Skokal WA. Drug Disasters Extravasation. Rn, September 2001: Volume 64 (9); 56-62.
3M Skin Health Program, Clinical Tool. IV Complications: Infusion Site Management. www.3M.com