Download Appendix A: Guidelines for Extravasation of Non

UPMC PRESBYTERIAN SHADYSIDE
NURSING POLICY AND PROCEDURE
Policy Title:
Extravasation of Intravenous
Non-Chemotherapeutic Agents
Last Review Date: June 2013
Policy Number: P-IV-14
POLICY
It is the policy of UPMC Presbyterian Shadyside that the professional nurse will minimize the risk of
extravasation. If extravasation occurs, the nurse will recognize and manage the extravasation according
to policy.
GENERAL INFORMATION
1. The best treatment is prevention. Assess IV for blood return before administering any medication.
2. Stop the infusion immediately. Leave the needle/catheter in place.
3. Slowly aspirate as much of the drug as possible. Do not apply pressure to the area.
Attempt to estimate volume. Recommend plastic surgery consult if more than 25-50ml.
4. Remove IV access while aspirating. Do not use this site for IV access any longer.
5. Assess the severity of the extravasation. Minor extravasations do not require treatment. An
extravasation is considered severe and the patient’s physician or physician extender should be
contacted if any of the following occur:
a. the patient is experiencing pain or,
b. the skin around the area is discolored or,
c. the area is inflamed (larger than a quarter) or,
d. the extravasation involves amiodarone, epinephrine, norepinephrine, phenylephrine, dopamine, or
calcium chloride or,
e. he extravasation involves a chemotherapeutic agent. (Please refer to UPMC Presbyterian
Shadyside Nursing Policy, “Management of Antineoplastic Infiltration, Extravasation and
Anthracycline Flare Reaction” – Policy number P-Onc-14).
6. If it is determined that treatment is needed, initiate substance-specific measures. See Appendix A.
a. Warm or Cold compresses
(1) Cold/Warm Compress Procedure
(a) Apply to affected area for 30 minutes
(b) Check the patient’s skin after 5 minutes. Remove the compress if the skin shows
excessive redness, maceration or blistering, or if the patient experiences pain or
discomfort.
(c) Repeat procedure 4 times/day x 24 hours or until inflammation/discomfort has
resolved.
(2) Decision to use Cold versus Warm Compresses
(a) Although compresses are helpful, published recommendations regarding the temperature
of compresses may vary and are not available for all extravasation types.
P-IV-14 Extravasation of Intravenous Medications Non-Chemotherapeutic Agents
Page 2 of 7
(b) Warm compresses promoted vasodilation, increasing drug distribution and decreasing
local drug concentrations. However, the application of moist heat may lead to
maceration and necrosis.
(c) Cold compresses promote vasoconstriction, localizing the extravasation and allowing
time for local vascular and lymphatic systems to disperse the agent.
b. Antidote – MUST BE ORDERED BY A PHYSICIAN or physician extender. A physician or
physician extender should assess the patient be fore an antidote is administered. An antidote is
not needed for most extravasations. In addition, published recommendations for antidote
use/selection are not available for all extravasation types.
c. Consider marking the leading edge of the extravasated area and/or obtaining a photograph to
determine improvement or worsening.
d. Consult Plastic Surgery only if one of the following occur:
(1) the surrounding tissues are discolored or tense or,
(2) the patient reports severe pain or,
(3) the extravasation involves calcium chloride.
7. Elevate the area for 48 hours to minimize swelling. Elevate the extravasated area above the level of
the heart to effectively reduce edema.
8. Document monitoring and interventions in the medical record as per Appendix B. Complete an
incident report in RiskMaster.
References:
N 1 Infusion Nurses Society (2002). Policies and Procedures for Infusion Nursing (2nd ed.): Infusion
Nurses Society, Inc.
N 2 Journal of Infusion Nursing (2011). Infusion related complications: extravasation. Infusion Nursing
Standards of Practice, 34 (1S), S67.
R 1 Hurst S, McMillan M. Innovative solutions in critical care units: extravasation guidelines.
Dimensions Critical Care Nursing 2004; 23(3): 125-8.
E 1 Martin SM, Cooper TY, Sterling J. Guide to extravasation management in adult patients. Hospital
Pharmacy 2005. Wall chart.
E 2 The National Extravasation Information Service. Extravasation treatment: warm versus cold.
http://www.extravasation.org.uk/home.html (accessed 2009 Mar 30).
Date Reviewed/Revised: 3/07, 3/08, 3/09, 3/10, 3/11, 3/12, 11/12, 6/13
© 2013 UPMC All Rights Reserved
Appendix A: Guidelines for Extravasation of Non-Chemotherapeutic Agents
Medication
Aminophylline
Amiodarone
Warm or Cold Compress#
Contrast Dye+
Cold
(cold –Phillips 2005, warm –
Josephson 2004)
Warm-(Gahart 2012,
Josephson 2004, UKansas
guidelines), (cold –Phillips
2005)
Warm-(Gahart 2012,
Josephson 2004, UK
guidelines)
(cold –Phillips 2005)
Cold
Dextrose >10%
Diazepam
Cold
Cold
Calcium Chloride
Calcium Gluconate
Dobutamine
Dopamine
Doxycycline
Epinephrine
Erythromycin
Esmolol
Lorazepam
Magnesium sulfate
Mannitol
Metoprolol
Nafcillin
Norepinephrine
Pamidronate
Penicillin
Phenobarbital
Phenylephrine
Phenytoin
Warm (Josepheson 2004, Hurst
2004)
Cold (Phillips 2005, UKansas
guidelines)
Warm(Josepheson 2004, Hurst
2004)
Cold (Phillips 2005, UKansas
guidelines)
Cold
Warm Josepheson 2004, Hurst
2004)
Cold (Phillips 2005, UKansas
guidelines)
Cold
Cold
Cold
Cold
No specific compress found
Cold
Cold
Warm Josepheson 2004, Hurst
2004)
Cold (Phillips 2005, UKansas
guidelines)
No specific compress found
Cold
no specific compress found
Warm Josepheson 2004, Hurst
2004)
Cold (Phillips 2005, UKansas
guidelines)
Cold
Antidote
**For severe extravasation**
Must be ordered by a physician
Hyaluronidase
Phentolamine (Phillips 2005,
Josephson 2004)
Hyaluronidase*
Hyaluronidase
Hyaluronidase (Hurst 2004, Cochran
2002, Rowlett 2012, St Joseph Health
System)
Hyaluronidase
No specific antidote (maybe 10ml of
1% lidocaine + heparinization – case
study – Weigand 2010)
Phentolamine
Phentolamine
(no specific antidote found)
Phentolamine
No specific antidote
No specific antidote
No specific antidote
No specific antidote
Hyaluronidase
No specific antidote
Hyaluronidase
Phentolamine
No specific antidote
Hyaluronidase/
no specific antidote found
Phentolamine
Hyaluronidase- listed as a possible
option with Nitroglycerin- Hurst (all
P-IV-14 Extravasation of Intravenous Medications Non-Chemotherapeutic Agents
Piperacillin
Piperacillin/Tazobactam
Potassium
Promethazine
Sodium Bicarbonate
Sodium Thiopental
Total Parenteral Nutrition (TPN)
Tromethamine
Vancomycin
Vasopressin
Cold
Cold
Cold (Phillips 2005, Hurst
2004)
Warm (Gahart 2012, Josephson
2004, UKansas guidelines)
Cold
Cold (Hurst 2004)
Warm (Gahart 2012, UKansas
Guidelines, Josephson 2004)
Cold
Cold
Cold
Cold
Warm (Wickham 2006)
Page 4 of 7
other sources- non specific)
No specific antidote
No specific antidote
Hyaluronidase
No specific antidote, sympathethic
block + heparinization (Gahart 2012)
Hyaluronidase + procaine 1% to
reduce vasospasm (Phillips 2005,
Josephson 2004)
(no specific antidote found – except
liposuction-Steinman case report
2005)
Hyaluronidase
Hyaluronidase(Josephson 2004) or
Phentolamine (Gahart 2012,
Josephson 2004) + procaine 1% to
reduce vasospasm (Josephson 2004)
Hyaluronidase
Phentolamine (Wickham 2006, St
Joseph Health Sysem)
* Plastic surgery consultation is recommended for any extravasation of calcium chloride.
+ For contrast infiltrates or extravasations, contact Radiology (PUH: 412-647-7368; SHY: 412-623-1051) or the
Emergency Department (PUH: 412-647-3333; SHY: 412-623-2063).
# WARM versus COLD compresses: Although sources agree that compresses are helpful, published
recommendations regarding the temperature of the compresses may vary.
If it is determined that intervention is needed, and the drug in question is not included on this list, the following
resources may be consulted:
 Plastic Surgery Service: At PUH, dial 412-647-7000 and ask for a Plastics consult.
 Toxicology Service: At PUH, dial 412-647-7000 and ask for a Toxicology consult.
 Drug Information Center: Dial 412-647-3784 (7-DRUG).
 PUH Pharmacy: 412-647-3350. (Select Option 1.) SHY Pharmacy: 412-623-4060.
 For contrast infiltrates or extravasations, contact Radiology (PUH: 412-647-7368; SHY: 412-623-1051)
or the Emergency Department (PUH: 412-647-3333; SHY: 412-623-2063).
Hyaluronidase* administration:
1. Hyaluronidase is most effective if administered within 60 minutes of severe extravasations warranting
hyaluronidase use. However, use may be beneficial up to 12 hours following the event.
2. Hyaluronidase should not be used in an inflamed area that may be infected.
3. If hyaluronidase use is appropriate, withdraw a total of 1 mL of the 150 or 200 units/mL solution (depending
on product available) into a 1 mL syringe.
4. Inject 0.2 mL portions of the solution subcutaneously in a clockwise pattern using a 27 G needle around the
leading edge of the extravasation site for a total of 5 injections (total = 1 mL). Change the needle between
injections.
Phentolamine*administration:
1. Use within 12 hours following the extravasation.
2. Withdraw 2 mL (5 mg) of reconstituted phentolamine solution using a 10 mL syringe. Add 0.9% sodium
chloride for injection for a total of 5 mL (1 mg/mL).
3. Inject 0.5 mL portions of the final solution subcutaneously with a 27 G needle in a clockwise pattern around
the extravasation site for a total of 6 injections (total = 3 mL), changing the needle between injections.
P-IV-14 Extravasation of Intravenous Medications Non-Chemotherapeutic Agents
Page 5 of 7
Antidote availability may vary due to recent drug shortages. If an antidote is deemed necessary and not available
through Pharmacy, Plastic Surgery should be contacted to determine if an alternate therapy is appropriate.
Alternate methods of antidote administration: See UPMC PUH SHY Nursing Policy P-ONC-14 for detailed
directions.
P-IV-14 Extravasation of Intravenous Medications Non-Chemotherapeutic Agents
Page 6 of 7
Appendix B: Recommended documentation of extravasation management within the medical record
1. Detailed description of extravasation site or flare reaction in nurse’s notes, including date and time of
event. Include size, location, color, erythema, etc.
2. Patient’s subjective description of discomfort and/or sensation.
3. Type of needle/catheter, size and insertion site.
4. Name of agent(s), concentration (dosage/dilution), sequence of administration, IV solution.
5. Procedure and administration technique.
6. Estimation of amount of fluid and drug infiltrated by noting the amount injected/infused between blood
return checks. Note electronic infusion device settings.
7. Management of extravasation. (Radiology studies performed, local treatments, limb elevation, attempted
withdrawal of fluid/drug, heating/cooling, drugs administered, patient instructions.)
8. Physician notification.
9. Photograph of extravasation site should be taken when indicated by physician or physician extender. (See
UPMC PUH SHY Nursing Policy P-ONC-14 for detailed directions.)
10. Patient education and follow-up assessment/instructions for monitoring of the extravasation site.
11. Referrals (vascular surgery, plastic surgery, radiology).
P-IV-14 Extravasation of Intravenous Medications Non-Chemotherapeutic Agents
Page 7 of 7
UPMC Presbyterian Shadyside – Appendix C
FLUSHING AND DRESSING REQUIREMENTS
FOR VARIOUS VASCULAR ACCESS DEVICES
MAINTENANCE CARE
Note: When positive pressure patency cap is used,
flush using push–pause method with recommended
amount of NSS. Do not push the last 0.5 CC to prevent
backflow of blood. Disconnect the syringe and engage
slide clamp, if present.
NSS FLUSH
BETWEEN
MEDS
NSS FLUSH AFTER
BLOOD
SAMPLING AND
ADMINISTRATION
Peripheral
3cc NSS daily and after each use.
3 - 5cc
5-10 cc
Midline
With positive pressure patency cap in place, administer
9.5 cc NSS every shift and after use.
10cc
20cc
PICC
With a positive pressure patency cap in place,
administer 9.5cc NSS every shift and after use.
10 cc
20cc
Valved PICC
Administer 10cc NSS weekly and after use.
10 cc
20cc
Tunneled CVC
With a positive pressure patency cap in place,
administer 9.5 cc NSS every shift and after use. If CVC
lumen(s) not in use, flush with 3cc 100u/ml heparin*
every shift.
10 cc
20cc
Every 7 days
Tunneled Groshong
Administer 9.5 cc NSS weekly and after use.
10 cc
20cc
Every 7 days
Implanted Port
including Pharmacia
PAS Port
Implanted Port with
Groshong Catheter
Administer 9.5 cc NSS and 5cc 100u/ml heparin*
monthly and after use. Implanted Port - no need for
heparin flush during active use.
Administer 9.5cc NSS monthly and after use.
10 cc
20cc
Every 7 days with
needle change.
10 cc
20cc
Every 7 days with
needle change.
10cc
10cc
Every 7 days
Tunneled Long
Term Apheresis
Catheter (Neostar
Triple Lumen, Bard
Trifusion) (Stem
Cell Transplant)
- Post-catheter placement administer 1000u/ml
heparin* to equal lumen priming volume every72hrs
and after use. Do not infuse heparin; withdraw prior
to use.
-During mobilization, apheresis, and in post- apheresis
pre-transplant period administer 1000u/ml heparin* to
equal lumen priming volume every72hrs and after use.
Do not infuse heparin; withdraw prior to use.
- Post-transplant and during inpatient admission other
than apheresis refer to Tunneled CVC for
maintenance.
10cc
20cc
Every 7 days
Short Term CVC
Percutaneously
Inserted (Arrow,
Hohn)
With a positive pressure patency cap in place,
administer 9.5 cc NSS every shift and after use.
10 cc
20cc
Every 7 days
DEVICE TYPE
Short Term or Bard
Double Lumen
Apheresis Catheter
(Oncology)
- Use only with approval from MD and apheresis staff.
- During apheresis period administer 1000u/ml
heparin* locking volume to equal lumen priming
volume every 72 hrs and after use. Do not infuse
heparin; withdraw prior to use.
TRANSPARENT
DRSG CHANGE
With insertion/site
change and PRN.
Initially at 48° to
remove gauze pad,
then at 7 days.
Initially at 48° to
remove gauze pad,
then at 7 days.
Initially at 48° to
remove gauze pad,
then at 7 days.
* If heparin is contraindicated in certain patient situations, line patency can be maintained with NSS 10cc every
shift.