With more than 90% of hospitalized patients receiving some type of IV therapy through a vascular access device, it is not surprising that the number of serious IV injuries has dramatically increased. Infusion-related complications of infiltration and extravasation cause nerve injury, muscle injury, and tissue injury, which can lead to skin grafts and in many cases amputation.
Infiltration is the inadvertent infusion of non-vesicant solutions or medications into the surrounding tissue. Extravasation is the inadvertent infusion of vesicant solutions into the surrounding tissue. A vesicant is defined as a drug that is capable of causing tissue injury.
Infiltration versus extravasation
Small infiltrations of non-vesicant medications happen frequently with no negative outcomes to the patient. The solutions/medications are absorbed by the blood vessels over time. However, large infiltrations can cause compartment syndrome, which can require an emergent fasciotomy. If not recognized and treated promptly and properly, the patient may be left with a permanent nerve injury, severe scaring, and reduced functional capacity of the extremity.
Extravasation is a much more serious complication. Vesicant drugs, in many cases, cause no damage to the vein. However, when vesicant medications leak out of the vein and make contact with the tissue, the damage begins. Non-chemotherapeutic vesicant drugs include sodium bicarbonate, calcium chloride, calcium gluceptate, esmolol, concentrated potassium chloride, and dopamine. Chemotherapeutic vesicant drugs include doxorubicin, vinblastine, vincristine, mithramycin, and vinorelbine.
The amount of tissue damage is directly related to the concentration of the drug infusion and the amount of drug in the tissue. This chemical fact has a direct correlation to the nursing care of the patient during the infusion. When non-vesicants are infusing, it is reasonable that the IV infusion is assessed every four hours because the volume of the IV fluids in the tissue is the main predictor of potential injuries. Vesicant infusions are totally different. Concentrated vesicant infusions should be assessed every 15 to 30 minutes. Diluted vesicant infusions should be assessed every one to two hours.
Dealing with extravasation
The best treatment for extravasation is prevention. When the extravasation occurs, commonly used antidotes may or may not work. According to the Oncology Nursing Societys Chemotherapy and Biotherapy Guidelines and Recommendations for Practice, treatments using sodium thiosulfite and DMSO have shown very limited success. In some cases, the manufacturer has specific recommendations for treatment of an extravasation. When doxorubin extravasates, for example, the manufacturer recommends applications of cool packs to the swollen area. When vinca alkaloids extravasate, the recommendation is warm packs to the swollen area. In all cases of suspected or actual extravasation, the physician should be notified immediately and given specific information about the drug and drug concentration, as well as an accurate, detailed description of the appearance of extravasated area.
Hospitals may have specific extravasation policies and procedures. It is the nurses responsibility to know the hospitals policy. In some cases, the protocol may include subcutaneous steroid injections and/or application of steroid or Silvadene creams. In most cases, once the infusion has extravasated, the only thing that can be done is to monitor the site until tissue damage demarcation is complete. At this point, the site will be assessed for maximum tissue damage. In many cases, a split or full thickness skin graft may be required. In the worst case scenario, amputation above the injury may be required to remove the dead tissue or to stop the spread of the tissue damage.
To help prevent extravasation, two myths need to be dispelled: The first is that a new IV device should be used for each vesicant infusion. A new IV site is not guaranteed to work better than an existing one. The second myth is that a peripheral IV catheter should be checked for a blood return prior to the infusion and during the infusion. According to Infusion Therapy in Clinical Practice, obtaining a blood return on a peripheral IV catheter is an inconclusive assessment tool and should not be relied on to determine if the IV catheter is properly seated within the vein. Obtaining a blood flash or obtaining no blood return from a peripheral IV catheter is not an indication of catheter placement within the vein.
The most reliable tests are flushing the catheter before and during the procedure with copious amounts of saline and observing the site for swelling. A complete assessment of the IV site prior to the infusion is essential. A free flowing bag of normal saline should be infusing for IV push or IV piggyback vesicant injections. The vein should be completely flushed with at least 20 mL to 30 mL of saline after the vesicant infusion is complete to prevent the vesicant from tracking when the IV catheter is removed. The site should be continually assessed for swelling, coolness, stinging, or burning. When in doubt, the IV device should be removed. Any patient complaint is an indicator that the catheter may be malfunctioning.
Central venous catheters
Although extravasation is not as common as with peripheral IV devices, central venous catheters are not without their problems. In most cases, central line extravasation occurs when the catheter tip is malpositioned or the catheter is malfunctioning. According to Chemotherapy and Biotherapy Guidelines and Recommendations for Practice, it is of the utmost importance to verify catheter tip placement in the superior vena cava or atrial/ caval junction via X-ray. If during the vesicant infusion the patient has complaints of chest, back, neck, or shoulder pain or discomfort, the infusion should be stopped immediately, and the catheter should be X-rayed again. Vesicants have been infused through malpositioned central catheters in the chest cavity, brain, pleural space, and lung. The outcome can often be the demise of the patient.
Before any drug is administered through any central venous catheter (including ports, PICC and all multi- lumen catheters), a substantial free flowing blood return of 3 mL to 5 mL must be obtained. The superior vena cava has a blood flow of 2,000 mL/min. Obtaining a flash of blood or no blood return is a signal that the catheter is malfunctioning. This is usually due to the formation of a fibrin sheath on the outside catheter surface.
When vesicants are administered through a catheter with a fibrin sheath, the drug will leak retrograde around the catheter, causing the vesicant to leak into the port pocket or around the catheter exit site. This has caused extensive chest burns, which have resulted in extensive chest skin grafting. In many women, the drug leaks into the breast, requiring a mastectomy.
In summary, when administering vesicant drugs through peripheral and central venous catheters, be sure that the catheter is properly placed in the vein and is functioning properly. If there is any doubt, dont use the catheter for vesicant infusions. Prevention is key, as there are no viable or reliable treatments for most vesicant extravasations. The Infusion Nurse Society Standards of Practice mandate that continuous vesicant infusions should be administered through a central venous catheter. Since extravasations are classified as stage 4 chemical burns, The Joint Commission considers them sentinel events, and INS suggests a variance report be completed.
There have been numerous malpractice cases against nurses who administered vesicants improperly through peripheral and central venous catheters. In many cases, nurses are the primary defendants, since they administer the medications and monitor the IV sites during infusions. Not only do the nurses lose the cases, but the patient can be left with injuries that range from small tissue burns to major chest burns to total arm amputations. Taking time to prevent extravasation injuries is the best course of action for nurses who administer vesicant infusions.