Response to extravasation incidents
Extravasation of a vesicant is a medical emergency, and immediate action must be taken to avoid severe and permanent tissue damage.
Tissue damage from extravasation is time-dependent and management of extravasation aims at minimising ongoing cellular injury through dilution, reversal of effect or dispersion.
First 60 seconds
- Stop the infusion. Call for assistance
- Do not remove the intravenous cannula or needle
- Aspirate residual solution or medicine
- DO NOT FLUSH
Minutes 1 to 5
- Notify the team
- Refer to local extravasation policy and obtain extravasation kit
- Identify the medicine
- Find the medicine in the list below and choose the antidote or management strategy
- Outline affected area with marker and document/photograph affected area in medical notes
Minutes 5 to 30
- Administer the antidote if indicated
- Apply the compress
- Provide pain relief as required
- Elevate limb to minimise swelling
First 24 hours
- Continue compresses, photography and documentation
- Request surgical consult assessment if indicated
First 7 days
- Daily reassessment of tissue site
- Compress continuation as per management strategy
- Escalation if necrosis develops
Subcutaneous Hyaluronidase
- Hydrolyses hyaluronic acid in connective tissue stroma, promoting dispersion and absorption of extravasated fluid. May be used to reduce necrosis in severe extravasation
- Warm dry compresses are often used in conjunction with hyaluronidase to facilitate its mechanism of action
- Preparation:
- Dissolve hyaluronidase powder (1500 international units) in 1 mL of water for injection
- Further dilute with water for injection or sodium chloride 0.9% to a total volume of 10 mL = 150 units/mL
- Instructions:
- Administer after saline washout
- Inject up to 5 injections of 0.2 mL around the edge of the extravasation site
- Usual total dose = 150 units (1 mL)
- Needle should be changed after each injection
- Dose may be repeated after 30-60 minutes
Subcutaneous Phentolamine
- Alpha adrenergic receptor antagonist, used to counter the effects of vasoconstriction and ischemia in the event of vasopressor extravasation
- Preparation:
- 5 mg made up to 10 mL with 0.9% sodium chloride = 0.5 mg/mL
- Instructions:
- Inject in 4–5 small aliquots intradermally across the site of injury
- Dose 0.1–0.2 mg/kg to a maximum of 5 mg
- May be repeated in adults
- Ideally injection is administered as soon as possible, but may be used up to 12 hours following injury
Other antidotes may also be used e.g. topical glyceryl trinitrate or terbutaline. Check local guidelines.
Compresses must remain dry as moist or wet compresses will contribute to skin breakdown and may worsen the injury.
Cold dry compress
- Induces vasoconstriction and limits spread of medication or solution, reducing damage to surrounding tissue. Also contributes to reduction in inflammation
- Use ice in sealed bags or gel packs if available
- Protect the skin by wrapping the gel pack or ice
- Use cold compress for 20 minutes every 4 to 6 hours for 24–72 hours
- Keep the site dry
Warm dry compress
- Increases vasodilation and encourages medication or solution dispersion away from the affected area
- Use gel pack or wipes warmed in microwave for 1 minute
- Protect the skin by wrapping the gel pack or wipes
Response by medicine
For a medicine specific response, find the medicine in the list below.
This drug list is not exhaustive, as it is a list of non-cytotoxic medicines with vesicant or irritant qualities only. Contact a pharmacist or medicines information service for treatment options for other medications.
Adrenaline (epinephrine)
Vesicant
Risk of injury from extravasation: High
Mechanism of injury: Vasopressor
Treatment
Warm dry compress only
Antidote
Subcutaneous Phentolamine
Additional information
Avoid ice packs and hyaluronidase monotherapy
Aciclovir
Irritant with vesicant properties
Risk of injury from extravasation: High
Mechanism of injury: pH
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase (only with warm compress)
Additional information
Avoid attempts to neutralise pH
Aminophylline
Vesicant
Risk of injury from extravasation: Low
Mechanism of injury: Osmolarity
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Supportive therapies for wound healing
Amiodarone
Vesicant
Risk of injury from extravasation: High
Mechanism of injury: pH
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Avoid attempts to neutralise pH
Amphotericin B
Irritant
Risk of injury from extravasation: Low
Mechanism of injury: Chemical irritation
Treatment
Cold dry compress (initially followed by warm after 48hrs)
Antidote
No antidote identified
Additional information
None
Argipressin (vasopressin)
Vesicant
Risk of injury from extravasation: High
Mechanism of injury: Vasopressor
Treatment
Warm dry compress only
Antidote
Subcutaneous Phentolamine
Additional information
Avoid ice packs and hyaluronidase monotherapy
Benzylpenicillin
Irritant
Risk of injury from extravasation: Low
Mechanism of injury: Unknown
Treatment
Warm dry compress or cold dry compress
Antidote
Subcutaneous Hyaluronidase (only with warm compress)
Additional information
Compress should be guided by patient comfort
Calcium chloride 10%
Vesicant
Risk of injury from extravasation: High
Mechanism of injury: Osmolarity
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Delayed tissue injury can occur
Calcium gluconate
Vesicant
Risk of injury from extravasation: High
Mechanism of injury: Osmolarity
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Delayed tissue injury can occur
Cefazolin
Irritant
Risk of injury from extravasation: Low
Mechanism of injury: pH/Osmolarity
Treatment
Warm dry compress or cold dry compress
Antidote
No antidote identified
Additional information
Compress should be guided by patient comfort
Cefotaxime
Irritant
Risk of injury from extravasation: Low
Mechanism of injury: pH/Osmolarity
Treatment
Warm dry compress or cold dry compress
Antidote
No antidote identified
Additional information
Compress should be guided by patient comfort
Ceftazidime
Irritant
Risk of injury from extravasation: Low
Mechanism of injury: pH/Osmolarity
Treatment
Warm dry compress or cold dry compress
Antidote
No antidote identified
Additional information
Compress should be guided by patient comfort
Ceftriaxone
Irritant
Risk of injury from extravasation: Low
Mechanism of injury: pH/Osmolarity
Treatment
Warm dry compress or cold dry compress
Antidote
No antidote identified
Additional information
Compress should be guided by patient comfort
Cefuroxime
Irritant
Risk of injury from extravasation: Low
Mechanism of injury: pH/Osmolarity
Treatment
Warm dry compress or cold dry compress
Antidote
No antidote identified
Additional information
Compress should be guided by patient comfort
Ciprofloxacin
Irritant
Risk of injury from extravasation: Low
Mechanism of injury: pH
Treatment
Warm dry compress or cold dry compress
Antidote
No antidote identified
Additional information
Compress should be guided by patient comfort
Clindamycin
Irritant
Risk of injury from extravasation: Low
Mechanism of injury: pH/Osmolarity
Treatment
Warm dry compress or cold dry compress
Antidote
No antidote identified
Additional information
Compress should be guided by patient comfort
Dantrolene
Vesicant
Risk of injury from extravasation: Medium
Mechanism of injury: pH
Treatment
Cold dry compress only
Antidote
No antidote identified
Additional information
None
Dextrose (10-50%)
Vesicant
Risk of injury from extravasation: Medium
Mechanism of injury: Osmolarity
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Supportive therapies for wound healing
Diazepam
Vesicant
Risk of injury from extravasation: Medium
Mechanism of injury: Osmolarity
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Supportive therapies for wound healing
Digoxin
Vesicant
Risk of injury from extravasation: Medium
Mechanism of injury: Osmolarity
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Supportive therapies for wound healing
Dobutamine
Vesicant
Risk of injury from extravasation: High
Mechanism of injury: Vasopressor
Treatment
Warm dry compress only
Antidote
Subcutaneous Phentolamine
Additional information
Avoid ice packs or hyaluronidase monotherapy
Dopamine
Vesicant
Risk of injury from extravasation: High
Mechanism of injury: Vasopressor
Treatment
Warm dry compress only
Antidote
Subcutaneous Phentolamine
Additional information
Avoid ice packs or hyaluronidase monotherapy
Doxycycline
Irritant with vesicant properties
Risk of injury from extravasation: High
Mechanism of injury: pH
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Avoid attempts to neutralise pH
Erythromycin
Irritant
Risk of injury from extravasation: Medium
Mechanism of injury: Osmolarity
Treatment
Cold dry compress only
Antidote
No antidote identified
Additional information
Conservative treatment
Esmolol
Vesicant
Risk of injury from extravasation: High
Mechanism of injury: pH
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Avoid attempts to neutralise pH
Etomidate
Vesicant
Risk of injury from extravasation: Medium
Mechanism of injury: Osmolarity
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Supportive therapies for wound healing
Flucloxacillin
Irritant
Risk of injury from extravasation: Medium
Mechanism of injury: Osmolarity
Treatment
Cold dry compress only
Antidote
No antidote identified
Additional information
Conservative treatment
Ganciclovir
Vesicant
Risk of injury from extravasation: Medium
Mechanism of injury: pH
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Avoid attempts to neutralise pH
Gentamicin
Vesicant
Risk of injury from extravasation: Low
Mechanism of injury: pH
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Avoid attempts to neutralise pH
Iron (various IV formulations)
Irritant with vesicant properties
Risk of injury from extravasation: Low
Mechanism of injury: Chemical irritation
Treatment
Warm dry compress or cold dry compress
Antidote
No antidote identified
Additional information
Compress should be guided by patient comfort
Lorazepam
Vesicant
Risk of injury from extravasation: Medium
Mechanism of injury: Osmolarity
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Supportive therapies for wound healing
Magnesium sulphate
Vesicant
Risk of injury from extravasation: Low
Mechanism of injury: Osmolarity
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Supportive therapies for wound healing
Mannitol
Vesicant
Risk of injury from extravasation: High
Mechanism of injury: Osmolarity
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Supportive therapies for wound healing
Meropenem
Irritant
Risk of injury from extravasation: Low
Mechanism of injury: pH
Treatment
Warm dry compress or cold dry compress
Antidote
No antidote identified
Additional information
Compress should be guided by patient comfort
Methylene blue
Vesicant
Risk of injury from extravasation: High
Mechanism of injury: Vasopressor
Treatment
Warm dry compress only
Antidote
Subcutaneous Phentolamine
Additional information
Avoid ice packs and hyaluronidase monotherapy
Metronidazole
Irritant with vesicant properties
Risk of injury from extravasation: High
Mechanism of injury: pH
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Avoid attempts to neutralise pH
Nicardipine
Vesicant
Risk of injury from extravasation: High
Mechanism of injury: pH
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Avoid attempts to neutralise pH
Noradrenaline (norepinephrine)
Vesicant
Risk of injury from extravasation: High
Mechanism of injury: Vasopressor
Treatment
Warm dry compress only
Antidote
Subcutaneous Phentolamine
Additional information
Avoid ice packs and hyaluronidase monotherapy
Nutrition (IVN – peripheral)
Irritant
Risk of injury from extravasation: High
Mechanism of injury: Osmolarity
Treatment
Warm dry compress or cold dry compress
Antidote
Subcutaneous Hyaluronidase (only with warm compress)
Additional information
Compress should be guided by patient comfort
Nutrition (IVN – central)
Vesicant
Risk of injury from extravasation: High
Mechanism of injury: Osmolarity
Treatment
Warm dry compress or cold dry compress
Antidote
Subcutaneous Hyaluronidase (only with warm compress)
Additional information
Supportive therapies for wound healing
Pentamidine
Vesicant
Risk of injury from extravasation: Low
Mechanism of injury: pH
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Avoid attempts to neutralise pH
Phenobarbital
Vesicant
Risk of injury from extravasation: Medium
Mechanism of injury: pH/Osmolarity
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Avoid attempts to neutralise pH
Phenylephrine
Vesicant
Risk of injury from extravasation: High
Mechanism of injury: Vasopressor
Treatment
Warm dry compress only
Antidote
Subcutaneous Phentolamine
Additional information
Avoid ice packs and hyaluronidase monotherapy
Phenytoin
Vesicant
Risk of injury from extravasation: Medium
Mechanism of injury: pH/Osmolarity
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Avoid attempts to neutralise pH
Piperacillin + tazobactam
Irritant
Risk of injury from extravasation: Low
Mechanism of injury: pH/Osmolarity
Treatment
Warm dry compress or cold dry compress
Antidote
No antidote identified
Additional information
Compress should be guided by patient comfort
Potassium chloride (greater than 40 mmol/L)
Vesicant
Risk of injury from extravasation: High
Mechanism of injury: Osmolarity
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Supportive therapies for wound healing
Potassium phosphate
Vesicant
Risk of injury from extravasation: High
Mechanism of injury: Osmolarity
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Supportive therapies for wound healing
Promethazine
Vesicant
Risk of injury from extravasation: High
Mechanism of injury: pH
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Avoid attempts to neutralise pH
Propofol
Irritant
Risk of injury from extravasation: High
Mechanism of injury: Chemical irritation
Treatment
Warm dry compress or cold dry compress
Antidote
Subcutaneous Hyaluronidase (only with warm compress)
Additional information
None
Remdesivir
Vesicant
Risk of injury from extravasation: Low
Mechanism of injury: pH
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
None
Sodium bicarbonate
Vesicant
Risk of injury from extravasation: High
Mechanism of injury: Osmolarity
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Supportive therapies for wound healing
Sodium chloride ≥3%
Vesicant
Risk of injury from extravasation: High
Mechanism of injury: Osmolarity
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Supportive therapies for wound healing
Sodium valproate
Irritant with vesicant properties
Risk of injury from extravasation: High
Mechanism of injury: Unknown
Treatment
Cold dry compress only
Antidote
No antidote identified
Additional information
Supportive therapies for wound healing
Sulfamethoxazole + Trimethoprim
Irritant
Risk of injury from extravasation: Medium
Mechanism of injury: pH
Treatment
Warm dry compress or cold dry compress
Antidote
No antidote identified
Additional information
Compress should be guided by patient comfort
Terlipressin
Vesicant
Risk of injury from extravasation: High
Mechanism of injury: Vasopressor
Treatment
Warm dry compress only
Antidote
Subcutaneous Phentolamine
Additional information
Avoid ice packs or hyaluronidase monotherapy
Tobramycin
Irritant
Risk of injury from extravasation: Low
Mechanism of injury: pH/Osmolarity
Treatment
Warm dry compress or cold dry compress
Antidote
No antidote identified
Additional information
Compress should be guided by patient comfort
Vancomycin
Irritant with vesicant properties
Risk of injury from extravasation: High
Mechanism of injury: pH
Treatment
Warm dry compress only
Antidote
Subcutaneous Hyaluronidase
Additional information
Avoid attempts to neutralise pH
Medicine name
Vesicant Irritant Irritant with vesicant properties
Risk of injury from extravasation: High Medium Low
Mechanism of injury: Short text
Treatment
Cold dry compress only
Warm dry compress only
Warm dry compress or cold dry compress
Antidote
Subcutaneous Hyaluronidase
Subcutaneous Phentolamine
No antidote identified
Additional information
Text to appear here
Background
Extravasation and infiltration refer to the unintentional leakage of medicine from the vessel or direct infiltration into the extravascular space. Extravasation of a vesicant is a medical emergency, and prevention strategies are key to reducing the risk of extravasation and minimising tissue damage.
Infiltration – unintentional leakage of intravenous fluid or non-vesicant medication into the extravascular tissue from an intravenous vascular access device, such as a peripheral cannula or central venous catheter. The resulting injury is likely to be minor.
Extravasation – unintentional leakage of a medication or intravenous solution into the extravascular tissue from an intravenous vascular access device, such as a peripheral cannula or central venous catheter, which may result in local tissue damage. The risk of tissue injury is high and likely to be serious.
Vesicant medication – medication that has the potential to cause blistering, tissue damage or necrosis when inadvertently administered into surrounding tissues. There are 4 main groups of vesicant medicines or solutions: chemotherapy agents, medicines with non-physiological pH (low or high pH), vasopressors and hyperosmolar solutions.
Irritant (non-vesicant) medication – medication that can cause pain, inflammation or irritation at the site of extravasation, but is less likely to cause necrosis or permanent tissue damage.
Irritant with vesicant properties – medications that are difficult to classify as either a vesicant or irritant. They can cause tissue damage and ulceration which is proportional to the amount and concentration of the drug extravasated into the extravascular tissue.
Phlebitis – inflammation of a vein wall associated with a peripheral intravenous catheter, usually from mechanical irritation, chemical irritation, or bacterial contamination, typically presenting with pain, redness, warmth, swelling and/or tenderness along the course of the vein. It is distinct from extravasation as the inflammation occurs within the vein rather than from leakage into surrounding extravascular tissue.
Risk factors for extravasation injury include:
- Very young or very old age
- Patients with an altered level of consciousness or sensation
- Oncology patients
- Patients with difficult IV access (BMI over 30, patients with deep vessels, IV drug users or patients with chronic loss of peripheral veins)
- Patients with dementia, delirium or learning disabilities
- Patients with age-related or medical comorbidities that alter the integrity of the skin and subcutaneous tissue or impair tissue perfusion (e.g. peripheral vascular disease, diabetes)
Irritant or vesicant medications should be administered through a central venous access device where possible. If no central access is available, a large peripheral intravenous device should be used and closely monitored. A large vein is preferred due to their larger diameter which allows for easier access and stability during intravenous administration. Common large veins include: the median cubital vein, the cephalic vein and the accessory cephalic vein.
Recognising extravasation:
- Pain and burning at the insertion site and along the vein path
- Erythema and oedema
- Blistering of the skin
- Tissue sloughing becomes apparent within a week up to 4 weeks
- Necrosis can involve a small area or a large area and can include underlying connective tissue, muscle, tendons and bone which may necessitate surgical intervention
To minimise the risk of extravasation:
- Know the properties of the medication or fluid that you are administering. The drug monographs include labels for medications known to be vesicants, irritants or irritant with vesicant properties
- Only nurses who are skilled and experienced in administration of vesicant or irritant medications should administer these
- Use the appropriate dilution and rate of administration
- Flush the line with a compatible fluid after giving the medication
- Encourage patients to report any pain or burning during administration