31: Peripheral IV Extravasation and Infiltration: Initial Management

I. INDICATION

To minimize initial injury resulting from infiltration of IV fluids into the tissue. Infiltration refers to the inadvertent leakage of nonvesicant (nonirritating) fluid from the vein into the surrounding tissues. Infiltration is usually considered benign unless a very large amount of fluid causes compression of nerves or compartment syndrome. Extravasation refers to the inadvertent leakage of vesicant fluid (highly caustic fluid or medication that is capable of causing tissue necrosis) from the vein into the surrounding tissues. This can cause a mild skin reaction or severe tissue necrosis or an injury so severe it leads to amputation.

II. PROCEDURES

1. Initial treatment is determined by the stage of the infiltration, the type of infiltrating solution, and the availability of specific antidotes. There is a lack of conclusive evidence regarding optimal care after IV extravasation in the newborn. Available information in the literature is primarily anecdotal or from descriptive case reports. A staging system has been proposed that provides guidance concerning the appropriate initial treatment options (Table 31–1). This chapter refers only to the initial management and not to the management of long-term complications (scarring, contractures, tissue loss, vascular compromise).

2. Specific antidotes

   1. Hyaluronidase

      1. Appropriate for stage III extravasation of IV fluids except vasoconstrictors.

      2. Administer within 1 hour after insult if possible, and not after 3 hours.

      3. Clean area with antimicrobial agent.

      4. Inject 1 mL (150 U) as 5 separate 0.2-mL subcutaneous injections around the periphery of the extravasation site. Use aseptic technique and change the needle after each injection.

      5. Cover with hydrogel dressing (Intrasite, Smith and Nephew, London) for 48 hours.

   2. Phentolamine (Regitine)

      1. The drug of choice for extravasation of dopamine and other vasoconstrictors.

      2. Clean area with antimicrobial agent.

      3. Inject a 0.5-mg/mL solution subcutaneously into the affected area. Usual amount needed is 1–5 mL, depending on size of infiltrate. May repeat if necessary.

3. Multiple needle puncture technique

   1. May be used to create an avenue for fluid to escape and help to minimize tissue damage.

   2. Clean with antimicrobial agent.

   3. Using a 20-gauge needle, puncture the skin subcutaneously in multiple areas of the edematous tissue. Change the needle after each injection.

   4. Cover with saline-soaked gauze to absorb the fluid, and elevate the extremity.

   5. Evaluate every 1–2 hours for 48 hours.