Chapter 42: Peripheral Intravenous Extravasation and Infiltration: Initial Management

I. INDICATION

To manage and minimize the initial injury resulting from infiltration of intravenous (IV) fluids or medications into tissue. Infiltration rates are high among neonates (up to 70%), with extravasation occurring in up to 23%. Risk factors associated with a higher risk of complications within 48 hours after puncture were: endotracheal intubation, total parenteral nutrition, blood transfusion, other medications, presence of infection, body weight at the day of insertion, and type of infusion (intermittent vs continuous).

1. Infiltration refers to the leakage of nonvesicant (nonirritating) fluid from a catheter into the surrounding tissues. Infiltrates are usually benign unless a large amount of fluid causes compression of nerves or compartment syndrome. Typically involves routine IV solutions.

2. Extravasation refers to the inadvertent leakage of vesicants (highly caustic fluid or medication that is capable of causing tissue necrosis) from a catheter into the surrounding tissues; this can occur from displacement of the catheter or increased vascular permeability. Common vesicants include total parenteral nutrition (TPN), potassium, bicarbonate, and high-dextrose concentrates. Extravasation can cause a mild skin reaction, severe tissue necrosis, or an injury so severe it leads to surgical intervention, including amputation.

II. PROCEDURES

1. Prevention of extravasation and infiltration should be the goal. This strategy includes frequent monitoring of puncture sites, appropriate infusion rates for the size of the catheter, and prompt evaluation if concerns of infiltration exist. Implementation of an IV infiltration management program or evidence-based guideline and checklist for IV infiltrate injuries was found to be effective in decreasing the IV infiltration rate and increasing the rate of early detection of infiltration. Cochrane review found insufficient evidence to recommend a single dressing or securement method over another for peripheral IVs and percutaneously inserted central catheters to prevent complications. Another consideration for prevention is to minimize vesicant administration through peripheral catheters as opposed to central lines.

2. Initial treatment is determined by the stage of the infiltration/extravasation, the type of solution, and the availability of specific antidotes. There is a lack of conclusive evidence regarding optimal care after IV extravasation in the newborn. Available literature is primarily anecdotal or descriptive case reports. A staging system has been proposed that provides guidance concerning the appropriate initial treatment options (Table 42–1). This chapter refers only to initial management and not to the management of long-term complications (scarring, tissue loss, vascular compromise).

3. Specific antidotes

   1. Hyaluronidase. Indicated for high osmotic solutions and drugs such as high-dextrose solutions, TPN, blood, calcium, penicillin, nafcillin, methicillin, potassium chloride, and vancomycin.

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

      2. Administer within 1 hour after insult if possible, and no later than 3 hours.

      3. Clean area with antimicrobial agent and maintain aseptic conditions.

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

      5. Cover with hydrogel dressing (IntraSite; Smith and Nephew, Andover MA) and elevate for ...