Peak Development for ...

Medication Administration

Vol. 15 Issue 11
November 2014

IV Therapy: Extravasation
Prevention and Management
Peak Development Resources
P.O. Box 13267
Richmond, VA 23225
Phone: (804) 233-3707
Fax: (804) 233-3705
Email: editor@peakdev.com

Peak Development for Medication

Administration and Competency
Assessment Tool for Medication
Administration are components of
a site license for the Peak
Development Resources
Competency Assessment System
for Medication Administration
and may be reproduced for this
individual facility only. Sharing
of these components with any
other freestanding facility within
or outside the licensees corporate
entity is expressly prohibited.

The information contained in

Peak Development for Medication
Administration is intended only as
a guide for the practice of
licensed nursing personnel who
administer medications. Every
effort has been made to verify the
accuracy of the information
herein. Because of rapid changes
in the field of drug therapy, the
reader is advised to consult the
package insert, facility pharmacist
or patients physician for relevant
information. This is particularly
important for new or seldom used
drugs. Use of professional
judgment is required in all patient
care situations. It is the readers
responsibility to understand and
adhere to policies and procedures
set forth by the employing
institution. The editor and
publisher of this newsletter
disclaim any liability resulting
from use or misuse of
information contained herein.
Copyright 2014

After completion the learner should be able to:

1. Define extravasation.
2. Identify risk factors for extravasation.
3. Discuss nursing actions to prevent and
manage extravasation.
The Institute of Safe Medication Practices
reported the case of a 19-year old woman who
went to the emergency department with flu-like
symptoms. She received a dose of IV
promethazine (Phenergan), and experienced
severe pain during the injection. She continued
to complain of pain after the injection, and the
nurse reassured her and left the room. Shortly
thereafter, her arm and fingers turned purple.
She was hospitalized for 30 days, as her fingers
turned black and several had to be amputated,
including her thumb.
IV therapy is one of the most common
invasive procedures performed in hospitals, with
90% or more of patients receiving some type of
IV therapy. More than 200 million peripheral IV
(PIV) devices and over 5 million central venous
access devices (CVADs) are inserted each year
in the US. With any invasive medical treatment,
there are possible risks and complications, and
IV therapy is no exception. One potentially
serious risk of IV therapy is extravasation. This
occurs when vesicants, which are medications
or other fluids that can cause blistering and
tissue damage, inadvertently leak into the
tissues surrounding the vein. Infiltration is a
similar process, in which medications or other
fluids leak outside the vein, but this involves non
-vesicant substances that do not typically cause
the extensive tissue damage that extravasation
can. Extravasation can cause blistering,
necrosis, full-thickness skin loss, damage to
tendons, nerves and muscles, and tissue death
leading to gangrene and amputation.
Factors Affecting Vesicant Tissue Damage
Vesicant drugs and solutions can cause
injury to surrounding tissues based on several
factors:

Acid/base balance: Drugs and solutions that

have a very high or very low pH are most likely
to cause tissue damage. Ranges for greatest
risk include pH of less than 5 or greater than 9.
Osmolarity: The concentration of a drug/
solution plays a significant role in possible tissue
damage. Hypertonic drugs and solutions, such
as dextrose 10% or greater, parenteral nutrition
and sodium bicarbonate, can cause serious
tissue injury.
Effect on cells: Antineoplastic agents
administered to treat cancer can be grouped into
DNA binding and non-DNA binding. Some
agents, such as anthracyclines and alkylating
agents (for example, doxorubicin and
mechlorethamine) bind irreversibly to DNA in the
cells. These agents cause prolonged and severe
tissue damage, because the drug remains in the
tissues. Non-binding agents, such as vinca
alkaloids and taxanes (for example, vincristine,
vinblastine and paclitaxel) tend to cause less
damage, as they are cleared from the tissue
more quickly, and cell repair and healing are
more likely to occur.
Effect on blood vessels: Drugs that constrict
blood vessels, such as dopamine and
norepinephrine, are more likely to cause
ischemic injury to surrounding tissues.
Volume and contact: The larger the amount
of drug/solution in the tissues, and the longer
contact it has with the tissues, the greater is the
degree of possible tissue damage.
While antineoplastic drugs are commonly
associated with vesicant effects, there are many
other drugs also identified as vesicants.
Selected drugs and solutions include:
Antineoplastic agents: Alkylating agents,
anthracyclines, antitumor antibiotics, vinca
alkaloids
Other drugs: Alteplase, aminophylline,
diazepam, digoxin, dopamine, dobutamine,
magnesium sulfate, midazolam, nitroprusside,
norepinephrine, phenytoin, potassium chloride,

promethazine, radiographic contrast agents, sodium

bicarbonate, vancomycin
Solutions: dextrose 10% or greater, parenteral nutrition,
sodium chloride 1.8% or greater
Risk Factors and Mechanisms of Extravasation
Any patient receiving intravenous drugs or solutions with
vesicant properties may experience tissue damage due to
extravasation. However, some patients are at higher risk than
others. These include the very young and very old, those with
small, fragile, mobile or sclerosed veins, poor circulation,
obesity, and impaired communication or sensory perception,
such as dementia, neuropathy, sedation or language barriers.
Extravasation occurs when the IV access device is not
completely within the confines of an intact vein. This may occur
if the tip of the device punctures the vein or the vein erodes
around the tip or ruptures due to vein wall damage.
Extravasation occurs most commonly with peripheral IV devices.
It can also occur with CVAD, but the risk is significantly reduced.
Prevention and Management
While proper technique and careful monitoring can help to
decrease the risk of extravasation, not all cases can be
prevented. General guidelines for prevention and management
of extravasation will be presented here. Always be familiar with
and follow the guidelines of your facility.
When inserting a PIV catheter in an upper extremity, begin
at a distal point, lowest on the arm. If the insertion is
unsuccessful, further attempts should be made proximal to this
point, moving upward on the arm. This prevents leakage of
irritating substances from the previously-punctured veins. For
administration of vesicant drugs via a PIV, avoid placing the
catheter in the back of the hand or wrist, as these sites have
little underlying tissue and damage to nerves and tendons may
be more extensive. Areas of movement, such as the antecubital
space, should also be avoided. A firm, stable area with
subcutaneous tissue, such as the forearm, is usually preferable.
For PIVs, rigid needles, such as a butterfly type, should be
avoided, as these are more likely to puncture through the vein.
The smallest-gauge flexible catheter that will provide proper
infusion should be used, as this tends to cause less vein trauma
and allows maximum blood flow around the catheter to dilute the
drug. The device should be firmly anchored in place, with a
transparent dressing that allows direct observation of the site.
Use of a CVAD is preferable for continuous or ongoing
administration of vesicants.
Prior to vesicant drug administration, the prescriber should
inform the patient about the possibility of extravasation and
tissue damage. As the treatment is started, the patient should be
encouraged to protect the IV site and limit its movement, if
possible. The nurse should review signs of extravasation with

the patient and instruct him/her to report any changes around

the site immediately. The nurse should also be familiar with the
recommended initial actions to treat extravasation for that drug,
such as the availability and appropriate use of the extravasation
kit and whether warm or cold compresses should be used.
Before a vesicant drug is administered, the function of the
IV should be assessed according to facility policy. This may
involve, for example, flushing a PIV with normal saline to check
for infiltration, or withdrawing blood from a CVAD. If proper
placement within the vein cannot be verified, the drug should not
be administered using that site. Prior to infusion, the drug should
be diluted as recommended or ordered. Observation and
documentation of the site during infusion, every 5-10 minutes, is
essential for early detection of problems. After the infusion is
complete, the line should be flushed with normal saline to
prevent drug contact with tissues when the device is removed.
Initial signs of extravasation are often similar to those of
infiltration fullness or swelling at the site with taut, cool skin,
palpable sub-q fluid, leaking from the insertion site and
decreased flow rate. Mild to severe pain, often described as
burning or stinging, is common, although may not occur in all
cases. Redness, blanching or warmth may also occur. This may
progress to blisters, mottling, ulceration, tissue sloughing and
eschar formation. Additional signs with a CVAD may include
aching in the shoulder or neck, cough, dyspnea and chest pain.
Progressive tissue damage can continue for days, weeks, and
even months.
If extravasation occurs, the infusion should be disconnected
immediately, leaving the catheter in place. The amount of
extravasated fluid should be estimated, the physician notified,
and facility policy and physician orders followed. A syringe
should be attached to the catheter to aspirate as much fluid from
the site as possible, and the arm elevated. The site should not
be flushed with saline, as this may spread the vesicant. The
boundaries of the affected area should be marked with
permanent marker, and photographs taken of the site, per facility
policy. Pulses, sensation and mobility in the affected area should
be assessed frequently. Warm or cold compresses are typically
ordered, depending on the drug type. Treatment of extravasation
may include injection of antidote medications systemically or into
the site, through the catheter and/or directly into the skin. Some
of these drugs include hyaluronidase, dexaroxane, phentolamine
and steroids. Ensure that the patient receives analgesics for
pain relief, if needed. Thorough documentation of the condition
of the site and actions taken is critical. The facilitys policies for
reporting/documenting an adverse event should be followed.
Extravasation is a serious medical complication that can
result in pain, prolonged recovery, disability and amputation.
Through careful IV management, observation and early
detection of IV abnormalities, this risk can be reduced.

Peak Development for Medication Administration

IV Therapy: ExtravasationPrevention and Management

Page 2

Peak Development for ...

Medication Administration
Competency Assessment Tool

Vol. 15 Issue 11
November 2014

IV Therapy: Extravasation
Prevention and Management
NAME:

DATE:

UNIT:

Directions: Place the letter of the one best answer in the space provided.
_____1. The majority of hospitalized patients receive some type of IV therapy.
A. True
B. False
_____2. The major difference between infiltration and extravasation is the:
A. location of the event
B. type of fluid or medication infused
C. amount of fluid or medication infused
D. cause of the event
_____3. Which of the following best describes a vesicant drug:
A. is more likely than other drugs to leak outside the vein
B. produces clots that occlude the IV access device
C. causes blistering
D. all of the above
_____4. Antineoplastic agents that bind to DNA in the cells cause greater damage on extravasation
than drugs that do not bind to DNA.
A. True
B. False
_____5. Which of the following antineoplastic drugs is likely to cause the most tissue damage if
extravasation occurs:
A. vinblastine
B. paclitaxel
C. vincristine
D. doxorubicin

_____6. Tissue damage with extravasation is most likely to occur with drugs that:
A. have a pH range of 6 to 8
B. are hypertonic
C. cross the blood-brain barrier
D. cause dilation of blood vessels
_____7. The risk of extravasation is eliminated if a central venous access device is used for drug
administration.
A. True
B. False
_____8. The preferred placement of a peripheral IV when administering vesicant drugs is the:
A. back of the hand
B. wrist
C. forearm
D. antecubital space
_____9. Signs of extravasation may include:
A. pain, often described as burning or stinging
B. swelling of the area around the insertion site
C. redness and/or blister formation
D. all of the above
_____10. When extravasation occurs in a peripheral IV catheter, the nurse should immediately:
A. disconnect the tubing, leaving the catheter in place
B. leave the tubing connected and flush the line with normal saline through a port
C. remove the catheter, allowing as much fluid to leak out as possible
D. contact the physician for orders to stop the infusion

Competency Assessment Tool

IV Therapy: ExtravasationPrevention and Management

Page 2

Peak Development for ...

Medication Administration

Month: November 2014

Issue:
IV Therapy: Extravasation
Prevention and Management

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IV Therapy: ExtravasationPrevention and Management

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