Peripheral venous extravasation injury

Extravasation is the inadvertent administration or leakage of blood, lymph or other fluid (including medication) into the subcutaneous or subdermal tissues, instead of the intended vascular or lymphatic pathways.^1,2

It remains a well-established risk of injection of peripheral i.v. medications with reported rates between 0.1% and 6.5%. Whilst most events have only minor sequelae, certain ‘vesicant’ drugs can cause catastrophic tissue injury.^3,4

This Essential Notes article aims to promote risk awareness, timely recognition and optimal management of peripheral venous extravasation injury within anaesthesia and critical care medicine.

Aetiology

There are several risk factors for extravasation from a peripheral vein.⁴ These can be categorised as:

• (i)
  Patient-related factors

  • •
    Increased skin and vein fragility (extremes of age, corticosteroids, chemotherapy and i.v. drug use)
  • •
    Altered pain perception (peripheral vascular disease, diabetes mellitus and stroke)
  • •
    Impaired venous return (venous insufficiency and superior vena cava obstruction)
  • •
    Communication impediment (language issues, sedated, unconscious or confused)
• (ii)
  Vein selection

  • •
    Cannula sited distal to previously attempted venepuncture/cannulation site
  • •
    Cannulation of periarticular areas, such as the foot, ankle and antecubital fossa (greater risk of catheter dislodgement), and sites of previous radiation or surgery and after lymph node clearance/lymphoedema
• (iii)
  Drug provision factors

  • •
    Inadequately secured or non-visible insertion sites (opaque dressings and bandage)
  • •
    Drug given by distracted, untrained or inexperienced personnel
  • •
    Use of power injectors (routine in diagnostic and interventional radiology settings)
  • •
    Use of drug delivery device without a pressure-limiting mechanism or resistance alarm
  • •
    Use of steel-winged infusion devices (e.g. metal butterfly needles)
  • •
    Prolonged infusion or high infusion rate

Identification and importance of early detection

Various symptoms and signs can indicate extravasation. Tenderness, discomfort, swelling, taut skin, induration, leakage of fluid, blanching, erythema, fixed staining (purpura or bruising), blisters, weeping and necrosis around the injection site are all concerning features. Tingling, burning and stinging pain during injection; absent backflow of blood; abnormal resistance detected on the syringe plunger during injection of a bolus; and an infusion that is not flowing freely or has stopped should also raise suspicion of extravasation.

Early recognition and diagnosis are critical, as delays in identification and management may increase the likelihood of irreversible tissue injury. Severe aesthetic and functional consequences may occur. These include blistering; peeling; tissue necrosis; chronic pain, including complex regional pain syndrome; damage to tendons, nerves and joints; functional and sensory impairment; permanent physical defects; and loss of limb or tissue. In addition, the cost of prolonged hospitalisation and reconstructive surgery, psychological distress and litigation may all be avoided with greater awareness of and responsiveness to the features detailed earlier.⁴

Management

Early management

Figure 1 summarises the initial actions that should occur once extravasation is detected or suspected to minimise ensuing tissue injury.⁵

Figure 1.

Algorithm for the timely management of extravasation injury.⁵ ∗Please see ‘Evolving tissue injury risk assessment’ section for definition of ‘high risk’.

Evolving tissue injury risk assessment

Drugs have the potential to cause tissue damage through various pathophysiological mechanisms. Such processes include vasoconstriction and ischaemic necrosis, direct toxicity, osmotic damage and volume-related mechanical compression (Table 1).^3,6,7

Table 1.

Drug classification definitions and mechanisms of vesicant toxicity. • = Cool compress, • = Warm compress.

A high risk of ensuing tissue injury exists in the following scenarios:

• (1) Vesicant drug extravasation (any volume)

• (2) Moderate (or greater) volume of irritant drug extravasation (≥5 ml)

• (3) Grade 3 to 4 severity (any agent)

• (4) High volume (>50 ml; smaller volume in young children) and suspicion of compartment syndrome (any agent)

Subsequent management

Because only 11–21% of all extravasation events require any surgical intervention, low-risk cases may be managed conservatively by the usual care team.³ Low-risk inpatients should receive four-hourly observations for the first 72 h and the plastic surgery team contacted if deterioration is observed. Outpatients and day-case patients should only be released from the hospital after an initial 4 h period of observation, provided that any signs and symptoms that were present initially have improved or that new symptoms have not developed during the observation period. Because severe extravasation injuries can develop slowly, every patient who is discharged should be given clear instructions concerning where and when to seek additional medical attention (for severe or progressive pain, development of paraesthesia, diminished range of motion and new skin ulceration or blistering).

Simple management includes giving analgesia, the application of serial non-constrictive dressings, elevation of the affected limb and local thermal therapy (cool or warm compress application for 15–20 min, and then four hourly for 24–48 h). The cool compress is used to ‘localise and neutralise’ (limiting drug dispersion and damage of adjacent tissue), whilst the warm compress is used to ‘dilute and disperse’ (aiding dispersion and decreasing drug accumulation in the local tissue). However, care must be taken to apply the correct temperature compress (Table 1), as incorrect application may exacerbate tissue injury.^4,8

Where high-risk events occur, referral to the plastic surgery team is mandatory. A variety of specialist-delivered management options are available, especially if the injury occurs within the necrosis interval/window of opportunity (4–6 h after extravasation).

Specific antidotes

Subcutaneous hyaluronidase is a suitable antidote for all non-vasoactive agents, where a ‘dilute and disperse’ approach is indicated. It enzymatically increases tissue permeability, which facilitates diffusion and systemic absorption. Additional specific antidotes for vasoconstrictor agents include topical nitroglycerine 2% ointment, subcutaneous phentolamine and subcutaneous terbutaline. Each of these vasodilator agents may reduce tissue ischaemia and necrotic injury.^3,8

Specialist surgical interventions

• (i)Low to moderate volume (≤50 ml): liposuction; modified Gault flush-out technique, which typically involves performing multiple incisions across the extravasation area and then sequentially flushing saline through each of the incisions to disperse the noxious agent and encourage egress of irrigation fluid and extravasate via the remaining incision sites
• (ii)High volume (>50 ml) without evidence of compartment syndrome: squeeze technique, which typically involves performing multiple punctures near the catheter insertion site and then manually squeezing the edges of the distended area towards the puncture points to ‘milk’/promote efflux of the extravasate
• (iii)High volume (>50 ml) with evidence of compartment syndrome: fasciotomy
• (iv)Other: excision and debridement of wound and rarely amputation and reconstruction³

Conclusions

In anaesthesia and critical care medicine, where the provision of i.v. therapy is commonplace, the potential for extravasation injury cannot be disregarded.

Management of these events remains challenging because of the vast array of agents used and the general paucity of evidence to support a standardised approach. This Essential Notes article describes this lack of evidence and optimises the management of this potentially devastating, yet preventable, iatrogenic injury.

Acknowledgements

The authors acknowledge the contributions of Mr David Wallace MRCS, MSc, DIC, FRCS (Plast) (consultant plastic surgeon; University Hospital Coventry and Warwickshire NHS Trust) and Mrs Julie Midgley LLB LPC (head of Legal Department; University Hospital Coventry and Warwickshire NHS Trust) for their assistance in the production of this article.

Declaration of interest

The authors declare that they have no conflicts of interest.

Biographies

Mat Billingham MRCP FRCA is a specialty registrar in anaesthesia in the West Midlands Deanery with an interest in paediatric anaesthesia and advanced vascular access techniques.

Rohit Mittal FRCA is a consultant neuroanaesthetist with an interest in TIVA, depth of anaesthesia and patients' safety.

Matrix codes: 1A02, 1I01, 1I05, 2A06, 2D03 and 3H00