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BEST EVIDENCE-BASED PRACTICES

TO TREAT INTRAVENOUS INFILTRATION


OVERVIEW

CLINICIAN-RELATED RISKS

The purpose of our research is to identify the best practice for


IV infiltration management. Although IV infiltration is a common
occurrence, extensive
research on the subject
is limited. We explored
several medical journals,
reviewed case studies and
web-based articles in an
effort to compile effective
practices to improve
patient outcomes.

Inadequate nursing knowledge pertaining to:


F Peripheral IV Insertion
F Identification of vesicant vs. non-vesicant agents
Poor assessment skills
F Hourly assessments recommended
Geriatrics, Pediatrics and infusion of vesicants
F Assessments every 4 hours recommended
Patients receiving infusion of non-vesicant/irritants
Negligence in overall nursing care planning, intervention and
follow-up care

RECOGNIZING INFILTRATION IN
OUR PATIENTS

WHAT IS IV
INFILTRATION?
Displacement of non-vesicant, or irritant medications or
fluids into surrounding tissues
F Aldesleukin (interleukin-2)
F Ifosfamide
F Bleomycin
Displacement of vesicant medications into surrounding
tissues is known as extravasation
F Antibiotics
F Lactated Ringers
F Dilantin
F Cytotoxic (chemotherapy drugs), and non-cytotoxic
drugs (Digoxin, Diazepam, TPN)
F DNA binding (Anthryacycline Antibiotics)
F Non-DNA binding (Alkylators, antitumor antibiotics)

DEVICE-RELATED RISKS
Metal needles, large-gauge catheters
F Smaller is better!
Inadequately secured IV needle or catheter
F Use a transparent dressing!
F Crisscross tape after the transparent dressing
is applied
Undesirable IV site location
F Avoid areas of flexion
F Avoid hard, cordlike veins
F Avoid veins of the hand
F Avoid the antecubital fossa
F Veins of the forearm are preferred

PATIENT-RELATED
RISKS
Pre-existing
medical conditions
Age
F
F

Pediatrics
Geriatrics
Communication
barrier
Fragile veins

Source: (Sauerland, C., Engelking, C., Wickham, R., & Corbi, D., 2006)

Chemotherapy patients
Diabetics
Hypovolemia
Cultural groups
F Asian Culture
F
F
F

Source: (Sauerland, C., Engelking, C., Wickham, R., & Corbi, D., 2006)

Infiltration
Blanched skin
F Swelling
Possible numbness
F Redness
Circulatory impairment
F Edema
Skin tight and leaking
F Pain
INS Infiltration Scale
F Grade 0: No symptoms
F Grade 1: Skin blanched; edema <1 in any direction;
cool to touch; may have pain
F Grade 2: (same as Grade 1) to include edema 1-6
in any direction
F Grade 3: Skin blanched; translucent; gross edema
>6 in any direction; cool to touch; mild to moderate
pain; possible numbness
F Grade 4: Typically considered extravasation; skin
discolored, bruised, swollen; circulatory impairment;
moderate to severe pain;

BEST EVIDENCE-BASED PRACTICES FOR


TREATMENT OF IV INFILTRATION
Remove cannula immediately
Assess site
Evaluate ROM and sensation in affected limb
Assess for sensory deficit
Measure area of infiltration
F Cautious use of warm or cold compresses
F
F
F
F
F

Sources: (Dougherty, L., 2008); (Schulmeister, L., 2009); (Sauerland, C., Engelking, C.,
Wickham, R., & Corbi, D., 2006); (Schummer, W., et. al., 2005)

RECOGNIZING EXTRAVASATION IN
OUR PATIENTS
Typically classified as Grade 4 on INS Infiltration Scale
Degree of injury is proportionate to:
Amount of drug infused
Location of peripheral IV site
Concentration of the drug
F All of which can lead to:
Ulceration within days or weeks
Severe, continuous pain
Tissue damage and possible
impairment of affected limb
F
F

Source: (Dougherty, L., 2008); (Sauerland, C.,


Engelking, C., Wickham, R., & Cordi, D., 2006)

BEST EVIDENCE-BASED PRACTICES FOR


TREATMENT OF EXTRAVASATION
Factors to consider prior to treatment:
F The individual
F Type of vesicant used
F Institutions protocol for treatment
Systematic Approach
F Stop infusion immediately
F Determine substance and amount used
F Consider location of peripheral catheter
F Length of contact with the substance
F Cold or hot compresses?
Use of Hot or Cold compresses?
F Cold
Used to treat DNA-binding vesicant infiltration
- Results in vasoconstriction, localizing extravasation
- Apply 15-20 mins 3-4 x daily for up to three days, or as
indicated by the physician
F Hot
Used to treat Non-DNA binding vesicant infiltration
- Results in vasodilation
Reduces local drug concentration
Decreases pain
Helps with reabsorption of local swelling
- Apply via electric heating pad or covered hot water bottle
for up to 24 hours, or as prescribed by the physician
Elevation of affected limb
Antidotes
F Steroid Cream
Reduces local trauma and irritation
Hyaluronidase
F An enzyme that helps to reduce tissue
damage
F Promotes drug absorption
F Usually injected around the
extravasation site
F Itching and redness may occur
Dimethyl Sulfoxide (DMSO)
F Topical solution
F Antidote to cytotoxic drugs such
as anthracyclines
F Itching and redness may occur
Dextrazoxone
F Reduces the size and duration
of the wound
F Must be administered within 6
hours of extravasation
F Only used with anthracycline cytotoxic drugs
Surgical Intervention
F Surgical Incision
Effective if lesion is of a certain size or there is residual
pain or minimal healing
F Flush-Out Technique
Infiltration of the area with a local anesthetic
Making a number of small stab incisions
Tissue is flushed out using normal saline
Effective if performed immediately after extravasation
Usually performed by a plastic surgeon
Source: (Dougherty, L., 2008); (Schulmeister, L., 2009); (Sauerland, C., Engelking,
C., Wickham, R., & Corbi, D., 2006)

PREVENTING EXTRAVASATION
F
F
F
F
F
F
F
F
F
F

Hourly assessments
Cover site with
transparent dressing
Stabilize equipment
Proper site selection
Use smallest gauge
plastic cannula possible
Prepare and organize
material prior to insertion
Vesicant education for
all nurses
Pharmacy
involvement
Interdisciplinary
approach
IVT (Intravenous
Therapy) Teams
The Journal
of Clinical
Innovations
suggests IVT
Teams reduce
the occurrences
of complications
associated with
peripheral IVs.
Evidence is limited pertaining to the Cost
effectiveness of implementing such teams.
Based on the academic review and appraisal
of a multitude of articles, case studies and
random clinical trials, it is our suggestion
that hospitals conduct an independent study
to determine the effectiveness of IVT Teams
in relation to cost.

POLICY CHANGES

12. Infiltration/Extravasation
Remove catheter.
Warm/Cool compresses:
a. Warm compresses:
i. All chemotherapy agents

STANDARD OF PRACTICE
STANDARD NUMBER: 1624,320
STANDARD TITLE: Peripheral Intravenous Therapy
REGULATORY STANDARD:
EFFECTIVE DATE: 05/06
REVISION DATE: 11/2008, 6/2010, 08/2010, 9,2011

ii. Dopamine
b. Cool compresses
i. All hypertonic solutions and antibiotics
refer to 1624.140 Extravasation

STATEMENT:
c. For drug specific detail,
Peripheral intravenous (IV) therapy will be provided based on physician order in a safe,
Management policy
aseptic manner for short-term vascular access and fluid administration.

Complete an Adverse Drug Event form


Detail charting to include:
a. Site of infiltration
b. Assessment of surrounding area
Complete infiltration scale in HED.
Document further skin assessment in HED.
GUIDELINES:
Notify physician if the infiltration is Stage 3 or greater and for all
1. Observe proper hand-hygiene procedures either by washing hands with
extravasations. (refer to policy 1624.140 Extravasation Management)
conventional antiseptic-containing soap and water or with waterless alcoholbased gels or foams. Observe hand hygiene before and after palpating
catheter
Do not start IV in the same extremity.
SCOPE:
All patients with peripheral IV sites
RESPONSIBILITY:
RN, IV Credentialed LPN

Insertion sites, as well as before and after inserting, replacing, accessing,


repairing or dressing an intravascular catheter. Palpation of the insertion site
should not be performed after the application of antiseptic, unless aseptic
technique is maintained. Use of gloves does not obviate the need for hand
hygiene.
2. The drip rate safety feature on the IV pump will be utilized for all IV Heparin,
Insulin, Vasoactive and Antiarrhythmic drugs.
a. In emergency situations, continuous vasoactive drugs and propofol, if
started peripherally, should be changed to central line access as soon as
practical.

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