BEST EVIDENCE-BASED PRACTICES
TO TREAT INTRAVENOUS INFILTRATION
OVERVIEW
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.
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 Pediatrics
F Geriatrics
• Communication
barrier
• Fragile veins
Source: (Sauerland, C., Engelking, C., Wickham, R., & Corbi, D., 2006)
CLINICIAN-RELATED RISKS BEST EVIDENCE-BASED PRACTICES FOR PREVENTING EXTRAVASATION
Inadequate nursing knowledge pertaining to: Hourly assessments
F Peripheral IV Insertion
TREATMENT OF EXTRAVASATION F
F Cover site with
F Identification of vesicant vs. non-vesicant agents Factors to consider prior to treatment: transparent dressing
Poor assessment skills F The individual F Stabilize equipment
F Type of vesicant used
F Hourly assessments recommended F Proper site selection
F Institution’s protocol for treatment
• Geriatrics, Pediatrics and infusion of vesicants F Use smallest gauge
F Assessments every 4 hours recommended
Systematic Approach plastic cannula possible
• Patients receiving infusion of non-vesicant/irritants F Stop infusion immediately F Prepare and organize
Negligence in overall nursing care planning, intervention and F Determine substance and amount used material prior to insertion
F Consider location of peripheral catheter
follow-up care F Vesicant education for
F Length of contact with the substance
Source: (Sauerland, C., Engelking, C., Wickham, R., & Corbi, D., 2006) all nurses
F Cold or hot compresses?
F Pharmacy
RECOGNIZING INFILTRATION IN Use of Hot or Cold compresses?
F Cold
involvement
F Interdisciplinary
OUR PATIENTS • Used to treat DNA-binding vesicant infiltration
approach
Infiltration - Results in vasoconstriction, localizing extravasation F IVT (Intravenous
F Swelling • Blanched skin - Apply 15-20 mins 3-4 x daily for up to three days, or as Therapy) Teams
F Redness • Possible numbness indicated by the physician • The Journal
F Hot
F Edema • Circulatory impairment of Clinical
• Used to treat Non-DNA binding vesicant infiltration
F Pain • Skin tight and leaking Innovations
INS Infiltration Scale - Results in vasodilation suggests IVT
F Grade 0: No symptoms • Reduces local drug concentration
Teams reduce
F Grade 1: Skin blanched; edema <1” in any direction; • Decreases pain
the occurrences
cool to touch; may have pain • Helps with reabsorption of local swelling
of complications
F Grade 2: (same as Grade 1) to include edema 1-6” - Apply via electric heating pad or covered hot water bottle associated with
for up to 24 hours, or as prescribed by the physician
in any direction peripheral IV’s.
F Grade 3: Skin blanched; translucent; gross edema Elevation of affected limb • Evidence is limited pertaining to the Cost
>6” in any direction; cool to touch; mild to moderate Antidotes effectiveness of implementing such teams.
pain; possible numbness F Steroid Cream • Based on the academic review and appraisal
F Grade 4: Typically considered extravasation; skin • Reduces local trauma and irritation
of a multitude of articles, case studies and
discolored, bruised, swollen; circulatory impairment; Hyaluronidase random clinical trials, it is our suggestion
moderate to severe pain; F An enzyme that helps to reduce tissue
that hospitals conduct an independent study
damage to determine the effectiveness of IVT Teams
F Promotes drug absorption
BEST EVIDENCE-BASED PRACTICES FOR F Usually injected around the
in relation to cost.
TREATMENT OF IV INFILTRATION extravasation site
F Itching and redness may occur
F Remove cannula immediately
Dimethyl Sulfoxide (DMSO)
F Assess site F Topical solution POLICY CHANGES
F Evaluate ROM and sensation in affected limb F Antidote to cytotoxic drugs such
F Assess for sensory deficit
as anthracyclines
F Measure area of infiltration F Itching and redness may occur
F Cautious use of warm or cold compresses
Dextrazoxone 12. Infiltration/Extravasation
Sources: (Dougherty, L., 2008); (Schulmeister, L., 2009); (Sauerland, C., Engelking, C., • Remove catheter.
F Reduces the size and duration • Warm/Cool compresses:
Wickham, R., & Corbi, D., 2006); (Schummer, W., et. al., 2005)
of the wound STANDARD OF PRACTICE a. Warm compresses:
i. All chemotherapy agents
F Must be administered within 6
RECOGNIZING EXTRAVASATION IN hours of extravasation
STANDARD NUMBER: 1624,320
STANDARD TITLE: Peripheral Intravenous Therapy
OUR PATIENTS F Only used with anthracycline cytotoxic drugs
REGULATORY STANDARD:
EFFECTIVE DATE: 05/06 ii. Dopamine
Surgical Intervention
F Typically classified as Grade 4 on INS Infiltration Scale
F Surgical Incision
REVISION DATE: 11/2008, 6/2010, 08/2010, 9,2011
STATEMENT:
b. Cool compresses
i. All hypertonic solutions and antibiotics
F Degree of injury is proportionate to: c. For drug specific detail,
Peripheral intravenous (IV) therapy will be provided based on physician order in a safe,
refer to 1624.140 Extravasation
FChemotherapy patients • Effective if lesion is of a certain size or there is residual aseptic manner for short-term vascular access and fluid administration. Management policy
• Amount of drug infused • Complete an Adverse Drug Event form
FDiabetics pain or minimal healing SCOPE:
All patients with peripheral IV sites
• Detail charting to include:
• Location of peripheral IV site a. Site of infiltration
FHypovolemia F Flush-Out Technique RESPONSIBILITY: b. Assessment of surrounding area
• Concentration of the drug RN, IV Credentialed LPN
• Complete infiltration scale in HED.
Cultural groups • Infiltration of the area with a local anesthetic GUIDELINES: • Document further skin assessment in HED.
F All of which can lead to: • Notify physician if the infiltration is Stage 3 or greater and for all
F Asian Culture • Making a number of small stab incisions 1. Observe proper hand-hygiene procedures either by washing hands with
extravasations. (refer to policy 1624.140 Extravasation Management)
• Ulceration within days or weeks conventional antiseptic-containing soap and water or with waterless alcohol-
• Tissue is flushed out using normal saline • catheter
based gels or foams. Observe hand hygiene before and after palpating Do not start IV in the same extremity.
Insertion sites, as well as before and after inserting, replacing, accessing,
• Severe, continuous pain repairing or dressing an intravascular catheter. Palpation of the insertion site
• Effective if performed immediately after extravasation should not be performed after the application of antiseptic, unless aseptic
• Tissue damage and possible technique is maintained. Use of gloves does not obviate the need for hand
• Usually performed by a plastic surgeon hygiene.
2. The drip rate safety feature on the IV pump will be utilized for all IV Heparin,
impairment of affected limb Insulin, Vasoactive and Antiarrhythmic drugs.
Source: (Dougherty, L., 2008); (Schulmeister, L., 2009); (Sauerland, C., Engelking, a. In emergency situations, continuous vasoactive drugs and propofol, if
started peripherally, should be changed to central line access as soon as
Source: (Dougherty, L., 2008); (Sauerland, C., C., Wickham, R., & Corbi, D., 2006) practical.
Engelking, C., Wickham, R., & Cordi, D., 2006)