Understanding IV Extravasation
Intravenous (IV) therapy is a cornerstone of modern medicine, but it is not without risks. One of the most serious complications is extravasation, which occurs when a vesicant drug—a medication capable of causing severe tissue damage—leaks from the vein into the surrounding subcutaneous tissue [1.9.2]. This is distinct from infiltration, which involves non-vesicant fluids [1.7.1]. The incidence of extravasation in adults is reported to be between 0.1% and 6% and can lead to severe consequences including pain, inflammation, blistering, tissue necrosis (death), and even limb loss, potentially requiring surgical intervention [1.9.2, 1.7.2].
The damage is dependent on several factors, including the type and concentration of the drug, the volume extravasated, and the time until intervention [1.9.2]. Prompt recognition and management are crucial to mitigate harm. Healthcare providers should be trained to identify early signs like pain, burning, swelling, redness, and a lack of blood return from the IV catheter [1.9.2, 1.11.2].
Immediate General Management Steps
Before administering a specific antidote, a series of immediate, universal steps should be taken as soon as an extravasation is suspected [1.2.1, 1.8.2]:
- Stop the infusion immediately: This is the most critical first action to prevent more fluid from leaking [1.2.3].
- Leave the catheter in place: Do not remove the IV cannula right away. It can be used to attempt to aspirate the extravasated drug and, if indicated, to administer an antidote directly to the site [1.2.1].
- Aspirate residual fluid: Gently try to aspirate as much of the leaked solution as possible from the catheter and surrounding tissue [1.2.5].
- Notify the physician: The responsible provider must be informed immediately to oversee further treatment decisions [1.2.5].
- Remove the catheter: After aspirating and administering any local antidote, the catheter can be removed [1.2.1].
- Elevate the affected limb: Raising the limb helps reduce swelling and edema by decreasing hydrostatic pressure [1.8.1].
- Apply compresses: The choice between warm and cold compresses depends on the extravasated agent. Warm compresses cause vasodilation and help disperse the drug, while cold compresses cause vasoconstriction, limiting the drug's spread [1.8.3, 1.2.2].
Specific Pharmacological Antidotes
The choice of antidote is entirely dependent on the class and mechanism of the extravasated drug. There is no single universal antidote. An extravasation kit should be readily available in areas where IV medications are administered [1.2.2, 1.9.2].
Hyaluronidase
Hyaluronidase is an enzyme that breaks down hyaluronic acid in connective tissue, increasing tissue permeability. This action helps to disperse the extravasated drug over a larger area, facilitating its absorption and reducing local toxicity [1.5.4, 1.8.3].
- Indications: It is the antidote of choice for extravasation of many non-vesicant agents, hyperosmolar solutions (like total parenteral nutrition or concentrated dextrose), contrast media, and certain chemotherapy agents like vinca alkaloids [1.2.1, 1.5.4].
- Administration: It is typically diluted (e.g., 150 units in 1 mL of normal saline) and administered via subcutaneous injections in a radial pattern around the extravasation site as soon as possible, ideally within 1-2 hours of the event [1.5.4, 1.10.2]. Warm compresses are often used in conjunction with hyaluronidase [1.8.3].
Phentolamine
Phentolamine is a nonselective alpha-adrenergic antagonist. It works by causing vasodilation, which counteracts the intense vasoconstriction caused by extravasated vasopressor medications [1.4.3]. This reversal of vasoconstriction restores blood flow and helps prevent tissue ischemia and necrosis.
- Indications: It is the antidote of choice for the extravasation of vasopressors such as norepinephrine, dopamine, epinephrine, and phenylephrine [1.4.2].
- Administration: It is diluted and injected subcutaneously into the blanched, ischemic area. Treatment should begin as soon as possible but can be effective up to 12 hours after the event [1.4.3, 1.4.5]. Due to national shortages of phentolamine, alternatives like topical nitroglycerin and subcutaneous terbutaline have been used [1.4.3].
Dexrazoxane (Totect®)
Dexrazoxane is the only antidote specifically approved by the FDA for treating anthracycline extravasation [1.2.3, 1.6.1]. Anthracyclines (e.g., doxorubicin, daunorubicin) are chemotherapy agents that are highly damaging to tissue [1.6.4]. Dexrazoxane is believed to work by chelating iron, which prevents the formation of destructive free radicals generated by the anthracycline [1.2.3].
- Indications: Used exclusively for extravasation of anthracycline chemotherapy [1.6.4].
- Administration: Unlike other antidotes, dexrazoxane is administered systemically via intravenous infusion into a large vein in a limb away from the affected site. The first dose must be given within 6 hours of the event, followed by two more doses on the subsequent two days [1.2.3, 1.6.2].
Sodium Thiosulfate & Dimethyl Sulfoxide (DMSO)
- Sodium Thiosulfate: This agent acts as a chemical neutralizer for certain alkylating agents. It creates an alkaline environment, causing the vesicant to bind to it instead of the tissue, with the byproduct excreted in the urine [1.2.3]. It is primarily recommended for mechlorethamine extravasation [1.8.4]. It is injected subcutaneously around the site [1.2.3].
- Dimethyl Sulfoxide (DMSO): This is a solvent applied topically to the skin over the affected area. It enhances the absorption of the extravasated drug and has anti-inflammatory and free-radical scavenging properties [1.2.3]. It is used for some chemotherapy extravasations, including anthracyclines and mitomycin [1.8.4].
Comparison of Common Antidotes
| Antidote | Mechanism of Action | Common Indications | Administration Route |
|---|---|---|---|
| Hyaluronidase | Degrades hyaluronic acid to disperse drug [1.5.4] | Vinca alkaloids, taxanes, hyperosmolar solutions [1.8.4, 1.5.4] | Subcutaneous (local) [1.10.2] |
| Phentolamine | Alpha-adrenergic antagonist; vasodilates [1.4.3] | Vasopressors (e.g., Norepinephrine, Dopamine) [1.4.2] | Subcutaneous (local) [1.4.3] |
| Dexrazoxane | Iron chelator; inhibits topoisomerase II [1.2.3] | Anthracyclines (e.g., Doxorubicin) [1.6.4] | Intravenous (systemic) [1.6.2] |
| Sodium Thiosulfate | Chemical neutralization [1.2.3] | Mechlorethamine (nitrogen mustard) [1.8.4] | Subcutaneous (local) [1.2.3] |
| DMSO | Enhances absorption, free-radical scavenger [1.2.3] | Anthracyclines, Mitomycin C [1.8.4] | Topical [1.2.3] |
Conclusion
Answering "What is the antidote for IV extravasation?" requires identifying the specific drug that has leaked into the tissue. While immediate non-pharmacologic steps like stopping the infusion and elevating the limb are universal, the pharmacological intervention is highly specific. From locally injected agents like hyaluronidase and phentolamine to the systemic treatment with dexrazoxane for toxic chemotherapy spills, a rapid and correct response is vital. Following institutional guidelines and ensuring staff are well-trained in both prevention and management protocols are the best ways to protect patients from the severe and lasting damage that extravasation can cause [1.2.2, 1.9.2].
For more information on extravasation management, refer to the guidelines from the Oncology Nursing Society.
