Understanding Extravasation: A Critical Overview
Extravasation is the unintentional leakage of intravenous (IV) fluids or medications from a blood vessel into the surrounding subcutaneous or subdermal tissues [1.4.6, 1.7.4]. While infiltration refers to the leakage of a non-vesicant solution, extravasation specifically involves agents that can cause tissue damage [1.4.5]. This medical emergency can lead to a range of injuries, from mild irritation to severe tissue necrosis, blistering, and functional impairment, sometimes necessitating surgical intervention [1.3.7, 1.7.6]. The severity of the injury depends on several factors, including the type and concentration of the drug, the volume extravasated, the location of the injury, and the time to intervention [1.3.5]. Early recognition and prompt, appropriate management are paramount to mitigating harm [1.3.7].
Drug Classification and Potential for Harm
IV medications are often classified based on their potential to cause tissue damage upon extravasation [1.4.1, 1.4.6].
- Vesicants: These are agents capable of causing severe tissue damage, pain, inflammation, blistering, and necrosis [1.4.1, 1.4.2]. The damage can be extensive and may require surgical debridement or skin grafting. Vesicants are further divided into DNA-binding (e.g., anthracyclines like doxorubicin) and non-DNA-binding (e.g., vinca alkaloids like vincristine) categories. DNA-binding agents can persist in tissue for long periods, causing progressive cell death [1.3.1].
- Irritants: These drugs can cause inflammation, aching, tightness, or phlebitis at the injection site but typically do not cause tissue necrosis [1.5.4]. However, a large volume of an irritant can lead to more severe reactions [1.4.1]. Examples include carboplatin and etoposide [1.4.6].
- Exfoliants: This is a less common classification for drugs that can cause inflammation and shedding of the skin but are less likely to cause tissue death than vesicants [1.4.1].
- Non-vesicants (or Neutrals): These agents are unlikely to cause tissue damage if they extravasate [1.4.6].
The Immediate Extravasation Management Protocol
When an extravasation is suspected, a swift and standardized response is crucial. Healthcare providers should follow these immediate steps [1.2.2, 1.3.2, 1.3.3]:
- Stop the Infusion: Immediately stop administering the IV fluid or medication [1.3.2].
- Leave Cannula in Place: Do not remove the IV catheter or port needle initially [1.2.4].
- Aspirate the Drug: Disconnect the IV tubing and attach a 3-10 mL syringe to the cannula hub. Attempt to aspirate as much of the residual drug and blood from the line and surrounding tissue as possible [1.2.2, 1.2.3].
- Administer Antidote (if applicable): If a specific antidote is available and ordered, it may be administered through the existing catheter before its removal or injected subcutaneously around the site [1.2.2, 1.3.6].
- Remove the Cannula: After aspiration (and antidote administration, if done via the catheter), remove the IV access device [1.2.3].
- Elevate the Limb: Raise the affected extremity to help reduce swelling and decrease hydrostatic pressure [1.2.2, 1.3.3].
- Apply Thermal Compresses: Apply either a cold or warm compress, depending on the specific drug extravasated. This is a critical step where the correct choice is vital [1.2.3].
- Notify and Document: Notify the physician immediately. Thoroughly document the event, including the date, time, site, drug, estimated volume, patient symptoms, interventions performed, and photographic evidence if possible [1.2.2, 1.3.5].
Comparison of Thermal Treatments: Cold vs. Warm Compresses
The choice between a cold and warm compress is not arbitrary; it depends on the mechanism of action of the extravasated drug. Applying the wrong type of compress can worsen tissue damage [1.2.3, 1.3.4]. The typical application schedule is 15-20 minutes every 4-6 hours for 24 to 48 hours [1.2.2, 1.3.3].
| Thermal Treatment | Mechanism of Action | Indicated For | Contraindicated For |
|---|---|---|---|
| Cold Compress | Causes vasoconstriction, which limits the local spread and dispersion of the drug. It also reduces local inflammation and pain [1.2.2, 1.2.3]. | Most vesicants and irritants, including DNA-binding agents like anthracyclines (doxorubicin) and mitomycin [1.2.2, 1.2.3, 1.3.5]. | Vinca alkaloids (vincristine, vinblastine), etoposide, and vasopressors. Cold can worsen the ulceration caused by these drugs [1.2.3, 1.3.4]. |
| Warm Compress | Causes vasodilation, which increases local blood flow. This helps to disperse the drug over a larger area, diluting its concentration and enhancing its removal from the tissue [1.2.2, 1.3.4]. | Vinca alkaloids (vincristine, vinblastine), epipodophyllotoxins (etoposide), and vasopressors [1.2.3]. | Most DNA-binding vesicants, as dispersal could increase the area of tissue damage [1.3.5]. |
Pharmacologic Interventions and Antidotes
For certain types of extravasation, specific antidotes can neutralize the drug or help disperse it to minimize damage [1.5.5].
- Hyaluronidase: This enzyme breaks down hyaluronic acid in the subcutaneous tissue, increasing tissue permeability and allowing the extravasated drug to be dispersed and absorbed more quickly [1.3.6]. It is the primary antidote for extravasation of vinca alkaloids (e.g., vincristine) and taxanes (e.g., paclitaxel) [1.2.3, 1.5.5].
- Dexrazoxane (Totect®): This is the only FDA-approved antidote specifically for treating anthracycline extravasation [1.3.1, 1.5.5]. It is administered intravenously in a limb away from the extravasation site. Dexrazoxane is thought to work by chelating iron and inhibiting topoisomerase II, protecting healthy tissue from the anthracycline's damaging effects [1.3.1, 1.3.6].
- Sodium Thiosulfate: This agent neutralizes mechlorethamine (a nitrogen mustard) by providing an alternative substrate for alkylation [1.3.1, 1.5.5]. It may also be used for high-concentration cisplatin extravasations [1.2.3].
- Dimethyl Sulfoxide (DMSO): Applied topically, DMSO is a free-radical scavenger that can rapidly penetrate tissue and may enhance the absorption of the extravasated drug [1.3.1, 1.5.5]. It is often used for extravasations of anthracyclines (when dexrazoxane is not used) and mitomycin [1.2.3, 1.3.6].
Conclusion: The Importance of Prevention and Preparedness
While knowing the treatment protocol is essential, the best approach to extravasation is prevention [1.2.3]. This involves careful vein selection, using the appropriate catheter size, ensuring IV patency before and during infusion, and educating patients to report any pain or swelling immediately [1.8.1, 1.8.2]. Healthcare institutions should maintain readily accessible extravasation kits containing all necessary supplies, including syringes, needles, and key antidotes like hyaluronidase and sodium thiosulfate [1.2.2, 1.3.5]. Ongoing education and training for all healthcare professionals involved in IV therapy are fundamental to reducing the incidence of extravasation and ensuring that when it does occur, it is managed swiftly and effectively to protect patient safety and well-being [1.2.1, 1.3.2].
For more detailed guidelines and drug-specific recommendations, consult the Oncology Nursing Society (ONS).
