Immediate Nursing Actions: The First Steps
When a nurse suspects or identifies an IV extravasation, immediate action is paramount to mitigate tissue injury. The initial steps, often remembered by mnemonics, are critical for patient safety. Prompt recognition of symptoms, such as pain, swelling, burning, or a sudden change in infusion pressure, triggers a standardized emergency protocol. A nurse should follow these steps immediately:
- Stop the Infusion: Halt the IV push or infusion immediately to prevent further leakage of the drug into the surrounding tissue. This is the single most important action.
- Disconnect Tubing, Leave Cannula: Disconnect the IV tubing from the catheter, but do not remove the intravenous access device (cannula) yet. Removing it prematurely can reduce the opportunity to aspirate the extravasated fluid or administer an antidote through the existing access point.
- Attempt Aspiration: Use a small syringe (e.g., 3-5 mL) to gently attempt aspiration of as much of the extravasated drug and fluid as possible through the still-in-place cannula. This step is not recommended for radiographic contrast media.
- Remove Cannula: After attempting aspiration, remove the IV cannula or port needle.
- Notify Provider: Immediately notify the healthcare provider of the incident. This triggers the medical team's response and allows for timely antidote orders or surgical consults if needed.
Non-Pharmacologic Site Management
After the initial emergency steps, non-pharmacologic interventions focus on controlling the local spread of the drug and reducing symptoms.
- Elevate the Extremity: Position the affected limb above the heart level to minimize swelling and encourage resorption of the extravasated fluid via the lymphatic system.
- Apply Thermal Compresses: The choice of a warm or cold compress depends on the specific drug's properties and its effect on local tissue.
- Cold Compresses (Vasoconstriction): Generally recommended for most vesicant and irritant drugs, as it causes vasoconstriction, limiting drug dispersion and reducing pain and inflammation.
- Warm Compresses (Vasodilation): Recommended for drugs like vinca alkaloids, epipodophyllotoxins (etoposide), and vasopressors. The heat promotes vasodilation, increasing local blood flow and enhancing drug removal from the tissue.
- Mark the Area: Use a surgical marker to outline the area of extravasation. This provides a clear reference point for monitoring the spread or resolution of the injury. Photographic documentation is also highly recommended.
Pharmacologic Interventions: Administering Antidotes
When ordered by a healthcare provider, specific antidotes can counteract the harmful effects of certain extravasated drugs. Nurses must be aware of the appropriate antidote based on the medication involved and administer it correctly.
- Hyaluronidase: An antidote for hyperosmolar agents and certain non-DNA-binding vesicants, such as vinca alkaloids. It disperses the extravasated drug by breaking down hyaluronic acid in the tissue, facilitating reabsorption. Administer subcutaneously using the "pin cushion" technique.
- Sodium Thiosulfate: An antidote for agents like mechlorethamine and certain concentrations of cisplatin.
- Dexrazoxane: Specifically used for extravasation of DNA-binding vesicants like doxorubicin, daunorubicin, and epirubicin.
- Phentolamine: An antidote for vasopressors like dopamine and norepinephrine.
Essential Documentation and Reporting
Thorough and accurate documentation of an extravasation incident is a critical nursing responsibility for both patient safety and legal purposes. The report should include:
- Patient's name and number.
- Date and time the extravasation occurred and was noticed.
- Name, concentration, and volume of the extravasated drug.
- Description of the IV access (catheter type, gauge, and location).
- Detailed description of the extravasation area (size, appearance, patient symptoms).
- List of all management steps taken, including times and specific thermal applications or antidotes administered.
- Provider notification time and name of the provider.
- Photographs of the affected site.
Comparison of Thermal Applications for Different Medications
| Medication Category | Recommended Thermal Application | Rationale |
|---|---|---|
| Most Irritants and Vesicants | Cold Compress | Causes vasoconstriction to limit local drug spread and reduce pain. |
| Vinca Alkaloids (Vincristine, Vinblastine) | Warm Compress | Promotes vasodilation, increasing blood flow to disperse the drug. |
| Etoposide (Epipodophyllotoxins) | Warm Compress | Enhances local blood flow for better drug absorption and dilution. |
| Vasopressors (Dopamine, Norepinephrine) | Warm Compress | Vasodilation counteracts the vasoconstrictive effects of the drug. |
| Hyperosmolar Agents (High-concentration Dextrose) | Warm or Cold Compress | Clinical judgment is used, though warm compresses are often preferred for larger dispersal. |
Patient Monitoring and Follow-Up Care
After initial interventions, the nurse's role shifts to vigilant monitoring and patient education. Continued assessment is necessary as some injuries, particularly with vesicant drugs, can worsen or lead to delayed complications.
Monitoring the Site
- Frequency: Regular site assessments should occur every 1 to 4 hours for the first 12 to 24 hours, then every shift until healed.
- Assessment Points: Evaluate the site for any changes in erythema, edema, blistering, temperature, or pain.
- Neurovascular Status: For severe cases, assess the affected extremity's sensation, movement, and distal pulses to rule out compartment syndrome.
Educating the Patient
- What to Watch For: Instruct the patient to monitor for increased pain, swelling, blistering, skin changes, or signs of infection.
- Aftercare Instructions: Provide written and verbal instructions on continuing elevation, applying thermal compresses as prescribed, avoiding tight clothing, and protecting the site from sunlight.
- Contact Information: Give the patient clear instructions on who to contact and when to seek immediate medical attention.
When to Consider a Surgical Consult
- A plastic surgery consultation may be necessary for severe extravasations involving blistering, necrosis, large volumes, or compromised neurovascular status.
Conclusion
The nursing response to an IV extravasation is a critical, time-sensitive process requiring a systematic and knowledgeable approach. By immediately stopping the infusion, aspirating the residual fluid, notifying the provider, and applying the correct thermal therapy and antidotes, nurses can significantly reduce the risk of severe tissue damage and long-term complications. Meticulous documentation and diligent follow-up care are essential components of this process. The ability to identify, manage, and monitor an extravasation event effectively is a cornerstone of safe and competent intravenous therapy administration.
Understanding extravasation injuries: A complication of IV cannulation
