Extravasation protocols

[LPNfurever]

Hi All,

Do your facilities have protocols for extravasation(non chemo)? If so what are they for antibiotics, iron(venofer/feraheme) and others such as Demerol/morphine? Other than stopping the infusion, elevation and a compress(warm/cold/compression) I wondered if there was anything else.

Thanks!

[icuRNmaggie, BSN, RN]

If you are encountering extravasation of any drug and especially a vesicant drug such as Vanco while working in a LTC facility, call poison control and talk to a pharmD.

Have the recommendations faxed to you and notify the provider for appropriate orders.

The effects of an extravasation can be devastating to the patient, it's a potential sentinel event and the liability is huge.

[IVRUS, BSN, RN]

Not all vesicant medications have antidotes. If a medication extravasates into the tissue, the nurse must ALREADY have orders from the MD or LIP on what to do in the event that this should occur. One should not wait till it occurs, and then put a call out to the MD.

Does the site need ice, or heat..Should I infiltrate the area with it's antidote, as well as not pull the line until the antidote was infused into said IV catheter... What are your orders? What does your facility P&P denote?

Knowing which medication is a irritant versus vesicant is important for you to know as a nurse, as well as knowing your internal policies.

[dream'n, BSN, RN]

This is what I do: 1. Stop the infusion and inspect the site. 2. Call the pharmacist, some medications have antidotes such as Vancomycin (5 SQ injections of the site of a certain medication I can't remember). The pharmacy can recommend whether heat or cold is better and other helpful ideas. 3. Notify the Dr. and inform them of my assessment of the site and the pharmacists recommendation. 4. Implement orders received and inform charge. 5. Continually assess the site and chart. 6. Complete Incident Report.

IVRUS, I've very, very rarely seen an antidote ordered already for a medication just in case of an infiltration/extravastion. Never seen Vancomycin ordered with its antidote, just in case. But I have instant access to pharmacy/Dr.

For all you LTC nurses, I would recommend having the Vancomycin antidote on hand at all times because you won't be able to wait for the pharmacy to drive it to your facility. Same goes for all vesicant/irritant medication given IV in your facility.

[IVRUS, BSN, RN]

[ The pharmacy can recommend whether heat or cold is better and other helpful ideas. 3. Notify the Dr. and inform them of my assessment of the site and the pharmacists recommendation. 4. Implement orders received and inform charge. 5. Continually assess the site and chart. 6. Complete Incident Report.

IVRUS, I've very, very rarely seen an antidote ordered already for a medication just in case of an infiltration/extravastion. Never seen Vancomycin ordered with its antidote, just in case. But I have instant access to pharmacy/Dr.

For all you LTC nurses, I would recommend having the Vancomycin antidote on hand at all times because you won't be able to wait for the pharmacy to drive it to your facility. Same goes for all vesicant/irritant medication given IV in your facility.

But remember Dream'n, just because "one" has never seen something done, doesn't mean that it isn't an appropriate standard of care. I believe that if an antidote is available for a particular medication, (And Vanco doesn't have one, that I've seen) then it should be ordered when the medication is ordered. If not, then if or when an extravasation occurs, you waste precious time tyring to contact and get orders from the MD, and then as in LTC, you do wait, and wait, and wait for the contracted pharmacy to deliver the medication.. Auughhh...

[dudette10, MSN, RN]

But remember Dream'n, just because "one" has never seen something done, doesn't mean that it isn't an appropriate standard of care. I believe that if an antidote is available for a particular medication, (And Vanco doesn't have one, that I've seen) then it should be ordered when the medication is ordered. If not, then if or when an extravasation occurs, you waste precious time tyring to contact and get orders from the MD, and then as in LTC, you do wait, and wait, and wait for the contracted pharmacy to deliver the medication.. Auughhh...

The term "standard of care" is misused in this case. That phrase has taken on a specific meaning with regard to medical and nursing care, and ordering an antidote to a medication "just in case," is certainly not a standard of care. I would even argue that because we've never seen it done means that it is NOT a standard of care, but it could be a good idea in some cases.

A discussion of the difference between "best practice" and "standard of care" to help support my point.

Medical malpractice: Equating standard of care to best practice

[IVRUS, BSN, RN]

The term "standard of care" is misused in this case. That phrase has taken on a specific meaning with regard to medical and nursing care, and ordering an antidote to a medication "just in case," is certainly not a standard of care. I would even argue that because we've never seen it done means that it is NOT a standard of care, but it could be a good idea in some cases.

A discussion of the difference between "best practice" and "standard of care" to help support my point.

Medical malpractice: Equating standard of care to best practice

STANDARD 48.1 (Infiltration and Extravasation) Infusion Nurses Society - INS states, " The assessment and treatment of infiltration and extravasation shall be in the organizational policies, procedures, &/or practice guidelines." Therefore the standards say that the treatment of the extravasation of a vesicant, should be in an orginizations policies and procedures BEFORE the medication is even ordered. But once ordered, the nurse should write the protocal for that particular medication. Now, given that this is a standard, and the strength of the body of evidence is a level 1, this means that the nurse needs to activate treatment protocals upon assessment of this complication. How can one care for and intiate the treatment protocols if he/she is standing around waiting for the MD or LIP to call back with specific orders? No, it should be written initiallly. Now, can the nurse write, "Extravasation protocals per XYZ policy" Yes, that too, without writing the specific order may be done, as long as there is a specific policy in place for the treatment of this complication.