extravasation vs. infiltration

caroladybelle, BSN, RN · Sep 8, 2009

Extravesation generally refers to infiltration of vesicant or irritant drugs, and requires more intervention than standard infiltration. It also generally causes more extensive long term damage/problems.

Some chemotherapies are vesicants and do major damage to tissues if infiltrated, often require skin grafts. The most common are the red anthracycline chemos (idarubicin, daunarubicin, doxirubicin, epirubicin, etal), the blue chemos (mitoxantrone,mutimycin), and the vinca alkaloids (vincristine, vinblastine, etal.) While there are others, those are the most common in use.

There others like mustargen, but very very few nurses ever give that one, and all of them are specially trained.....the drug is very unstable, must be infused immediately mixing and can aerosolize easily.

Some chemos/other drugs are classed as vesicant/irritants. The potential to damage tissue varies with how they are mixed. For a long time taxol was not classed as vesicant, yet I have had some patients that had to be grafted from an extravasation of the drug. Taxol is now classed as vesicant/irritant. Potassium for central IV administration, given peripherally comes to mind, as does inadequately diluted phenergan, or IVPB dilantin. Currently places are trying to phase out phenergan, and substitute cerebyx for IV dilantin, because of lawsuits resulting from use of those drugs.

And some drugs that are not listed as irritants/vesicants normally, can be irritants in some dilutions. Many chemos/other drugs fall in this category.

For some severe vesicants, there are procedures and agents that can help reduce damage to tissue. When utilizing vesicant or irritant drugs, ALWAYS!!!!! make sure that you have a fully confirmed patent IV (either by an excellent blood return/easy flushing or by xray confirmation and easy flushing) and ALWAYS!!!!!!!! make you pt aware to report any pain/burning at injection site or along the vessel in which it is being infused. While this not perfect (at least two of the central line extravasations that I have seen had acceptable blood return, but the pt felt pain), it is prudent. Also know what procedure is if you suspect extravasation (stop the drug), and what the common treatment is for that drug (it varies, some use cold application and some require warm compresses, etc.).

Daytonite, BSN, RN · Sep 8, 2009

iv fluid will leak into surrounding tissues when the tissues are compressed or there is restriction of the blood flow. when ivs are on pumps that have enough pressure to push fluid past venous restriction a infiltration can result.

these two terms, infiltration and extravasation, are often used interchangeably, but there really is a difference. (page 260-1, intravenous therapy: clinical principles and practice, by judy terry, leslie baranowski, rose anne lonsway and carolyn hedrick, published by the intravenous nurses society)

". . .an infiltration is an inadvertent administration of a nonvesicant into the surrounding tissue. [infiltration most often occurs as a result of dislodging of the iv cannula.] extravasation is defined as an inadvertent delivery of a vesicant into the tissues. vesicants cause blistering, severe tissue damage, and even necrosis if extravasated.

[pathophysiology] when fluid leaks into tissue, the tissue is compressed because of restriction of blood flow, which decreases the amount of oxygen to the site and thus lowers the cellular ph. there is a loss of capillary wall integrity, increase in edema and, depending on severity, eventual cell death.

[more pathophysiology on extravasation] an oversimplification of the chemistry of an extravasation divides [vesicant] drugs into two categories, those that bind to dna and those that do not. the drugs that do not bind to dna cause immediate damage but are quickly metabolized or inactivated. this type of injury is similar to a burn in which the damage is immediate, followed by repair using the normal healing process.

the second class of drugs are those that bind to dna and not only cause immediate damage but lodge in the tissue, producing a prolonged effect. because of this binding effect, the cells lose their ability to heal spontaneously. . .drugs that bind to dna include alkylating agent nitrogen mustard. . .[some] antibiotics"

(page 422)

"it is essential that an extravasation be noted early before extensive fluid is allowed to infiltrate the interstitial tissues. a complete assessment of the patient, the intravenous site, the involved extremity, and the infusion system should be performed at regular intervals. the flow rate should never be increased to determine the infiltration of a vesicant, nor should a blood return be used as a reliable method to determine an infiltration. fluid can seep into the tissues from a previous puncture site or the vein insertion site, and increase the potential for tissue necrosis.

initial indications that tissue sloughing may occur include pain or burning at the site with progression to erythema and edema. tissue sloughing is usually apparent within 1 to 4 weeks because of tissue necrosis. necrosis can involve a small area or large area, including underlying connective tissues, muscles, tendons and bone, necessitating surgical intervention.

the severity of damage is directly related to the type, concentration, and volume of fluid infiltrated into the interstitial tissues. the most harmful of the vesicant medications are the antineoplastic agents, with doxorubicin (adriamycin) causing the most severe tissue necrosis. other medications that act as vesicants and cause tissue necrosis include dopamine hydrochloride, norepinephrine, potassium chloride in high doses, amphotericin, calcium and sodium bicarbonate in high concentrations.

nursing interventions

when an extravasation is suspected, the infusate is discontinued immediately. treatment protocols established in written policies and procedures are initiated, and a new site is established, preferably in the opposite extremity or in a site above and away from the extravasated site.

institutional policies vary as to the treatment of the tissues in which an extravasation has occurred. usually, the cannula is left in place until after any residual medication and blood are aspirated, and an antidote particular to the vesicant is instilled into the tissues. after the cannula is removed, a dry, sterile dressing is applied to the site. and either cold or warm compresses are applied. cold compresses are usually used for the alkalating and antibiotic vesicants, whereas warm compresses are applied to an extravasation of the vinca alkaloids. the extremity is elevated and observed regularly for erythema, induration, and necrosis. the physician is notified, and tissue damage is evaluated by the physician for the possibility of surgical intervention."