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Extravasation management

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Extravasation of a vesicant is a medical emergency.

  • Prevention strategies are key to reducing the risk of extravasation and minimising tissue damage.
  • All clinicians who prescribe, supply and administer intravenous anti-cancer therapies and contrast media should be educated and competent in extravasation management. 
  • Early detection, assessment and prompt action ('SLAP') is required to minimise patient harm.
  • For more details about extravasation management, refer to Clinical procedure - extravasation management of intravenous anti-cancer therapies and contrast media.

This document provides a guide to health professionals for a comprehensive approach to the prevention, assessment and management of intravenous anti-cancer therapy and contrast media extravasation. The information in this document should be used in conjunction with clinical expertise, the patient and local policies and procedures.

Clinicians require education prior to extravasation management- see Extravasation eLearning for further information.

Definitions

Extravasation The unintentional instillation or leakage of a drug or solution out of the  blood stream into surrounding tissue.
Vesicant

Drugs or solutions that can cause tissue destruction (necrosis) when extravasate.r They can include:

  • DNA-binding vesicants, 
  • non-DNA binding vesicants or
  • contrast media.r
Extravasation of a vesicant is a medical emergency. Prevention strategies are key to reducing the risk of extravasation and minimising tissue damage.
Irritant with vesicant properties Drugs or solutions that are difficult to classify as either a vesicant or irritant. They are capable of causing tissue damage and ulceration which is proportional to the amount and concentration of the drug extravasated into the tissue.r
Irritant  Drugs or solutions that cause stinging, inflammation, aching, tightness, and phlebitis but without necrosis when extravasated.
Non-irritant (neutrals) Drugs or solutions that do not cause local irritation when extravasated.

Preventative strategies are key to reducing the risk of extravasation. Strategies that reduce the risk of extravasation include:rrrrrr

  • clinicians that are educated and competent in vascular access device (VAD) management and safe administration of anti-cancer therapies and contrast media
  • informed patients: VAD insertion, prevention of extravasation
  • standardised, evidence-based VAD selection, insertion, and management
  • safe administration of intravenous systemic anti-cancer therapies (refer to Anticancer Drug Administration Course eLearning)
  • assessing VAD, CVAD or TIVAD patency immediately prior to administration of medications or solutions with vesicant, irritant with vesicant, and irritant properties and not proceeding unless there is easy aspiration and easy injection ability. 

An extravasation kit containing instructions, materials and antidotes is stored in close proximity to patient care area where anti-cancer therapy and contrast media is administered.

Refer to Extravasation eLearning module for further information about prevention and risk factors for extravasation.

Symptoms and signsr

  • discomfort, burning, stinging or pain
    • peripheral intravenous cannula (PIVC): distal to PIVC tip
    • central venous access device (CVAD): in the chest, neck, shoulder, arm or near the CVAD
  • local swelling, oedema, erythema, pruritis, leakage at the site
  • increase in resistance during administration
  • alteration or slowing of flow rate, or alarming of infusion pump if being used (CVAD administration)
  • sluggish or absence of blood return from VAD.

Signs of extravasation can be immediate but may be delayed for days to weeks. Late symptoms of an extravasation injury include inflammation, discolouration, induration and/or blistering.

Assessment criteria

In the event of an extravasation, the following factors are assessed:

  • drug, dose administered, concentration, volume
  • position and size of injury
  • presence and degree of swelling, erythema
  • severity of pain
  • amount and type of exudate.

Link to the Extravasation assessment and documentation tool.

Extravasation from a CVAD

In the event of a suspected extravasation from a CVAD, flow studies may assist in diagnosis and location of the damage, leak, fracture or a malpositioned non-coring needle for a totally implantable venous access device (TIVAD).

Grading

Grading scale 0 1 2 3 4
Skin colour Normal Pink Red Blanched Blackened
Skin temperature Normal Warm Hot  
Skin integrity Unbroken Blistered Superficial skin loss Tissue loss exposing subcutaneous tissue Tissue loss, muscle/bone exposure, deep crater or necrosis
Oedema Absent Non-pitting Pitting  
Mobility Full Slightly limited Very limited Immobile  
Pain Grade using a scale of 0-10: 0 = no pain, 10 = worse pain
Systemic temperature Normal Elevated  

Adapted from © Kim et al 2020r

Extravasation management includes:rrrr

Primary actions: SLAP

STOP

 Stop the injection or intravenous infusion immediately and send for help

LEAVE

 Leave the VAD in situ

ASPIRATE

 Aspirate any residual drug or solution from the VAD with a syringe

PLAN

 Plan subsequent actions or management

Secondary actions

  • call for assistance
  • complete assessment of affected area
  • collect extravasation kit
  • outline affected area with marker pen
  • photograph affected area for medical record
  • initiate appropriate drug specific management measures.

Conservative managementrrrrrrrr

Surgical management

  • There is no optimal timeframe for referral to specialist surgical, plastics, wound care or other members of the healthcare team. Referral is based on the individual extravasation and patient.
  • Possible indications:
    • vesicant extravasations
    • extravasations that involve a damaged CVAD
    • development of pain or delayed healing affected area
    • large volume extravasations.

Refer to Clinical procedure - extravasation management of intravenous anti-cancer therapies and contrast media for more detailed information about extravasation management.

Clinical management includes:r

  • regular assessment of affected area
  • regular review of pain management
  • referral to members of the healthcare team as indicated e.g. surgery, pain management, wound management
  • replacing items from extravasation kit (including antidotes) from pharmacy if required.

Documentation

A suspected or actual extravasation is documented include the drug/solution, assessment findings, interventions, patient response, education and post-acute management planning using a standardised tool e.g. Extravasation of intravenous anti-cancer therapies or contrast - assessment and documentation tool.

Patient education continues into the post-acute management phase. Includes:

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Bibliography

NSW Health. 2020. Consent to Medical and Healthcare Treatment Manual . NSW Ministry of Health.
NSW Health. 2017. Infection Prevention and Control Policy PD2017_013 Clinical Excellence Commission (CEC).
SafeWork NSW. 2017. Cytotoxic Drugs and Related Waste Risk Management Guide.
Correspondence with Roche Australia, April 2022.
Micromedex® (electronic version): Dexrazoxane Hydrochloride. IBM Watson Health, Greenwood Village, Colorado, USA. Available at: https://www.micromedexsolutions.com.acs.hcn.com.au/ [accessed November 2021]
MIMSOnline Prescribing information: Brentuximab vedotin. © 2022 MIMS Australia Pty Ltd. [Accessed April 2022]
MIMSOnline Prescribing information: DBL Cisplatin Injection. © 2021 MIMS Australia Pty Ltd. [Accessed November 2021]
MIMSOnline Prescribing information: Sacituzumab govitecan. © 2022 MIMS Australia Pty Ltd. [Accessed May 2022]

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Version 6

Date Summary of changes
16/10/2023
  • eviQ extravasation documents reviewed and updated by pharmacy/nursing and radiation oncology internally to include contrast media content.
  • Radiation oncology clinical resource ID 3373 "Management of extravasation during intravenous (IV) contrast for radiation therapy simulation scans"  superseded and discontinued.
  • ID 3373 superseded by ID 157 "Extravasation management".
  • Approved by internal review for publication on eviQ website.

Summary of changes:

  • Classified as providing a guide to health professionals for a comprehensive approach to the prevention, assessment and management of intravenous anti-cancer therapy and contrast media extravasation.
  • Hyaluronidase administration eviQ ed rapid learning added to 'Related eLearning'.
  • Updated the bibliography with the relevant NSW Health policies and documents, removing obsolete references. The bibliography relates to ID 4156: "Clinical procedure - extravasation management of intravenous anti-cancer therapies and contrast media" and ID 1002: "Quicklink summary table - treatments for extravasation of intravenous anti-cancer therapies". Retained all references that are related to updates or changes in management for specific drugs that were identified in the 2022 review of these documents.
  • Version number increased to V.6.
  • No change to review due date of 
25/01/2024 Review due date aligned with eviQ Education modules: 31 December 2025.
History related to ID 3373 - Management of extravasation during intravenous (IV) contrast for radiation therapy simulation scans:
Date Summary of changes
19/02/2018 Approved for publishing on eviQ.
27/04/2018 CTCAE information updated to v5.0 published November 27, 2017.
02/08/2019 Internal review, and alignment with ID 157. Version number increased V.2. Addition of RANZCR cold/warm compress recommendation.                                                                                                                                                                                          

Version 5

Date Summary of changes
14/07/2022

eviQ extravasation documents reviewed and updated by pharmacy/nursing committee.

Updated document to be used in conjunction with eviQ Education Extravasation eLearning module and eviQ extravasation documents:

  • ID 1002 Quicklink summary table - treatments for extravasation of intravenous anti-cancer therapies
  • ID 489 Extravasation of intravenous anti-cancer therapies assessment and documentation tool
  • ID 4156 Clinical procedure - extravasation management of intravenous anti-cancer therapies.
  • ID 3069 Extravasation kit

Background definition and risk factors moved to eviQ Education Extravasation eLearning module. Assessment grading scale updated. Details for conservative management clinical procedure moved to ID 4156.

Version number changed to V.5, review in 2 years.

Version 4

Date Summary of changes
19/10/2007 Originally approved.
28/05/2009 Information rewritten and reviewed 2009 NRC and pharmacy.
Miscellaneous drug category changed to Irritant with Vesicant Properties.
Safety information around DMSO 99% solution added.
All vinca alkaloid management changed to warm compress.
01/10/2009 Transferred to eviQ
29/10/2010 Changes to Extravasation Table - Tomudex changed to raltitrexed.
09/12/2010 Changes to Extravasation Table - amsacrine added.
17/01/2011 Action bar changed from hot to warm.
13/05/2011 All eviQ extravasation documents discussed and reviewed at the combined nurse/pharmacist extravasation meeting.
21/10/2011 All eviQ extravasation documents updated with amendments from meeting and published.
04/09/2015 All eviQ extravasation documents reviewed and updated by pharmacist/nursing committee and two clinicians and published.
31/05/2017 Transferred to new eviQ website. Version number change to V.3.
24/04/2018 CTCAE information updated to v5.0 published November 27, 2017.
05/04/2019 eviQ extravasation documents reviewed and updated by pharmacist/nursing committee and published. Version number changed to V.4.

This document reflects what is currently regarded as safe practice. While every effort has been made to ensure the accuracy of the content at the time of publication, the Cancer Institute NSW does not accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work. Any reference throughout the document to specific pharmaceuticals and/or medical products as examples does not imply endorsement of any of these products. While eviQ endeavours to link to reliable sources that provide accurate information, eviQ and the Cancer Institute NSW do not endorse or accept responsibility for the accuracy, currency, reliability or correctness of the content of linked external information source. Use is subject to eviQ’s disclaimer available at www.eviQ.org.au

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First approved:
Last reviewed:
Review due:

The currency of this information is guaranteed only up until the date of printing, for any updates please check:

https://www.eviq.org.au/p/157

11 Oct 2024