Clinical procedure - management of extravasation during intravenous (IV) contrast administration for radiotherapy simulation scans

The following is a list of recommended equipment to perform this procedure:

• from the extravasation kit:
  • 10 mL syringes
  • gauze squares
  • disposable paper tape measure
  • permanent marker pen
• Trolley cleaned with approved cleaning agent
• personal protective equipment (PPE)
• protective cloth or gauze covering
• cold or warm pack
• medication chart
• equipment to remove intravenous cannula (IVC)  
• bin and sharps container
• camera

1. STOP the injection or intravenous infusion immediately.
2. Explain to the patient the intended procedure and obtain consent. 
3. Perform hand hygiene
4. Put on personal protective equipment (PPE).
5. Set up equipment.
6. Disconnect intravenous infusion line(s).
7. LEAVE the intravenous cannula (IVC) in place.
8. ASPIRATE any residual IV contrast if institutional policy advises, attach a sterile 10 to 20mL syringe and gently aspirate as much of the IV contrast as possible.
9. Notify medical staff, pharmacist and/or senior nurse of extravasation.
10. Assess the affected area
    • mark the area of erythema and induration with a marker pen
    • measure and photograph the area.
11. Remove cannula or needle
    • avoid applying pressure to the area
    • if the site is bleeding apply gentle pressure only.
12. Assess the patient for presence of pain
    • administer pain relief as prescribed if required.
13. Apply a cold or warm compress, if institutional policy advises
    • cover the cold or warm pack with a waterproof covering and place over affected area
    • leave for 15 to 20 minutes (no moisture should come in contact with the patient's skin).
14. Consider elevating the affected limb if it provides comfort to the patient, otherwise encourage patient to use limb normally.
15. Dispose of all waste as per institutional guidelines.
16. Remove PPE. 
17. Perform hand hygiene
18. Document details of the extravasation in the patient's notes including:
    • type of contrast extravasated, approximate dose and volume
    • the position and size of injury
    • amount and type of exudate
    • presence of swelling or oedema
    • extent and spread of erythema
    • presence of pain and analgesia administered
    • management steps taken
    • education given to patient.
19. Complete incident form as per institutional guidelines.
20. Educate and provide written information to patient on extravasation - see patient education section below.

Referral

There are no uniform guidelines in the literature on the surgical management of IV contrast extravasation injuries, including guidelines on the optimal timeframe for referral to a plastic surgeon.

In most patients conservative management is sufficient. However in those where conservative measures fail or functional damage is suspected, surgical intervention may be required.

Clinical assessment of the individual case is paramount in determining if surgical review is necessary. Referral to a plastic surgeon or other specialist surgeon (according to individual case and site of extravasation) is recommended for:

• extravasations at the discretion of the medical officer
• in the event that the patient develops pain or the area is not healing
• progressive swelling or pain
• skin ulceration or blistering
• altered tissue perfusion or sensation 
• large volume extravasations (the volume which constitutes a large extravasation is undefined in the literature and clinical judgement must be used).

Follow up care

• The patient is to monitor the affected area daily for any skin changes or breakdown, and to notify medical team immediately if there are any changes.
• Careful monitoring by a healthcare professional is recommended; the length of monitoring should be at the advice of the medical officer, and will depend on the contrast extravasated and the clinical course of the injury. 
• It is important to note that early extravasation signs or symptoms can be subtle, and not always evident until several days or weeks later. Regular patient review is recommended, consider daily or second daily review for the first week, and then weekly until complete resolution of symptoms.
• Patients should be informed about the follow-up policy before leaving the treatment area.
• Obtain photographs at follow up appointments.
• Community nurse or GP referral may be required for follow up care.

In the event of an extravasation injury, educate the patient (and provide written information) on:

• what an extravasation is
• what treatment has already been given
• measures for general management and reducing further damage:
  • do not rub or scratch the area
  • do not wear tight clothing on area
  • protect the area from sunlight
  • raise the affected arm on a pillow if it provides comfort
  • move/exercise the affected arm gently
  • do not use creams or lotions on affected area without speaking with your doctor or nurse
• the equipment required to care for the injury
• how to check the affected area daily and report any skin changes or increase in pain
• how to monitor temperature and seek urgent medical attention if temperature 38°C or higher 
• contact numbers for during and after hours
• when to contact the clinic or present to emergency
• dates and times of follow up appointments
• the importance of follow up.

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