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

In the event of an extravasation, the initial steps are as follows:

Extravasation management equipment

• Trolley cleaned with approved cleaning agent
• Personal protective equipment (PPE) as per institutional policy
• 10-20 mL syringes
• Gauze squares
• Marker pen
• Camera
• Disposable paper tape measure
• Equipment to remove intravenous cannula (IVC)  or disconnect central venous access device (CVAD) if required
• Medication chart

If any items are used or if products have expired, replacement should be arranged. Regular quality checks should be undertaken to ensure all contents are present and have not expired. Additional products may be required according to individual department guidelines.

1. Ensure the IV contrast infusion has been stopped.
2. Notify medical staff, pharmacist and/or senior nurse of extravasation.
3. Explain the intended procedure to the patient and obtain consent.
4. Perform hand hygiene.
5. Put on PPE as per institutional policy.
6. Set up equipment.
7. Disconnect the infusion line.
8. If local hospital policy advises to aspirate IV contrast, attach a sterile 10 to 20mL syringe and gently aspirate as much of the IV contrast as possible.
9. Assess the affected area:
   1. mark the area of erythema and induration with a marker pen
   2. measure and photograph the area.
10. Remove cannula and dispose of as per institutional guidelines. If a central line is in situ this should remain in position - refer to a medical officer for further instructions.
11. Assess the patient for presence of pain and administer pain relief as prescribed if required
12. If local hospital policy advises to apply cold or warm compress, apply cold or warm compress to affected area as per policy (ensure compress is covered with a waterproof covering).
13. Consider elevating the affected limb if it provides comfort to the patient, otherwise encourage patient to use limb normally.
14. Dispose of all hazardous waste as per institutional guidelines.
15. Remove PPE.
16. Perform hand hygiene.
17. Document details of the extravasation in the patient notes including:
    • type of IV contrast extravasated, approximate dose and volume 
    • the position and size of the 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.
18. Complete incident form as per institutional guidelines.
19. Educate and provide written information to the patient on extravasation – see patient education section below.
20. Observation and additional tests should be performed as per local hospital policy and at the discretion of the medical officer.

Surgical intervention

There are no uniform guidelines in the literature on the surgical management of IV contrast extravasation injuries.

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 a medical officer
• progressive swelling or pain
• skin ulceration or blistering
• altered tissue perfusion 
• any changes in sensation
• distal paraesthesia.

Follow-up care

• The patient should monitor the affected area daily for any skin changes or breakdown or changes in sensation, and notify the 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 clinical course of the injury. Consider daily or second daily review for the first week, and then weekly until complete resolution of symptoms. Assess patient for the following:
  • residual pain
  • blistering, redness or other skin colour change
  • hardness
  • increased or decreased temperature of skin at extravasation site
  • change in sensation.
• Obtain photographs at follow up appointments.
• Community nurse or GP referral may be required for follow up care.

Document details of the extravasation in the patient notes and complete incident form as per institutional guidelines.

For further information, read the Management of extravasation during intravenous contrast administration.

Educate the patient and provide written information on:

• what an extravasation is
• what treatment has already been given
• how to safely care for the injury and specific management required
• how to check the affected area daily and report any skin changes, increase in pain or changes in sensation
• 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 clinic or present to emergency
• dates and times of follow-up appointments
• the importance of follow-up.