The risk of extravasation can be reduced by taking the following preventative measures:rrrr
- administration and management of IV contrast by trained and accredited health professionals.
- insertion, access and management of IVCs and CVADs by trained and accredited health professionals
- identify high risk patients
- educate patients and carers to monitor and immediately report symptoms such as pain, burning, stinging, swelling, or erythema during and after administration of IV contrast
- use an appropriate gauge IVC
- do not use winged steel infusion devices for cannulation
- administer IV contrast through an IVC that has been inserted for less than 24 hours
- identify most appropriate site for IVC insertion
- avoid multiple punctures
- do not insert an IVC distal to a previous venepuncture site
- ensure the IVC is stabilised and secure with a transparent dressing to allow the site to be visualised
- when accessing and before IV contrast administration, ensure patency of the CVAD or IVC by checking
- for blood return
- no resistance is felt when flushing with 0.9 % sodium chloride or other compatible fluid.
- do not inject against resistance
- observe the commencement of IV contrast and monitor for signs of extravasation.
In the event of an extravasation, the initial steps are as follows:
STOP the injection or intravenous infusion immediately if:
- patient complains of burning, stinging, pain or discomfort
- there is evidence of swelling, oedema, erythema, leakage at the VAD site
- there is a change of blood flow and resistance felt on syringe plunger or absence of free flow of infusion
- there is no blood return.
LEAVE the VAD in place.
ASPIRATE any residual drug from the VAD using a sterile syringe.
- CALL for assistance - notify medical officer, pharmacist and/or a senior nurse.
- COLLECT the extravasation kit.
- ASSESS the affected area for the presence of symptoms e.g. erythema, swelling, burning, pain and TRACE the affected area with a marker pen.
- PHOTOGRAPH the area.
- REMOVE the VAD. Do not apply pressure. If a central line is in situ this should remain in position - refer to a medical officer for further instructions.
- INITIATE appropriate drug specific management measures as per protocol.
- ADMINISTER pain relief if indicated.
- REFER to a plastic surgeon or other specialist surgeon (according to individual case and site of extravasation) if clinically indicated.
Link to Clinical procedure - Management of extravasation during intravenous contrast administration for radiotherapy simulation scans.
Cold and warm compresses
- There is no evidence demonstrating the efficacy of cold or warm compress in managing IV contrast extravasation injuries.rr
- There are anecdotal reports of using cold compress to relieve pain and warm compress to improve absorption of the extravasation and improve blood flow.rr
- Elevation of the affected limb may be recommended to promote resorption of the extravasted fluid.rr
- There are however no controlled studies demonstrating the efficacy of elevation of the affected limb.rr
There is no consistent evidence demonstrating the efficacy of aspirating through an intact IV cannula after extravasation to minimise the severity of injury.r r There are also no controlled studies demonstrating the efficacy of corticosteroids or antidotes such as hyaluronidase.r r
There are no uniform guidelines in the literature on the surgical management of IV contrast extravasation injuries.
Clinical assessment of the individual case is paramount in determining if surgical review is necessary. The decision to refer for surgical consultation should be based on the signs and symptoms of extravasation injury.rr Referral to a plastic surgeon or other specialist surgeon (according to individual case and site of extravasation) is recommended for:rrrr
- extravasations at the discretion of the medical officer
- progressive swelling or pain
- skin ulceration or blistering
- altered tissue perfusion
- any changes in sensation
- distal paraesthesia.
Document details of the extravasation in the patient notes complete incident form as per institutional guidelines. For further information, read the Clinical procedure - management of extravasation during intravenous contrast administration.
Follow up care
- The patient should monitor the affected area daily for any skin changes or breakdown or changes in sensation, and to notify medical team immediately if 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.
- Obtain photographs at follow up appointments.
- Community nurse or GP referral may be required for follow up care.