Management of extravasation during intravenous (IV) contrast for radiotherapy simulation scans

Evidence in the area of IV contrast extravasation management is extremely limited. Recommendations regarding the treatment of extravasation are based on animal models, case reports and a limited number of small uncontrolled studies, and are often conflicting.^r

Extravasation is the unintentional instillation or leakage of a drug or substance out of a blood vessel into surrounding tissue. The majority of IV contrast extravasation injuries resolve without adverse effects; however, severe extravasation injuries have been reported after administration of both ionic and non ionic contrast media.^rr

Risk factors

Risk factors for extravasation may be patient or contrast/infusion related.^rrrrr

Patient related risk factors include:

• small and/or fragile veins (e.g. in the elderly and children)
• hard and/or sclerosed veins
• limited vein availability (due to lymph node dissection, lymphoedema)
• obesity in which peripheral access is difficult
• patient movement
• predisposition to bleeding, increased vascular permeability or coagulation abnormalities
• altering sensory perception that may impair patient’s ability to detect sensory changes at the site of administration
• diseases with impaired or altered circulation (e.g. advanced diabetes, Raynaud syndrome, superior vena cava syndrome)
• impaired communication (e.g. non-English speaking patients, patients with communication difficulties, sedation, young children)
• disseminated skin disease (e.g. eczema, or psoriasis).

Contrast/infusion related risk factors include:

• volume of contrast administered
• vesicant potential of the contrast
• chemical properties of the contrast.

Device and access related risk factors

• multiple attempts at cannulation
• unfavourable cannulation site
• choice of equipment (e.g. cannula choice, size, steel “butterfly” needle)
• inadequate dressing or poor fixation of the intravenous cannula (IVC).

Clinician related risk factors:

• untrained or inexperienced staff in vascular access 
• interruption or distractions during contrast administration.

Signs and symptoms

Extravasation should be suspected if the following occurs:^rr

• patient complains of burning, stinging, pain or discomfort
• patient complains of thoracic pain
• evidence of swelling, oedema, erythema, leakage at the site
• absence of free flow
• change in flow i.e. slow or sluggish
• loss of blood return or change in blood flow
• increase in resistance when administering IV bolus.

Late symptoms of an extravasation injury include inflammation, induration and/or blistering.

Investigations

In the event of an extravasation, important assessment parameters include:

• contrast extravasated, dose, volume
• position and size of injury
• amount and type of exudate
• presence of swelling, oedema
• extent and spread of erythema 
• pain.

Assessment should be ongoing to allow for the early detection and management of skin changes such as ulceration and necrosis.

Grading

Common Terminology Criteria for Adverse Events (CTCAE) v5.0, 27 November, 2017

Prevention ^rrrr

The most effective approach to extravasation injury is prevention. It is important that a multidisciplinary approach is taken to mitigate risks of extravasation. The risk of extravasation can be reduced by taking the following preventative measures:

Patient education

• identify high risk patients
• ensure there are no barriers to effective communication for the purpose of assuring immobility and compliance during IVC insertion, and cooperation during administration of contrast.

Clinician training

• do not inject against resistance
• administration and management of contrast by trained and accredited health professionals
• insertion, access and management of IVCs by trained and accredited health professionals
• ensure knowledge and access to current literature in extravasation management and international guidelines.

Appropriate vascular access

• identify most appropriate site for IVC insertion
  • large veins in the forearm are recommended for insertion of an IVC
  • avoid insertion of an IVC over joints, the inner wrist, lower extremities, antecubital fossa or where lymphoedema is present
  • avoid multiple punctures
  • do not insert an IVC distal to a previous venepuncture site
• sites should be selected in the following order of preference: forearm (basilica, cephalic, and median antebrachial), dorsum of hand, wrist, antecubital fossae
• avoid sites with sclerosis, thrombosis, scar formation or previously irradiated areas.

Safety procedures

• when accessing and before contrast administration, ensure patency of the IVC by checking
  • for blood return
  • no resistance is felt when flushing with 0.9% sodium chloride or other compatible fluid
  • infusion flows freely
• monitor the patient and IVC site regularly for the appearance of symptoms such as swelling, pain, erythema or a change in the infusion rate.

Device selection

• do not use winged steel infusion devices for cannulation (“butterfly” needles), flexible cannulas should be used
• use the smallest adequate and appropriate size cannula in the largest available vein
• ensure the IVC is stabilised and secure with a transparent dressing to allow the site to be visualised
• if unable to confirm patency of IVC, insert a new IVC.

Treatment

It is recommended that an extravasation kit containing instructions, and materials, is kept in each patient care area where contrast is administered. 

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

STOP the injection or intravenous infusion immediately.
LEAVE the IVC in place.
ASPIRATE any residual drug from the IVC using a sterile syringe (if institutional policy advises)
PLAN

• 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 IV device. Do not apply pressure. If a central line is in situ this should remain in position - refer to a medical officer for further instructions.
• ELEVATE the limb if it provides comfort to a patient
• INITIATE appropriate drug specific management measures as per protocol.
• ADMINISTER pain relief if indicated.
• APPLY a cold or warm compress (if institutional policy advises).
• REFER to a plastic surgeon or other specialist surgeon (according to individual case and site of extravasation) if clinically indicated.
• AVOID applying direct pressure to the extravasation site. 

Link to Clinical procedure - Management of extravasation during intravenous contrast administration for radiotherapy simulation scans. 

Cold or warm compresses

• The Royal Australian and New Zealand College of Radiologists iodinated contrast media guidelines recommend the use of cold or warm compresses.^r
• 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
• However, there is limited published data demonstrating the efficacy of cold or warm compress in managing IV contrast extravasation injuries.^rr

Intermittent cooling is thought to:

• cause vasoconstriction, localising the extravasation
• reduce local inflammation and pain.

Instructions for use:

• cover a cold pack with a waterproof covering and place over the affected area
• leave for 15 to 20 minutes (no moisture should come in contact with the patients skin)
• apply every 6 hours for 48 hours
• refer to your local institutional guidelines on using cold packs.

Intermittent warming is thought to:

• increase the blood flow which results in enhanced resolution of pain and reabsorption of local swelling.

Instructions for use:

• cover a warm pack with a waterproof covering and place over the affected area
• leave for 15 to 20 minutes (no moisture should come in contact with the patient's skin)
• apply every 6 hours for 48 hours
• refer to your local institutional guidelines on using warm packs.

Aspiration

• The attempted aspiration of contrast media has no evidential support for the treatment of a contrast media extravasation.^r
• Refer to your local institutional guidelines.

Limb mobilisation

• A study evaluating the efficacy of limb elevation post an infiltration injury found that a 10 cm elevation of the extremity made no difference in the rate of fluid reabsorption.
• Movement should be encouraged to prevent adhesion of damaged areas to underlying tissues.
• Elevate the limb if it provides comfort to a patient.

Surgical intervention

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.

Follow up care

• Patient to monitor the affected area daily for any skin changes or breakdown, and to notify medical team immediately of 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. Consider daily or second daily review for the first week, and then weekly until complete resolution of symptoms.
• 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. 
• Patients should be informed about the follow-up policy before leaving the treatment area.
• Take photographs at follow up appointments.
• Community nurse or GP referral may be required for follow up care.

Patient education should be a multidisciplinary approach. Clinicians involved hold responsibilities for informing patients about potential administration issues, in order to mitigate the risk of extravasation. It is important to educate the patient and provide written information regarding:

• the potential complications associated with administering contrast and potential risks of an extravasation
• keeping the extremity still when receiving contrast via an IVC
• immediately reporting any pain, swelling, redness, discomfort, burning or stinging.

In the event of an extravasation injury, educate and provide patient with 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
  • avoid occlusive dressing over the 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
• how to safely care for the injury and specific management required
• equipment required to care for the injury
• how to check the affected area daily and report increase in pain or any skin changes (such as change in colour, temperature or breakdown)
• 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.

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