Intravenous Extravasation: A Comprehensive Management Algorithm

Purpose:

Plastic surgeons are often requested to play a role in the management of intravenous extravasation injuries. However, we were unable to identify in the literature a comprehensive treatment protocol for these clinical problems. Given this deficiency, our goal was to evaluate published recommendations and to construct a comprehensive algorithm for the management of extravasation injuries.

Methods:

A thorough literature search of IV extravasation and management (criteria: “Intravenous extravasation injury and treatment or management”) included 1042 publications with 152 reviewed.  A treatment algorithm was developed integrating information culled from articles reviewed independently by two of the co-authors.

Results:

One hundred and fifty-two publications were reviewed for content related to the management of extravasation injury and a treatment algorithm was constructed.

Initial management includes discontinuing the administration of the agent, withdrawing as much infiltrate as possible, and removing the IV. Further intervention for the injured site begins only after identifying and documenting (photographing) the location, the type of infiltrate, the duration/dose/volume/concentration, and stage of the injury (as per INS guidelines).  For stage I injuries, the affected area should be elevated immediately.  For stage II injuries (and worse) subcutaneous hyaluronidase injection should be undertaken. Following the initial steps of management, we suggest adherence to our algorithm with respect to the extravasant in question. 

For extravasation of parenteral nutrition, extravasated contrast material, basic electrolyte solution, or antibiotics, surgical consultation should be requested within 24 hours for stage III or IV injuries. In certain severe cases, surgical drainage and the saline flush-out technique may be warranted.

In regards to vasoactive substance extravasation, early plastic surgery consultation is necessary. Treatment begins with injection of subcutaneous phentolamine and application of topical nitroglycerin. The decision for further surgical intervention depends on the initial examination as well as injury evolution over the following 6 hours.

The management of chemotherapeutic extravasation is more complex in that there are dozens of agents within several categories, necessitating a more customized treatment approach.  Verification of the particular drug in question should be made and consultation with the algorithm prior to treatment. 

Conclusion:

We present a comprehensive algorithm for the management of extravasation injuries in an attempt to promote quality care and patient safety.  When prevention fails, prompt and thoughtful action is necessary to prevent serious complications.