Guideline No: 2016-9057 v2
Guideline: Intravenous Extravasation - Management
INTRAVENOUS EXTRAVASATION -
MANAGEMENT
PRACTICE GUIDELINE ©
DOCUMENT SUMMARY/KEY POINTS
• Intravenous extravasation is the inadvertent administration of a drug or IV fluid into the
surrounding tissue which has the potential to cause tissue damage
• Injuries are classified according to the degree of tissue involvement which also
determines initial First Aid Management of the injuries.
• Stage 4 intravenous (IV) Extravasation is classified as a Medical Emergency and
requires escalation as per Between The Flags (BTF) : Clinical Emergency Response
System (CERS)
• Immediate first aid management for hazardous and cytotoxic drug extravasation follow
the SLAP procedure.
• Children who are non-verbal, have a neuro-sensory deficit, an intellectual disability,
and/or children receiving hazardous or irritant drugs are more at risk of extravasation
injuries and therefore should be closely monitored for behavioural cues suggesting pain
or discomfort.
• Peripheral and central vascular access devices should be monitored regularly while in
use to assess for signs and symptoms of development of an extravasation injury.
• Early detection is important to minimise damage to surrounding tissue. Throughout the
administration of intravenous fluids and medication, request the patient and/or family to
monitor the vascular access device site and notify staff immediately if they have any
concerns. The vascular device site should also be checked regularly by nursing staff
during use.
• For guidance on the most appropriate intravenous device for your patient, please refer
to the SCHN Peripheral Intravenous Catheters - Clinical Standard Procedure Document
or the SCHN Central Venous Access Device Practice Guideline
This document reflects what is currently regarded as safe practice. However, as in any clinical situation, there may be
factors which cannot be covered by a single set of guidelines. This document does not replace the need for the
application of clinical judgement to each individual presentation.
Approved by: SCHN Policy, Procedure and Guideline Committee
Date Effective: 1st February 2023 Review Period: 3 years
Team Leader: Vascular Access Clinical Nurse Specialist 2 Area/Dept: Vascular Access
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This Guideline may be varied, withdrawn or replaced at any time.
Guideline No: 2016-9057 v2
Guideline: Intravenous Extravasation - Management
CHANGE SUMMARY
• Revised Extravasation grading tool
• Inclusion of a medication list identifying those at high risk
• Link to eVIQ for antidotes.
• 10/02/23: Minor review.
o Link to Appendix B: Intravenous Extravasation Risk: Medication List added to
change summary
o All documents are able to be printed from auxiliary document page on ePolicy
o Clarification: In the event of an extravasation of a hazardous drug the initial
management should occur as SLAP (Page 8).
• 26/07/23: Minor review to update locations of Extravasation kits, see Appendix 1.
• 21/08/23: Minor review. Location of Extravasation kits updated to include OTC and
Variety, see Appendix 1.
READ ACKNOWLEDGEMENT
• All clinical staff working in clinical areas should read and acknowledge they understand
the contents of this document.
This document reflects what is currently regarded as safe practice. However, as in any clinical situation, there may be
factors which cannot be covered by a single set of guidelines. This document does not replace the need for the
application of clinical judgement to each individual presentation.
Approved by: SCHN Policy, Procedure and Guideline Committee
Date Effective: 1st February 2023 Review Period: 3 years
Team Leader: Vascular Access Clinical Nurse Specialist 2 Area/Dept: Vascular Access
Date of Publishing: 21 August 2023 3:05 PM Date of Printing: 21 August 2023 Page 2 of 15
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This Guideline may be varied, withdrawn or replaced at any time.
Guideline No: 2016-9057 v2
Guideline: Intravenous Extravasation - Management
TABLE OF CONTENTS
1 Extravasation Definition ............................................................................................. 4
2 Drug Definitions........................................................................................................... 4
3 Risk Factors for Extravasation ................................................................................... 5
4 Prevention Strategies.................................................................................................. 6
5 The assessment of PIVC function: Decision tree ..................................................... 7
6 Extravasation Grading and Management of Non Hazardous Drugs ....................... 9
7 Documentation of Extravasation Injuries ................................................................ 10
7.1 Handing Over .............................................................................................................. 10
7.2 Documentation ............................................................................................................ 10
8 Discharge Planning ................................................................................................... 11
Appendix A: Extravasation Kit ............................................................................................ 11
Appendix B: Intravenous Extravasation Risk: Medication List ....................................... 12
Appendix C: Vasoactive medications: Vasopressors: ..................................................... 12
Appendix D: eviQ Chemotherapy Extravasation Flow Chart ........................................... 13
Appendix E: Antidote Guidance ......................................................................................... 13
Appendix F: Application of Compresses ........................................................................... 13
Appendix G: Assessment of Swelling ................................................................................ 14
References ............................................................................................................................15
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This Guideline may be varied, withdrawn or replaced at any time.
Guideline No: 2016-9057 v2
Guideline: Intravenous Extravasation - Management
1 Extravasation Definition
Extravasation is defined as the inadvertent administration of a drug or IV fluid into the
surrounding tissue instead of into the intended vascular pathway (Clark et al. 2013).
Extravasation has the potential to cause tissue necrosis which may result in the loss of the
full thickness of the skin and underlying structures including: (Simona 2012; Little 2020).
• Scarring around tendons, nerves and joints
• Contracture of affected limb
• Amputation of digits and limbs
• Moderate to severe extravasation injuries have the potential to cause long term pain
and tissue damage, increase hospital length of stay and cause significant distress for
the patient and family (Simona, 2012).
Note: Extravasation injuries can occur from both peripherally or centrally inserted vascular
access devices: the term ‘vascular access device’ in the remainder of this document refers
to ALL peripherally and centrally inserted devices.
2 Drug Definitions
These definitions can be found at the eVIQ resource page.
Irritant agents have the potential to cause pain, aching, tightness and phlebitis in the vein
or in the surrounding tissue during administration. There may be an inflammatory response,
with or without erythema at the site. Often when an infiltration occurs with an irritant agent,
local treatments such as application of heat or cold may improve the reaction and decrease
the pain. Finally, irritant extravasations may cause sclerosis and hyperpigmentation along the
vein. Usually the symptoms disappear without long-term sequelae.
Vesicant agents are those capable of causing tissue damage after leakage into a vein and
may cause progressive tissue damage over time. An extravasation can cause reactions
ranging from pain, erythema, and soft tissue damage, with or without necrosis. These injuries
can result in acute inflammation of the surrounding tissues, erythema, soft tissue damage
with or without necrosis, and potential structural damage, depending upon the cause of the
extravasation. These drugs include Vasoactive medications or Vasopressors, further
information regarding these can be found in Appendix C.
Neutral agents are inert or neutral compounds which do not cause local damage or
inflammation. However, if large volumes are extravasated into surrounding tissue, damage
can occur.
Cytotoxic/ Hazardous agents may be classified as either irritant, vesicant or neutral agents
dependent on the individual drug, review via eviQ
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This Guideline may be varied, withdrawn or replaced at any time.
Guideline No: 2016-9057 v2
Guideline: Intravenous Extravasation - Management
3 Risk Factors for Extravasation
Potential risk for extravasation exists for all patients with a vascular access device,
irrespective of the child’s age, site or type of vascular device or type of fluid or medication
being infused.
Additional risk factors for extravasation include (Clark et. al 2013; Tofani et. al 2012;
Moureau 2019):
• Device related factors
o Length of catheter in vein
o History of difficult IV access and multiple cannulation attempts
o Unfavourable insertion site e.g. over area of flexion
o Poor dressing adherence and securement of the device
o Port needle dislodgement
o Retrograde flow on injection secondary to complete fibrin sheath development
o Catheter damage or breakage
• Patient risk factors
o Small, fragile veins
o Communication skills/impaired communication
o Activity level
o Neurological or cognitive impairment
• Medication/infusion related factors
o Irritant or vesicant potential of the drug
o Drug concentration
o High flow pressure (e.g. use of infusion pump or syringe driver)
o Volume of drug/infusion administered
o Chemical properties of the drug e.g. pH, osmolarity.
o Repeated administration of irritant or vesicant via the same vein
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This Guideline may be varied, withdrawn or replaced at any time.
Guideline No: 2016-9057 v2
Guideline: Intravenous Extravasation - Management
4 Prevention Strategies
Refer to information regarding administration of hazardous and vesicants:
At SCHN see: Hazardous and Cytotoxic Medications - Administration and Handling
Ensure appropriate vascular access device choice and maximise first insertion success and
escalate patients with difficult IV access in accordance with the SCHN Peripheral
Intravenous Catheters - Clinical Standard
• Identify and implement prevention strategies for patients considered to be at high risk of
developing an extravasation injury
• Avoid vascular access device insertion over areas of flexion if possible e.g. antecubical
fossa.
• Ensure the vascular access device is patent, in the correct position and suitable for
administration of a vesicant prior to administration.
• Comply with:
o Intravenous Fluid Management – CHW
o Intravenous Fluid and Electrolyte Therapy - SCH
• Clinical staff must complete the recommended education and training prior to the use of
vascular access devices, administration of intravenous medications and fluids and
administration of high risk medications.
• Consider the insertion of a central venous access device (CVAD) where appropriate, to
avoid administering irritant or vesicant solutions via a peripheral venous access device
for an extended period of time. This is to reduce the risk of phlebitis, thrombosis and the
risk of extravasation.
• Infuse solutions as per the Paediatric Injectable Medicines Handbook
• Ensure the vascular access device is dressed using a sterile, transparent semi-
permeable dressing and secured in accordance with the Central Venous Access
Devices (CVAD) and the SCHN Peripheral Intravenous Catheters - Clinical Standard
and ensure adequate ability to visualise the vascular access device insertion site.
• Ensure regular flushing of vascular access devices to assess and maintain patency
including prior to the administration of vesicant and non-vesicant medications and
intravenous fluids
• Ensure patency of vascular access device before beginning infusion by ensuring the
device flushes without pain or resistance (also obtaining blood return if administration is
via a CVAD). If device occlusion is encountered, cease the infusion and refer to the
assessment of PIVC function decision tree or the Central Venous Access Devices
(CVAD) practice guideline for recommended management of impaired vascular access
device function.
• Undertake regular assessment of peripheral IV and CVADs as per the Central Venous
Access Devices (CVAD) and the SCHN Peripheral Intravenous Catheters - Clinical
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Guideline No: 2016-9057 v2
Guideline: Intravenous Extravasation - Management
Standard guidelines and complete the recommended documentation of vascular access
devices.
• Ensure vascular access devices are assessed for removal when no longer clinically
required
5 The assessment of PIVC function: Decision tree
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Guideline No: 2016-9057 v2
Guideline: Intravenous Extravasation - Management
Immediate Management of a Hazardous Drug Extravasation
This can be found on The Extravasation management page on EVIQ
• Extravasation should be suspected if the patient complains of burning, stinging, pain or
discomfort or there is swelling, oedema, erythema, leakage at the site.
• Inflammation and blistering are the late symptoms of an extravasation.
• In the event of a mixed drug extravasation it is recommended to act in accordance with
the drug that has the most harmful properties.
In the event of an extravasation of a hazardous drug the initial management should occur as
SLAP
STOP the injection or intravenous infusion immediately.
LEAVE the vascular access device in place.
ASPIRATE any residual drug from the vascular access device using a sterile syringe.
PLAN
o CALL for assistance: notify medical officer, pharmacist and/or a senior nurse
o COLLECT the extravasation kit – Refer to Appendix A
o ASSESS Drug extravasated, dose, volume
Position and size of wound
Amount and type of exudate
Presence of swelling, oedema
Extent and spread of erythema, trace the affected area with pen
o PHOTOGRAPH the area – Refer to SCHN Clinical Images Policy
o ADMINISTER pain relief if indicated
o INITIATE appropriate drug specific management measures as per protocol
o REMOVE the vascular access device or Port needle once instructed by treating
team. Do not apply pressure. If a central venous access device is in
situ this should remain in position - refer to a medical officer for
further instructions
o REFER to a plastic surgeon if indicated
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This Guideline may be varied, withdrawn or replaced at any time.
Guideline No: 2016-9057 v2
Guideline: Intravenous Extravasation - Management
6 Extravasation Grading and Management of Non Hazardous Drugs
This document is able to be printed from Extravasation Grading Tool, auxiliary
document
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This Guideline may be varied, withdrawn or replaced at any time.
Guideline No: 2016-9057 v2
Guideline: Intravenous Extravasation - Management
7 Documentation of Extravasation Injuries
7.1 Handing Over
Ensure the following information is included when handing over the injury:
o Where is the vascular access device inserted?
o What was infusing?
o How much was infusing (approximately)?
o How is the perfusion above and below the injury site?
o What stage is the injury?
o How much swelling is present?
o What damage to the skin integrity has occurred?
o What first aid/ nursing interventions have been initiated?
7.2 Documentation
Document an extravasation injury in the patients Clinical Progress Notes and include the
following information:
o Date and time of incident
o Insertion site location
o Drug/fluid being administered at time of injury
o Rate and volume of infusion
o % of extravasation swelling and amount of fluid if known
o Patient’s symptoms and appearance of site including skin integrity
o Measure and document size of affected area using tape measure
o Initial First Aid Management provided
o Time parents/carers informed
o Time Nurse in Charge informed and their name/designation
o Time Medical Officer informed and their name/designation
o Photograph taken and consent obtained (if Stage 3 or 4 extravasation Injury). Use
Photography consent form. Refer to SCHN Clinical Images Policy.
o Enter this as an incident into ims+ and record the incident number in the medical
records
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Guideline No: 2016-9057 v2
Guideline: Intravenous Extravasation - Management
8 Discharge Planning
• Discharge plan including need for follow up of dressings/ wound management to be
determined by treating team and/or plastics team following individual assessment of
the injury.
• Follow up to be arranged with either GP, Outpatient Department or appropriate service
dependant on extent of injury.
Appendix A: Extravasation Kit
• Extravasation kit - recommended contents
• These Kits can be located in the flowing places:
o Camperdown Ward
o CICU
o C2W
o C2N
o Oncology Treatment Centre (OTC)
o Variety Ward
o Pharmacy
o Afterhours Drug Cupboard
• If any items are used or if products or drugs have expired, replacement should be
arranged through Pharmacy.
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Guideline No: 2016-9057 v2
Guideline: Intravenous Extravasation - Management
Appendix B: Intravenous Extravasation Risk: Medication List
Appendix C: Vasoactive medications: Vasopressors:
Extravasation of a vasopressor causes swelling and local hypothermia, followed by purple
discolouration and extreme pain. The resulting necrosis may require aggressive tissue
debridement, grafting or amputation.
For the purpose of extravasation management, vasopressors include:
Medication Antidote for extravasation Other management
Adrenaline (epinephrine)
Noradrenaline Warm compress
Phentolamine
(norepinephrine) Elevation of area if possible
Dilute 5 to 10 mg in 10–20 mL of
Dopamine sodium chloride 0.9% and give multiple
Dobutamine DO NOT use ice/cold
intradermal injections across the area.
Phenylephrine compress
May be administered up to 12 hours
Argipressin (vasopressin) after injury; preferable to treat as soon
Metaraminol Urgent referral to Plastics Team
as possible
Methylene blue required
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This Guideline may be varied, withdrawn or replaced at any time.
Guideline No: 2016-9057 v2
Guideline: Intravenous Extravasation - Management
Appendix D: eviQ Chemotherapy Extravasation Flow Chart
Extravasation management - immediate management flow chart
Appendix E: Antidote Guidance
Extravasation management: antidote guidance
Appendix F: Application of Compresses
The drug or agent causing the extravasation will determine whether or not a warm or cold
compress should be applied to an IV Extravasation Injury.
Compresses are never applied on infants less than 12 months
Do not apply compresses directly to the skin.
Cold Pack: Place in freezer for at least 2 hours prior to use, Wrap in a light towel before
placing cold pack to required area. Do not apply directly to skin. The compress can be stored
in the freezer until needed. In the absence of DRYPAC, a convenient source of ice and a
pliable waterproof container may be used.
Hot Pack: Place in hot water for approximately 5 mins (no more than 10 mins) until desired
heat is achieved. Test the hot-pack before applying to ensure it is not too hot. Wrap in light
towel before placing heat pack to the required area.
Caution: Heating in the microwave is not recommended as settings can vary and one area of
the heat pack may be significantly hotter than another.
Apply a warm or cool compress to affected area for 15-20 mins every 6 hours for a maximum
of 48 hours. While using compresses, it is important to maintain vigilant monitoring of the
patients skin for marked increase in redness, swelling, pain, and oedema.
Do not use towels, or any other linen heated in a microwave as a warm compress.
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Guideline No: 2016-9057 v2
Guideline: Intravenous Extravasation - Management
Appendix G: Assessment of Swelling
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This Guideline may be varied, withdrawn or replaced at any time.
Guideline No: 2016-9057 v2
Guideline: Intravenous Extravasation - Management
References
1. Australian Commission on Safety and Quality in Health Care (ACSQHC). (2021). Management of
Peripheral Intravenous Catheters Clinical Care Standard. Sydney: ACSQHC.
2. Cincinnati Children’s. (2017). Cincinnati Paediatric Intravenous Extravasation Assessment System.
3. Chan, K. M., Chau, J. P. C., Choi, K. C., Fung, G. P. G., Lui, W. W., Chan, M. S. Y., & Lo, S. H. S.
(2020). Clinical practice guideline on the prevention and management of neonatal extravasation injury: a
before-and-after study design. BMC pediatrics, 20(1), 1-10.
4. Cooke, M., Ullman, A. J., Ray-Barruel, G., Wallis, M., Corley, A., & Rickard, C. M. (2018). Not" just" an
intravenous line: Consumer perspectives on peripheral intravenous cannulation (PIVC). An international
cross-sectional survey of 25 countries. PloS one, 13(2), e0193436.
5. Hawthorn, A., Bulmer, A. C., Mosawy, S., & Keogh, S. (2019). Implications for maintaining vascular
access device patency and performance: Application of science to practice. The journal of vascular
access, 20(5), 461-470.
6. Little, M., Dupré, S., Wormald, J. C. R., Gardiner, M., Gale, C., & Jain, A. (2020). Surgical intervention
for paediatric infusion-related extravasation injury: a systematic review. BMJ open, 10(8), e034950.
7. Paquette, V., McGloin, R., Northway, T., DeZorzi, P., Singh, A., & Carr, R. (2011). Describing
intravenous extravasation in children (DIVE Study). The Canadian journal of hospital pharmacy, 64(5),
340.
8. Rickard, C. M., Webster, J., Wallis, M. C., Marsh, N., McGrail, M. R., French, V., ... & Whitby, M. (2012).
Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised
controlled equivalence trial. The Lancet, 380(9847), 1066-1074.
9. Schults, J., Rickard, C., Kleidon, T., Paterson, R., Macfarlane, F., & Ullman, A. (2019). Difficult peripheral
venous access in children: an international survey and critical appraisal of assessment tools and
escalation pathways. Journal of Nursing Scholarship, 51(5), 537-546.
10. Simona, R. (2012). A pediatric peripheral intravenous infiltration assessment tool. Journal of Infusion
Nursing, 35(4), 243-248.
11. Tong, R. (2007). Preventing extravasation injuries in neonates. Nursing Children and Young People,
19(8).
Copyright notice and disclaimer:
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everything practicable to make this document accurate, up-to-date and in accordance with accepted
legislation and standards at the date of publication. SCHN is not responsible for consequences arising
from the use of this document outside SCHN. A current version of this document is only available
electronically from the Hospitals. If this document is printed, it is only valid to the date of printing.
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