Home About Apex News Neonatal Extravasation

Services

Latest News

A study by Regenstrief Institute and U.S. Department of Veterans Affairs investigators provides the first in-depth look at how health care providers react to medication alerts generated by electronic medical record systems. The researchers plan to use...
Neonatal Extravasation Print E-mail

Introduction

Approximately 4% of neonates develop skin necrosis as a result of extravasation of an intravenous infusion. A small but significant proportion of these infants develop long-term cosmetic or functional compromise as a result of the injury. Extravasation may occur due to either the cannula piercing the vessel wall or from distal venous occlusion causing backpressure within the vessel.Peripheral and central venous catheters are both capable of causing extravasation. A Cochrane review shows that centrally placed catheters undergo extravasation as frequently as peripheral.

The aim of this guideline is to define the grading and management of extravasation injuries, it is intended to use for neonatal patients by medical and nursing staff.

Limiting the intravenous pump cycle to one hour may minimise the extent of tissue damage from extravasation providing the entry site is observed concurrently. Intravenous pumps do not always alert staff to an extravasation injury in progress.

The degree of tissue damage due to extravasation is dependent upon: the volume of the infusate, its pH & osmolarity, the dissociation constant and pharmacological action of any drug(s) being infused. Examples of commonly used solutions with the potential to cause skin necrosis: Phenytoin, Amphotericin B, TPN, Dopamine, KCl, Calcium Salts, and X-Ray contrast.

Definition of terms:

  • Extravasation – the leakage of intravenous fluid from the vein into the surrounding tissue

  • Vesicant – a solution with the potential to form blisters if extravasated

Assessment

The grading of extravasation injuries is shown in the table below:

 

  Grade 1

  Grade 2

  Grade 3

  Grade 4

Pain at infusion site

Pain at infusion site

Swelling

No skin blanching

Normal capillary refill and peripheral pulsation

Pain at infusion site

Swelling

Skin blanching

Cool blanched area

Normal capillary refill and peripheral pulsation

Pain at infusion site

Swelling

Skin blanching

Cool blanched area

Reduced capillary refill

+/- Arterial occlusion

+/- Blistering

 

Investigations

No specific investigations are required. However, if the wound appears infected, a wound swab, full blood count, CRP and blood culture should be taken and the infant commenced on intravenous vancomycin and gentamicin.

Management

Acute management:

Grade 1

Grade 2

Grade 3

Grade 4

Stop infusion

Remove cannula and splints/tapes

Elevate limb

Stop infusion

Remove cannula and splints/tapes

Elevate limb

Stop infusion

Leave cannula in situ until review by Doctor

Consider irrigation of affected area

Remove constricting tapes

Elevate limb

 

 

Stop infusion

Leave cannula in situ until review by Doctor

(Photograph lesion - providing no delay in further treatment)

Irrigate affected area

Elevate limb

Inform Neonatal Consultant +/- plastic surgery

Most extravasation injuries are of Grades 1 & 2 and do not require extensive intervention to prevent long-term skin and soft tissue damage. Grade 3 & 4 injuries have a greater potential for skin necrosis, compartment syndrome and need for future plastic surgery, depending on the type of solution extravasated.

Further assessment

  • Documentation of the site, extent and management of the injury should be completed in the medical notes.

  • Following irrigation treatment, all injuries should be reviewed within 24 hours of the extravasation occurring.

  • Irrigation of major grades of extravasation has been used to prevent extensive skin loss and need for plastic surgery and skin grafting. However, the evidence for the use of irrigation in preventing long-term injury is limited to case reports.

Follow-up and review

  • This is determined by the grade of extravasation.

  • Minor grades should be reviewed after 24 hours by neonatal medical staff.

  • Grades 3 & 4 should be reviewed by neonatal and plastic surgery staff within 24 hours to assess the degree of tissue damage and outcome of the irrigation procedure if performed.

 

We are using Narcotic Assistant by Apex Custom Software within Mercy and it has greatly improved our audit trail and workflow process. Their solutions are designed for specific needs at resonable prices. 

Jeff Amstutz RPh
Pharmacy IS Coordinator
Mercy Health Partners
 

Clients

Parkland Health & Hospital System

National Institute of Health

Community Health Systems

Mercy Health

Mylan Pharmaceuticals

Singapore General Hospital