Peripheral extravasation injuries: Initial management and washout procedure

Key points

• Early identification and appropriate management of extravasation are crucial to prevent serious adverse outcomes.
• Do not flush the intravenous device after extravasation: stop the infusion, leave the line in place and try to aspirate the remaining drug.
• Management is guided by the estimated swelling (below 30% or 30% and more) and the drug risk list (green, yellow or red).
• Any extravasation of a vasoactive medication needs immediate review and preparation for phentolamine; ice or cold compresses must not be used.
• Neurovascular compromise or suspected compartment syndrome is a surgical emergency.

Overview

This Royal Children's Hospital Melbourne guideline explains how to recognise, grade and initially manage peripheral extravasation injuries in children, including antidotes and the saline washout procedure. Extravasation is leakage of fluid or medication from a peripheral intravenous cannula or central venous access device into extravascular tissue; prompt recognition and management can prevent surgery, permanent scarring or loss of function.

Risk factors and recognition

Risk factors include neonatal age, small or fragile veins, lines across joints, poorly secured lines, sedation, paralysis or inactivity, paraesthesia or neuropathy, and impaired neurocognition or communication. Severity depends on the infused volume and the drug properties (pH, osmolarity, pharmacological action). The site is checked when a drug is given and frequently during infusions by looking, palpating and comparing with the other side; signs may appear many hours later. Warning signs include a sudden change in infusion pressure or speed, leakage, pain, burning or tingling, swelling, skin changes and reduced capillary return. All injuries are photographed.

Grading severity

Step 1 estimates the percentage of swelling; step 2 assigns the infusate to a risk list. Examples: green (low risk) ceftriaxone or sodium chloride 0.9%; yellow (intermediate risk) midazolam or radiographic contrast; red (high risk) calcium salts, glucose above 12.5%, potassium chloride above 40 mmol/L, parenteral nutrition, vancomycin and vasoactive drugs. Neurovascular status, compartment syndrome and impending tissue ischaemia are also assessed.

Initial management

Stop the infusion, keep the line, elevate the limb without pressure, do not flush, aspirate, give analgesia, and mark and photograph the area. A warm compress may disperse drugs such as glucose, antibiotics, parenteral nutrition or electrolytes; a cold compress may limit IV contrast but is never used for vasoactive drugs. Red-list drug with swelling of 30% or more: review within 30 minutes and washout as soon as possible, within 12 hours. Red list with under 30%: review within 30 minutes and hourly reassessment for 48 hours. Yellow or green list with 30% or more: review within 30 minutes, hourly reassessment for 48 hours, washout if swelling exceeds 60% or ischaemia is impending. Yellow or green list with under 30%: non-urgent review and 4-hourly checks for 24 hours.

Antidotes and washout

Phentolamine 0.1-0.2 mg/kg (maximum 5 mg) is injected intradermally in 4-5 small aliquots, ideally as soon as possible and up to 12 hours after the injury. Hyaluronidase (1000 units/mL) is given as 0.2 mL at 5 sites around the edge, together with washout. For washout, after analgesia or sedation (for example 1% lidocaine 3 mg/kg, maximum 200 mg, without adrenaline), multiple vertical punctures 1 cm apart are made with a 25G needle and 0.9% sodium chloride is infused subcutaneously through a 23G needle at least 2-3 times the estimated extravasated volume. The wound is reviewed at least 6-hourly for the first 24 hours and the limb is kept warm and elevated for at least 24 hours.

Frequently asked questions

Should the cannula be flushed after extravasation?

No. The infusion is stopped, the line is left in place and the remaining drug is aspirated with a small syringe.

When is a washout needed?

For red-list drugs with swelling of 30% or more, within 12 hours; otherwise when the injury progresses or tissue ischaemia is impending, or for yellow or green drugs when swelling exceeds 60%.

When should the surgical team be involved?

With neurovascular compromise or concern for compartment syndrome, any red-list extravasation and any injury with swelling of 30% or more; consultation with the local paediatric team should be considered for all children.

Source

The Royal Children's Hospital Melbourne. Clinical Practice Guidelines: Peripheral extravasation injuries: Initial management and washout procedure. Last updated December 2023. Endorsed by the Paediatric Improvement Collaborative (PIC). Summary prepared by Medpresso from the original guideline; it is not a substitute for the full text or for medical advice.