Extravasation is the unintentional leakage of medications from the vein into the perivascular space and should be treated as a medical emergency. Although most cases of extravasation will not cause significant injury, severe tissue necrosis can occur.

The risk of a serious extravasation injury depends on drug characteristics, including osmolarity, pH, cytotoxicity, and vasoactivity. (Vasoconstrictors, such as norepinephrine, have a higher potential for causing injury than vasodilators). Drugs that tend to result in an inflammatory reaction at the site of administration are considered irritants. Clinical signs include erythema, warmth, swelling, induration, and tenderness. Symptoms are of short duration, with no long-term sequelae. Drugs that have the potential to cause skin necrosis, ulceration, gangrene, and complications that may lead to limb amputation are referred to as vesicants. If possible, vesicants should be administered through a central venous catheter to reduce the risk of a severe extravasation injury.


Any patient receiving IV medication is at risk of extravasation. The first symptom is often stinging or burning at the site of administration. Patients who are unable to communicate pain (pediatric population, non-English speakers) are at higher risk of having their extravasation go unnoticed. Agitation and delirium are also risk factors because interference with the catheter may lead to decannulation. Finally, patients with fragile skin or veins (neonates and geriatric patients) are also at higher risk of extravasation. 


If a patient complains about burning 
during an IV infusion, the etiology should be promptly investigated. Extravasation should be suspected in the following situations:


  • Erythema, swelling, or leakage is observed at the injection site. 

  • An IV infusion does not flow freely or the rate is reduced.

  • Resistance is felt during administration of IV push medications.

  • No blood return occurs with 
aspiration. 


Notably, blood return does not exclude extravasation, and ruling out infiltration because of blood return has been implicated in a number of serious extravasation injuries.


Although no guidelines apply to the management of all drug extravasations, some general recommendations do exist. If extravasation occurs, the injection should be stopped immediately and the IV tubing disconnected. Avoid applying pressure to the site, and do not flush the line. Leave the original catheter in place, and attempt to aspirate as much of the infiltrated drug as possible. Additional measures include application of topical corticosteroids (hydrocortisone 1%), a thermal compress, and elevation of the affected limb. Thermal compresses should be applied only after determining if the extravasated drug requires a hot or a cool compress. Applying a compress that is the wrong temperature can exacerbate the injury. Further management depends upon the particular drug extravasated. 


Extravasation of chemotherapy agents deserves special acknowledgment because these drugs are cytotoxic by nature and many are known vesicants. Additionally, some antineoplastic agents have antidotes that may be used if extravasation occurs. Most hospitals and health care centers that administer chemotherapy have protocols or extravasation kits available to provide rapid assistance to the clinician in the event of drug infiltration.


No single agent is used to treat extravasation of noncytotoxic medications. Early identification and intervention at the first sign of infiltration is probably the most critical step. If the decision is made to use an antidote, it should be administered as soon as possible. Phentolamine (Oraverse, Regitine, generic) may be given in cases of vasopressor extravasation (dopamine, norepinephrine [Levophed, generics], epinephrine). Hyaluronidase (Amphadase, Vitrase) has been used off label for vesicant drug extravasation, but it should not be used for infiltration of vasopressors. Knowing when these agents are indicated is crucial. Hospital protocols may prove useful.


Finally, if extravasation occurs, the site should be monitored every 2 hours for 24 hours, every 8 hours for 72 hours, and then daily for erythema, blanching, necrosis, swelling, drainage, pain, and temperature. The affected extremity should be elevated for 24 to 48 hours and assessed every 8 hours for sensation, movement, and pulses. If there is any deterioration of the affected area (continued pain, necrosis, ulceration, suspected compartment syndrome), surgery should be consulted immediately. Some protocols recommend early surgical consult if a known vesicant is extravasated, but this practice is controversial. JAAPA

Larissa DeDea, PharmD, BCPS, PA-C, is a clinical pharmacist with Northern Arizona Healthcare, Flagstaff, Arizona. In addition to being board certified in pharmacotherapy, she is a graduate of the Yale University PA program.