Management of Extravasation of Non-Chemotherapeutic Agents Adult/Pediatric- Inpatient/Ambulatory Consensus Care Model For changes contact the Drug Policy Program Email DrugPolicyProgram@uwhealth.org Target Population: Adult and pediatric patients experiencing an extravasation event, i.e. the unintentional administration of a medication into the tissue surrounding the intended vascular channel. This summary addresses non-chemotherapeutic medications. See separate summary for management of chemotherapy extravasation. Instructions for Management of Extravasation: Enter “Extravasation Management” into the search box in Lexicomp OR click the appropriate link depending on worksite: UW Health Swedish American Guidance/Guideline Overview The Lexicomp resource includes: • Definitions • Prevention tactics • Steps for initial management • Extravasation management for specific vesicant agents - including antidote and supportive management instruction • Supportive management • Detailed information on specific antidotes Immediate Signs and Symptoms (not all signs and symptoms may be detected) • Pain: burning, stinging, sensation of coolness, etc. • Redness in area of administration site • Swelling • Loss of blood return from IV device • Resistance during IV bolus • Leaking around catheter or implanted port needle • Temperature change in tissue surrounding infusion site Supportive Management • When specific guidance is not provided in Lexicomp or guidance is conflicting, follow recommendations below: • Doxycycline Apply dry cold compress1 • Erythromycin lactobionate Apply dry cold compress1 • Phenobarbital Apply moist heat compress2 • Promethazine Apply dry cold compress*1 • Verteporfin Apply dry cold compress and protect area from light3 *Because evidence is of low quality, resulting recommendations are weak; other alternatives may be equally reasonable. Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 07/2023 Effective 1/25/2022. Contact CCKM@uwhealth.org for previous versions. Documentation Recommended elements for documentation • Date and time of occurrence • Site of administration and condition of vein based on “touch, look, and feel assessment”; see https://uconnect.wisc.edu/clinical/references/infection-control/infection-control/hai/piv-complication-prevention/resources/name-143798-en.file • Apparatus and method of administration • Patient complaint and statements • Extravasated medication • Medications also administered in same time frame • Treatments applied and/or administered including concentration and estimated volume extravasated • Provider notification • Completion of wound sheet • Plan for follow up Investigational Drug Instructions • Vesicant potential may not be known during clinical trials. Known vesicants will be identified in the Health Link medication record. Vesicant precautions are required for investigational drugs which are known vesicants. • Refer to the investigational drug monograph for additional information. • Provider and study group must be notified of any extravasation involving investigational drugs UW Health Resources • Peripheral Intravenous (PIV) Bundle: https://uconnect.wisc.edu/clinical/references/infection-control/infection- control/hai/piv-complication-prevention/resources/name-145226-en.file • UW Health Safety “What I Need to Know”: IV extravasation: https://uconnect.wisc.edu/clinical/patient-safety/patient-safety- program/safety-winks/resources/name-172719-en.file • Healthcare Event Reporting Online (HERO): https://uconnect.wisc.edu/clinical/patient-safety/hero/ Selected General References • Gorski et al. Infusion therapy standards of practice. J Infus Nurs. 2016. • Gorski et al. Development of evidence based list of non-cytotoxic vesicant medications and solutions. J Infus Nurs. 2017. • Reynolds et al. Management of extravasation injuries: focused evaluation of noncytotoxic medications. Pharmacotherapy 2014 Cited References 1. Hurst S, McMillan M. Innovative solutions in critical care units; extravasation guidelines. Dimen Crit Care Nurs. 2004;23(3):125. 2. Phenobarbital sodium [prescribing information]. West-Ward Pharmaceutical Corp.; Eatontown, NJ 2011. 3. Verteporfin (Visudyne®) [prescribing information]. Bausch and Lomb; Bridgewater, NJ. 2017. Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 07/2023 Effective 1/25/2022. Contact CCKM@uwhealth.org for previous versions. Appendix A: Management of Extravasation: Chemotherapeutic and Non-chemotherapeutic Agents Figure 1: Workflow algorithm Stop infusion at first suspicion of extravasation. Disconnect the IV tubing but DO NOT remove the catheter or needle. Gently aspirate extravasated drug. Do NOT flush the line with normal saline or dextrose Determine if an antidote will be given. For non-chemotherapy, work with provider to order appropriate medication in Health Link. For chemotherapy, order antidote by delegation protocol #23. Remove the catheter or needle unless it will be used to administer an antidote into the extravasation site. Then remove catheter/needle after administration of the antidote, if given by this route. Elevate the affected extremity. Apply dry compresses to the area if indicated. Relative temperature of compress (i.e. warm or cold) is determined by the vesicant extravasated. Mark the extravasated site with a surgical marker and take photograph if possible. Notify attending physician if not already done and consider need for Plastic Surgery consultation. Document extravasation in the electronic medical record AND submit adverse event to the Healthcare Event Reporting Online (HERO) system. Observe patient for appropriate period (e.g. 48-72 hours). Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 07/2023 Effective 1/25/2022. Contact CCKM@uwhealth.org for previous versions.