Chapter 20 IV infiltration

20.1 General Treatment

  • Stop IV infusion
  • Leave catheter in place - attempt aspiration, inject reversl agent through infiltrated catheter
  • Remove needle, elevate affected limb to minimize swelling
  • Warm compresses for vasopressors- they dilate blood vessels and improve drug removal
  • Cord compression for irritant drugs (TPN)

20.2 Hypertonic Extravasations (TPN, Ca)

20.2.1 Hyaluronidase

Mechanism: Hyaluronidase functions via depolymerization of glycosaminoglycans such as chondroitin sulfate and hyaluronic acid, which is thought to increase tissue permeability and subsequently aid in dispersion of the infiltrated agent

Pediatric Patients

  • Dose: 15 Units of Hyaluronidase (Maly et al. 2018)
  • Dilution: 0.1 ml (150 unit/ml) dilute with 0.9 ml of NS to achieve 15 units/ml
  • Administration: within 3 hrs of insult maximum benefit.
  • Needle: 27-30 gauze needle
  • Prepare five different TB syringes with 0.2 ml of solution and attach 5 needles.
  • Intradermal injections of 0.2 ml (total 5 of them) around the infiltration site in a circular pattern

Adult Patients

  • Dose is 150 Units
  • Hylenex (Baxter) Contains 150 Unites/ml - no dilution in adult
  • Vitrase 2ml of 200 Units -dilute 3:1 (0.75ml of vitrase solution with 0.25 ml of Normal Saline)

20.3 Vasopressors Extravasations

  • Dopamine, Epinephrine, Norepinephrine, Dobutamine, Vasopressin

20.3.1 Phentolamine

Mechanism: Phentolamine is a reversible alpha-adrenergic receptor antagonist

  • No benefit after 13 hours of injury.

For neonates

  • Dose: 0.5 mg
  • Dilution: 1:10 dilution of the commercial 5 mg/mL phentolamine to a concentration of 0.5 mg/mL,
  • Needle: 27-30 gauze needle
  • Prepare five different TB syringes with 0.2 ml of solution and attach 5 needles.
  • Intradermal injections of 0.2 ml (total 5 of them) around the infiltration site in a circular pattern

For infants, children, and adults

  • Dose: 2.5 to 5 mg
  • Dilution: 5mg of phentolamine reconstituted with 5ml of NS (1mg/ml) Or 1:5 dilultion of 5mg/ml to attain 1mg/ml
  • Needle: 27-30 gauze needle
  • Intradermal infections of 0.5-1ml aliquots 5 times around injection site.

20.3.2 Nitroglycerine

  • Augments phentolamine-mediated vasodilation.
  • Topical application of 2.5 cm of 2% nitroglycerin paste with reapplication every 8 hours has been shown to initiate reperfusion.

20.4 Grading of Extravasation in Neonates

(Simona 2012)

Grade 1 Grade 2 Mild Grade 3 Moderate Grade 4 Severe
localize swelling (1%-10%) Slight swelling at site (upto 1/4 th of extremity above or below site 10%-25% of extremity above or below site) Moderate swelling at site (1/4th to 1/2 of extremity above or below site 25%-50% of extremity above or below site) Severe swelling at site (more than 1/2 of extremity above or below site >50% of extremity above or below site)
flushes with difficulty Presence of redness Pain at site Infiltration of blood products, irritants, and/or vesicants (any amount of swelling)
pain at site Pain at site Skin cool to touch Skin cool to touch
Blanching Pain at site
Diminished pulse below site Blanching
Skin breakdown/necrosis
Blistering
Diminished or absent pulse below site
Capillary refill >4 Seconds

References

Maly, Connor, Kenneth L Fan, Gary F Rogers, Benjamin Mitchell, June Amling, Kara Johnson, Laura Welch, Albert K Oh, and Jerry W Chao. 2018. “A Primer on the Acute Management of Intravenous Extravasation Injuries for the Plastic Surgeon.” Plastic and Reconstructive Surgery – Global Open 6 (4): e1743.
Simona, Rodica. 2012. “A Pediatric Peripheral Intravenous Infiltration Assessment Tool.” Journal of Infusion Nursing 35 (4): 243–48.