Learning objectives 

• Identify the risk factors associated with extravasation injuries
• Recognize the differential diagnosis of extravasation injuries
• Manage and prevent extravasation injuries
• Recognize warning signs of extravasation injuries

Definition and mechanisms

• The unintentional injection or leakage of fluid in the perivascular or subcutaneous space
• Resulting from solution cytotoxicity, osmolality, vasoconstrictor properties, infusion pressure, and regional anatomical peculiarities
• May cause significant tissue necrosis resulting in the amputation of an extremity

Risk factors

• Preexisting cutaneous, vascular or lymphatic pathophysiology
• Fragile or mobile veins
• Site of injection
• Toxicity of the drug
• Amount of agent extravasated
• Duration of tissue exposure
• Decreased vigilance of doctor or patient

Three categories of anesthetic/ICU agents causing extravasation injury

Differential diagnosis

• Propofol, ondansetron, rocuronium, and cyclizine can all cause discomfort or pain on injection 
• Venous spasms may occur and can lead to localized skin blanching

Management

Prevention

• Avoid IVs in the hand/wrist as the most appropriate site is considered to be the forearm
• Careful insertion of peripheral venous catheters
• Flush catheter with sterile saline
• Apply a suitable dressing to prevent movement of the catheter and avoid unreassuring IVs
• Inspect the catheterization site regularly
• Regulated delivery of intravenous fluids from continuous infusion pumps
• Hyperosmolar fluids, acidic or alkaline solutions, or infusates with irritant or vesicant properties should be given through central venous lines, if possible, or should be diluted or neutralized
• For slow infusion of high-risk drugs, a central line or peripherally inserted central catheter (PICC) line should be used
• Keep antidotes and the worksheet in the room with the patient
• 10 mg of phentolamine mesylate can be added to each liter of solution containing norepinephrine (the vasopressor effect of norepinephrine is not affected)

Suggested reading

• Al-Benna S, O’Boyle C, Holley J. Extravasation injuries in adults. ISRN Dermatol. 2013 May 8;2013:856541.
• Lake C, Beecroft CL. Extravasation injuries and accidental intra-arterial injection, Continuing Education in Anaesthesia Critical Care & Pain, Volume 10, Issue 4, August 2010, Pages 109–113.
• Schummer W, Schummer C, Bayer O, Müller A, Bredle D, Karzai W. Extravasation Injury in the Perioperative Setting. Anesthesia & Analgesia: March 2005 – Volume 100 – Issue 3 – p 722-727.