Prevention and Treatment of Neonatal Extravasation Injury

• Introduction
• High risk situations
• Drug factors affecting extravasation
• Appendix 1: Drugs with high or low pH
• Appendix 2: Drugs with high osmolarity

Introduction

There is a high incidence of extravasation with intravenous infusions in newborn infants. If not recognised promptly this can lead to significant scarring and a poor cosmetic and functional outcome. Many of these injuries are potentially preventable.

This document outlines prevention and treatment strategies for extravasation injuries within the neonatal service. It should be read in conjunction with the existing policies on the use of central lines and umbilical arterial catheters.

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High risk situations

The following situations carry a high risk of extravasation and extra care should be taken-

• TPN infused via a peripheral cannula or peripherally sited long line
• Hypertonic solutions of glucose (>12.5%) or sodium chloride (>0.9%)
• Infusion of fluids containing calcium
• Infusion of caffeine solutions
• Infusions of inotropes other than via a central venous line
• Infusions of irritant drugs

To help prevent these injuries the care of peripheral and central lines is essential. This includes:

• Ensure central line position is confirmed by medical staff by X-ray before commencement of fluid infusions.
• All line sites must be checked hourly to observe for redness, swelling, leakage and blanching.
• Line insertion sites should be covered with an appropriate transparent dressing (Tegaderm or Opsite).
• Lines must not be bandaged or covered with a gauze dressing as this does not allow adequate inspection of the line.
• Ensure pressures on the administration pump are set 30mmHg above the opening pressure on the line. (ie if opening pressure is 15mmHg, set maximum pressure to 45mmHg)
• If the pressure alarm sound check site for redness, swelling, leakage and blanching before commencement of the infusion.

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Drug factors affecting extravasation

1. Irritant Drugs
The following factors need to be considered prior to giving an intravenous drug: -

• PH
  Solutions with a high or low pH will cause more tissue damage if they are extravasated. See Appendix 1 for list of drugs.
• Osmolarity
  Solutions with an osmolarity greater than that of plasma (> 290mOsmol/L) may cause tissue damage. The presence of these solutions can lead to an osmotic imbalance across the cell membrane, a breakdown of the cellular transport mechanisms and cell death. Most intravenous drugs are formulated to have an osmotic pressure equal to that of plasma, so that the solution to be injected into the patient is unlikely to cause disturbance to the tissues. Appendix 2 shows a list of drugs that have high osmolarity and may potentially cause a problem if extravasated. For this reason, extra care should be taken when administering these drugs.

2. Vasoactive drugs
Due to their direct vasoconstrictive action on blood vessels, drugs such as adrenaline, noradrenaline, dobutamine, dopamine and vasopressin reduce the ability of blood vessels in the extravasated area to allow blood to flow freely. This may result in ischaemic injury in the concerned area. If this ischaemia is severe and/or prolonged, necrosis may develop in the extravasated area.

Dopamine: Peripheral infusions of inotropic doses should be avoided as vasoconstriction and gangrene of the fingers or toes may occur.

Dobutamine: Avoid extravasation as this may cause tissue sloughing and necrosis.

Extravasation of vasoacdrugs is a medical emergency and must be acted upon urgently. Call for senior help and notify medical staff as soon as you suspect an extravasation injury.

1. Stop the infusion immediately. Note the fluids or drug that was being infused.
2. If possible, aspirate any fluid from the affected area through the intravenous cannula before it is removed.
3. Remove the intravenous cannula
4. If the skin is only mildly inflamed then elevate the limb and observe. There is no role for compression dressings.
5. If the skin is inflamed with a well-demarcated area of injury (see picture below) then perform the saline flush out method as described below. This should be performed immediately. Do not wait for the skin to become purple or necrotic. The earlier the irritant is flushed out the better.

An acute extravasation injury that requires urgent treatment.

Before performing the flush-out, photograph the injury and record in the medical notes.

1. Clean the affected area and surrounding skin with Chloraprep®
2. Open the emergency extravasation pack (located in treatment room)
3. Infiltrate the site with 1ml of 1% lignocaine. Ensure the area around the injury is well anaesthetised before proceeding further.
4. Reconstitute the hyaluronidase powder with 1.5ml of water for injection, to produce a solution of 1000units/ml. Inject 0.5-1ml (500 - 1000 units) of the hyaluronidase solution subcutaneously into the damaged skin.
5. Make 4 puncture holes in the tissue plane around the damaged area using a white (19G) needle or a fine scalpel blade (see below)
6. Draw up 10ml of 0.9% sodium chloride in a syringe with a white (19G) needle. Insert the white needle through one of the puncture sites, so that the tip is in the damaged subcutaneous tissue. Flush the saline into the subcutaneous tissue plane to irrigate the area. Saline should flow freely out of the other incisions.

1. If the area becomes swollen, gentle massage the fluid out of the puncture sites. Repeat the process, injecting sodium chloride through one of the other puncture sites. Improvement is usually seen after 2 x 10mls of sodium chloride. The procedure may be repeated up to 5 times (5 x10mls=50mls) immediately after extravasation.
2. If the limb becomes oedematous during the procedure, the excess fluid should be removed by gentle massage towards the incision.
3. After adequate flushing photograph again and then dress the skin (see below).
4. Ensure the injury, the fluid that caused it and the treatment steps are well documented in the notes. Complete a Datix form online.
5. Ensure the parents are informed of the injury and the treatment given.
6. If the skin is necrotic or there is likely to be skin loss or permanent injury then make an early referral to plastic surgery and consult the tissue viability nurse.

Dressings
If the skin has broken down the best dressing is Duoderm®. This should be applied to the area and left in place until the adhesive loses its tack, unless there are signs of infection. Removing the Duoderm® too frequently causes problems with epidermal skin stripping. Check for signs of infection regularly, but prophylactic antibiotics are not normally required. If in doubt discuss with a tissue viability nurse

Ischaemic injuries
In general ischaemic injuries are more likely to be due to mal-position of lines or thrombo-embolism than extravasation, but if limb ischaemia is associated with extravasation of vasoactive drugs such as dopamine there is some limited evidence that application of a small GTN patch proximal to the ischaemic area may be of benefit. Cut down an adult GTN patch to at least a quarter size. Monitor for systemic hypotension.

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