NICU extravasation

1. EXTRAVASATIONIn
NICU
By
Dr. Mohammed Said

2. • Many medications given to neonates have the
potential to injure when an extravasation
occurs.
• An extravasation is described by the Infusion
Nurses Society (INS) as the inadvertent
administration of a vesicant solution or
medication into the surrounding tissues.[1]

3. A vesicant
is defined as a solution or medication that causes
the formation of blisters leading to tissue
necrosis and sloughing.

4. Extravasation
Inadvertent administration of vesicant
medication or solution into the surrounding
tissue.
Infiltration
the inadvertent administration of non-
vesicant medication or solution into the
surrounding tissue.

5. Interstitial
• Any type of fluid in the interstitial space or
the space between tissue layers and outside
of the vein
Occlusion
Blockage that stops the passage of infusate or
normal saline flush into the lumen.Often
accompanied by an increase in pressure
reading on the IV pump.

6. Infiltration Is Common Among Neonates
• The peripheral intravenous (PIV) catheter is the
most used vascular access device for the
administration of medications in hospitalized
neonates; however 95% of PIV catheters are
removed due to complications such as leaking,
occlusion and infiltration.[4]
• Infiltration rates among neonates are as high as
57%–70% with extravasation occurring in 11–
23%.[5] Both infiltration and extravasation are
destructive

10. • Extravasations have the potential to cause
peripheral tissue injury depending on the type
of vesicant, concentration of the vesicant,
location, amount, and duration of exposure to
the vesicant.
• Damage from a vesicant may progress over
time and become evident 48–72 hours after
the extravasation occurs.

11. The preterm and sick neonate is more
susceptible to skin injury and complications
from extravasation injury than their mature,
healthy counterparts.
• Their immature skin structures,
• flexible subcutaneous tissue,
• small blood vessels and poor venous integrity
increase the risk of complication from
venipuncture and IV infusions.[5,8]

12. • The goal in neonatal care is to prevent skin
breakdown whenever possible. Similarly,
attention to thermoregulation, pain and stress
that infants endure as a result of repeated IV
attempts or restarts, and infiltrations and
extravasations must be considered and
managed

13. Inflammation in the Premature Infant
• The neonatal immune system is poorly
regulated compared to adults and
dysregulation is magnified when neonates are
born early.[11-13] While intravenous therapy is
necessary in this population, it is not without
its risks.

14. • Vesicants can harm the endothelial lining of
the blood vessel, triggering production and
release of oxygen free radicals that spur
inflammation.[14,

15. • which is common in prematurity, or the
inflammatory assault is severe, endothelial
dysfunction leads to programmed cell death
(apoptosis).[16]
• The load of oxidative stress in premature infants
is especially of concern as it has been linked to
various neonatal morbidities including
necrotizing enterocolitis,[16,17] retinopathy of
prematurity,[18-20] and chronic lung disease.[16,21-
23]

16. Pathophysiology of Vascular Injury

17. The Neonatal Intensive Care Unit
(NICU) Nurse's Role
• NICU nurses monitor the PIV site with
vigilance to aid in early identification of
infiltration and extravasation and prevent this
type of injury whenever possible. Identifying
an infiltration may be difficult, even for the
most experienced nurse.[10]

18. • The NICU nurse is aware of the subtle changes
in heart rate, oxygen saturations, apnea, and
the more obvious change in behavior such
crying and agitation that may indicate
problems with the PIV therapy.[4

19. Potential Origins of Infiltration
• There is a supposition that an infiltration or
extravasation is caused by IV catheter dislodgement or
puncture of the vein during insertion or during
handling of the infant.
• Chemical composition of medications also impacts risk
of vein rupture.[5]
• The vein's tolerance to an infusion is affected by the
osmolality and pH of the vesicant, the duration of the
exposure, and irritation to the endothelial cells.[4]
• An additional factor in causing a cannulated vessel to
rupture and leak is the pressure in which the
medication is being delivered by the infusion pump.[3,5]

20. Irritants and Vesicants Given to
Neonates
• ntravenous medications can be divided into
three major subcategories: 1) non-vesicants,
2) irritants, and 3) vesicants. In order for an
infiltration to be a true extravasation, the
offending agent, by definition, must be a
vesicant. There are a number of different
qualities that affect the potential for a
medication to result in tissue damage. These
include, but are not limited to: osmolarity, pH,
direct medication effects and solubility.[27]

21. • ntravenous medications can be divided into
three major subcategories: 1) non-vesicants,
2) irritants, and 3) vesicants. In order for an
infiltration to be a true extravasation, the
offending agent, by definition, must be a
vesicant. There are a number of different
qualities that affect the potential for a
medication to result in tissue damage. These
include, but are not limited to: osmolarity, pH,
direct medication effects and solubility.[27]

23. Nursing Actions to Prevent Vascular
Injury
• The best method to decrease complications of PIV
therapy is to prevent them in the first place.[2]
• Serious complications are not entirely preventable, but
following recommended standards of IV therapy is the
best approach for avoiding complications.[3]
• The decision to place a peripherally inserted central
catheters (PICC) or central venous lines (CVL) might be
needed if vascular access is difficult or long-term
parenteral therapy is planned. However

24. Recommendations for Practice to
Prevent Vascular Injury.
Peripheral IV Insertion and Maintenance
Use small enough plastic/silicone catheter to avoid restriction of blood flow
Avoid repeated use of a vein
Avoid placing a PIV in an areas difficult to immobilize
Use transparent tape to secure
Cover the site with a sterile semi-permeable transparent dressing that will permit
ongoing visualization of the insertion site
Upper extremities less likely to infiltrate or leak compared with peripheral IV in
lower extremities or scalp veins
Place tape loosely over boney prominences to avoid restricting blood flow to the
extremity
Infusion Maintenance
Limit PIV glucose to 12.5%
Dilute medications as much as possible before administration are other solutions

27. Key Actions to Minimize Injury When
Extravasation Occurs
• Once an infiltration or extravasation is
discovered, immediate treatment is the key to
preventing progressive damage from the
vesicant.[2]
• Treatment decisions are based on the size and
appearance of the injury, type of IV infusing,
duration of exposure and location.[8] Protocols
and algorithms can be used to assist nurses in the
steps needed to minimize the potential damage
and start the treatment process.

28. • Stopping the infusion and elevation of the extremity is
the first actions followed by placement of a saline
soaked gauze or prepackaged normal saline pad.
• The saline draws out the vesicant, and impedes a scab
from forming to allow fluid to leak out.
• Gently squeezing the fluid from the open insertion site
can also help to remove the offensive agent.[8] While
the saline soaks are held in place, assistance with the
various tasks that are required for treatment may
require additional personnel.

29. • Documentation:
Following an IV insertion, document the
following information in the patient record:
 Date and time of procedure.
 Gauge and type of access device used.
 Site of insertion.
 Patient’s tolerance of the procedure.
 type of solution, additives and rate of
infusion
•

30. Wound care
• Cleansing:
· Normal saline. Any wound swabs should only be taken after cleansing.
• Moisture and autolytic debridement:
· Water-based wound gel (hydrogel).
• Protection and Absorption:
· An absorptive layer such as Aquacel® can be placed directly over the
wound to prevent
any dressing from sticking to the wound and to absorb necrotic material as
it softens.
· Cover with a hydrocolloid or clear acrylic dressing. A thin product
conforms better with
infant’s small limbs. Use only enough to give approximately a 1 cm border
around the
• Assess dressings a minimum of q4h and prn for integrity and drainage.

31. • Replace dressing q 7 days or PRN if the dressing being saturated
with exudate or is lifting
significantly. A hydrocolloid will have a “swiss cheese” appearance
when saturated. If the
edges begin to lift they can be reinforced with a transparent
dressing.
• If there are signs of systemic sepsis such as fever or temperature
instability etc, or local
inflammation around the area of the wound, remove the dressing
and assess for wound infection
evidenced by purulent drainage and peri-wound erethema. Send
wound swab after cleansing the
wound bed with saline and consult wound and skin assessment
team for a dressing protocol for an
infected wound.

32. • Saline Flush Technique:
This procedure involves making
small puncture marks around the
edge of the area of extravasation
and the inserting a cannula into each
of the puncture sites in turn and
flushing normal saline through each
puncture site. The volume in the
literature is 500 mls, although this
should be modified down in the
neonate. The goal is that the flush
solution will exit out of the other
puncture site.

42. Hyaluronidase
• Hyaluronidase is an enzyme that breaks down
hyaluronic acid, a compound best described as the
"glue" which holds cells together. When this
extracellular glue is dissolved, cells are separated. This
is helpful in extravasations as it allows for the
medication to distribute through a larger area by
breaking down the walls that keep it localized. This not
only helps to decrease the concentration effects of the
extravasated product, but also exposes the medication
to more capillary beds that allows for reduction of
edema via more rapid reabsorption and removal of the
product from the damaged area.

43. Phentolamine
• Phentolamine is an antidote that will counteract the effect of
vasoactive agents such as dopamine, epinephrine, norepinephrine
and phenylephrine.[8] These medications result in vasoconstriction
via stimulation of alpha-receptors.
• Phentolamine acts to block the activity of alpha-receptors and
subsequently will help relax vascular smooth muscle. This will
improve circulation in the area of the extravasation and thus
decrease ischemia and cell death. Phentolamine can also be utilized
for vasopressin or dopamine extravasation.[28]Phentolamine should
be administered within 12 hours of initial exposure but
administration should occur as soon as possible. Prepare a 0.5 to 1
mg/mL solution and administer 0.1 mg/kg (to a max of 2.5 mg in
neonates,

44. • Nitroglycerin Ointment (2%)
• Nitroglycerin 2% is an option to treat extravasations.[8]Nitroglycerin
acts to relax smooth muscle resulting in arteriolar, arterial and
venous vasodilation that results in increased capillary blood flow,
counteracting the effects of vasoactive medications. This will help
to reverse tissue ischemia and cell death. In the neonatal
population, there is a case report describing the use of 1 inch of 2%
nitroglycerin ointment for treatment of a dopamine extravasation,
located in the dorsum of the left hand, in a 1.8 kg 34 week preemie.
This resulted in return of circulation within a few minutes. Of note,
treatment was started almost 12 hours after the extravasation was
initially noted and patient had no significant change in
hemodynamics.[33]

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