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Extravasation.pptx
- 1. Extravasation EL-RAML PEDIATRIC HOSPITAL CLINICALPHARMACY ESRAAABDELLATIF BSC, PHARMD, E-CSRT
- 2. Drug escapesinto the extravascular space, either by leakage from a vessel or by direct infiltration. Injury appears within 30 min up to 12 hour causing damage ranges from skin irritation to tissue damage and necrosis. Injury's degrees vary according to type od drug : irritant or vesicant.
- 3. Irritants vs Vesicants Irritant drug: cause inflammation (warmth, erythema, tenderness) at the administration site and along the vein, cause tissue necrosis if given in large doses. Vesicant drugs: cause tissue necrosis (blistering, sloughing of tissue, and varying degrees of deep tissue damage) with a more severe and/or lasting injury than is typically seen with irritants because they are inherently toxic.
- 4. Incidence Up to11% in pediatric ICU. Up to 45 % of peripheral venous catheters inserted into newborns; 19 % were stage I and 11 % were stage IV. Brazil 2018
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- 6. Risk factors leadingto extravasation Drug Environment Patient
- 7. Drug related factors: Nature of drug vesicant (can cause tissue necrosis) or irritant (can cause inflammation (warmth, erythema, tenderness) but rarely cause tissue toxicity (necrosis)) Solution PH (≤ 5.5 or ≥ 8.5) Solution hypo or hyperosmolarity (< 180 or> 290 mOsm/L)
- 8. High risk drugs Highrisk Intermediate risk Low risk Calcium (all salts ) Glucose (higher than 12.5%) Mannitol (20 & 25%) Potassium (higher than 60 meq/L) Caffeine citrate acyclovir Sodium bicarbonate Sodium chloride (higher than 3%) Vasopressors TPN (higher than 950mOsm/L) Amikacin Amphotericin B (conventional) Ciprofloxacin Glucose (10-12.5%) Diazepam Midazolam Ondansetron Phenobarbital Phenytoin Potassium (lower than 60 meq/L) TPN (lower than 950mOsm/L) Vancomycin Aminophylline Unasyn Cefotaxime Ceftazidime Ceftriaxone Cefuroxime Clindamycin Glucose (lower than 10%) Furosemide Gentamycin Heparine Imipenem IVIG Meropenem Magnesium sulphate (bolus) Normal saline
- 9. Patient related factors Centralline Peripheral line
- 10. Peripheral line relatedfactor Small and/or fragile veins, or limited vein availability Sclerosed veins due to numerous venipunctures. Obesity Prolonged infusion duration Patient movement, particularly if the intravenous catheter is placed near a joint. Use of winged steel infusion devices ("butterfly needles")
- 11. Central line relatedfactors A deeply implanted port device Presence of a fibrin sheath or thrombus at the catheter tip Catheter migration from the vein into the tissue
- 12. Recognition of Medication Extravasation Initially: Local burning or tingling at the infusion site, mild erythema, pruritus, and swelling
- 13. Recognition of Medication Extravasation Within two to three days: Increased erythema, pain, brawny discoloration, induration, dry desquamation, and/or blistering.
- 14. Recognition of MedicationExtravasation comment Extravasation may produce local tissue necrosis within and outside the venous system. This may result in loss of the skin and underlying structures. Symptoms may last according to severity of injury.
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- 16. Stop the infusion Takea picture Assess the pain and administer pain relief Elevate the affected extremity (Don't flush the line) Aspirate fluid (gently removed from SQ tissue & avoid direct manual pressure to the affected area) Remove the catheter Mark the suspect area Administer the suitable antidote or N.S wash (if antidote is not available) Elevate affected extremity Apply local anti- inflammatory Apply dry compress for 20minutes 4 times daily for 2 days Complete required documentation Follow up Report event to the pharmacovigilance reporter
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- 18. Preipheral line extravasation Avoidjoints and antecubital fossa. Secure a new route for vesicant drugs. Do not with opaque gauze. Watch for edema, inflammation, and pain during administration. Secure during the administration. Check for blood backflow before/during administration. Rinse with NS between administrations. Dilute stimulant drugs as much as possible
- 19. Central line extravasation Check forblood backflow before injection. 1 Check if there is discomfort or swelling by running a saline. 2 After the injection, make sure to run a saline solution through the catheter 3
- 20. Extravasation kit An emergencytool. Easily accessible to quickly respond in NICU & PICU
- 21. Extravasation kit Instructionsfor use Copy of list of classification of drugs and antidotes - 3 x 10 mL syringes 5 x 1 mL syringes 4 x 5 mL sterile water for injection NS Baxter 2 vials hyaluronidase 1500 International Units (in refrigerator) if available 2 vials Phentolamine 10 mg/ml (available) Gauze squares (assortment of sizes) Surgical gloves (assortment of sizes) 2 pairs latex gloves Alcohol wipes Hydrocortisone cream 2 hot packs for warm compresses 2 cold packs for cold compresses (in refrigerators) Permanent marker pen
- 22. Antidotes and compressors Hyalouridase Calciumchloride Calcium gluconate Potassium chloride Sodium bicarbonate 4.2 % & 8.4% Sodium chloride 3 % TPN dextrose>10 % Mannitol ≥15% Phenytoin Phentolamine •Dopamine Epinephrine •Norepinephrin e
- 23. Hyaluronidase Doses forneonates and smaller infiltrations are 15 units/ml. SQ or ID May be repeated. Administer within 1-2 hour of insult (however, it may still be beneficial when given up to 12 hours after the event). Should not be used to treat vasoconstrictive agents.
- 24. Phentolamine Dilute to0.5-1 mg/ml Antidote Extravasation of sympathomimetic vasopressors within 12 hours of extravasation. Total dose required depends on the size of extravasation; Dose may be repeated if required. Monitor Extravasation site resolution, blood pressure, heart rate, skin color, local perfusion, Ampoule should protected from heat &light. “ Nitroglycerin Ointment ”
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- 28. Reporting system To befilled by nurse, Revised and signed by physician, Inform pharmacovigilance team.
- 29. References: www.uptodate.com •www.rch.org.au •https://www.jeehp.org/DOIx.php?id=10.3352/jeehp.2020.17.21 Guidelines for the management of extravasation