Despite close observation, occasionally peripheral IV lines will infiltrate and the infusing fluids extravasate into the tissues. Hyperosmolar solutions containing calcium, potassium, hypertonic or basic medications, or high concentrations of dextrose cause significant tissue injury.  Nurses should complete a Veritas report for IV infiltrates to monitor this problem and the outcomes in our unit.  The Wound Care Team should be consulted for full thickness wounds resulting from IV infiltrates.

An IV suspected of infiltration should have the infusing fluids stopped immediately.  Prior to removing the cannula, the nurse should aspirate as much of the extravasated fluid as possible and notify the housestaff.  Additionally, the physician or nurse may use a needle to inject small holes in a circumferential manner around the site of injury to allow more of the fluid to escape.  This is a key factor in the treatment of IV infiltrates and will help to minimize the injury with prompt removal of the offending agent. Depending on the type of extravasation, further management with hyaluronidase or phentolamine may be warranted and must be ordered by a physician in a timely manner.  Agents are dispensed by pharmacy in a kit with instruction for prompt use.   

Acute IV infiltrates should also be managed by elevating the edematous limb or at least making sure the site is non-dependent and no pressure is applied.  Pain control measures may be appropriate for the patient.  If the injured area sloughs and ulcerates, the patient has a full thickness wound. The injury should then be managed according to current wound care guidelines.

In previous years, hyaluronidase (Wydase®) was injected subcutaneously in a circumferential manner into severe acute IV infiltrates in an effort to ameliorate tissue injury by allowing the offending fluid to disperse more dilutely through the connective tissues.  Wydase® is, however, no longer commercially available and has been replaced with Amphadase®.

Hyaluronidase (Amphadase®) may be used to treat extravasations of dextrose >10%, calcium salts, potassium salts, sodium bicarbonate, blood, and parenteral nutrition. Hyaluronidase is an enzyme that reduces or prevents injury by breaking down the tissue barrier (hyaluronic acid) and promotes diffusion and reabsorption of extravasated fluids.  Hyaluronidase is dispensed by pharmacy as a 150 unit/mL solution.  Prepare a hyaluronidase 15 unit/mL dilution.  Withdraw 0.1mL hyaluronidase (150 units/mL) and add 0.9 mL NS.  Inject 0.2mL of hyaluronidase 15units/mL into the needle through which the IV was running.  Inject four aliquots of 0.2 mL hyaluronidase15 units/mL locally by subcutaneous injection into the periphery or leading edge of the site, changing the needle after each injection.  Administer within one hour of insult.  There is little or no advantage if administered more than three hours of extravasation.

Particularly severe injuries can occur if vasopressors (dopamine, dobutamine, epinephrine, etc.) extravasate from an IV.  Pressors cause vasoconstriction of the small blood vessels and resultant ischemic tissue injury.

Phentolamine (Regitine), an α-receptor blocker, can be injected into the area of local vasoconstrictor excess.  Resuspend 5 mg of Phentolamine in 9mL of normal saline to make a 0.5mg/ml solution.  Use 26g (TB or insulin) syringes to perform 5 subcutaneous injections of 0.2 mL of diluted phentolamine each (total injected volume of 1 mL) clockwise around and into the area of vasopressor extravasation within 12 hours of the infiltration. Change needles for each new skin puncture.

References:

Siwy BK, Sadove AM. Acute management of dopamine infiltration injury with Regitine. Plast Reconstr Surg 1987; 80: 610.

Raska WV Jr, Kueser TK, and Smith FR.  1990.  The use of hyaluronidase in the treatment of intravenous extravasation injuries.  Journal of Perinatology 10(2):  146-149.

Laurie SWS, et al.  1984.  Intravenous extravasation injuries: The effectiveness of hyaluronidase in their treatment.  Annals of Plastic Surgery 13(3):  191-194.

Brown AS, Hoelzer DJ, and Piercy SA.  1979.  Skin necrosis from extravasation of intravenous fluids in children.  Plastic and Reconstructive Surgery 64(2):  91-96.