Treat Non-Chemo Extravasations Based on the Offending Agent

You’re on the front line to guide management of non-chemo extravasations.

Think of non-chemo vesicants as those that cause damage due to vasoconstriction, hyperosmolarity, pH extremes, etc.

When these vesicants leak into the tissue around an IV catheter, they can cause tissue necrosis. This extravasation is different than an infiltration...when a NON-vesicant is the culprit.

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For a suspected extravasation, first ensure the infusion is stopped. Check that the nurse has slowly aspirated as much as possible...and elevated the limb.

Next select treatment based on the offending agent and develop a protocol. But be aware, efficacy data are very limited.

Generally try a warm or cold compress, depending on the culprit. For example, use a warm compress for vasopressor extravasations...cold therapy can worsen vasoconstriction.

Then consider additional therapies.

Hyperosmolar agents (calcium chloride, parenteral nutrition, etc) lead to osmotic shifts, which cause inflammation and cell death.

Think of adding hyaluronidase. It makes connective tissue more permeable, which also diffuses the vesicant to decrease the concentration in local tissues.

Vasopressors (norepinephrine, etc) can lead to ischemia and necrosis if extravasated...due to their vasoconstricting properties.

Consider the alpha-1 blocker phentolamine to counteract vasoconstriction. If it’s unavailable, try subcutaneous terbutaline or topical nitroglycerin.

But if the extravasation is due to vasopressin or methylene blue, jump to topical nitroglycerin before phentolamine.

Don’t use hyaluronidase for pressors. It can spread the pressor through the tissue, which can cause more extensive vasoconstriction.

Acidic (amiodarone, etc) or alkaline (acyclovir, etc) agents can cause tissue damage and vasoconstriction due to their pH extremes.

Consider hyaluronidase when compresses aren’t enough. Limited data suggest it may work in some cases.

Avoid neutralizing acidic extravasations with agents such as sodium bicarb...this can produce gas or heat, making it worse.

Regardless of the agent infusing, focus on prevention.

For example, if promethazine is still allowed at your institution, limit dosage...and require it to be diluted first and infused slowly.

Promote central lines in certain cases, such as for most parenteral nutrition. But be aware, there are growing data to support giving pressors or 3% sodium chloride peripherally in some cases...such as if only a single pressor at a low rate is needed.

For more information to update your protocols, see our resource, Management of Non-Chemo Drug Extravasation.

Key References

  • Stefanos SS, Kiser TH, MacLaren R, et al. Management of noncytotoxic extravasation injuries: A focused update on medications, treatment strategies, and peripheral administration of vasopressors and hypertonic saline. Pharmacotherapy. 2023 Apr;43(4):321-337.
  • David V, Christou N, Etienne P, et al. Extravasation of Noncytotoxic Drugs. Ann Pharmacother. 2020 Aug;54(8):804-814.
  • Ong J, Van Gerpen R. Recommendations for Management of Noncytotoxic Vesicant Extravasations. J Infus Nurs. 2020 Nov/Dec;43(6):319-343.
Hospital Pharmacist's Letter. July 2024, No. 400718

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