PREVENTION AND MANAGEMENT OF

INFILTRATION AND EXTRAVASATION - GUIDELINES FOR

ANTIDOTE ADMINISTRATION

POLICY STATEMENTS
Peripheral intravenous sites are not recommended for infusions of vesicant agents but may be used for direct
IV injections and intermittent infusions, in which case the peripheral IV site must be visualized continuously
throughout the infusion.
If patency of infusion device (peripheral or central) cannot be determined, the site must not be used to deliver
medications/fluids.
DEFINITIONS
Extravasation: The unintentional leakage of vesicant intravenous fluids or medication into the perivascular,
subcutaneous tissue or interstitial space which is capable of causing pain, necrosis and/or sloughing of tissue.
Immediate emergency management of suspected vesicant extravasation must be performed to minimize tissue
damage.
Infiltration: The inadvertent leakage of a nonvesicant solution into surrounding tissue. Infiltration of non-
vesicant agents generally does not cause tissue necrosis, but can sometimes result in long-term disability due
to local inflammatory reactions caused by their irritant properties or by compression of surrounding tissues by a
large volume of infiltrate, known as acute limb compartment syndrome (ALCS).
Vesicant: An agent that can cause redness, pain, blistering and serious progressive tissue damage if it leaks
into tissue outside the vein (extravasates). Can cause blistering and local or extensive tissue necrosis with or
without ulceration and may become evident only days or weeks after exposure.
Irritant: An agent that can inflame tissue but not cause tissue necrosis if extravasation occurs. Reactions
range from mild erythema and burning to pain and inflammation at the injection site.
Flare Reaction: Localized, venous, inflammatory response with release of histamine. Flare reactions may
include erythema, urticaria and phlebitis along the vein. Symptoms usually subside 30 minutes after the
infusion is stopped, although they may last for 1-2 hours and up to 24 hours. Patients who experience flare
reactions may require premedication with anti-histamine or corticosteroids before future administrations of the
offending agent.
PREVENTION STRATEGIES: Peripheral IV
1. ASSESS existing IV site for patency by aspirating Great care must be taken to ensure that vesicant
for blood return, flushing with 0.9% sodium chloride agents are given into an intact vein with a good free
(NS), observing site closely for signs of infiltration flow of blood in order to avoid potential
and observing patient for any adverse effects. If extravasation. Drug may leak from sites of recent
patency cannot be determined, do not use site and punctures or from veins which are occluded from any
establish a new site. cause, (tight clothing, obstructing masses, and
2. SELECT a large vein away from joints or tendons, clots). Therefore, the injection site should not be distal
above previous venipuncture sites. to a recent venipuncture or in a limb with compromised
circulation. It is preferable to select, if possible, a large
vein which is not adjacent to a joint or tendon. The
antecubital fossa and other joints are to be avoided
because of the risk of undetected extravasation and
permanent damage.
Sites of choice in children include, in order of
preference: dorsal hand, forearm, dorsal foot.
3. ENSURE intravenous entry site is visible Allows for early identification of and prompt
throughout administration of vesicant. intervention for extravasation.
4. INJECT drug slowly, monitoring site constantly Signs of infiltration include (pain, swelling, redness,
throughout injection/infusion for signs of infiltration. occlusion alarms or change in quality of infusion).

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 PREVENTION AND MANAGEMENT OF
INFILTRATION AND EXTRAVASATION - GUIDELINES FOR
ANTIDOTE ADMINISTRATION

5. CHECK for blood return every 1-2 mL for direct IV

injections. To check for blood return, aspirate gently
until blood seen in tubing.
6. FLUSH thoroughly with NS following injection or at Clears tubing and needleless connector of medication.
completion of infusion.
7. RESUME IV fluids or SALINE LOCK IV as ordered
or DISCONTINUE IV if no longer needed.
8. If discontinuing IV, ELEVATE limb and maintain
gentle pressure over venipuncture site for 5
minutes after needle removed.
PREVENTION STRATEGIES: Central Venous Line (CVL), Peripherally Inserted Central Catheter
(PICC) or Implanted Port:
1. ASSESS central line patency by aspirating for Extravasation through a central line may occur
blood return, flushing with 0.9% sodium chloride because of line migration, fractured line, or backflow
(NS) and observing site closely for signs of due to fibrin sheath or thrombosis.
infiltration and observing patient for any adverse
effects.
2. REFER to occlusion protocol for management if
unable to obtain blood return. Do not administer
vesicant agent until line patency is confirmed.
3. ENSURE site is visible throughout Allows for early identification of and prompt
injection/infusion. intervention for extravasation.
4. OBSERVE site continuously during IV direct
injection and at least hourly during
intermittent/continuous infusions.
5. CHECK for blood return if any problems identified
with infusion (e.g. occlusion alarms, any signs or
symptoms of extravasation).
6. FLUSH thoroughly with NS following Clears tubing and catheter of medication.
injection/infusion.
7. RESUME IV fluids or HEPARIN LOCK central line
as ordered.
NOTE: If extravasation of a vesicant/irritant agent or solution is suspected, follow procedure as outlined in
Management of Infiltration/Extravasation.
MANAGEMENT Rationale
1. SUSPECT infiltration/extravasation if the following Allows for early identification of and prompt
signs and symptoms are present during an intervention for extravasation.
infusion/injection of vesicant agents:
o Subjective patient complaints (pain, burning,
stinging, itching)
o Absence of blood return
o Appearance of site: swelling, blotchy redness,
redness, warmth, blanching, hematoma
Refer to Appendix A: Assessment of Extravasation
versus Other Reactions chart for detailed description
of possible reactions and treatment.
2. STOP injection or infusion immediately. Stops further infusion of offending agent.
3. NOTIFY physician immediately. An anti-dote may The use of an antidote requires a physician’s order.

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ANTIDOTE ADMINISTRATION

be ordered. See Appendix B: Guidelines for Antidotes, other than dimethylsufoxide (DMSO) and
Antidote Administration. dexrazoxane are to be administered by a physician.
4. DISCONNECT syringe or IV tubing and with an Aspirating residual drug from tubing and surrounding
empty, sterile 10 mL syringe, attempt to aspirate subcutaneous tissue helps prevents further damage.
remaining drug from tubing.
5. REMOVE needle if peripheral IV or implanted port
while simultaneously aspirating as much agent as
possible as the needle is withdrawn. Do not apply
pressure to site.
6. ELEVATE and IMMOBILIZE affected area and To limit contact of the medication with subcutaneous
APPLY cold or warm compresses as indicated: tissue, local cooling is the recommended treatment for
For Vinca Alkaloids (eg. vincristine, infiltration of all fluids except vinca alkaloids. Unlike
vindesine, vinblastine): APPLY warm other vesicant drugs that lodge in tissue and produce
pack for 15-20 minutes every 4 hours prolonged effects, these drugs don't bind to DNA and
for 24-48 hours. are quickly metabolized. Applying heat helps reduce
pain and swelling associated with the acute phase
For other Vesicant Agents: APPLY following extravasation.
cold pack for 15-20 minutes every 4
hours for 24-48 hours.
For Adrenergic agonists/
sympathomimetics: Application of
warm or cold packs is not
recommended.

7. ENSURE patient has adequate analgesia and Pain is a common symptom of extravasation and
sedation. should be adequately managed.
8. OBTAIN photograph of injury site. Records condition of site at time of event to compare
with subsequent photographs.
9. PREPARE for antidote administration as indicated. It is difficult to be certain that injection of antidotes into
the area of extravasation is of benefit and reports are
conflicting. Most small extravasations do not result in
serious problems without injection of antidotes, so that
injection of specific antidotes should likely be restricted
to larger extravasations (>1-2 mL).
10. INITIATE Extravasation Flowsheet . Comprehensive documentation tool.
11. MONITOR site 1, 3, 5, 7 and 14 days post- To determine if further interventions are necessary.
extravasation. Evaluate more frequently or longer Continual observation over a period of several weeks
if skin breakdown progresses. is important.
12. DOCUMENT assessment, interventions and follow- Communication to additional members of the health
up on Flowsheet. COMPLETE patient safety care team.
event.
Assists with meeting Professional Standards for
documentation and legal requirements.
13. KEEP site clean and dry. Blisters should be kept Decreases risk of infection.
intact if present. A light non-occlusive dressing
may be used.
14. CONSULT wound team or plastic surgery Areas of extensive blistering or ulceration, progressive
depending on extent of tissue damage. induration and erythema, or persistent severe pain, are
indications for surgical assessment and possible

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excision of the injured tissue.

15. For Central line extravasations, INVESTIGATE
cause after management of extravasation and
DISCUSS future IV access needs.
16. PROVIDE patient/family teaching including: To reinforce verbal information on home management
o management at home of the injection site.
o signs and symptoms of worsening of the
wound
o follow-up visits for assessment by the staff

GUIDELINES FOR ANTIDOTE ADMINISTRATION

It is difficult to be certain that injection of antidotes into the area of extravasation is of benefit and reports are
conflicting. Most small extravasations do not result in serious problems without injection of antidotes, so that
injection of specific antidotes should likely be restricted to larger extravasations (>1-2 mL).
The use of an antidote requires a physician’s order. Antidotes, other than dimethylsufoxide (DMSO)
and dexrazoxane are to be administered by a physician.
Extravasated Drug Suggested Antidote Method of Administration
daunorubicin dimethylsulfoxide (DMSO) Apply to an area twice that affected by the
doxorubicin 99% topical solution (4 extravasation, allow to air dry, do not cover, repeat 4
epirubicin drops per 10 cm2 area) times per day for at least 7 days.
mitomycin
Do not use DMSO in conjunction with dexrazoxane.
This combination may increase tissue damage.
dexrazoxane intravenous 1. Dilute reconstituted dexrazoxane with Dextrose 5%
(IV) daily for 3 days or 0.9% sodium chloride to a final concentration of
1.3 to 5 mg/mL.
2. Administer daily over 1-2 hours 24 hours apart for 3
consecutive days:
Days 1 & 2: 1000 mg/m2/day (max 2000 mg)
Day 3: 500 mg/m2 (max 1000 mg)
3. Administer as soon as possible and within 6 hours of
extravasation.
4. Remove cooling packs (if used) at least 15 minutes
prior to start of dexrazoxane infusion.
5. Do not use DMSO in conjunction with
dexrazoxane. This combination may increase
tissue damage.
6. Monitor for neutropenia, thrombocytopenia.
vinblastine hyaluronidase 1500 units Administration by physician only.
vincristine subcutaneous (SC) or 1. Reconstitute hyaluronidase 1500 U vial with 1 mL
vindesine intradermalreconstituted normal saline (NS).
vinorelbine and further diluted to 150 2. Dilute to 150 U/mL: add 1 mL of 1500 U/mL
aminophylline unit/mL concentration hyaluronidase to 9 mL NS.
calcium chloride (> 10%) 3. Use four or five 1 mL syringes and draw up 0.2 mL
DO NOT ADMINISTER
cloxacillin into each syringe.
INTRAVENOUSLY.
dextrose (> 10%) 4. Use immediately following reconstitution.
hyaluronidase (Hyalase®) is
magnesium sulfate 5. Using a 27-30 gauge needle, inject 0.1-0.2 mL
available through Health
(>20%) subcutaneously or intradermally in 4 to 5 sites
Canada Special Access
mannitol around the circumference of infiltrate, using a new

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Parenteral Nutrition (PN) Program. needle with each injection.

phenytoin 6. Wait 10-15 minutes and inject 3-5 mL 0.9% sodium
potassium chloride (> chloride into each injection site.
2meq/mL) 7. Most benefit if injected within 1 hour of
radio contrast media extravasation.
sodium bicarbonate
(8.4%)
vancomycin
dobutamine Administration by physician only.
phentolamine (1mg/mL)
dopamine 1. Reconstitute 5 mg phentolamine vial with 5 mL
subcutaneous (SC)
epinephrine normal saline (NS) to achieve a 1 mg/mL dilution
norepinephrine DO NOT ADMINISTER 2. Use four or five 1 mL syringes and draw up 0.2 mL
phenylephrine INTRAVENOUSLY. into each syringe
3. Using a 27-30 gauge needle, inject 0.1-0.2 mL
subcutaneously in 4 to 5 sites around the
circumference of infiltrate, using a new needle with
each injection.
Neonates:Do not exceed 0.1 mg/kg or 2.5 mg
total
Infants & Children: Do not exceed 0.2 mg/kg or
5 mg total
4. Wait 10-15 minutes and inject 3-5 mL normal saline
into each injection site.
5. Blanching should reverse within 1 hour.
Monitor site:If blanching recurs, additional
phentolamine may be needed.
6. Most benefit if injected within 1 hour of extravasation
but can be used up to 12 hours after extravasation.

REFERENCES
BC Cancer Agency. Extravasation of Chemotherapy, Prevention and Management Policy and Procedure,
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COG Pharmacy Committee/COG Nursing Clinical Practice Committee: Acute/Palliative Care Section. (2007).
Extravasation Guidelines. Children’s Oncology Group.
DeLemos, ML. (2004). Role of dimethysulfoxide for management of chemotherapy extravasation. Journal of
Oncology Pharmacy Practice. 10(4):197-200.
Doellman, D et al. (2009). Infiltration and Extravasation: Update on Prevention and Management. Journal of
Infusion Nursing. 32(4):203-211.
Hadaway, L. (2010). IV Essentials: Extra! Extra! Preventing extravasation. Nursing Made Incredibly Easy!
8(2):13-14.
Hadaway, L. (2007). Infiltration and Extravasation: preventing a complication of IV catheterization. American
Journal of Nursing. 107(8):64-72.
Hadaway, L. (2004). Preventing and Managing Peripheral Extravasation. Nursing. 34(5):66-67.
Hadaway, L. (2004). Preventing Extravasation from a Central Line. Nursing. 34(6):22-23.

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INFILTRATION AND EXTRAVASATION - GUIDELINES FOR
ANTIDOTE ADMINISTRATION

Hadaway, L. (2002). IV infiltration not just a peripheral problem. Nursing. 32(8):36-42.

Kane, RC, McGuinn Jr, WD, Dagher, R, Justice, R, and Pazdur. (2008). Dexrazoxane (Totect™): FDA
Review and Approval for the Treatment of Accidental Extravasation Following Intravenous Anthracycline
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Kline, Nancy (ed). (2011). The Pediatric Chemotherapy and Biotherapy Curriculum Third
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Llinares, ME, Bermudez, M and Fuster, JL. (2005). Toxicity to Topical Dimethyl Sulfoxide in a Pediatric Patient
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Mouridsen, HT, Langer, SW, Buter, J, Eidtmann, H, Rosti, G, de Wit, M, Knoblauch, P, Rasmussen, A,
Dahlstrøm, K, Jensen PB, and Giaccone, G. (2007). Treatment of anthracycline extravasation with Savene
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Schulmeister, L. (2007). Extravasation Management. Seminars in Oncology Nursing. 23(3):184-190.
Schulmeister, L and Camp-Sorrell, D. (2000). Chemotherapy Extravasation from Implanted Ports. Oncology
Nursing Forum. 27(3):531-538.
Schulmeister, L. (2008). Managing Vesicant Extravasations. The Oncologist. 13:284-288.
Seivers, TD and Andam, R. (2004). Chemotherapy Administration and Immediate Post-administration Issues in
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