• Approximately 4% of babies develop skin necrosis as a result of extravasation of an IV infusion
• A small proportion of these babies develop long-term cosmetic or functional compromise 
• Extravasation may be due to:
  
  • cannula piercing the vessel wall or 
  • from distal venous occlusion causing backpressure and increased vascular permeability
• Cochrane review shows that centrally placed catheters may cause extravasation as often as peripheral cannulae
• Extravasation can lead to both short and long-term complications
• Use this guideline to define the grading and management of subcutaneous extravasation injuries in babies, either from peripheral or central lines
• Limiting the IV pump cycle to 1 hr may minimise the extent of tissue damage from extravasation providing the entry site is observed concurrently 
• Degree of tissue damage due to extravasation is dependent upon: 
  
  • volume of infusate, its pH and osmolality
  • the properties of any drug(s) being infused

Grading of extravasation injuries

Investigations

• No specific investigations required. However, if wound appears infected:
  
  • wound swab
  • FBC
  • CRP 
  • blood culture 
  • start appropriate antibiotics [see Infection (late onset) guideline]

Select grade:

• Most extravasation injuries are of Grades 1 and 2 and do not require extensive intervention
• Grade 3 and 4 injuries have a greater potential for skin necrosis, compartment syndrome and need for future plastic surgery, depending on type of solution extravasated

Irrigation of affected area

• A Cochrane review concluded that there is insufficient evidence to assess the effects of irrigation, with or without hyaluronidase
• The procedure itself may cause scaring whilst not all extravasation injuries leave scars
• Irrigation should only be considered in the most serious injuries with large volume extravasation of caustic solutions (e.g. calcium) 
• For details of procedure see below

Wound dressings

• When choosing wound dressing, consider need to prevent:
  
  • further trauma
  • epidermal water loss
  • contractures by allowing a full range of limb movements
• Dressings must be:
  
  • easy to apply to small body surface areas
  • sterile
  • suitable for use in humidified/incubator environments 

Most commonly used dressings

• Hydrocolloid 9 (e.g. Duoderm®) or hydrogel (e.g. Intrasite gel, Intrasite conformable)
  
  • if in doubt, seek advice from tissue viability nurse

Documentation

• Document extent and management of the injury in the medical record

• Determined by grade of extravasation
  
  • neonatal medical staff review minor grades after 24 hr
  • neonatal/plastic surgery staff/tissue viability nurse review Grades 3 and 4 within 24 hr to assess degree of tissue damage and outcome of irrigation procedure if performed

Other considerations

• Family-centred care – inform parents of extravasation injury and management plan

Special considerations

• Infection prevention – observe standard infection prevention procedures 

• Complete an incident report for Grade 3 and 4 extravasations

   

   

Procedure

• Withdraw as much of the drug and or fluid as possible via cannula or catheter
• Infiltrate the site with lidocaine 1% 0.3 mL/kg before to reduce pain
• Using a scalpel, make 4 small incisions around periphery of extravasated site
• Insert blunt Tuohy needle, or pink cannula with needle removed, into each incision in turn, and irrigate damaged tissue with hyaluronidase* followed by sodium chloride 0.9%. It should flow freely out of other incisions
• Massage out any excess fluid using gentle manipulation
• Cover with paraffin gauze for 24–48 hr

*Preparation of hyaluronidase

• Reconstitute a 1500 unit vial of hyaluronidase with 3 mL of water for injection
• Use 1–2 mL shared between each incision then irrigate with sodium chloride 0.9%

Documentation

• Person performing procedure must document in baby's medical record