Extravasation Injury - Podcast Version TeachMeSurgery 0:00 / 0:00 1x 0.25x 0.5x 0.75x 1x 1.25x 1.5x 1.75x 2x Extravasation is the inadvertent leakage of intravenously administered fluid or medication into the surrounding extravascular tissues. This can lead to tissue inflammation and irritation, and in some cases tissue necrosis. Extravasation is an inherent risk of intravenous therapy, with reported rates ranging from 0.1% to 6.5%. Most cases are minor and resolve without long-term consequences. However, certain medications can cause significant soft tissue injury if extravasated. Early recognition and prompt management are therefore essential to minimise morbidity. In this article, we discuss the pathophysiology, clinical assessment, and management of extravasation injuries. Pathophysiology In the context of extravasation injuries, medications are commonly classified into three groups: Non-vesicants – unlikely to cause significant tissue damage but may produce swelling and discomfort due to the volume of fluid accumulating in the tissues Irritants – cause inflammation and pain at the infusion site, but only rarely progress to tissue damage Vesicants – agents with corrosive properties that can cause severe tissue injury, including blistering, ulceration, and necrosis. Vesicants are often subdivided into DNA-binding and non-DNA-binding agents The severity of tissue damage depends on several factors, including the type of agent, its concentration, the volume extravasated, and the anatomical site of injury. Clinical Features A focused history should be obtained in any patient with suspected extravasation. Important points include: Substance infused Estimated volume extravasated Time of the event Any interventions already performed Examination should focus on identifying signs of local tissue injury and any evidence of neurovascular compromise. Inspect the affected region for any swelling, skin discolouration or erythema, skin blanching, or blistering or ulceration Ensure to assess distal perfusion and neurological status of the affected limb. Differential Diagnoses There are two important differential diagnoses that should be considered when assessing suspected extravasation injuries: Venous irritation – presents with erythema and pain that track along the course of the vein rather than being localised to the infusion site Symptoms typically resolve when the infusion is stopped Flare reactions – rare allergic-like reactions, most commonly associated with certain chemotherapy agents (e.g. doxorubicin) They present with erythema and itching along the vein but are usually painless; symptoms typically subside within 30-60 minutes and do not result in tissue injury Management Initial Management Management of an extravasation injury should be performed in a stepwise manner. Immediate management requires stopping the infusion, leaving the cannula in-situ (not flushing the cannula), and attempting to aspirate any residual drug or fluid through the cannula using a syringe. Once aspiration has been attempted, the cannula can be removed unless it is required for administration of a specific antidote. Elevate the affected limb to reduce swelling. Any area of skin change should be marked and labelled with the date and time. Clinical photographs are often useful to monitor progression. Operative Management Certain extravasation injuries, particularly those involving vesicants, may require surgical intervention. One commonly described technique is the modified Gault flush-out technique, which aims to dilute and remove the offending agent from the tissues. This is most effective when performed as early as possible after the injury. Modified Gault Flush-Out Technique After infiltration of local anaesthetic, multiple small stab incisions are made around the affected area. Saline is then introduced through these incisions using a cannula, allowing the extravasated substance to be diluted and washed out of the tissues. In selected cases, hyaluronidase may be infiltrated subcutaneously to increase tissue permeability and promote dispersion and absorption of the extravasated drug. Some medications also have specific antidotes. For example: Dexrazoxane for anthracycline extravasation Phentolamine for vasopressor extravasation Topical dimethyl sulfoxide (DMSO) for certain chemotherapy agents, such as mitomycin C Many oncology units maintain dedicated extravasation kits containing the equipment and medications required for immediate management. Ongoing Monitoring Patients should be monitored for progression of tissue injury following extravasation. Low-risk inpatient cases are commonly reassessed at regular intervals during the first 24–72 hours. Tissue injury may evolve over several days, therefore patients should be provided with clear safety-netting advice regarding worsening pain, increasing swelling, blistering, or reduced limb function. Complications The most significant complication of an extravasation injury is tissue necrosis, which may require surgical debridement and subsequent reconstruction. Very rarely, large-volume extravasation injuries may lead to compartment syndrome, particularly in the forearm or hand. Summary Extravasation is the inadvertent leakage of intravenously administered fluid or medication into the surrounding extravascular tissues For any suspected extravasation, ensure to clarify the substance infused, the estimated volume extravasated, the time of the event, and any interventions already performed For any suspected cases, ensure to stop the infusion, leaving the cannula in-situ, and attempt to aspirate any residual drug or fluid The majority of extravasation cases require monitoring only, however select cases will require operative intervention Rate This Article