This document discusses the management of extravasation injuries in the neonatal intensive care unit (NICU). It notes that extravasations are a significant problem in the NICU, occurring in 11-23% of infants. If not properly treated, 4% of infants may leave the NICU with functionally or cosmetically significant scars from extravasation injuries. The document outlines risk factors for extravasations in neonates, provides definitions, and describes a grading scale for assessing extravasation injuries. It also discusses treatment options, including the use of hyaluronidase to disperse fluids and reduce tissue damage from extravasations.

1. Timothy W. King, MD, PhD, FAAP, FACS
Associate Professor of Surgery
Director of Plastic Surgery Research
Children’s of Alabama Hospital &
University of Alabama at Birmingham
World Union of Wound Healing Societies
Neonatal Wounds Workshop
September 27, 2016
Management of Extravasation
Injuries in the NICU

2. Problem / Incidence
Management of Extravasation
Injuries in the NICU

3. Problem
§ IV fluids are almost ubiquitous in the NICU
§ Infiltration/Extravasations are a significant
problem in the NICU
w Infiltration Incidence: 22-70%
w Extravasation Incidence: 11-23%
§ ~4% of infants leave NICUs with cosmetically
or functionally significant scars 2°
extravasation injuries
Journal of Neonatal Nursing 1999;5:10–13.
AACN Clin Issues. 1998;9:49-63.
Early Hum Dev 1990;21:1–10.

4. Neonates: Increased Risk of Extravasation
Neonates
w poor venous integrity
w greater risk of capillary leaking
w decreased peripheral circulation
w cannot verbalize pain
w subcutaneous tissue is more flexible
s expands quickly
s significant tissue damage occurs rapidly

5. Definitions of Extravasation vs Infiltration
§ Extravasation: The inadvertent administration
of a vesicant solution or medication into
surrounding tissue.
§ Infiltration: The inadvertent administration of a
nonvesicant solution/medication into a
surrounding tissue.
§ Vesicant: A solution or medication that causes
a blistering process when inadvertently
administered into the surrounding tissue.
NO STANDARD LIST OF VESICANTS!!

6. Clincially Useful Extravasation vs
Infiltration
Extravasation – “out of the vessel”
Inadvertent Deposition of Intended
Intravenous Fluids Into Surrounding
Tissues
Infiltration – Purposeful subcutaneous
injection of fluids
Example: “The skin was infiltrated
with local anesthetic solution before
incision”
From Rineair – Cincinnati Children’s Hospital

7. Causes/Risk Factors
Management of Extravasation
Injuries in the NICU

8. Causes of Extravasation
§ IV dislodgment or puncture of the vein during
insertion
§ Vessel rupture caused by fluids being infused
(usually hyperosmolar solutions)
§ Leaking at the infusion site resulting from
backflow of infused fluids
AACN Clin Issues. 1998;9:49-63.

9. Patient Risk Factors for Extravasations
§ Preterm infants
§ Neonates
§ ICU patients
§ Comorbidities (diabetes, circulatory disorders,
obesity)
§ Inability to verbally communicate pain

10. Mechanical Risk Factors
§ Small, fragile, mobile or hard sclerosed veins
§ Large catheter size relative to vein
§ Choice of IV site (joints, flexors, dominant
hand)
§ Unstable catheter
§ Uncontrolled patient movements

11. Mechanism of Tissue Injury
§ Volume (Compartment Syndrome)
§ Chemical Injury (pH)
§ Osmolality (hyper or hypo)
§ Biological Tissue Damage
w Vasoactive Drugs
w Chemotherapy
J Infus Nurs. 2013;36(1):37-4

12. Assessment
Management of Extravasation
Injuries in the NICU

13. From Rineair – Cincinnati Children’s Hospital
Journal of Pediatric Nursing (2012) 27, 682–689
TOUCH (TOQUE) LOOK (MIRE) COMPARE (COMPARE)
TLC For IV Safety Touch, Look, and COMPARE
Vía intravenosa segura: Toque, mire y COMPARE
IV Checks must happen
even when asleep
Los controles deben hacerse
mientras duerme
Call your nurse if you notice anything
wrong or if you have questions or concerns.
Llame a la enfermera si ve que algo no
está bien o si tiene dudas o inquietudes
IV should feel:
Soft
Warm
Dry
Pain Free
El lugar de la vía debe estar:
Blando
Tibio
Seco
Sin dolor
IV site should be:
Uncovered
Dry
Without Redness
El lugar de la vía debe estar:
Destapado
Seco
Sin enrojecimiento
IV site should be:
Same size as other side
Without Swelling
El lugar de la vía intravenosa:
Debe tener el mismo tamaño
que el otro lado
No debe estar hinchado
Touch every 60 Minutes
Toque cada 60 minutos
Look every 60 Minutes
Mire cada 60 minutos
Compare every 60 Minutes
Compare cada 60 minutos
3926 1012 XXXXXX

14. Compare one side to the other

15. Must see entire limb or anatomic region!

16. Infiltration/Extravasation Grading Scale
Stage Findings
0
Absence of redness, warmth, pain, swelling, blanching, mottling,
tenderness or drainage. Flushes with ease.
1
Absence of redness, swelling. Flushes with difficulty.
Pain at site.
2
Slight swelling at site. Redness. Skin cool to touch. Pain at site.
Good pulse below site. 1-2 second capillary refill below site.
3
Moderate swelling above or below site. Blanching. Pain at site.
Good pulse below infiltration site. 1- to 2-second capillary refill
below infiltration site. Skin cool to touch.
4
Severe swelling above or below site. 6 Blanching. Pain at site.
Decreased or absent pulse.
Capillary refill greater than 4 seconds. Skin cool to touch.
Skin breakdown or necrosis.
Pediatr Nurs. 1993;18:44-47.
Adopted by the Task Force of the Pediatric Nursing Research Committee in 1994

17. Infiltration/Extravasation Grading Scale
Stage Findings
0
Absence of redness, warmth, pain, swelling, blanching,
mottling, tenderness or drainage. Flushes with ease.
1
Absence of redness, swelling. Flushes with difficulty.
Pain at site.
2
Slight swelling at site. Presence of redness. Pain at site.
Good pulse below site. 1-2 second capillary refill below site.
3
Moderate swelling above or below site. Blanching. Pain at site.
Good pulse below infiltration site. 1- to 2-second capillary refill
below infiltration site. Skin cool to touch.
4
Severe swelling above or below site. 6 Blanching. Pain at site.
Decreased or absent pulse.
Capillary refill greater than 4 seconds. Skin cool to touch.
Skin breakdown or necrosis.
X

18. Infiltration/Extravasation Grading Scale
Stage Findings
0
Absence of redness, warmth, pain, swelling, blanching, mottling,
tenderness or drainage. Flushes with ease.
1
Absence of redness, swelling. Flushes with difficulty.
Pain at site. Blanching
2
Slight swelling at site. Redness. Skin cool to touch. Pain at site.
Good pulse below site. Blanching. 1-2 second cap refill below site.
3
Moderate swelling above or below site. Blanching. Pain at site.
Good pulse below infiltration site. 1-2 second cap refill below
infiltration site. Skin cool to touch.
4
Severe swelling above or below site. Blanching. Pain at site.
Decreased or absent pulse.
Capillary refill greater than 4 seconds. Skin cool to touch.
Skin breakdown or necrosis.
Pediatr Nurs. 1993;18:44-47.
Adopted by the Task Force of the Pediatric Nursing Research Committee in 1994

19. Infiltration/Extravasation Grading Scale
Stage Findings
0
Absence of redness, warmth, pain, swelling, blanching, mottling,
tenderness or drainage. Flushes with ease.
1
Absence of redness, swelling. Flushes with difficulty.
Pain at site. Blanching
2
Slight swelling at site. Redness. Skin cool to touch. Pain at site.
Good pulse below site. Blanching. 1-2 second cap refill below site.
3
Moderate swelling above or below site. Blanching. Pain at site.
Good pulse below infiltration site. 1-2 second cap refill below
infiltration site. Skin cool to touch.
4
Severe swelling above or below site. Blanching. Pain at site.
Decreased or absent pulse.
Capillary refill greater than 4 seconds. Skin cool to touch.
Skin breakdown or necrosis.
Pediatr Nurs. 1993;18:44-47.
Adopted by the Task Force of the Pediatric Nursing Research Committee in 1994

20. Infiltration/Extravasation Grading Scale
Stage Findings
0
Absence of redness, warmth, pain, swelling, blanching, mottling,
tenderness or drainage. Flushes with ease.
1
Absence of redness, swelling. Flushes with difficulty.
Pain at site. Blanching
2
Slight swelling at site. Redness. Skin cool to touch. Pain at site.
Good pulse below site. Blanching. 1-2 second cap refill below site.
3
Moderate swelling above or below site. Blanching. Pain at site.
Good pulse below infiltration site. 1-2 second cap refill below
infiltration site. Skin cool to touch.
4
Severe swelling above or below site. Blanching. Pain at site.
Decreased or absent pulse.
Capillary refill greater than 4 seconds. Skin cool to touch.
Skin breakdown or necrosis.
Pediatr Nurs. 1993;18:44-47.
Adopted by the Task Force of the Pediatric Nursing Research Committee in 1994

21. Why Eliminate Grading System
§ Doesn’t distinguish outcome based upon the
grade
§ Eg: vesicant extravasation = grade 4
w 1 mL or 500 mL is the same
w No vesicant list
The INS Grading system NO LONGER RECOMMENDED by INS!

22. New Assessment Tool
From Rineair – Cincinnati Children’s Hospital
Journal of Pediatric Nursing (2012) 27, 682–689

23. RN palpates the swelling at
the widest dimension. It
measures 3cm. X = 3cm
RN measures length from
longest fingertip to axilla.
It measures 30 cm.
Y = 30cm
From Rineair – Cincinnati Children’s Hospital
Journal of Pediatric Nursing (2012) 27, 682–689
Extravisation Scenario
3cm
30cm
X
Y
x 100
x 100
=10%
It can be greater than 100!

24. New Assessment Tool
From Rineair – Cincinnati Children’s Hospital
Journal of Pediatric Nursing (2012) 27, 682–689

25. From Rineair – Cincinnati Children’s Hospital
J Infus Nurs. 2013;36(1):37-4
Medication Assessment

26. Venous Infusion Extravasation Risk
This is an estimate of risk for phlebitis or local tissue injury due to extravasation from any intravenous infusion device.
Risk derived from available evidence, CCHMC data and CCHMC expert opinion, subject to review and change as further evidence becomes available.
For Treatment of Extravasation, Refer to CCHMC Policy P&T II-112
This does not apply in situations of emergency medical treatment.
If a medication is not on this list, please refer to the CCHMC formulary or contact pharmacy (6-4291) for information
Green
+ Lower Risk
Aminophylline
Amphotericin B Liposomal
Ampicillin
Ampicillin/Sulbactam
Cefazolin
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Clindamycin
D5LR
Dextrose < 10%
Fentanyl
Fosphenytoin
Furosemide
Gentamicin
Heparin
Imipenem
IVIG
Lactated Ringers
Lipids
Magnesium sulfate (bolus)
Meropenem
Methylprednisolone Piperacillin/tazobactam
Normal saline Ticarcilllin
Pentamidine Ticarcillin/clavulanate
Piperacillin Tobramycin
Yellow
Intermediate Risk
Acetazolamide
Allopurinol
Amikacin
Amphotericin B (conventional)
Arginine
Ciprofloxacin
Dextrose 10% to <12.5%
Diazepam
Erythromycin
Ganciclovir
Lorazepam
Midazolam
Morphine
Ondansetron
Nafcillin
Non-Ionic Radiology Contrast
Phenobarbital
Phenytoin
Potassium < 60 mEq/L
TPN <950 mOsm/L
Vancomycin
Red
Higher Risk
Acyclovir
Amiodarone
Caffeine Citrate
Calcium (all salt forms)
Dextrose > 12.5%
Doxycycline
Esmolol
Mannitol 20% & 25%
Promethazine
Potassium >60 mEq/L
Sodium bicarbonate > 3%
Sodium chloride > 3%
TPN > 950 mOsm/L
Vasopressors such as Dopamine
Chemotherapy Drugs
Extravasation treatment:
Refer to policy P&T II-113
June 19, 2013
+ NOTE:
No intravenous infusate
is “safe”.
Gross extravasation,
even of normal saline,
may result in serious
harm including
compartment
syndrome, causing
ischemia and loss of
tissue or permanent
loss of limb function.
© 2009 – 2013 Cincinnati Children’s
Hospital Medical Center

27. Document

28. Treatment
Management of Extravasation
Injuries in the NICU

29. Assessment Tool Dictates Treatment
% Swelling and Infusate Action
≥ 30% and
RED
Treat with Hyaluronidase per
provider order
≤ 30% and
RED
Assessment by attending (or VAT
Medical director) to determine if
Hyaluronidase is indicated.
Decision criteria- imminent skin
loss &/or compartment syndrome
≥ 30% and
YELLOW or GREEN
Assessment by attending (or VAT
Medical director) to determine if
Hyaluronidase is indicated.
Usually NOT indicated
≤ 30% and
YELLOW or GREEN
No treatment indicated
Any % and RED
Vasoactive Medication
Consult attending and treat with
Phentolamine if indicated (usually
not needed) Hyaluronidase
Contraindicated!
In Plain English
TREAT
Probably TREAT
Probably DO
NOT TREAT
DO NOT TREAT

30. Hyaluronidase
§ Hyaluronidase is an enzyme that disperses
offending IV fluids and medications into the
tissue and decreases tissue damage.
§ Works by modifying the permeability of
connective tissue to enhance the absorption
and dispersion of other injected drugs.
Ann Plas Surg 1984 13(3): 191

31. Hyaluronidase
§ Do not give hyaluronidase IV
§ Do not use with should NOT be used to treat
vasoconstrictive agents (eg.: dopamine,
dobutamine, epinephrine or norepinephrine).
§ Hyaluronidase treatment can be repeated.
§ Inject into the extravasation zone through
multiple needlesticks (30G) sq or ID
§ DOSE: 15 U/mL inject a total of 1 mL divided
into 5-6 injections

32. Agent Specific Treatments
§ For some agents, antidotes are available and
should be used to treat extravasations
§ Eg.:
Daunorubicin can be treated with
Dexrazoxane (Hyaluronidase does not work)

33. Wound Care
§ Note there is no debridement in the protocol
§ Wounds will usually heal with conservative
management
§ Scar contracture, if it occurs, can be treated at
a later date

34. Initial consult (Day “0”)
Photos courtesy of B. Bauer, MD

35. 19 days
Photos courtesy of B. Bauer, MD

36. 27 days
Photos courtesy of B. Bauer, MD

37. 40 days
Photos courtesy of B. Bauer, MD

38. 54 days
Photos courtesy of B. Bauer, MD

39. 2-year follow up
Photos courtesy of B. Bauer, MD

40. Prevention
Management of Extravasation
Injuries in the NICU

41. Survey of Level III NICUs
(care of <1kg infants)
§ In 1999: 25% no documented skin care protocols.
§ Type of adhesive products used to secure the IV:
w 29% transparent dressing only
w 71% had some type of tape dressing.
§ By 2013 - 92% had documented protocols
§ DO NOT USE TAPE ON IV sites – It covers the
site and decreases the ability to detect early
infiltrations
Neonatal Network. 1999;18:25-31
BMC Pediatrics 2013, 13:34

42. Decreasing Risk
§ Use oral medications when possible
§ Give “toxic” (RED) drugs centrally
w Central Venus Catheters (CVC): lower risk v PIV
s Decreased # of insertion attempts (p = .008)
s Decreased # of catheters used (p = .002)
s No difference in incidence of sepsis, number of
courses of antibiotics, or total duration of IV use.
s Mechanical problems occurred in 43% of the CVC
s Use of CVC catheters, (eg PICC):
• may decrease the #of painful procedures and
complications for the neonate.
J Pediatr Surg. 2000;35:1040-1044

43. Prevention
§ Requires a hospital wide commitment to
prevent (minimize) IV Injuries
§ Requires HOURLY assessments
§ Requires simple/easy implementation and
documentation
§ Requires feedback from all parties involved on
ways to improve your implementation
§ Change is possible and will make a difference

44. Further Resources
http://cincinnatichildrens.org/vascularaccess
THANKS FOR LISTENING!!
twking@uab.edu

45. 5th
mee'ng
of
the
Interna'onal
Society
of
Pediatric
Wound
Care
(ISPeW)
In
conjunc'on
with
Bri'sh
Associa'on
of
Paediatric
Surgeons
(BAPS)
18th
July
2017
Hilton
London
Metropole
London,
England
Execu've
board:
S
Keswani
(President)
S
Akita,
G
Ciprandi,
CM
Durante,
R
Kirsner,
G
La
Scala,
M
Romanelli,
AK
Saxena,
AB
Schluer
www.ispew.org