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Extravasation of Radiologic Contrast
PA PSRS Patient Saf Advis 2004 Sep;1(3):1-5.    
 

Extravasation of radiologic contrast media accounts for a substantial proportion of reports submitted to PA-PSRS. Intravenous complications account for approximately 5% of all reports submitted to PA-PSRS. Complications related to administration of radiologic contrast media account for approximately 11% of these IV complications.

Occurrences related to radiologic contrast administration are reported to PA-PSRS as either infiltrations or extravasations. Over half of the contrast administration issues are categorized as infiltrations. The terms “infiltration” and “extravasation” seem to be used interchangeably as they elate to contrast media. However, there is an important difference between these terms.

The Infusion Nurses Society (INS) defines an infiltration as the inadvertent administration of a nonvesicant solution into surrounding tissue, instead of into the intended vascular pathway. Extravasation is the inadvertent administration of a vesicant solution into surrounding tissue, instead of into the intended vascular pathway.1 A vesicant is an agent that has the potential to cause blistering or tissue necrosis.2 Radiologic contrast media are considered to be vesicant solutions.

Though chemotherapy/antineo-plastic medications are well-known vesicants, other vesicant solutions include certain vasodilators and vasopressors, parenteral nutrition, certain antibiotics, and certain electrolyte solutions.3 See the inset article “Common and Lesser Known Vesicants” for a detailed list.

Vesicant solutions are capable of causing significant injury to patients. Such injuries depend upon such factors as: the type of vesicant, amount and concentration infused, and the length of time the drug remains in the tissue. Once extravasation occurs, damage can continue over a long period of time, involving skin, nerves, connective tissue, and joints.4-6 Consequences of extravasation may include infection, loss of function, necrotic ulcers, disfigurement, reflex sympathetic dystrophy, surgical debridement/plastic surgery, skin grafting, amputation, and skin sloughing.2-4,6 Severe extravasation injuries associated with contrast media include: skin ulceration, necrosis, hypoasthesias, marked deformity of the extremity involved, weakness, pain, decreased range of motion, flexion contractures, difficulty performing activities of daily living, and surgical debridement including skin graft procedures.5

Approximately 3% of PA-PSRS reports relating to contrast occurrences categorized as infiltrations or extravasations were Serious Events with harm scores of E or F. In one case, the “hold” button of the power injector used to administer a vesicant did not function. A clinician had to shut off the main power to the injector to stop the injection. Thereafter, the patient was admitted to the hospital for three days for treatment of the extravasation site. In another case, a patient developed compartment syndrome, resulting in an operative procedure.

Risk factors for contrast extravasation and subsequent severe injuries include the following.5,7 [Table 1 indicates how some risk factors are reflected in PA-PSRS.] Patients with major extravasation injury tend to be under 11 or over 70 years of age. Approximately half of the contrast extravasation events reported to PA-PSRS occurred in patients within those age ranges. Greater morbidity from extravasations occurs when the dorsum of the hand, the foot or the ankle are used to inject contrast media. Patients with arterial insufficiency, compromised venous/lymphatic drainage, venous thrombosis, altered perfusion in the extremity injected are at increased risk for contrast extravasation. Health problems reflecting abnormal circulation/perfusion may include: atherosclerotic peripheral vascular disease, diabetic vascular disease, connective tissue disease, Raynaud phenomenon, regional node dissection, prior radiation therapy to limb injected. Also considered at increased risk are non-communicative/unconscious patients, severely debilitated/chronically ill patients, and those with significant weight loss or extensive metastatic disease. Severe damage to extravascular tissue is more likely to occur when large volumes of contrast media are extravasated.5 While serious extravasation injuries are more likely with ionic contrast8, the clinical literature also contains case reports of significant extravasation injury associated with nonionic contrast.9,10


Table 1. Presence of Risk Factors in PA-PSRS Reports Categorized as Contrast Extravasation or Infiltration

  Table 1. Presence of Risk Factors in PA-PSRS Reports
  Categorized as Contrast Extravasation or Infiltration



The use of certain equipment may also increase the risk of contrast extravasation.4,5 Extravasation is more likely when a tourniquet is used but not released during injection. Administering contrast via indwelling intravenous lines in place longer than 20 hours also increases extravasation risk. Extravasations are more likely to occur through metal needles than through plastic catheters. Multiple attempts at intravenous access at the same site or through different sites in the same vein also increase extravasation risk. Finally, the risk of extravasation of contrast media is greater when using an automated power injection device, compared to hand injection or drip infusion.

To treat contrast extravation, the clinical literature suggests elevation of the extremity to disperse the contrast for quicker absorption2,3,5,8,11,12 and contrast aspiration using the needle through which the extravasation occurred.7,8 There appears to be some difference of opinion in the literature concerning the issue of skin temperature pertaining to treatment of contrast media extravasation. One resource indicates the use of warm compresses,13 while another indicates that cold or warm packs are appropriate to apply to the extravasated area.11 Most of the clinical literature indicates that application of cold significantly reduces skin toxicity in the event of a contrast extravasation.2-6,8,14-17 Most reports of contrast extravasation submitted to PA-PSRS (65%) do not specify a treatment regimen. Ice or cold compresses are specified in 25% of the reports, while 11% indicate hot compresses. Elevation is indicated in 10% of the reports. Warm, then cold compresses were documented in one report.

A formal policy/protocol concerning the administration of contrast media may be a helpful first step in reducing the incidence of contrast extravasation.5,7 Currently some facilities may address extravasation protocols within their policies on the use of chemotherapy agents. However, these policies may not be accessible or perceived as applicable when extravasation of a non-antineoplastic agent occurs.14

Some elements to consider in an extravasation prevention/treatment program include: education and training required to administer contrast;15,11 identification of patients with selected risk factors; interventions based on volume of extravasation and type of contrast;5,8,11 and observation, follow-up, and availability of extravasation response/antidote kits.2,5

In terms of tracking cases of extravasation, elements to consider documenting include:5,15

  • Description of symptoms
  • Interventions
  • Date/time orders received from physician
  • Date/time nursing unit notified
  • Date/time of discovery
  • Time of vesicant administration
  • Time elapsed since onset of extravasation
  • Vein location
  • Type, gauge, and size of catheter
  • Type of media administered
  • Amount of contrast infused
  • Mode (e.g., power injector, hand injection)
  • Patient complaints
  • Clinical signs (e.g., estimated size/extent of extravasation)
  • Image of extravasation site for medical record
  • Patient education/instructions

Cohan, et al.,5 and the Oncology Nursing Society2 describe the use of an extravasation form to capture the above information. Such forms can be placed in the medical record or outpatient notes and can be used to collect data as part of a quality management/performance improvement program. Collection of such data will help to identify trends that may be useful in educational programs and policy or protocol revisions, as indicated.11,16,19

Reports submitted to PA-PSRS suggest that several facilities provide an instruction sheet to patients who have a contrast extravasation. Some injuries from extravasation may not become apparent for several days (sometimes after a patient has been discharged). Instruction sheets may be helpful for reminding patients about what types of symptoms to report.

The following selected resources may be useful in developing or evaluating extravasation protocols.

Resources

American College of Radiology. ACR practice guideline for the use of intravascular contrast media (Res 5.1). 2001. Available from Internet: http://www.acr.org/departments/stand_accred/standards/pdf/iv_contrast_media.pdf.

Infusion Nurses Society (INS) [Web site]. Norwood (MA): INS. Available from Internet: http://www.ins1.org.

Lynn Hadaway Associates [Web site]. Milner (GA): Lynn Hadaway Associates, Inc. Available from Internet: http://hadawayassociates.com.

League of Intravenous Therapy Education (LITE) [Web site]. White Oak (PA): LITE. Available from Internet: http://www.lite.org.

National Extravasation Information Service (NEIS) [Web site]. Birmingham (United Kingdom): NEIS. Available from Internet: http://www.extravasation.org.uk/home.html.

Brown KA, Esper P, Kelleher LO, et al., eds. Chemotherapy and biotherapy: Guidelines and recommendations for practice. Pittsburgh (PA): Oncology Nursing Society; 2001.

Notes

  1. Intravenous Nursing Society. Infusion nursing standards of practice. J Intrav Nurs 2000 Nov/Dec;23(6S):S67-8.
  2. Brown KA, Esper P, Kelleher LO, et al., eds. Chemotherapy and biotherapy: Guidelines and recommendations for practice. Pittsburgh (PA): Oncology Nursing Society; 2001.
  3. Hadaway L. Preventing and managing peripheral extravasation. Nursing 2004;34(5):66-7.
  4. National Extravasation Information Service (NEIS) [Web site]. Birmingham (United Kingdom): NEIS. Available from Internet: http://www.extravasation.org.uk/home.html.
  5. Cohan RH, Ellis JH, Garner WL. Extravasation of radiographic contrast material: Recognition, prevention, and treatment. Radiol Sep 1996;200(3):593-604.
  6. MacCara ME. Extravasation: a hazard of intravenous therapy. Drug Intell Clin Pharm 1983;17:713-7.
  7. Federle MP, Chang PJ, Confer S, Ozgun B. Frequency and Effects of Extravasation of ionic and nonionic CT contrast media during rapid bolus injection. Radiol 1998;206:637-40.
  8. Sistrom CL, Gay SB, Peffley L. Extravasation of iopamidol and iohexol during contrast-enhanced CT. Report of 28 cases. Radiol 1991 Sep;180(3):707-10.
  9. Pond GD, Dorr RT. Skin ulceration from extravasation of low-osmolality contrast medium: a complication of automation [letter]. AJR 1992 Apr;158(4):915-6.
  10. Memolo M, Dyer R, Zagoria RJ. Extravasation injury with nonionic contrast material [letter]. AJR Jan 1993;160:203-4.
  11. American College of Radiology (ACR). Manual on Contrast Media, 4th ed., 1998. Reston (VA): ACR.
  12. Lamagna P, MacPhee M. Troubleshooting pediatric peripheral IV’s: Phlebitis and infiltration. Nurs Spectr 2004 Jun 28. Available from Internet: http://community.nursingspectrum.com/ MagazineArticles/article.cfm?AID=12206.
  13. D’Alessandro MP. Virtual children’s hospital [Web site]. Treatment of a contrast extravasation [online]. The University of Iowa, 2004. Available from Internet: http://www.vh.org/pediatric/provider/radiology/PAP/MiscTech/TechMiscConExtrvTx.html.
  14. Rastegari EC. Extravasation: Does your knowledge match your patient’s needs? [online] Nurs Spectr 2003 Sep 1. Available from Internet: http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=10640.
  15. Skokal WA. Drug disasters: Extravasation [online]. RN 2001 Sep 1(9):56. Available from Internet: http://www.rnweb.com/be_core/r/templates/issue/internallinks.jsp?filename=/be_core/content/journals /r/data/2001/0901/ivextrav.html.
  16. Elam EA, Dorr RT, Lagel KE, Pond GD. Cutaneous Ulceration due to contrast extravasation: Experimental assessment of injury and potential antidotes. Invest Radiol 1991:26:13-6.
  17. Camp-Sorrell D. Developing extravasation protocols and monitoring outcomes. J Intrav Nurs 21(4):232.
  18. American College of Radiology. ACR practice guideline for the use of intravascular contrast media (Res 5.1). 2001. Available from Internet: http://www.acr.org/departments/stand_accred/ standards/pdf/iv_contrast_media.pdf.
  19. Hadaway L. Treatment for infiltration and extravasation [online]. Available from Internet: http://www.hadawayassociates.com/article6.htm. 

Common and Lesser-Known Vesicants

Chemotherapy Drugs—Vesicants

Vinca Alkaloids

  • Vinblastine sulfate (Velban)
  • Vincristine sulfate (Oncovin)
  • Vindesine (Eldisine)
  • Vinorelbine (Navelbine)

Alkylating Agents

  • Cisplatin (Platinol)
  • Dacarbazine-Dric-Dome
  • Mechlorethamine HC.—Mustargen
  • Nitrogen mustard

Anthracyclines/Antitumor Antibiotics

  • Dactinomycin (Actinomycin D)
  • Daunorybicin HCl (Cerubidine)
  • Doxorubicin HCl (Adriamycin)
  • Mitomycin (Mutamycin)
  • Mitomycin C
  • Epirubicin HCl (Ellence)
  • Idarubicin (Idamycin)
  • Esorubicin
  • Mitoxantrone, Novantrone

Other

  • Paclitaxel (Taxol)
  • Carmustine
  • Pliamycin
  • Streptozocin
  • Amsacrine
  • Mithramycin
  • Mustine
  • Melphalan

Lesser-Known Vesicants

Hyperosmolar Agents

  • Calcium chloride
  • Calcium and Calcium-containing compounds
  • Calcium gluconate 10%
  • Glucose/dextrose in concentrations ≥10%
  • Hypertonic saline ≥10%
  • Magnesium sulfate
  • Mannitol 10% and 20%
  • Parenteral nutrition/hyperalimentation
  • High concentrations of potassium chloride
  • High concentrations of sodium bicarbonate
  • Radiographic contrast media
  • Solutions with pH <5.0 or >9.0 or osmolarity >500mOsm/L

Vascular Regulators

  • Dopamine
  • Epinephrine
  • Norepinephrine bitartrate (Levophed, Levarterenol)
  • Norepinephrine
  • Metaraminol bitartrate (Aramine)
  • Phenylephrine
  • Dobutamine
  • Dopamine
  • Vasopressin

Antibiotics

  • Vancomycin
  • Nafcillin
  • Doxycycline
  • Piperacillin
  • Zosyn (Piperacillin/Tazabactam)

Miscellaneous

  • Amphotericin B
  • Phenytoin (Dilantin)
  • Promethazine (Phenergan)
  • Diazapam (Valium)
  • Doxapram
  • Lorazepram
  • Thiopental

Sources

Camp-Sorrell D, Schulmeister L. Chemotherapy extravasation from implanted ports. Onc Nurs Forum 2000;27(3):521.

Duke University Medical Center. Vesicant or irritant? Vesicant chemotherapeutic agents [online]. 2001 Jul 24. Available from Internet: http://www2.mc.duke.edu/9200bm+/VesicantIrritant.htm.

Hadaway L. Central venous catheters: Checking for a blood return [online]. Available from Internet: http://www.hadawayassociates.com/article_blood.htm.

Hadaway L. IV infiltration: Not just a peripheral problem. Nursing 2002 Aug;32(8):39.

Hadaway L. Treatment for infiltration and extravasation [online]. Available from Internet: http://www.hadawayassociates.com/article6.htm.

Keen JH, Baird MS, Allen JH. Clinical Care and Emergency Drug Reference. St. Louis(MO):Mosby; 1996.

Lamagna P, MacPhee M. Troubleshooting pediatric peripheral IV’s: Phlebitis and infiltration. Nurs Spectr. 2004 Jun 28. Available from Internet: http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=12206.

Brown KA, Esper P, Kelleher LO, et al., eds. Chemotherapy and biotherapy: Guidelines and recommendations for practice. Pittsburgh (PA): Oncology Nursing Society; 2001.

Phillips L. Manual of IV Therapeutics. Philadelphia (PA): F.A. Davis; 1997.

Rastegari EC. Extravasation: Does your knowledge match your patient’s needs? Nurs Spectr. Available from Internet: http://community.nursingspectrum.com/ MagazineArticles/article.cfm?AID=10640.

Schrijvers DL. Extravasation: A dreaded complication of chemotherapy. Ann Oncol 2003;14 (Supplement 3): iii26-iii30.

Skokal WA. Drug disasters: Extravasation [online]. RN 2001 Sep 1(9):56. Available from Internet: http://www.rnweb.com/be_core/r/templates/issue/internallinks.jsp?filename=/be_core/content/journals/r/data/2001/0901/ivextrav.html.

 
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