Intravenous therapy has become the most common and widespread treatment method for hospitalized patients, spanning all clinical departments. As a result, there have been many infusion complications, such as drug leakage/extravasation, which is a common complication in clinical infusion safety management.
Concept
Extravasation: refers to the leakage of drugs into the extravascular space, including leakage from blood vessels or direct infiltration.
Drug exudation: refers to the leakage of non corrosive drugs into surrounding tissues outside the venous lumen due to various reasons during infusion.
Drug extravasation: refers to the infiltration of corrosive medication into surrounding tissues outside the venous lumen during infusion.
Chemotherapy drug extravasation: It refers to the leakage of chemotherapy drugs into surrounding tissues outside the venous lumen during intravenous infusion.
What are corrosive drugs
1. Corrosive drugsMainly including chemotherapy drugs, vasoactive drugs, hypertonic drugs, strong acid and strong base drugs, etc.
2. The commonly used high-risk drugs in clinical practice are:
Vasoactive drugs: dopamine, meta hydroxylamine, dobutamine, adrenaline, posterior pituitary hormone, norepinephrine, etc.
Hypertonic drugs: 20% mannitol, concentrated sodium chloride, 50% glucose, fat emulsion, compound amino acids, sodium bicarbonate, 3L nutrient solution, etc.
Chemotherapy drugs: doxorubicin, cisplatin, oxaliplatin, cyclophosphamide, fluorouracil, vinblastine, nitrogen mustard, daunorubicin, etc.
3. PH value:
The normal pH value of blood is 7.35-7.45, with pH<5 indicating strong acidity and pH>9 indicating strong alkalinity.
When the pH value of the drug is 4.5, it causes 100% severe peripheral venous inflammation, 50% mild to moderate venous inflammation when the pH value is 5.9, and 20% mild venous inflammation when the pH value is 6.3.
4. Osmotic pressure:The amount of non electrolyte or electrolyte contained in 1 liter of liquid (millimoles), expressed in millimoles of osmotic pressure, abbreviated as millimoles. Under physiological conditions, the normal human plasma osmotic pressure is 240-340 mmOs/L, with 285 mmOs/L being the isotonic standard line. The higher the osmotic pressure, the greater the stimulation on the vascular endothelium.
Low permeability solution:<240 mmOs/L, such as 0.45% sodium chloride solution;
Isotonic solution: 240~340 mmOs/L, such as 0.9% sodium chloride solution, 5% glucose solution, 5% GNS solution
Hyperosmotic solution:>340 mmOs/L, such as 10% glucose solution and 20% mannitol.
Permeation pressure<400 mOsm/L is considered low-risk,
A osmotic pressure of 400~600 mOsm/L is considered moderately dangerous,
An osmotic pressure greater than 600 mOsm/L is highly dangerous, and highly dangerous drugs can cause chemical phlebitis within 24 hours.
Common causes of drug extravasation
1. Drug factors:It is related to the acidity and osmotic pressure gradient of the drug solution. Long term input of hypertonic solutions and alkaline liquids that can irritate blood vessels, such as mannitol, sodium bicarbonate, and calcium gluconate, can cause thickening of the blood vessel wall, endothelial cell damage, vascular congestion, inflammation and edema of surrounding tissues. If necessary, a micro pump can be used for adjustment.
2. Physical factors:It is related to the environmental temperature, infusion volume, liquid temperature, speed, time, pressure, and the selection of infusion needles.
3. Mechanical factors:Inexperienced puncture techniques, improper positioning, excessive infusion speed, and prolonged time are the direct causes of vascular leakage due to various puncture injuries, such as needle tip puncturing blood vessels or incomplete entry of needle tip slope into the blood vessel cavity, unstable needle tip fixation, and thermal incompatibility leading to puncture of blood vessels, resulting in needle tip slipping off the blood vessel.
4. Vascular factors:It is related to the relaxation state of local blood vessels during infusion, whether the venous wall spasms, and whether the permeability increases.
Main manifestations of drug extravasation
1. Hyperosmotic drugs begin to swell, ache, and turn red for about 8-12 hours, appearing grayish white or subcutaneous bleeding, and after 2-3 days, appearing dark purple or black.
2. Vasoactive and irritant drugs extravasation for several minutes to 2-3 hours, causing local redness, swelling, or pale or red and white spots, appearing as stripes, stinging, burning pain, and approximately 8-10 hours of degeneration and necrosis.
3. Chemotherapy drugs immediately or within minutes can cause pain, and depending on the toxicity, they can cause degeneration and necrosis within minutes to hours. The local area may appear rosy, pale, grayish white, followed by the formation of black red, purple black, black scabs, or secondary infections.
Classification and staging of drug extravasation
Process for treating drug extravasation
General treatment of drug extravasation
1. When medication extravasation occurs, it should be stopped immediatelyDisconnect the infusion set, keep the puncture needle, connect the needle with a syringe to withdraw the medication, and reduce the damage of the medication to local tissues. Raise the affected limb again, measure and mark the extent of exudation/extravasation, observe and record the integrity of the skin, pain level, sensation, and limb motor function. Avoid strenuous activities.
2. General swelling:The general drugs and vitamins that need to be inputted can be given hot compress, usually with a hot water bag, wet hot compress, and a temperature of around 50 ℃. Observe the skin condition for 10-15 minutes. 25% to 50% magnesium sulfate or 75% to 95% alcohol can be used for hot and wet compress. Magnesium sulfate has a better effect, but it crystallizes cold. Large areas of redness and swelling appear in the local tissue, with cord like red lines along the blood vessels, and local swelling and pain. Raise the affected limb and increase the frequency of hot compress and ointment.
3. Closed treatment:When administering special medications such as chemotherapy drugs, vasopressors, and hypertonic drugs, regardless of whether there is redness, swelling, or inflammation, immediate blockade treatment should be taken.
Vasoconstrictors: such as dopamine, norepinephrine, posterior pituitary hormone, etc., immediately apply 654-2 drug hot compress or general hot compress; 0.9% saline 5ml+phentolamine 5mg local blockade.
Calcium supplements: hot compress, 1% procaine 2ml+physiological saline 2ml-5m1 or 1% procaine 2ml+dexamethasone 5mg+physiological saline 2ml-5ml local blockade.
Hyperosmotic solution, strong acid, strong alkali drugs: High osmotic drugs such as 50% glucose, 10% calcium gluconate, 10% potassium chloride, mannitol, sodium bicarbonate, etc. should be stopped immediately and given cold compress to reduce vascular constriction and drug absorption, and local occlusion should be given. 1% lidocaine 2ml+physiological saline 2ml-5ml or 1% lidocaine 2ml+dexamethasone 5mg+physiological saline 2ml-5ml should be used for local occlusion.
Chemotherapy drug extravasation: The infusion should be immediately stopped, and the residual drugs in the needle and infusion tube should be aspirated from the original vein. Then, the detoxifying agent and lidocaine solution should be dripped into the original venous pathway for local ring closure. If there is no antidote, the needle can be immediately removed and a local circular closure can be performed directly with 5 ml of 2% lidocaine, 5 mg of dexamethasone, and 10 ml of physiological saline. Ice pack cold compress for 15-30 minutes, 4 times a day for 3 days, and elevate the affected limb to constrict blood vessels, reduce drug absorption, and relieve pain.
4. Conventional methods of external application
(1) Cold compress and hot compress
Principle of action: Cold compress can cause constriction of blood vessels in the injured area, reduce blood flow, alleviate local swelling, inhibit drug metabolism in cells, and alleviate patient pain. Hot compress can dilate local blood vessels, accelerate blood circulation, thereby accelerating local metabolism and promoting absorption.
Operation method: Cold compress is used to inhibit drug metabolism in cells, but it must be done within 6 hours, followed by hot compress 24 hours later. But for vincristine and vasoactive drugs, early insulation and hot compress should be taken, and the affected limb should be raised to facilitate the absorption of local swelling.
(2) Magnesium sulfate wet compress
Principle of action: Magnesium sulfate is a hypertonic solution relative to tissue fluid. Through the penetration of magnesium ions, it improves the osmotic pressure between tissue gaps and cells, thereby allowing local tissue exudate to be absorbed and playing a role in anti-inflammatory and anti-inflammatory effects.
Operation method: Generally, magnesium sulfate solution is soaked in gauze for nursing care. When the water temperature is heated to 40 ℃, the gauze is taken out and covered on the swollen area. After 30 minutes of wet compress, the local skin is wiped dry with warm water twice a day.
However, during intravenous infusion, if the medication leaks or becomes infected, it can often cause passive effects on work. Therefore, prevention should be the top priority in work. In the clinical nursing guidelines, it is clearly stated that the prevention and treatment of extravasation and phlebitis caused by intravenous infusion should focus on prevention!
(3) Potato slices applied externally
Principle of action: Potato chips are a common food, but they have nourishing and softening ingredients that can promote blood circulation and skin metabolism, disperse blood stasis, detoxify and soften blood vessels, and have anti bacterial adhesion effects, thus promoting damaged tissue repair.
Operation method: In clinical practice, potatoes are generally washed and peeled, cut into thin slices, and covered with red, swollen, and hard lumps. After wrapping with gauze for 1 hour, the local skin is washed twice a day. But when it comes to choosing fresh potatoes, it may not be possible to purchase them in time for extravasation, and the swollen area may not be easily fixed in the joint area.
(4) Use drugs such as dexamethasone
Principle of action: Dexamethasone has anti-inflammatory and anti endotoxin effects, and produces local anesthetic effects by blocking nerve impulses. The combination of the two has good anti-inflammatory and analgesic effects.
Operation method: Seal the skin edge in a fan-shaped manner at the site of extravasation swelling, and inject medication while retreating.
(5) Use Hirudoid ointment
Mechanism of action: The main component of Hirudoid ointment is polysaccharide sulfate, which has anti-inflammatory properties, promotes edema and hematoma absorption, promotes local blood circulation, stimulates damaged tissue regeneration, and can alleviate pain and pressure. But prohibited for damaged skin.
Operation method: Squeeze the ointment onto the swollen area and gently massage it in a circular motion from the inside out to facilitate absorption, three times a day.
(6) Using certain liquid dressings can improve
Principle of action: For example, the main component of Sai Fu Run liquid dressing is fatty acid lipids, which can induce vasodilation, dilate arterioles and venules, improve local microcirculation, and alleviate the danger to the skin caused by pressure and immersion. And it can form a lipid protective film on the surface of the skin, covering and protecting the skin, promoting skin repair.
Operation method: Spray 1-2 drops on the swollen area, gently massage in a circular motion with fingertips to promote absorption, 3-4 times a day. However, it should be noted that it is contraindicated for individuals with skin damage or allergic reactions to skin moisturizing.
5. Treatment of large and small blisters:When local blisters are caused by drug leakage, try not to puncture them if the blisters are small and not yet ruptured. Non alcohol iodine can be applied externally; >0.5 cm blister, disinfected with iodine and then using a sterile syringe to remove exudate from the blister, followed by external application of alcohol free iodine. Newly formed blisters should be treated only after the skin tension of the blister has decreased.
6. Functional exercise:Guide and encourage patients to engage in reasonable elbow flexion, fist clenching, abduction, and internal rotation exercises to avoid serious consequences such as joint stiffness and muscle weakness.
Treatment of common drug extravasation in clinical practice
(1) Nursing care for leakage of mannitol solution
Once mannitol leaks, the infusion site should be immediately replaced and different treatment methods should be selected based on the degree of injury.
1. Hot compressPromote the dissipation and absorption of drugs that have leaked into tissues. Tissue damage caused by 20% mannitol leakage can be treated with 654-2 wet compress, which is effective when combined with local sealing with phentolamine. Alternatively, 50% magnesium sulfate wet compress can also be used.
2. Closed therapyClosed injection can prevent the combination of drugs with tissue cells. Local blockade can be achieved by adding 2ml of 1% procaine and 2ml-5ml of physiological saline, or adding 2ml of 1% procaine and 5mg of dexamethasone and 2ml-5ml of physiological saline.
3. Chinese and Western medicine preparationsA traditional Chinese medicine preparation made according to the method of dispelling blood stasis, promoting blood circulation, and reducing swelling in traditional Chinese medicine has good therapeutic effects on edema, congestion, and pain caused by drug leakage. For example, applying burn ointment to swollen areas has a good effect on treating infusion leakage.
4. Radiation therapyInfrared radiation can be used for about 10 minutes to dry the local tissue; Apply gauze soaked in 80000 U of gentamicin and 654-10mg to the exudate, and irradiate with ultraviolet light for about 20 minutes 2-3 times a day to achieve the effects of preventing infection, anti-inflammatory convergence, and promoting microcirculation.
(2) Fat emulsion leakage
1. Fat emulsion leaks out, forming fat droplets that cause local capillary or tissue blockage at the infusion site. Fat clots can be seen in the capillaries, causing skin redness, swelling, pain, bleeding, exudation, edema, necrosis, and fibrosis.
2. Apply alcohol locally to the skin area to dilate blood vessels and inhibit the hydrolysis of fat clots in the blood into free fatty acids. Hyaluronidase is an enzyme capable of hydrolyzing hyaluronic acid, which can promote the rapid diffusion of subcutaneous infusion or locally accumulated exudate or blood, facilitating absorption. It is often diluted and injected with a fine needle at 5 locations at the exudate site. To avoid local tissue necrosis, hyaluronic acid 150-300 μ m can be added to 10-15 ml of 0.25% procaine injection and partially blocked to promote diffusion and absorption.
3. Disinfect the skin at the site of extravasation with a 5% alcohol cotton ball, then grind Jidesheng snake medicine into powder and mix it with magnesium sulfate injection to form a paste and store it in a small bottle with a lid. Then use a cotton swab to apply the medicine to the skin at the site of extravasation, with an area 2-3cm beyond the edge of the extravasation and a thickness of 1-2mm. Wrap it with clean gauze, fix it with adhesive tape, and cover it with a bottle cap. Change the dressing every 4 hours.
(3) Prevention and treatment of extravasation of vasoactive drugs
1. Dopamine is an agonist of alpha, beta adrenergic receptors and dopamine receptors, which can enhance myocardial contractility and peripheral vascular constriction, thereby increasing blood pressure. It is a commonly used drug for anti shock treatment. However, during intravenous infusion, dopamine extravasation can cause varying degrees of tissue damage and necrosis.
2. Immediately after extravasation, thoroughly infiltrate and inject 10-15 ml of physiological saline containing 5mg of phentolamine Phentolamine is an alpha receptor blocker that can block the excitatory effect of alpha receptors, dilate blood vessels, relieve peripheral vascular spasms, and improve microcirculation. Due to the short duration of action of phentolamine, infiltration injection itself is a mechanical injury to muscle tissue.
3. In the early stage of extravasation, phentolamine diluent (50ml physiological saline plus 40mg phentolamine) or 25% magnesium sulfate wet compress can be used to reduce local tissue chemical reactions, alleviate patient pain, and prevent local tissue necrosis. Due to the weakened disease resistance of edematous tissues, they are susceptible to bacterial invasion and even local infections. Additionally, the regenerative and repair functions of edematous tissues are weakened, making it difficult for them to heal after injury. Therefore, timely treatment of liquid leakage is particularly important.
4. For substances such as dopamine, norepinephrine, and posterior pituitary hormone, immediately apply 654-2 medication hot compress or general hot compress; 0.9% saline 5ml+phentolamine 5mg local blockade.
(4) Prevention and treatment of calcium extravasation
1. Raise the affected limb to promote blood flow and reduce local swelling.
2. Using 0.25% to 0.5% procaine block therapy to alleviate inflammation and damage symptoms in swollen areas and correct vascular dysfunction is the most critical step in preventing necrosis of the site of calcium gluconate extravasation. 1% procaine 2ml+physiological saline 2ml-5m1 or 1% procaine 2ml+dexamethasone 5mg+physiological saline 2ml-5ml local occlusion.
3. Localized wet compress of Xiangdan (Compound Danshen) Injection, Xiangdan Injection is composed of Danshen and Jiangxiang. It is a traditional Chinese medicine medicine essential for promoting blood circulation and removing blood stasis. It can alleviate local congestion, improve blood circulation, and has effects such as strengthening the heart, resisting hypoxia, sedation, anti-inflammatory, and antibacterial. Therefore, local wet compress of Xiangdan injection is an important step in preventing necrosis at the site of calcium gluconate extravasation.
4. Magnesium ions can directly dilate the smooth muscle of surrounding blood vessels, causing dysfunction in sympathetic ganglion impulse transmission and leading to vasodilation. Hot compress the affected area with 50% magnesium sulfate solution has the effect of reducing inflammation and swelling.
5. Local irradiation with infrared lamps has the effects of reducing swelling, relieving pain, reducing exudate, promoting blood circulation, and removing blood stasis, achieving the goal of anti-inflammatory and swelling removal.
Common chemotherapy drugs for extravasation and their diagnosis
Note: Cisplatin is classified as a stimulant drug, but attention should be paid to the concentration and amount of extravasation. If a large amount of extravasation (>20ml) occurs at a high concentration (>0.5mg/ml) of cisplatin, it must be considered as vesicular drug extravasation and treated accordingly
(1) When there is mild extravasation
The leaked medication is minimal, and the patient's symptoms are mild, mainly characterized by mild local pain or tenderness, slight redness and swelling of the skin, small area, and sometimes accompanied by phlebitis.
(2) When there is slight extravasation
The patient's symptoms are slightly severe, mainly characterized by severe skin redness and swelling, even blisters, and obvious local pain.
(3) When there is severe extravasation
There is a significant amount of leakage of medication, which is detected later. The medication has a large area of tissue erosion, and if not handled properly or in a timely manner, it can lead to tissue necrosis, ulcers, functional damage, and easy co infection, making it difficult to heal.
Antidote for chemotherapy drug extravasation
(1) Cyclophosphamide, Vinblastine, Vinblastine, Changchun Dexin, Changchun Ruibin, Paclitaxel
Local injection of hyaluronidase 300 u+2 mL of physiological saline can destroy hyaluronic acid in tissues, thereby reducing ulcer incidence by 50%.
(2) Nitrogen mustard, cisplatin, streptomycin, and actinomycin
Choose intradermal/subcutaneous injection of sodium thiosulfate (where topical application of dimethyl sulfoxide can inhibit inflammatory response and prevent tissue necrosis).
(3) Anthracene ring
Antidotes such as dexmedetomidine and dexmedetomidine (approved for the treatment of leakage during intravenous injection of anthracycline antibiotics), in addition to topical application of dimethyl sulfoxide.
(4) Doxorubicin, Vinblastine, and Vinblastine
Local injection of 5 mL of 8.4% sodium bicarbonate and 5 mg of dexamethasone can reduce drug DNA binding and inflammation.
The treatment process of chemotherapy drug extravasation
The following is a detailed emergency treatment flowchart for chemotherapy drug extravasation, which can be collected and studied:
Source: Pre hospital Emergency Alliance