Commonly given intravenous (IV) drugs such as aciclovir, gentamicin and even furosemide, which are all vesicant, can all cause different degrees of tissue damage if they extravasate. Although extravasation and infiltration are major potential complications of IV therapy, especially in non-chemotherapy drug administration, awareness and recognition of these issues is shockingly low within IV therapy administration practice. However, the use of peripheral cannulas for vesicant drug administration is widespread.
To ensure safe IV drug administration, it is vital to understand exactly what a vesicant is. Vessel health is a priority, so the safest vascular access device must be selected for each individual patient. However, I wonder how many of us nurses fully explain to patients the consequences of administering an IV vesicant via a peripheral cannula?
In my experience, when I worked on the wards administering IV therapy, I never sat down to explain to patients which vascular access device might be the best in their case, or the risks of administering IV therapy generally, and specifically vesicant drugs. When a patient experiences an extravasation or a infiltration, this usually comes as a huge shock, as they are not prepared for such complications.
Over the past 12 months, I have seen an increase in the extravasation of IV calcium chloride in my practice. The tissue injuries have been extensive, and each time I looked into the events leading to the extravasation it was clear that all patients had been difficult to cannulate: the peripheral cannulas were not long enough to sit 80% of the cannula into the vessel for stability. None of the patients had had any information about the risks associated with tissue damage if the calcium chloride caused extravasation.
The drug profile states that it should be given centrally, so where do we stand once an injury has occurred and the patient decides to go down the litigation road? In my experience, it is difficult to defend a practice that we know can cause harm, even if our defence is that a drug was administered in an urgent situation. I was called to an emergency on a ward where the patient needed IV calcium chloride: on this occasion I was given the time to place a neck central venous catheter in order to give the drug safely – which is the recommended route – despite the urgency of the situation, because the risk of extravasation was acknowledged.
Attitudes towards vesicant drug administration via peripheral vessels and prioritising vessel health need to change. This is vital if we are to reduce the number of extravasation and infiltration injuries within general IV therapy practice. Such a knowledge shift will require staff to understand why these injuries happen, to recognise when extravasation has happened and to take the most appropriate action to treat the injury rapidly. Lost time is lost tissue when an extravasation occurs.
The NIVAS campaign and toolkit on how to prevent, recognise, manage and report extravasation injures is coming soon. We should all be taking the time to choose the right vascular access device for the patient's circumstances and ensure, where possible, that we obtain fully informed patient consent. Where elective IV iron is being given, for example, written consent with patient information literature should be the standard practice.
Longer length peripheral cannulas are very useful in ensuring that 80% of the catheter is siting within the vessel: this helps stabilise the catheter and reduce the risk of it migrating out of the vessel.
Having a vascular access team (VAT) service in a hospital can help achieve all IV therapy safety initiatives, and the NIVAS white paper on setting up vascular access teams continues to be available on the NIVAS website and is free to download (http://tinyurl.com/NIVAS-whitepaper-July2022). It can aid you in putting together a case to present to your Trust to fund a VAT service.
One conundrum I am trying to solve in practice is to reduce the rate of infiltration and extravasation of CT scanning contrast. The general practice is to place an 18 G green cannula in the antecubital fossa because the contrast requires high-pressure flow rates. However, due the practice of positioning the patient with their arms above their head in the CT scanner, in order to minimise artefacts and reduce radiation dose, the cannula may become partially occluded and dislodged under the injection pressure, resulting in extravasation. There must be a safer way to perform the scan, while reducing the risk of extravasation. If you have any suggestions on how this problem could be resolved, please do let me know.