Complications in clinical practice are not uncommon. For most patients, having a vascular access device or IV therapy will be the most invasive procedure they will experience during their hospital stay. Millions of vascular access procedures are undertaken in the NHS each year. So it's not surprising that sometimes things can go wrong and harms can occur. Extravasation and infiltration can cause significant harm to our patients and often the severity of these injuries is avoidable. That's why the National Infusion and Vascular Access Society (NIVAS) is so focused on preventing avoidable complications in IV therapy and vascular access. Often the cause of complications is because guidelines, policies and procedures are not followed. Sometimes there is an acceptable risk of complications that are unavoidable but the level of harm can be reduced, and sometimes there is little awareness that a complication might occur or what that complication looks like. In the last situation, we can do something to make a change and reduce the risk.
Infection, thrombosis, exit site infection, catheter occlusions and catheter migration are all well-known complications that staff involved with vascular access and IV therapy tend to be well informed about. However, infiltration and extravasation are often unrecognised, misdiagnosed and under-reported, especially in non-systemic anti-cancer treatment (non-SACT) IV therapy. Infiltration and extravasation are often confused, which is concerning because the symptoms can be serious and the treatments different. Infiltration is the inadvertent leakage of intravenous fluid or medication into extravascular tissue from an intravenous vascular access device. The resulting injury is likely to be minor unless large volumes of fluid are involved, in which case compartment syndrome is a risk. Infiltration of intravenous iron will cause permanent orange staining of the skin, causing physical and psychological harm. If the infiltrated fluid or medication is a vesicant, the injury would be classed as an extravasation. In such cases the risk of tissue damage and serious injury is high.
The likelihood of an extravasation injury occurring increases when patients with difficult IV access (DIVA) are involved. Hospitals with no vascular access service often struggle to manage DIVA patients' vascular access needs. Repeated cannulation or a poorly sited cannula, which can easily dislodge, can cause infiltration and extravasation. Misdiagnosis of extravasation injuries can result in mismanagement, often leading to the inappropriate use of antibiotics.
In response to this, NIVAS has published its Infiltration and Extravasation Toolkit in the hope that we can raise awareness of this complication and reduce the level of harm to which our patients are exposed. The toolkit, which was launched in March 2024, outlines the need for NHS hospitals to have an awareness of all extravasation and infiltration injuries regardless of the type of vesicant, SACT or non-SACT. NIVAS would like all NHS hospitals to have an extravasation lead who can oversee the implementation of the NIVAS toolkit, using the resources to create local guidelines and protocols and update local incident reporting systems with an extravasation and infiltration category.
We know that extravasation injuries are often missed and are not adequately followed up, especially in non-SACT patients. It can take weeks for a vesicant extravasation injury to evolve, which can often lead to tissue necrosis. The new NHS national incident reporting system does not explicitly contain a category for IV therapy complications, but local hospitals can create an IV therapy complications category and add infiltration and extravasation themselves – and NIVAS would urge them to do so.
With the launch of the NIVAS toolkit, the numerous webinars we have planned and the articles contained in this BJN supplement, I hope we can increase the awareness of infiltration and extravasation and lobby our patient safety teams to start recording these complications properly so we can audit the prevalence. I know the rates will be surprisingly high when local hospitals start recognising and reporting them. I hope we can move to a system of national reporting and start thinking about how we can standardise practice to reduce the number of incidents and the level of harm that currently occurs.
In the future, extravasation and infiltration will hopefully be considered to be on the same level as catheter-related bloodstream infections and thrombosis, so we can take national action to reduce the harm associated with these injuries. It will help us move to a place where it is recognised that a nurse-led vascular access service team, which can reduce the risks associated with infiltration and extravasation, is considered an essential service for all NHS hospitals.
For more information or to download the NIVAS toolkit visit the NIVAS website (www.NIVAS.org.uk) and see the article on page S18.