Extravasation is the leakage of a fluid out of its container into the surrounding area, especially blood or blood cells from vessels. In the case of inflammation, it refers to the movement of white blood cells from the capillaries to the tissues surrounding them. Wikipedia
Sites most often implicated in extravasation injuries include the dorsum of the hand and foot [5], ankle, antecubital fossa [6], and near joints or joint spaces [7] where there is little soft tissue protection for underlying structures [8]. Limbs with local vascular problems such as lymphoedema may have reduced venous flow causing pooling and potential leakage of infusates around the site of cannulation [5, 9]. Peripheral rather than central venous administration of antineoplastic agents is more likely to be associated with frequent cannulation which is a risk factor for extravasation, and this should be avoided [5, 7].
More extravasations occur at night and often go unnoticed [10]; however, data from the National Extravasation Information Service green card reporting database shows that 44% of extravasations occur between the hours of 2 pm and 10 pm, 10% occur between 10 pm and 6 am, and 38% occur between 6 am and 2 pm [11]. Inexperienced personnel may pose a higher risk, particularly during cytotoxic administration.
There are various patient factors that contribute to the aetiology of extravasation injuries. Veins of people receiving chemotherapy for cancer are often fragile, mobile, and difficult to cannulate [12, 13]. Patients who receive chemotherapy at the same site as radiotherapy may experience a reactivation of skin toxicity known as ‘‘recall” phenomenon [9, 14–17], and patients who have had an extravasation and receive further chemotherapy in a different site may experience an exacerbation of tissue damage in the original site. Patients who have undergone radical mastectomy, axillary surgery, or lymph node dissection may have impaired circulation in a particular limb which reduces venous flow and may allow intravenous solutions to pool and leak out [18].
Diabetic patients with peripheral neuropathy may not experience the pain of an infusate leaking into the subcutaneous tissues [2, 13, 19, 20], and those who suffer from superior vena cava syndrome have persistently elevated venous pressure which, again, may predispose to leakage at the intravenous site [5, 13]. Another more obvious risk is the one posed by intravenous drug users where vessels are often thrombosed and the number of accessible veins is limited, but those who require repeated infusions for their medical condition may experience the same difficulties [13, 21–23].
Patients with other diseases can have increased risk of extravasation injuries because of the same mechanism. This reduction in venous flow and risk of leakage at the intravenous site have been observed in patients with peripheral vascular disease [13, 18, 20, 24, 25] and in those with Raynaud’s phenomenon where arterial spasm may compromise the peripheral circulation [2, 19, 20]. The treatment of these diseases may also represent an increased risk of extravasation injury as shown in Table 1.
Table 1
Medications that may increase the risk of extravasation.
Medication Risk
Anticoagulants
Antifibrinolytics
Antiplatelets May exacerbate extravasation or cause a compartmental injury by increasing local bleeding
Vasodilators May increase local blood flow and enlarge the area of injury
Hormone Therapy Vasodilating properties
Steroids Vasodilating properties
Diuretics May increase local blood flow
Antihistamines May constrict capillaries and arterioles, resulting in ischaemic injury
Analgesics Reduced pain sensation may cause less reporting of extravasations
IV antibiotics Repeated venous insult may thrombose vessels
Al-Benna, S., O’Boyle, C., & Holley, J. (2013). Extravasation injuries in adults. ISRN dermatology, 2013, 856541. https://doi.org/10.1155/2013/856541
