My phone continues to ring with calls from attorneys about extravasation lawsuits. Over the past 20 years, I have been an expert on about 700 cases, with the majority having seriously bad outcome from extravasation. It is time to explore some myths that many nurses have about peripheral I.V. sites and the correct administration of vesicant I.V. medications.
Myth #1 – Infiltration and extravasation are the same thing.
Facts – The Infusion Nurses Society defines infiltration as the inadvertent administration of non-vesicant solution or medication into the surrounding tissue. Extravasation is the inadvertent administration of a vesicant medication into the tissue around the vein. A vesicant is any solution or medication capable of causing tissue damage when it enters tissue surrounding the vein.
Myth #2 – It is best to use the veins of the hand, wrist or antecubital fossa because those are the most visible veins.
Facts – Many studies now show that greater number and severity of I.V. complications occur in these areas of joint flexion. The Infusion Therapy Standards of Practice have stated for many years to avoid using these veins. They are NOT safe locations for any I.V. catheter. Learn to palpate for veins in the forearm and choose sites that are naturally splinted by the bones of the arm.
Myth #3 – An armboard is not necessary and should not be used because it is considered to be a restraint for the patient.
Facts – An armboard is NOT a restraint because it’s main purpose is for patient safety and prevention of complications. The Infusion Therapy Standards of Practice calls for the use of armboards, correctly applied, when your only choice is a vein in or close to an area of joint flexion. If veins in these sites must be used, the joint must be supported with an armboard to prevent erosion of the catheter through the vein wall. Think about the patient’s movement with that hand or arm as this leads to vein damage and extravasation.
Myth #4 – Only antineoplastic chemotherapy drugs for cancer patients are vesicants and I don’t give those drugs.
Facts – There are numerous non-cancer drugs given very frequently that are vesicants including calcium chloride and calcium gluconate, high concentration of potassium chloride, promethazine, phenytoin, sodium bicarbonate, high concentrations of dextrose, contrast agents in radiology, and vancomycin and nafcillin. These drugs can be given in numerous healthcare settings and can pose significant risk to your patients.
Myth #5 – If my employer thought I needed to know about these drugs and how to give them, they would provide inservice training.
Fact – This is an issue of competency and your professional responsibility to become competent and maintain your competency. It is your employer’s responsibility to assess and validate your competency. This means that you must perform peripheral I.V. catheter insertion according to the Infusion Therapy Standards of Practice which includes site selection for that catheter. This document also states, “The clinician reviews information regarding the prescribed medication/solution including indications, dosing, acceptable infusion routes/rates, compatibility data, and adverse/side effects for appropriateness prior to administration.” This is basic nursing responsibility. If the prescribed I.V. medication is a vesicant, it is the nurse’s responsibility to know this and to know how to safely give it. This means assessing the site every 5 to 10 mLs of infusion which includes checking for a blood return. If your pharmacy mixes a vesicant medication to be infused over a couple of hours, this puts an extra burden on you to remain with the patient, doing these frequent assessment, which must include the presence of a blood return before, during, and after administration. The goal is to stop the infusion immediately at the very first sign of a problem. This could be patient complaints of burning, lack of a blood return or any other compliant at the site.
The Bottom Line--
As a nurse, your actions and interventions are to protect your patients. If you do not have the appropriate knowledge, critical thinking, and psychomotor skills to safely administer a vesicant I.V. medication, then you must gain these skills or seek help from another nurse to give the drug. It is your responsibility not that of your employer.
I know this post sounds stern and harsh, but I am overwhelmed by seeing horrible, life-altering outcomes from I.V. extravasation injury. Protect your patient, your employer and yourself by safe infusion practices as outlined in the Infusion Therapy Standards of Practice. Ensure that your current policies and procedures incorporate these standards from the recent 2016 edition of this evidence-based document. I don’t want to read depositions in a future lawsuit where the nurses cannot answer basic questions about extravasation and vesicants.
To obtain this document, go to https://www.ins1.org/Store/ProductDetails.aspx?productId=241097 to purchase a printed or electronic copy.
Author: Lynn Hadaway
Lynn Hadaway has more than 35 years experience in infusion nursing and adult education. Her experience comes from multiple acute care settings, healthcare manufacturing, continuing professional education.