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.
Lisa Gorski
8/4/2016 12:33:20 am
Thanks Lynn for your insight based on your experiences and the recommendations in line with the INS Infusion Therapy Standards! Clearly clinicians must recognize the risks and severe complications associated with vesicant infusions. The work of the INS Vesicant Task Force charged with the development of a noncytoxic list of vesicants will be published on the INS website soon - a full explanation of the work and methodology will be published in the Journal of Infusion Therapy later. Thanks Lynn!
Lynn Hadaway
8/4/2016 05:36:58 am
Thanks Lisa. I am eager to see your work published.
Michael Jaqua
8/8/2016 02:54:23 pm
Excellent! I would love to make this list available in the institution where I work and have it posted for quick reference.
Lisa Sabinson
8/4/2016 02:28:38 am
Thank you for this refresher. One of the problems we continually run into as far as vesicants is, which medications are vesicants? There is not a standard list nationwide--these vary institution to institution. Our pharmacist and I are currently working on updating our vesicant policy, which includes a list of vesicants--problem is, the physicians sometimes do not agree with us when we state that a medication is a vesicant. Our argument is, if a medication has vesicant potential, it should be treated as a vesicant; if there is post-marketing data of an extravasation resulting in tissue necrosis, it should be labeled as a vesicant. Some physicians disagree. How do other facilities handle this?
Lynn Hadaway
8/4/2016 05:41:21 am
The INS will be publishing a list of non-cytotoxic medications shortly. This work will be based on exhaustive literature searches for the events you described. In the legal cases I review, I am seeing the worst situations where nurses do not even realize they are infusing a vesicant medication or what the potential risk actually are for that solution. Each organization should address this in policy and procedures. These documents have been through a full review process from all committees and stakeholders. No LIP can alter an approved and written policy without going back through those committees and that would take time. So for an individual patient situation, you would be required to follow your written and approved current policies, regardless of what the LIP desires.
Kathleen MOHN
8/4/2016 05:09:08 am
Lynn-are you going to cover this info in our Webinair on August 24th here in Las Vegas? I hope so!!
Kathleen MOHN
8/4/2016 05:13:22 am
This is great information-Thanks-Kathy Mohn.NEVVAN
Michael Jaqua
8/8/2016 02:52:36 pm
Excellent information. I would love to disseminate this information throughout the units of the hospital where I work, especially the E.D. 8/21/2016 03:02:37 pm
As a nurse this information is so helpful. As nurses and healthcare providers, we have seen the dramatic effects of infusing IV fluids to patients who are dehydrated, needing fluid replacement/supplement, those with symptoms resulting in electrolyte imbalance, or in other cases when taking oral intake of foods/fluids is not enough, and the list goes on. Using IV therapy in this manner is not a new nor a far fetched concept at all. As an infusion nurse, I totally get it, not against it, but very hesitant! I can also see where this service might be perceived as ‘encouraging” people to drink excessively and others may find it offensive. Many experts say this “out of the box” IV therapy remains controversial because of the lack of scientific evidence of the effectiveness of the treatment or the long term solution to health and well being. Comments are closed.
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Author: Lynn HadawayLynn Hadaway is an international thought leader in infusion therapy and vascular access, having been in this practice for more than 40 years. Her experience comes from hospital-based infusion teams, device manufacturers, and continuing education services. Her journal and textbook publications are extensive. She also maintains board certification in infusion nursing (CRNI) and nursing professional development (RN-BC). Categories
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