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A Collection of Acute Care & Emergency Department Guidelines

Peripheral Intravenous Extravasation Management

by Dr Anand Senthi

12/11/26

 

The main types of extravasation injury for which guidelines are readily available are:

  1. Extravasation of Anti-cancer Drugs
  2. Extravasation of Intravenous Contrast Media used in imaging
  3. Extravasation of Vasopressor medication
  4. Extravasation of other medications

Types 1 & 2 are addressed in the following EVIQ Guidelines

 

Types 3 & 4 are addressed for paediatrics in the Peripheral Extravasation Injuries Guideline by Royal Children’s Hospital (RCH).

While the RCH guideline is informative, an equivalent open-access adult guideline covering types 3 & 4 is not easily available in Australia.

Consequently, for adult vasopressor extravasation specifically, a summary of the approaches from a range of useful international resources is provided below.

 

Vasopressor Extravasation Management Summary (Adults)

 

Useful, quick reference, adult guideline summaries for vasopressor extravasation include:

 

Management summary:

  • Simple measures
    • Stop the vasopressor infusion.
    • Do not initially flush or remove the intravenous cannula – instead attempt to aspirate as much extravasated medication through the cannula as feasible.
    • Warm compress and elevate the limb
    • Assess for vascular ischaemia and compartment syndrome.
    • Refer to appropriate surgical team (e.g. plastics) as needed
  • Phentolamine
    • Phentolamine is widely recommended as first line treatment.
    • 5-10mg is diluted in 10mL saline. Approximately one-quarter to one-half of this volume (e.g. 2.5-5mL) is injected directly into the tissued intravenous (now interstitial) cannula (after first aspirating to confirm no blood is returned). Then the rest is injected via several subcutaneous injections with a 25g needle into the area of extravasation.
    • Phentolamine is commonly unable to be accessed in many hospitals in a timely manner or at all. Consequently this article specifically addresses alternative options for when phentolamine is not available
      • Terbutaline is the recommended injectable substitute, often more available in hospitals as an obstetric medication. 1mg can be diluted into 10mL of saline and used in the same way as Phentolamine above.
  • GTN (glyceryl trinitrate) ointment locally applied topically
    • This is often recommended as an adjuvant therapy to phentolamine or when phentolamine is not available.
    • While sources suggest the use of 2% GTN ointment (seemingly derived from neonatal extravasation literature), this is only available via Special Access Scheme in Australia so is generally unavailable in most hospitals. 0.2% GTN ointment (e.g. Rectogesic typically used for anal fissures) is more widely available and despite being one-tenth the dose, is still recommended in this neonatal guideline. In adults and older children it may be less effective and while substantial systemic absorption is unlikely, it is prudent to monitor blood pressure with its use.
  • Saline washout
    • In severe cases, saline washout is advocated in some guidelines via small incisions.
  • Hyaluronidase
    • Sometimes recommended to be injected subcutaneously for larger volume extravasations at highest risk of injury as it allows dispersion of extravasated fluid to reduce necrosis in severe extravasation
    • However its use is controversial for vasopressor extravasation specifically, with some sources recommending it while others actively recommending against it. Hyaluronidase facilitates dispersion of extravasated fluid but does not directly reverse vasoconstriction, which is the principal mechanism of tissue injury with vasopressors. There is also extreme variation in recommended doses of 15 IU to 1500 IU either used alone or with a saline washout.

 

Accidental Digital Injection of Adrenaline Auto-injector

While these guidelines refer to vasopressor infusion extravasation, similar principles are applied for the treatment of accidental digital injection of an adrenaline auto-injector (e.g. Epipen).  The evidence base for treatment stems primarily from case reports. While usually self resolving without pharmacological management using simple warm water immersion,  strategies advocated, particularly for more prolonged cases of reduced perfusion, include topical GTN ointment and phentolamine or terbutaline subcutaneous infiltration at the site of accidental injection. Note much smaller volumes of antidote medication (compared to those recommended in the above guidelines) will need to be used in digits to prevent inadvertently worsening ischaemia. e.g.

  • Phentolamine  – widely variant dosing regimes described, from 0.5-5mg of Phentolamine diluted to a total volume of 1-3mL with either saline or 2% lignocaine.
  • Terbutaline has been used undiluted as 1mg in 1mL (rather than diluted in 10mL.)

In some cases treatments may need to be repeated if their efficacy wanes.

Aside from using lignocaine to dilute phentolamine, it has also been used in case reports as a digital block to mitigate sympathetic nerve activity.

 

Reference List

 

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