EXTRAVASATION INJURY

Intravenous infusions frequently leak outside the vein, "go interstitial" in medial jargon. Such extravasation is generally little more than a source of discomfort and nuisance.

Practice Point

**Leakage of fluid under the skin from an intravenous infusion is common and not de facto evidence of substandard technique**

Some therapeutic agents, notably a number of medications used routinely in cancer chemotherapy, are irritants to the skin and underlying tissues, to greater or lesser degree. It is well known that the veins receiving the infusions require special care, and that the intravenous infusion be relocated at the first sign of extravasation.

Perhaps the most destructive agent in fairly common use does not appear to be recognised as such by many physicians. Intravenous calcium chloride is administered for prevention and rapid correction of calcium deficiency, among other indications. As the product monographs ¹ clearly warn, "10% Calcium Chloride Injection is irritating to veins and must not be injected into tissues, since severe necrosis and sloughing may occur. Great care should be taken to avoid extravasation or accidental injection into perivascular tissues."

Practice Point

**Failure to take special precautions to prevent extravasation of irritant fluids may prove a successful cause of action**

Thus, the intravenous infusion must be demonstrably free-running and showing no signs of leakage into the surrounding tissues before calcium chloride is administered. If these precautions are documented or claimed as routine, minor injury is probably defensible.

When significant extravasation occurs despite these safeguards, two procedures have been shown to minimise injury if undertaken promptly. Saline irrigation aims to dilute and washout the irritant substance, and liposuction targets the damaged fat under the skin ².

Without such remedial intervention, major limb muscles can be destroyed (myonecrosis) and flesh stripped down to bone.

Practice Point

**When extravasation occurs despite precautions, failure to remediate promptly may be found to be negligent**

Recent journal correspondence ³ and actions for medical malpractice suggest that there is insufficient awareness among physicians prescribing potentially irritant fluids in general, and calcium chloride in particular. If such cases were to proceed to trial, which is unlikely, it might prove necessary by appeal in Supreme Court to establish that current community standards of prevention and/or remediation are unacceptable.