What are the medical options for managing pain at the site of extravasation of a peripheral intravenous (IV) line?

Management of Pain at Peripheral IV Extravasation Sites

For pain at peripheral IV extravasation sites, the first-line treatment includes acetaminophen (650 mg every 4-6 hours) combined with dry cold compresses applied for 20 minutes several times daily for 1-2 days, and elevation of the affected limb. 1

Initial Assessment and Management

When extravasation is suspected or confirmed:

1. Stop administration immediately and disconnect the IV tube from the cannula
2. Do not remove the cannula immediately 2
3. Aspirate any remaining drug from the cannula if possible
4. Elevate the affected limb to reduce swelling 1
5. Document the extravasation with photographs if possible, including:
   • Date and time of extravasation
   • Name of drug extravasated and diluent used
   • Signs and symptoms reported by patient
   • Estimated extravasation area and amount 1

Pain Management Options

Non-pharmacological Approaches:

• Apply dry cold compresses for 20 minutes several times daily for 1-2 days 1
• Elevate the affected limb to reduce swelling and pain 1
• Avoid applying pressure over the extravasated area as this may worsen injury 1

Pharmacological Options:

First-line:

• Acetaminophen: 650 mg every 4-6 hours (maximum 4000 mg/day) 2
  • Use with caution in patients with liver disease
  • Monitor for hepatotoxicity with prolonged use

Second-line:

• NSAIDs (if no contraindications):
  • Ibuprofen: 400-600 mg every 6-8 hours 2
  • Naproxen: 250-500 mg every 12 hours 2
  • Caution with GI and renal toxicity

For moderate-to-severe pain:

• Tramadol: 50-100 mg every 4-6 hours (maximum 400 mg/day) 2
• Morphine: For severe pain, 25-100 μg/kg titrated to effect 2

Special Considerations Based on Extravasated Agent

For Vesicant Chemotherapy Agents:

• Dexrazoxane: For anthracycline extravasation, administer IV in a 3-day schedule (1000, and 500 mg/m²) starting within 6 hours 2, 1
• DMSO 99%: Four drops per 10 cm² of skin surface, covering twice the affected area, every 8 hours for 7 days 1
• Hyaluronidase: For vinca alkaloid extravasation, 1-6 ml of 150 U/ml solution injected through the existing IV line 2, 1

For Non-Cytotoxic Medications:

• Phentolamine: For vasopressor extravasation (intradermal) 3
• Hyaluronidase: For hyperosmotic agent extravasation 3

Monitoring and Follow-up

• Schedule follow-up within 7 days for reassessment 1
• Continue monitoring for 3-4 weeks, especially with vesicant agents 1
• Evaluate for signs of tissue necrosis or progressive damage
• Document wound healing progress and assess pain levels

Warning Signs for Surgical Consultation

Seek surgical consultation if:

• Pain persists for more than 10 days
• Tissue necrosis develops
• Conservative therapy fails 2, 1

Prevention of Future Extravasation

• Use large veins in the forearm for peripheral administration 2
• Avoid cannulation over joints, inner wrist, and lower extremities 2
• Use flexible cannulae instead of winged steel infusion devices 2
• Check for blood return before drug administration 2
• Monitor the cannulation site regularly during infusion 2

Pain at extravasation sites can range from mild discomfort to severe pain requiring multimodal analgesia. The approach should be tailored based on the severity of pain, the extravasated agent, and patient-specific factors such as comorbidities and contraindications to specific analgesics.