What is the management for extravasation of Total Parenteral Nutrition (TPN) through a peripheral Intravenous (IV) line?

Management of TPN Extravasation Through Peripheral IV

Immediately stop the infusion, leave the cannula in place to aspirate as much extravasated solution as possible, then apply dry cold compresses for 20 minutes four times daily for 1-2 days, elevate the limb, and provide analgesia as needed. 1, 2

Immediate Actions (First 5-10 Minutes)

Step 1: Stop and Secure

• Stop the TPN infusion immediately upon recognition of extravasation 2, 3
• Leave the IV cannula in place initially - do not remove it yet 1
• Disconnect the IV tubing from the cannula 2

Step 2: Aspirate Extravasated Fluid

• Gently aspirate as much of the extravasated TPN solution as possible through the existing cannula 1
• Document the volume removed in the patient record 1
• Avoid applying manual pressure over the extravasated area, as this can worsen tissue damage 1

Step 3: Consider Enzymatic Treatment

• Hyaluronidase (or chondroitinsulfatase where hyaluronidase is unavailable) should be administered subcutaneously around the extravasation site 4
• This enzyme facilitates dispersion and absorption of the extravasated fluid 4
• In documented cases, 150-200 turbidity-reducing units (TRUs) diluted in 2-3 mL of normal saline, administered in 6-8 subcutaneous injections around the affected area, successfully resolved TPN extravasation without sequelae 4

Supportive Care Measures

Thermal Application

• Apply dry cold compresses (ice packs) for 15-20 minutes, four times daily for 24-48 hours 1, 2
• Cold therapy promotes vasoconstriction, theoretically limiting drug dispersion and reducing site reaction 2
• Avoid alcohol-based compresses 1

Additional Supportive Measures

• Elevate the affected limb to reduce edema 1
• Administer analgesia as necessary for patient comfort 1
• Notify the physician immediately 2, 3

Critical Monitoring for Complications

Watch for Compartment Syndrome

• TPN extravasation can cause compartment syndrome, particularly when detection is delayed 5
• This is especially concerning with pressurized infusion pumps, which can force large volumes into tissue over several hours 5
• Monitor for signs including severe pain, tense swelling, paresthesias, and diminished pulses 5
• Emergency fasciotomy may be required if compartment syndrome develops 5

Assess for Tissue Necrosis

• Regularly inspect the site for progressive inflammation, skin necrosis, or ulceration 3, 5, 4
• TPN solutions can cause significant tissue harm due to their high osmolarity and nutrient content 4
• Surgical debridement or skin grafting may be necessary in severe cases 3, 5

Prevention Strategies

Catheter Selection and Monitoring

• Use the smallest gauge catheter compatible with therapy needs 6
• Consider midline catheters or PICCs when peripheral TPN is anticipated for >6 days 6
• Maintain peripheral TPN osmolarity <900 mOsmol/L to reduce thrombophlebitis and extravasation risk 1
• Inspect the insertion site visually at each shift change for warmth, tenderness, erythema, or palpable venous cord 6

Patient Assessment

• Regularly assess for patient-reported sensory changes, tingling, or burning 2
• Pay close attention to patient complaints, as these may be early warning signs 2
• Ensure adequate catheter fixation to prevent mechanical irritation and dislodgement 6

Important Caveats

Do NOT use subcutaneous corticosteroids - retrospective data from extravasation management shows that intralesional corticoids increased the need for surgical debridement from 13% to 46%, suggesting a deleterious effect 1

The evidence base for TPN extravasation management is largely extrapolated from chemotherapy extravasation guidelines and case reports, as there are no large prospective trials specifically addressing TPN extravasation 1, 2, 4. However, the principles of immediate cessation, aspiration, enzymatic dispersion, and cold therapy represent the current standard of care based on available evidence and expert consensus.