Infiltration and Extravasation: Clinical Guide to Recognition, Staging, and Treatment

Infiltration and extravasation represent the unintended delivery of infusate into surrounding tissue rather than the intended intravascular space. While infiltration (non-vesicant fluids) is painful and potentially serious, extravasation (vesicant agents) can cause severe tissue destruction, necrosis, and permanent functional impairment. Rapid recognition, staging, and agent-specific management are essential to minimize tissue injury.

Parent guide: Catheter Complications: Complete Clinical Reference

Definitions

Infiltration: The inadvertent administration of a non-vesicant fluid or medication into the surrounding tissue. The catheter tip has exited the vein lumen, or the vein has ruptured. Examples: normal saline, dextrose, standard antibiotics (non-vesicant).

Extravasation: The inadvertent administration of a vesicant medication or solution into the surrounding tissue. Vesicants can cause blistering, tissue necrosis, and permanent injury. Examples: anthracycline chemotherapy, vinca alkaloids, concentrated potassium, vasopressors at high concentrations.

Key distinction: The clinical response and urgency differ dramatically based on whether the infusate is a vesicant. Every medication infused via vascular access should be classified as vesicant or non-vesicant before infusion begins.

INS Infiltration Staging Scale

The INS staging scale (2021) provides a standardized framework for documenting the severity of infiltration.

Note for vesicant extravasation: Even a small infiltration of a vesicant may produce grade 4 injury over hours to days. Grade the infiltration at the time of recognition AND recognize that vesicant injury may worsen significantly after the infusion is stopped.

Vesicant Classification

Confirmed Vesicants (Central Access Required)

Anthracyclines (chemotherapy):

• Doxorubicin (Adriamycin)
• Epirubicin
• Daunorubicin
• Idarubicin
• Mitomycin C

Vinca alkaloids (chemotherapy):

• Vincristine
• Vinblastine
• Vinorelbine
• Vindesine

Taxanes:

• Paclitaxel
• Docetaxel
• Cabazitaxel

Other chemotherapy:

• Cisplatin (high concentration >0.4 mg/mL)
• Carmustine
• Streptozocin

Vasopressors (at pharmacologic concentrations):

• Norepinephrine
• Dopamine
• Vasopressin
• Phenylephrine

Other non-chemotherapy vesicants:

• Concentrated potassium chloride (>40 mEq/L)
• Calcium chloride 10% (not gluconate)
• Concentrated dextrose (>10%)
• Sodium bicarbonate 8.4%
• Phenytoin

Irritants (Not True Vesicants but Cause Significant Tissue Injury)

• Vancomycin (at high concentrations)
• Amiodarone
• Erythromycin
• Promethazine IV
• Acyclovir IV

Recognition

Signs of Infiltration/Extravasation

Subjective:

• Pain, burning, or stinging at the infusion site
• Pressure sensation
• Tightness or “fullness” in the arm
• Change in infusion feel

Objective:

• Swelling at or around the insertion site
• Blanching (pallor) or skin color change
• Firmness or induration of tissue
• Coolness of skin (non-vesicant: cool from fluid; vasopressor: cool from ischemia)
• Blistering or skin necrosis (late sign — indicates significant injury)
• Resistance to flushing or slowed infusion rate
• Absent blood return (may indicate catheter displacement)

Assessment Frequency for Vesicant Infusions

Per INS 2021 Standard 27 (Vesicant Therapy):

• Assess infusion site and distal circulation at least every 1–2 hours during vesicant infusion via peripheral IV
• Confirm blood return before vesicant administration and periodically during infusion
• For peripheral vesicant infusion (when unavoidably necessary): have antidote immediately available; do not leave patient unattended during infusion

Post-Infusion Assessment

Document site assessment after completion of any vesicant infusion:

• Site appearance (erythema, swelling, blistering)
• Patient subjective report
• Distal extremity circulation check

Emergency Response to Vesicant Extravasation

Immediate Actions (Within Minutes)

1. STOP the infusion immediately — disconnect infusion but do not remove the catheter yet
2. Do not apply pressure to the extravasation site — pressure disperses drug into a wider tissue area
3. Attempt to aspirate: Using the intact catheter, gently aspirate to remove as much vesicant as possible from the tissue. Withdraw slowly with maximum negative pressure (up to 5 mL); discard aspirate
4. Remove catheter after aspiration attempt is complete (do not remove before attempting aspiration)
5. Mark the extravasation area with a skin marker — outline the area of swelling/discoloration; this documents the extent at the time of recognition and allows comparison to subsequent examinations
6. Notify provider immediately — vesicant extravasation is a medical emergency
7. Photograph the site (per institutional policy)
8. Apply antidote if indicated (see table below)
9. Position: Elevate extremity above heart level (for most extravasations; exception: norepinephrine/vasopressor — see below)
10. Document full circumstances, extent, and actions in patient record

Warm vs. Cold Application

Cold compress (ice):

• Anthracyclines, taxanes, cisplatin, and most non-vesicant extravasations
• Cold reduces local blood flow, limiting drug spread
• Apply 15–20 minutes, 4 times daily × 24–48 hours
• Do not apply ice directly to skin; use ice pack with cloth barrier

Warm compress (dry heat):

• Vinca alkaloids, etoposide, vinorelbine
• Heat increases local blood flow and vascular absorption of the drug
• Apply 15–20 minutes, 4 times daily × 24–48 hours

Vasopressors (norepinephrine, dopamine):

• Warm if needed; apply phentolamine antidote

Antidote Reference Table

Note: Antidote availability and protocols vary by institution. Ensure antidotes are stocked and accessible before initiating vesicant infusions. Pharmacy consultation required for all significant extravasation events.

Follow-Up and Wound Care

Monitoring After Extravasation

• Photograph and document site every 8 hours for 24–48 hours
• Document pain level, swelling extent (in cm), skin changes
• Plastic surgery or wound care consultation for grade 3–4 extravasation
• Consider surgical debridement if blistering, skin necrosis, or tissue breakdown develops
• Functional assessment (range of motion, sensation) for extravasations near joints or nerve structures

Documentation

Required at the time of recognition and in follow-up:

• Date and time of recognition
• Vesicant name and estimated volume extravasated
• Stage of infiltration at recognition
• Catheter removal time, aspiration attempt and result
• Antidote administered: name, dose, route, time
• Cold/warm application: type, duration, frequency
• Photographs taken (per policy)
• Provider notification: name, time, response
• Patient education provided
• Follow-up assessment plan

Prevention

Primary prevention: Use central access for all vesicant infusions. All chemotherapy vesicants and concentrated vasoactive infusions should be administered via a central catheter (PICC, CVC, or port) to minimize extravasation risk. See Evidence-Based Device Selection for osmolarity and pH thresholds.

When peripheral vesicant administration is unavoidable:

• Use the largest accessible vein in the forearm; avoid hand, wrist, and antecubital fossa
• Confirm blood return before and periodically during infusion
• Have antidote immediately available at the bedside
• Assess site every 30–60 minutes during infusion
• Never leave patient unattended during peripheral vesicant infusion

Related Resources

Related guides:

• Phlebitis Recognition and Management
• Evidence-Based Device Selection

Related policies:

• Infiltration and Extravasation Management

References

1. Gorski LA, et al. (2021). INS Infusion Therapy Standards of Practice (Standards 27, 56, 57). J Infus Nurs, 44(Suppl 1).
2. Pérez Fidalgo JA, et al. (2012). Management of chemotherapy extravasation: ESMO-EONS Clinical Practice Guidelines. Ann Oncol, 23(Suppl 7):vii167–vii173.
3. Dougherty L. (2010). IV therapy: recognising the differences between infiltration and extravasation. Br J Nurs, 17(14):896–901.
4. Schulmeister L. (2011). Management of cancer therapy-associated extravasation. Semin Oncol Nurs, 27(4):355–369.