Infiltration and Extravasation Management

Standards of practice for the prevention, recognition, and management of infiltration and extravasation from peripheral and central vascular access devices, including antidote protocols.

policies•Jun 2023•Complication Management

Infiltration and Extravasation

Standards of Practice for Prevention, Recognition, and Management

Definitions

Infiltration refers to the inadvertent leakage of non-vesicant solution or medication from a vascular access device (VAD) into the surrounding tissue. Extravasation specifically describes the escape of vesicant agents—solutions or medications capable of causing tissue injury, necrosis, or blistering—into the perivascular space.

1.2 Core Standards

Three fundamental standards govern clinical practice in this area. First, organizations must reduce infiltration and extravasation risk through careful selection of appropriate VADs and insertion sites, combined with validation of device position and patency before and during infusion therapy. Second, clinical staff must regularly assess both peripheral and central vascular access device sites for signs and symptoms of infiltration and extravasation before and during each infusion. Third, appropriate interventions must be implemented immediately upon recognition of infiltration or extravasation, with the intervention matched to the characteristics of the solution or medication escaping from the vein.

Prevention Through Optimal Device Selection

2.1 Vascular Access Device Selection and Site Planning

Selecting the most appropriate VAD and insertion site represents the primary strategy for reducing infiltration and extravasation risk. Patients presenting with difficult venous access risk factors should be escalated to vascular access specialists or infusion teams as early as possible in their care trajectory.12345

Research consistently demonstrates significant educational needs among nursing staff regarding risk factors, optimal VAD selection, recognition of complications, and treatment strategies for infiltration and extravasation across all healthcare settings and patient populations.15678910 A controlled before-and-after study in a neonatal unit demonstrated that implementing clinical practice guidelines for peripheral intravenous catheter insertion and management significantly reduced extravasation events.7

2.2 Understanding Vesicant, Irritant, and Non-Vesicant Classifications

Clinical staff must recognize the critical differences between vesicant, non-vesicant, and irritant solutions and medications. Each organization should establish consensus on which medications are classified as vesicants and irritants based on their internal formularies and the specific patient populations they serve.1241112131415

The vesicant nature of certain antineoplastic and non-antineoplastic medications must be identified prior to administration. Clinical teams should be prepared to utilize recommended pharmacologic and non-pharmacologic treatments in the event of extravasation, or to escalate care to clinicians capable of managing these injuries.1567161715181920

Current literature reveals a paucity of data on extravasation incidence and treatment recommendations, with many guidelines based on animal studies and case reports. This area requires further study, and there are recommendations to establish extravasation registries to improve dissemination of outcomes data.10182021222324

Risk Factor Assessment

3.1 Framework for Risk Evaluation

Comprehensive evaluation of risk factors associated with infiltration and extravasation enables clinicians to determine appropriate monitoring frequency and evaluate alternative vascular access options for patients at increased risk, including consideration of central vascular access devices.15678172510

3.2 Patient-Specific Risk Factors

Multiple studies have identified patient-specific factors associated with increased risk of infiltration and extravasation.1451625261519272829303132

Sex and infection status play a role, with female patients and those with current infections demonstrating increased susceptibility. Sensory and communication factors create additional risk; patients with altered sensation near the VAD site due to neuropathy or application of pre-insertion pain relief products may not detect early warning signs, as may those who have difficulty communicating the onset of pain, tightness, or other discomfort.

Cognitive factors compound these risks. Patients with altered mental status or cognition—whether from encephalopathy, confusion, or sedating medications—cannot reliably report symptoms. Underlying disease processes that produce changes in vasculature or impaired circulation significantly increase vulnerability. These include malignancy, diabetes mellitus, lymphedema, systemic lupus erythematosus, Raynaud’s disease, peripheral neuropathy, and peripheral vascular disease. Venous access history matters as well; patients with difficulty establishing peripheral venous access related to history of multiple venipunctures or obesity present elevated risk.

Age-related factors deserve particular attention at both ends of the lifespan. Neonates and young children face increased risk due to their inability to communicate discomfort, fragile vasculature and skin, limited physiologic resources to repair cellular damage, and a lack of safe and effective VAD securement and dressing options appropriately sized for their anatomy.5833251026182434 Elderly patients experience anatomical changes including loss of thickness of the dermal skin layer, thickening of the tunica intima and media, and loss of connective tissue that contribute to vein fragility and create challenges in vascular access.

3.3 Mechanical Risk Factors

Mechanical causes of infiltration and extravasation require assessment and preventive action. Reduction or loss of patency of the VAD or vessel may result from abnormalities such as fibrin sleeve formation, venous thrombosis, pinch-off syndrome, and catheter fracture.16735

Patient movement and positioning affect VAD performance in multiple ways. Normal body movements, unpredictable patient activity (particularly in infants, children, and confused patients), events that increase tension on or malposition of the VAD (such as patient repositioning or transport), and procedures requiring specific positions (such as a “tucked arm” during surgery) all contribute to risk.253637

Events that increase the risk of vessel trauma include rapid infusions and use of bolus features on infusion pumps.3462338 Insertion of the VAD in an area of flexion creates additional vulnerability.5 Notably, infiltration and extravasation rates are significantly higher in peripheral intravenous catheters inserted in the emergency department compared to other units, likely due to high-volume infusions, frequent insertion at the antecubital fossa, use of large-bore catheters, and blood sampling through the device.3

Multiple insertion attempts, especially in the same anatomic location, increase infiltration risk.1425394041 Catheter malposition occurring during the lifespan of the VAD presents ongoing concerns.

3.4 Reducing VAD Malposition Risk

Clinicians should take specific steps to reduce VAD malposition during insertion and throughout post-insertion care. For intraosseous devices, adequate needle length for the patient must be ensured per manufacturers’ recommendations.3037 For peripheral intravenous catheters, adequate vein purchase—meaning sufficient length of the catheter residing within the vessel—should be confirmed.423443

Central vascular access devices require particular vigilance. Extravascular CVAD tip malposition, dislodgement, or fracture can occur in many anatomical locations and at any point during dwell time. Clinicians should measure vessel depth in tissue using ultrasound prior to CVAD insertion to ensure all lumen exit sites are within the patient’s vasculature, since partial dislodgement can result in more proximal lumen exit sites infusing into subcutaneous tissue.4445

Daily catheter position monitoring should be performed in inpatient settings, comparing measurements to those documented at insertion. In outpatient settings, regular monitoring should occur at appropriate intervals. All catheter lumens should be checked for blood return and flushed prior to use. Clinicians should not assume appropriate intravascular tip position of all lumens when blood aspirate is possible from one lumen but not all.4445

In addition to mechanical risk factors, CVADs may gradually become malpositioned due to growth of the infant or child with a long-term device in place.46 Clinicians should monitor for sudden changes in clinical condition in patients of all ages that may indicate extravascular administration of medication involving a centrally administered vesicant. Warning signs include new onset hypoxia, respiratory distress, hypotension, abdominal distension or pain, edema, and airway impingement.715184647484950

When evaluating new pleural effusion, abscess, or lesion in an area related to the CVAD, clinical criteria including radiologic imaging, laboratory values, and aspiration of fluid should be used to determine the presence of infiltration or extravasation versus other clinical complications. Administration of a vesicant (such as hypertonic parenteral nutrition in fragile vessels) and the mechanical forces of the catheter may cause vessel erosion, allowing the vesicant to invade surrounding structures including the liver, mediastinum, abdomen, and thoracic cavity.454748

Neonates face particularly high risk for extravasation with CVAD insertion, whether umbilical, peripherally inserted central catheter (PICC), or femoral catheter. Complications resulting in morbidity and mortality include ascites, abdominal compartment syndrome, hepatic laceration, hepatic necrosis, hepatic abscess, pleural effusion, pericardial effusion, and hemi-diaphragmatic paralysis.4650515253545556575859

Radiographic tests should be anticipated to validate CVAD tip location. Timing of CVAD removal depends on the plan of care based on identified extravascular location of the catheter tip. Assessment of the location of a subcutaneous tunnel or port pocket and its proximity to any wound helps determine if the long-term CVAD should be removed for healing to occur. Consultation with a wound care specialist should be considered.

3.5 Peripheral Intravenous Catheter-Specific Risk Factors

Several factors specific to peripheral intravenous catheters may increase infiltration and extravasation risk.23616602615271921323439

PIVC sites in the hand, wrist, foot, ankle, antecubital fossa, and areas with minimal subcutaneous tissue coverage present elevated risk. When insertion in an area of flexion is deemed necessary, more frequent monitoring is required, joint stabilization may be needed, and consideration should be given to early removal and reinsertion in a location with reduced risk of complication.

Additional PIVC-specific risk factors include use of steel “butterfly” needles, inadequate catheter securement, short PIVCs with dwell time longer than 24 hours, and increased manipulation of the PIVC at the catheter hub. Inability to establish patency through positive blood return or site assessment during flushing (such as when diffuse edema is present), delivery of a vesicant in an insertion site below a recent venipuncture (less than 24 hours prior), and depth of the PIVC (which may delay visual signs and symptoms of failure when the tip lies in a deep vein, particularly in non-verbal patients) all contribute to risk. PIVC administration of contrast media also increases vulnerability.

3.6 Pharmacologic and Physiochemical Risk Factors

The pharmacologic or physiochemical properties of infusates significantly influence infiltration and extravasation risk and severity of tissue damage. Contributing factors include length of infusion of vesicant via a PIVC, drug concentration, volume escaping into the tissue, ability of surrounding tissues to absorb the drug, hyperosmolarity, non-physiological pH, the medication’s ability to bind DNA, the medication’s capacity to kill replicating cells or cause vascular constriction, and excipients such as alcohol or polyethylene glycol used in drug formulation.15126166029155961

Early Recognition and Detection

4.1 Assessment Frequency and Visual Inspection

Limiting the extent of infiltration and extravasation injury requires both preventive measures and early recognition of signs and symptoms through regular visual inspection and bilateral palpation of limbs. VAD insertion sites should be assessed at a frequency based upon the specific patient population and characteristics of the infusion therapy.11267161962596364

Establishing monitoring standards for VADs utilized in intraoperative and intraprocedural areas represents an area requiring further research, given inherent barriers to visualization including sterile drapes, tucked limbs, competing priorities, and rapid infusions.3465666768

4.2 Recognizing Critical Complications

Acute abnormalities in pain, sensation, or circulation should be promptly recognized and reported. Compartment syndrome and arterial and nerve damage may result from infiltration or extravasation of sufficient infusate volume to cause tissue ischemia or injury. Significant long-term complications may include complex regional pain syndrome, neurovascular compromise, or limb amputation.16192123306667686970

High risk for these complications exists with VAD insertion in small vessels, areas of flexion, or areas with tight subfascial compartments such as the hand, wrist, and forearm. If compartment syndrome is suspected, the affected extremity should be elevated to the level of the heart to optimize perfusion, and the surgeon or plastic surgeon should be notified immediately when circulatory or neurological compromise is suspected.

4.3 Signs and Symptoms

Observation of the VAD site and areas proximal and distal to the insertion site should assess for several abnormalities.1414183071

Fluid leakage from the puncture site, subcutaneous tunnel, or port pocket may be visible or subcutaneous. Skin injury, including vesicle formation, may appear within hours (as with contrast media) or may be delayed for days (as with antineoplastic agents). Progression to ulceration may vary from a few days to one to two weeks, depending on the vesicant administered. Discoloration or hyperpigmentation may also be observed.

Other conditions with similar symptoms must be ruled out, including phlebitis, flare reactions, and rash.472 A notable case report illustrates subdural infiltration from a scalp PIVC in a neonate used to deliver fluid and blood products. The changes in neurovascular status were initially thought to represent intracranial hemorrhage but were found to result from significant intracranial infiltration.73

4.4 Extremity Assessment

Assessment of the extremity and areas proximal and distal to the insertion site, with comparison to the contralateral limb, should include the following elements.41271844

Palpation of the insertion site assesses for swelling and pain. Swelling or edema may appear as a raised area under the skin near the peripheral VAD site or as an enlarged and tense extremity due to fluid accumulating in compartments of the extremity. Edema from a CVAD may appear as a raised area on the neck, chest, or groin. Circumference of both extremities should be compared if unilateral edema is noted, with comparison to baseline measurement at insertion when available. Changes in color may include redness or blanching; however, infiltration or extravasation into deep tissue may not produce visible color changes.

The patient’s report of pain should be elicited, with observation of non-verbal patients for other cues indicating pain. Pain may be the initial symptom and may be sudden and severe when associated with rapid injection of solution or medications. Pain may be out of proportion to the injury or may appear with passive stretching of the muscles in the extremity. Pain intensity may increase over time, which may indicate compartment syndrome.456741823

4.5 Detection Technology

Infiltration and extravasation detection technology may aid in early recognition, though further research is needed to determine optimal use. Options under investigation include thermosensitive crystal film, near infrared camera, radiofrequency detection, gamma scintillation, color flow doppler, impulse oscillometry, and point-of-care ultrasound.751638767778798081

Careful assessment in conjunction with detection technology remains essential, as devices may fail to detect abnormalities or fail to adequately warn clinicians, especially in settings where the VAD is not readily accessible.7577 Critically, clinicians should not rely on alarms from electronic infusion pumps to identify infiltration and extravasation; alarms are not designed to detect the presence or absence of complications. Electronic infusion pumps do not cause infiltration or extravasation; however, they may mask or exacerbate the problem until the infusion is stopped.7536

4.6 Contrast Media Administration

When contrast administration is planned, a VAD designed for contrast administration should be inserted in an optimal location to ensure adequate monitoring during the procedure. Proper function should be assessed prior to, during, and following contrast media infusion, and delivery of contrast should be adjusted to conform to the chosen VAD.16233282

Extravasation can occur with both manual and automated delivery of contrast. Automated power or pressure injectors produce a jet of fluid exiting the catheter tip. Distal tip malposition has been documented following power injection in PICCs, and it has been postulated that this jet could induce vessel perforation and extravasation.16237069

Fluid warming may be associated with lower rates of extravasation. Fluid with high viscosity, such as contrast media, requires less force to administer when warmed to 37°C.16233283 Use of extravasation detection accessories, such as equivalent dose rate monitoring, should be considered to provide early detection, automated interruption of power injection, and guidance for contrast extravasation management.168485

Immediate Response to Infiltration and Extravasation

5.1 Initial Actions

Upon identification of an infiltration or extravasation injury, the infusion must be stopped immediately and appropriate interventions initiated.146716141582

Do not flush the VAD, as this will inject additional medication into the tissue. The administration set should be disconnected from the catheter hub, and aspiration from the catheter or implanted port access needle attempted with a small syringe, even though a very small amount of fluid may be retrieved. The role of aspiration is not clear with extravasation of contrast media.14671614151820212362

The peripheral catheter or implanted vascular access port access needle should be removed.1415208687 Application of pressure to the area should be avoided.41574 The extremity should be elevated to encourage lymphatic reabsorption of the solution or medication, unless compartment syndrome is suspected.261614212362 The affected extremity should be avoided for subsequent VAD insertion until resolved.86

5.2 Site Assessment Following Identification

Thorough assessment of the insertion site and surrounding tissue should include assessment of the area distal to the VAD site for capillary refill, sensation, and motor function.14742330 Using a skin marker, the area suspected of infiltration or extravasation should be outlined to assess progression.616 The area should be photographed to identify progression or exacerbation of the tissue injury in accordance with organizational policy.1617

The volume of solution that has escaped into the tissue should be estimated based on the original amount of solution in the container, the amount remaining when stopped, and rate and duration of injection or infusion.156270 Estimated extravasated volumes of contrast media less than 50 mL are more likely to resolve with conservative treatment, while volumes greater than 50 mL are at higher risk to cause tissue damage requiring treatment. However, the patient’s symptoms should dictate treatment options over the estimated extravasated volume. Radiologic imaging to evaluate a contrast extravasation is rarely indicated.16233270

5.3 Provider Notification and Treatment Protocol Activation

The provider should be notified about the event and the established treatment protocol or prescribed treatment activated.1461615192362

The need for surgical consultation is based on organizational policy, clinical signs and symptoms and their progression, volume of injury, and the tissue-destroying nature of a vesicant medication. Treatment options that may be considered include subcutaneous irrigation with or without hyaluronidase, open incision and irrigation, small incisions followed by massage to force drainage, and debridement with skin graft or flap as indicated. The paucity of evidence supporting one surgical intervention over another means consideration should be given to the risks and benefits of conservative versus invasive treatment.2181988

Treatment Protocols

6.1 General Treatment Principles

Treatment should be initiated promptly as appropriate for the type and volume of solution or medication in the tissue surrounding the VAD, with the goal of limiting damage from medication or solution exposure. Organizations should provide convenient access to the list of vesicants and irritants, infiltration and extravasation management protocols, electronic order forms, supplies, and other materials needed to manage the event.2714742162

Wet compresses should be avoided, as they may cause maceration.1574

6.2 Heat and Cold Application

High-quality evidence to recommend use of heat or cold application in the treatment of extravasation injury is lacking.141823 The rationale for cold application is to decrease absorption, keep the infusate localized, and decrease inflammation, while heat is used to encourage vasodilation and improve blood flow to disperse the medication through the tissue.1474

Use of cold and heat applications are recommended in contrast extravasation, with a general preference for cold due to the potential to reduce inflammation.1623 A scoping review on treatment of extravasation in infants and children found that cold and heat application is rarely used in this population.89

Dry, cold compresses should be applied for DNA-binding agents and valproate because the goal is to cause vasoconstriction to localize the medication in the tissue and reduce inflammation.1461562 Cold compresses should not be used with extravasation in the presence of agents that may cause vasoconstriction or in the presence of vaso-occlusive events such as sickle cell anemia.1474 If dexrazoxane is indicated, the cold compress should be removed 15 minutes before the infusion of dexrazoxane begins.161520

Dry, warm compresses should be applied for non-DNA binding agents to encourage vasodilation.1462

6.3 Antidotes

Dexrazoxane

Daily intravenous infusion of dexrazoxane over 3 days is the recommended antidote for anthracycline extravasation, including liposomal and pegylated anthracycline formulations.16 The infusion should begin within 6 hours of the extravasation and be infused into the opposite extremity.1615 Topical dimethyl sulfoxide (DMSO) should not be applied to patients receiving dexrazoxane, as it may diminish dexrazoxane efficacy.615

Hyaluronidase

Hyaluronidase is not considered an antidote to a specific vesicant but rather an enzyme that increases absorption and dispersion of the medication or solution in the tissue. Its use is reported with cytotoxic and non-cytotoxic agents, including both acidic and alkalotic drugs (such as amiodarone and phenytoin), vinca alkaloids, as well as hyperosmolar solutions (such as parenteral nutrition) and calcium salts. Recombinant hyaluronidase is not derived from animals and may have a lower risk of allergic response. Subcutaneous injection within 1 hour of the extravasation event produces the best response. Use of dry heat in conjunction with hyaluronidase works synergistically to increase blood flow and disperse the extravasated drug. Hyaluronidase is not considered first-line treatment for contrast extravasation.167161415232789

Subcutaneous saline irrigation or saline irrigation with prior hyaluronidase administration for vesicant removal and dispersion in neonates should be considered. Further study is needed in the use of this practice, as resolution with conservative treatment is common.755989

Sodium Thiosulfate

Sodium thiosulfate is recommended for mechlorethamine extravasation and has been suggested for bendamustine, calcium, and large extravasations of cisplatin.11268990

Phentolamine and Alternative Vasodilators

Phentolamine is preferred for vasopressor extravasation. Normal perfusion of the area may be seen within 10 minutes of administration. Repeated injection may be necessary if hypoperfusion is still present or if vasoconstriction is extending to a greater area.147462

Terbutaline injection has been used for vasopressor extravasation when phentolamine is not immediately available.1214 Topical nitroglycerin 2% may be applied as a 1-inch strip to the site of vasopressor extravasation in the absence of phentolamine, repeated every 8 hours as clinically indicated.121491

Corticosteroids

Use of oral, topical, or intralesional steroid should be considered on a case-by-case basis. Single-center studies and case reports have reported reduced inflammation and swelling; however, evidence of benefit is inconsistent and may not be recommended.1261615

6.4 Irrigation and Washout Procedures

Irrigation or washout may assist in removal of specific infusates from surrounding tissue, including acidic agents, alkalotic agents, contrast media, specific cytotoxic agents, and parenteral nutrition.6161821623592

Other treatments reported in the treatment of severe tissue injury due to extravasation include negative pressure wound therapy, needle aspiration, emergency evacuation with low-pressure suction, ethacridine lactate dressing with phototherapy, acellular fish skin graft dressing, and dehydrated human amniotic membrane allograft.219287292939495

Injection of an acidic or alkaline medication to neutralize the pH of an extravasated acidic or alkaline vesicant should be avoided, as the resulting chemical reaction could cause gas formation and exacerbate the tissue injury.1296

While skin discoloration from iron infiltration may be permanent, laser treatment has been reported to be successful in reducing staining.97

Documentation and Standardized Assessment

7.1 Standardized Assessment Tools

A standardized age- or population-specific tool or definition should be used to consistently evaluate infiltration and extravasation events from all types of VADs. The chosen tool should be valid, reliable, and clinically feasible. The selected scale should be accompanied by appropriate interventions to manage each level of injury on the scale. Several scales have been published; however, further research is needed to establish validity and interrater reliability for specific populations.4716101474212459

An infant infiltration scale was recently revised and found to be valid and reliable for this population in an observational, prospective study.98

7.2 Documentation Requirements

A standardized format should be used to document initial and ongoing assessment and monitoring of the infiltration or extravasation site and all factors involved with the event.675147420236234

Accuracy of PIVC complication rates (including phlebitis, extravasation, and occlusion) is reduced by clinical knowledge deficits in symptom recognition, gaps in documentation, and a lack of consistent PIVC outcome definitions used in the literature.135891099

Ongoing Monitoring and Follow-Up

Site monitoring should continue as needed based on severity of the event and the venue of care, as signs and symptoms of infiltration and extravasation may be delayed in presentation. Changes in the area should be assessed by measurement and photography, with observation of skin integrity, level of pain, sensation, and motor function of the extremity.1261710623472

Inflammation following contrast media extravasation generally peaks at 24-48 hours from the event.23 Conducting follow-up phone calls or a follow-up visit to evaluate progression of an extravasation in the outpatient setting should be considered.16177423

Patient and Caregiver Education

The patient and caregivers should be educated regarding extravasation risk to improve prompt recognition of symptoms.1412671615392371

Pre-infusion education should address the risks of receiving an infusion prior to administration, emphasizing the signs and symptoms to immediately report. Post-infusion education should cover the possible progression of signs and symptoms of infiltration or extravasation, the need to protect the site from sunlight, and the frequency of follow-up visits to the provider as needed.

Quality Improvement

Infiltration and extravasation incidents causing harm or injury should be reviewed using adverse event reports and health record reviews for quality improvement opportunities.1617196588

Organizations should consider performing an investigation of each significant extravasation event (such as root cause analysis) to identify and implement needed quality improvement strategies.

Structured IV infiltration management programs—incorporating standardized nursing assessment protocols, targeted staff education, and protocol-driven intervention—have demonstrated effectiveness in reducing infiltration rates in hospitalized pediatric populations.100

Appendix A: Quick Reference Tables

A.1 Patient Risk Factor Summary

CategoryRisk Factors
DemographicsFemale sex, age extremes (neonates/elderly), current infection
Sensory/CommunicationNeuropathy, pre-insertion analgesia, non-verbal status, altered mental status, sedation
Disease ProcessesCancer, diabetes, lymphedema, lupus, Raynaud’s, peripheral vascular disease
Vascular HistoryMultiple prior venipunctures, obesity, difficult access
Age-RelatedNeonates: fragile skin/vessels, limited repair capacity; Elderly: dermal thinning, vein fragility

A.2 Mechanical Risk Factors

CategoryRisk Factors
VAD/Vessel PatencyFibrin sleeve, venous thrombosis, pinch-off syndrome, catheter fracture
Patient FactorsNormal movement, unpredictable activity, repositioning, transport, “tucked arm”
Vessel TraumaRapid infusions, bolus features, areas of flexion, multiple insertion attempts, catheter malposition
PIVC-SpecificHand/wrist/foot/ankle sites, antecubital fossa, steel needles, inadequate securement, >24h dwell

A.3 Antidote Quick Reference

Extravasated AgentRecommended Treatment
Anthracyclines (including liposomal)Dexrazoxane IV x 3 days (start within 6 hours); cold compresses
DNA-binding agents, valproateCold compresses
Non-DNA binding agentsWarm compresses
Vinca alkaloids, hyperosmolar solutions, calcium saltsHyaluronidase; warm compresses
MechlorethamineSodium thiosulfate
VasopressorsPhentolamine (preferred), terbutaline, or topical nitroglycerin 2%

A.4 Immediate Response Checklist

  1. Stop infusion immediately
  2. Do NOT flush VAD
  3. Disconnect administration set
  4. Attempt aspiration with small syringe
  5. Remove peripheral catheter or port access needle
  6. Avoid pressure to area
  7. Elevate extremity (unless compartment syndrome suspected)
  8. Assess distal capillary refill, sensation, motor function
  9. Outline area with skin marker
  10. Photograph per organizational policy
  11. Estimate extravasated volume
  12. Notify provider and activate treatment protocol
  13. Avoid affected extremity for future VAD insertion until resolved

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Teams can standardize this procedure with version control and compliance tracking.

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