Intravenous Cannulation
Recognition and Management of Infiltration Injuries (including Clysis)

 

 Reviewed by Luanne Massey and Clinical Practice Committee
May 2010
Clinical Guidelines Back Newborn Services Home Page
Intravenous Infiltration Injuries Staging Severity Clysis References

Recognition and Prevention of IV Infiltration Injuries

Signs and symptoms of infiltration include:

Signs and symptoms of infiltration include:

Prevention Measures

RBP – Actions for Intravenous Infiltration Injuries

Step

Action
1 Remove I.V. immediately at first sign of infiltration.
2 If significant infiltration or necrosis occurs, notify CCN, NS-ANP, or Registrar immediately.
3 Estimate the severity of the injury by Millam’s 1988 Staging Guidelines.
4 For Stage 1 and 2 injuries:
  • Elevate limb, observe circulation, and document findings.
5 For all Stage 3-4 injuries:
  • An incident report must be initiated.
  • Photographs of the injury should be made for the medical notes and a digital copy made available for plastic surgeons.
  • Parents to be notified and informed of actions taken.
6 For Stage 3-4 injuries AND for extravasation injuries with potentially injurious solutions (caffeine, dopamine, dobutamine, blood, solutions containing ≥12.5% dextrose, or IVN)
  • Clysis treatment should be initiated as soon as possible following the discovery of a Stage 3-4 injury or extravasation of injurious solutions.
  • After clysis has been carried out, plastic surgery referral may or may not be required. This should be determined over the next few days of careful observation.
  • The plastic surgeon on call should be notified for all Stage 4 infiltrations if no improvement after clysis.

Staging Severity of IV Infiltration 1

Stage I
  • Painful IV site
  • No erythema
  • No Swelling
Stage II
  • Painful IV site
  • Slight swelling (0-20%)
  • No blanching
  • Good pulse below infiltration site
  • Brisk capillary refill below infiltration site
Stage III
  • Painful IV site
  • Marked swelling (30-50%)
  • Blanching
  • Skin cool to touch
  • Good pulse below infiltration site
  • Brisk capillary refill below infiltration site
Stage IV
  • Painful IV site
  • Very marked swelling (>50%)
  • Blanching
  • Skin cool to touch
  • Decreased or absent pulse*
  • Capillary refill > 4 seconds*
  • Skin breakdown or necrosis*

* The presence of any of these constitutes a stage IV infiltration

Clysis Therapy of Intravenous Fluid Extravasation

Step Action

1

 Most infiltrations are able to be treated with local anaesthesia and analgesia such as paracetamol.

2

 If area is very large, general anaesthesia may be indicated. This should be discussed with specialist on call.
3 Clysis is a sterile technique.
4 Place large waterproof guard under affected limb before creating sterile field.
5 Clean the affected area with a skin disinfectant appropriate for the infant's gestation and postnatal age. Allow to dry.
6 Infiltrate affected region with local anaesthetic (usually 1% xylocaine, maximum dose 0.3ml/kg). This should be concentrated in area proximal to (above) the wound, and within the central area of wound. Wait several minutes until effective.
7 Using size 15 scalpel blade, make several small (approximately 5mm long) stab wounds within affected region - these should be approximately 1-2 cm apart, and penetrate just below skin.
8 Take large (Size 14 or 16) angiocath and remove sharp needle leaving white cannula only.
9 Have 500 ml bag 0.9% NaCl ready on sterile field.
Push Chemospike into fluid bag to provide access port for refilling syringe.
Fill 20 ml syringe, attach to white cannula, and insert into stab wounds flushing with firm but gentle pressure in and around area of stab wound.
Fluid should be seen to leak from stab wound sites
10 Start in central part of affected area where the infusate is concentrated. Refill syringe and repeat as required.
11 A large volume of saline should be used -depending on size of baby and of wound, it is suggested that 200-500 ml saline will be needed:  Suggested volumes:
<1000g   200ml
1000-2000g 300ml
>2000g 500ml
12 When completed, cover area with sterile non-stick dressing (Mepitel or Intrasite Conformable gel dressing). Stab wounds should not be closed and may drain for some time. Elevate limb in comfortable position. Check wound 6-hourly over next 24 hours.
13 One dose of intravenous antibiotic (Flucloxacillin 50mg/kg) should be given if the baby is not already receiving antibiotics.
14 A clysis kit will be kept in the 'rarely - used stuff' cupboard in the storeroom.
  • Blue waterproof sheet
  • Dressing pack
  • 2 size 15 scalpel blades
  • 2x 16G angiocaths
  • 20ml syringe
  • 1 ml syringe and very fine 27G needle for local anaesthetic
  • REM Chemospike
     
  • You will also need to access 0.9%NaCl (500ml bag) and Mepitel dressing or Intrasite Conformable gel dressing

References

1 Millam DA. Managing complications of i.v. therapy. Nursing 1988;18(3):34-43.
2 Gault DT.  Extravasation injuries.  Br J Plast Surg 1993;46:91-6.
3 Casanova D, Bardot J, Magalon G.  Emergency treatment of accidental infusion leakage in the newborn: report of 14 cases.  Br J Plast Surg 2001;54:396-9.
4. Harris PA; Bradley S,H.Moss A. Limiting the Damage of Iatrogenic Extravasation Injury in Neonates. Plastic & Reconstructive Surg 2001;107(3): 893-894
5. Wilkins CE, Emmerson AJB. Extravasation Injuries on regional neonatal units. Arch Dis Child Fetal Neonatal Ed. 2004:89:F274-F275.
6. Sawatzky-Dickson D., Bodnaryk K. Neonatal Intravenous Extravasation Injuries: Evaluation of a Wound Care Protocol. Neonatal Network 2006;25(1): 13-19.