Skip to main content

Warning notification:Warning

Unfortunately, you are using an outdated browser. Please, upgrade your browser to improve your experience with HSE. The list of supported browsers:

  1. Chrome
  2. Edge
  3. FireFox
  4. Opera
  5. Safari
Patient safety supplement

Preventing Extravasation / Tissue Infiltration Injury - Updated

Published on: 09/10/2024

This Patient Safety Supplement aims to raise awareness among patients and healthcare staff of the risk of extravasation or tissue infiltration injury during intravenous (IV) treatment. IV treatment is given through a person’s vein using a vascular access device. Extravasation/tissue infiltration is the accidental leakage of any solution such as medication, blood or fluids from a vein into the surrounding tissue.

The supplement will also assist patients and healthcare staff in recognising the signs and symptoms of extravasation / tissue infiltration. This will support initiating timely and appropriate treatment to reduce and in some cases prevent such an injury completely.

Download the supplement as a PDF

Read the full supplement

This Patient Safety Supplement aims to raise awareness among patients and healthcare staff of the risk of extravasation or tissue infiltration injury during intravenous (IV) treatment. IV treatment is given through a person’s vein using a vascular access device. Extravasation/tissue infiltration is the accidental leakage of any

solution such as medication, blood or fluids from a vein into the surrounding tissue. While any extravasation/tissue infiltration can cause harm, some solutions, including chemotherapy drugs, dye (contrast media) for scans and specific antibiotics may cause more serious injury, and iron solutions can cause permanent skin staining.

Injuries caused can range from mild to severe and can result in damage to tissues and cause pain, redness and/or rash (erythema), swelling and blistering. In more serious cases or if left undiagnosed or inappropriately treated, injuries can lead to infection, death of the tissue (necrosis), and/or possible permanent damage to the limb involved.

The supplement will also assist patients and healthcare staff in recognising the signs and symptoms of extravasation / tissue infiltration. This will support initiating timely and appropriate treatment to reduce and in some cases prevent such an injury completely.

Ann's Story

Ann was admitted to hospital with severe shingles affecting her face and ear. Shingles is a painful infection caused by a virus. On admission Ann was prescribed aciclovir (a commonly used antiviral medication), which was administered intravenously using a vascular access device in her hand. Initial doses were administered without any issue, but the following day Ann reported that her hand was painful when the device was used. Ann continued to report increasing pain and on day three the device was removed and a new device inserted in her other arm, however her arm continued to be very painful and her hand very swollen. Medication was given for pain relief, but Ann was not medically reviewed at this time. Four days after the device was inserted Ann’s hand remained very swollen and painful, she was reviewed by the medical team and a diagnosis of cellulitis (a deep infection of the skin) was made and treatment (antibiotics and pain killers) started. Within an hour, Ann’s swollen hand was extremely painful. A further review was carried out where an extravasation injury, causing compartment syndrome (build-up of excess pressure within an enclosed space in the body) was diagnosed. Ann was then reviewed by a Consultant Plastic Surgeon and was immediately sent for surgery to relieve the pressure in her hand and arm. Ann required a prolonged hospital stay requiring multiple surgeries to treat this serious complication, ultimately resulting in permanent disability including finger amputation and loss of full use of her hand. Awareness of the potential for serious harm from extravasation, and timely recognition and treatment by the wider healthcare team may have prevented the serious injury which continues to impact Ann on a daily basis and will have lifelong consequences for her and her family.

Ann and her family are keen to share her story to increase awareness of extravasation/infiltration injury and help prevent similar injuries happening to others.

To help prevent an extravasation / tissue infiltration injury before you start an IV infusion think…

  • Does the treatment need to be given IV? Can it be given orally (by mouth)?
  • Has the patient been given clear information by the prescriber about the risks and benefits of drug groups which may cause harm if extravasated before consenting to the treatment?
  • Is local guidance/policy for intravenous care and consent being followed?
  • Is a care bundle* for the vascular access device being maintained?
  • Do the staff and the patient/relevant person know the potential risks of the infusion and the signs and symptoms of extravasation / tissue infiltration to look out for?
  • Has the patient been educated to alert staff immediately to any concerns?
  • Will the patient be able to report their concerns? Consider condition, age, language barriers etc.

*A care bundle is a grouping of evidence based best practices to improve care. All elements of the care bundle must be adhered to for every person every time the procure is performed.

Signs and symptoms of extravasation/tissue infiltration may include:

  • Discomfort, pain, stinging, leakage and burning at injection site. Note: stinging does not always signify an issue but if concerned ask the staff to check
  • Recent IV treatment or a vascular access device near the area of concern
  • Blood return at the vascular access device can be absent or sluggish
  • Sudden change in infusion pressure when infusing a medication / fluid
  • Skin changes around device or venepuncture site (area where blood sample has been drawn from) including erythema, hardening (induration), blistering, pallor or staining (following iron infusion)
  • Swelling at vascular access site including along the pathway of the vein which can last for several days
  • Symptoms can appear immediately but can be delayed for hours or days after discharge. Ensure:
    • Patient/relevant person knows the signs and symptoms to look out for and to seek help if concerned
    • Clinicians are aware to assess vascular access device / infusion history as device may be removed

What to do if you suspect an extravasation/ tissue infiltration may have occurred:

  • STOP the infusion immediately and mark the outline of the affected area
  • Do not flush the line or remove the cannula (may cause further extravasation / tissue infiltration) but disconnect any IV tubing from the cannula
  • Explain to the patient what is happening and what the next steps are
  • Elevate the limb and avoid putting pressure on the affected area
  • Follow local guidance/policy for treatment of extravasation / tissue infiltration injury, treatment may vary depending on the injury severity and the drug involved e.g. Systemic Anti-Cancer Therapy (SACT) refer to the National Cancer Control Programme (NCCP) guidance (see below)
  • Arrange a prompt clinical review of the patient and inform the clinician extravasation / tissue infiltration is suspected
  • If an extravasation / tissue infiltration injury has occurred then this must discussed with the patient and documented in their healthcare record; where there are delays in recognising and acting on such complications and a patient safety incident is reported, Open Disclosure with the patient must occur and the incident reported on the National Incident Management System (NIMS)

Examples of drug groups which may cause harm if extravasated:

  • Systemic Anti-Cancer Therapy (SACT)
  • Drugs with low pH (acidic) e.g. vancomycin (antibiotic), amiodarone (for treatment of irregular heartbeats), labetalol (for treatment of high blood pressure)
  • Drugs with high pH (alkaline) e.g. aciclovir (antiviral), phenytoin (for treatment of epilepsy), furosemide (for treatment of high blood pressure and oedema/swelling)
  • Vasopressors (used to increase blood pressure) e.g. noradrenaline (norepinephrine), phenylephrine
  • Hyperosmolar solutions (high concentration) e.g. contrast used in radiology, calcium solutions, potassium infusions
  • Iron infusions – may cause permanent staining of skin

Where can I get more information?

Refer to and follow any local guidance or policies on IV care, extravasation / tissue infiltration injury, consent etc. where available. For additional information, please see below:

- Procedure for prevention of PVC and CVC related infection - Guidance Booklet (https://bit.ly/3LfRIkA)

- Patient Information Leaflet: Learn about your IV line (https://bit.ly/3S2R3Xx)

- Extravasation and infiltration: under-recognised complications of intravenous therapy A. Barton, British Journal of Nursing Vol. 33, No. 7 (2024)

- Infiltration and Extravasation: A Toolkit to improve practice, NIVAS UK

- Antimicrobial Resistance and Infection Control Team (AMRIC) Hub in HSEland

- Infusion Therapy Standards of Practice, 9th Edition. Journal of infusion nursing: the official publication of the Infusion Nurses Society, 47 (1S Suppl 1), S1–S285

- National Cancer Control Programme Guidance: Prevention and Management of Extravasation of Systemic Anti-Cancer Therapy (https://bit.ly/3zFgMiR)

- Algorithm - Extravasation management of intravenous anti-cancer therapies

- HSE National Consent Policy 2022 (https://bit.ly/4bvwkCx)

This Patient Safety Supplement was developed by:

- Patients for Patient Safety Ireland

- Portiuncula University Hospital - Acute Oncology Services and ANP Oncology Team

- St Vincent’s University Hospital - Quality and Patient Safety Department and Medication Safety Coordinator

- Tallaght University Hospital – Director QSRM, Risk Management Lead & Medication Safety Manager

- Antimicrobial Resistance and Infection Control Team (AMRIC), HSE

- Irish Medication Safety Network

- Patient Safety Together, Incident Management Team, NQPSD, HSE

Approved for publication by the HSE National Patient Safety Alert Committee and the National Clinical Director, NQPSD

For further information on Patient Safety Supplements, see www.hse.ie/pst

All feedback on content or format of this supplement is welcome and can be sent to patientsafetytogether@hse.ie