Musculoskeletal & Integumentary · Topic 10 of 11

IV Infiltration & Extravasation

Skin & wounds · infusion-site injury

IV Infiltration & Extravasation

Stop the infusion, leave the catheter in to aspirate, elevate — then match the antidote and compress to the drug that leaked.

Key numbers

Pressor leak: infiltrate phentolamine 5–10 mgphentolamine 5–10 mg

Anthracycline leak: ice, dexrazoxane within 6 hoursdexrazoxane ≤ 6 h

Vinca leak: hyaluronidase plus moderate heathyaluronidase 150 units

01 · GivePressor leak: infiltrate phentolamine 5–10 mg

For norepinephrine or other vasopressor extravasation, infiltrate phentolamine 5–10 mg in 10–15 mL normal saline subcutaneously through the ischemic area as soon as possible, ideally within 12 hours; terbutaline or topical nitroglycerin are alternatives.

02 · GiveAnthracycline leak: ice, dexrazoxane within 6 hours

For doxorubicin, daunorubicin, epirubicin or idarubicin extravasation, apply ice 15 minutes 4 times daily for 3 days and start IV dexrazoxane within 6 hours: 1,000, 1,000, then 500 mg/m² on days 1–3.

03 · GiveVinca leak: hyaluronidase plus moderate heat

For vinca alkaloid (vincristine, vinblastine, vinorelbine) extravasation, inject hyaluronidase locally — eg, 150 units subcutaneously at about 5 points around the site — and apply moderate heat to disperse the drug.

What it is

Core idea

Extravasation = a vesicant leaked into tissue must knowInfiltration is leakage of a nonvesicant solution into surrounding tissue; extravasation is leakage of a vesicant — a drug that can cause blistering, severe tissue injury or necrosis.

Causes & risk factors

Why it happens

Pressors, hypertonic fluids, contrast can necrose tissueNon-chemotherapy drugs with vesicant or irritant properties include vasopressors (norepinephrine, dopamine, epinephrine), hypertonic and hyperosmolar solutions, contrast media, mannitol and some antibiotics.

Presentation

What you'll see

Swelling, burning, slowed flow, no blood returnEarly signs are swelling, stinging or burning pain, a slowed or stopped infusion, leaking at the site, loss of blood return and blanching or erythema; extravasation can occur even with a positive blood return.

Diagnosis & monitoring

Work-up

Grade infiltration by edema sizeInfiltration scale: grade 1 edema < 1 inch, grade 2 edema 1–6 inches, grade 3 edema > 6 inches; grade 4 adds tight or leaking skin, circulatory impairment, or any blood product, irritant or vesicant.

Follow DNA-binding vesicant leaks at least 3 weeksInjury from DNA-binding vesicants appears late and can progress for weeks (ulceration often after days to weeks): follow the site for at least 3 weeks and document drug, dose, timing, interventions and response.

Do right now

In this order

First moves

Stop, leave catheter in, aspirate, elevate

→

Pressor leak: infiltrate phentolamine 5–10 mgphentolamine 5–10 mg

→

Anthracycline leak: ice, dexrazoxane within 6 hoursdexrazoxane ≤ 6 h

→

Cold for most vesicants; warm for vincas

→

Call surgery for necrosis or compartment signs

Why each step

Stop, leave catheter in, aspirate, elevateAt suspected extravasation stop the infusion, leave the catheter in to aspirate residual drug, do not flush the line or press on the site, then elevate the limb (unless compartment syndrome is suspected).

Pressor leak: infiltrate phentolamine 5–10 mgFor norepinephrine or other vasopressor extravasation, infiltrate phentolamine 5–10 mg in 10–15 mL normal saline subcutaneously through the ischemic area as soon as possible, ideally within 12 hours; terbutaline or topical nitroglycerin are alternatives.

Anthracycline leak: ice, dexrazoxane within 6 hoursFor doxorubicin, daunorubicin, epirubicin or idarubicin extravasation, apply ice 15 minutes 4 times daily for 3 days and start IV dexrazoxane within 6 hours: 1,000, 1,000, then 500 mg/m² on days 1–3.

Cold for most vesicants; warm for vincasCold compresses (anthracyclines, alkylators, antimetabolites) localize the drug; warm compresses (vinca alkaloids, etoposide, oxaliplatin) disperse it. Apply 15–20 minutes, 3–4 times daily for 48–72 hours.

Call surgery for necrosis or compartment signsConsult surgery (plastics) promptly for severe or rapidly progressing tissue damage or suspected compartment syndrome; refer central-line vesicant leaks, high-volume leaks, DNA-binding vesicants and CTCAE grade ≥ 2 injuries early.

Management

Orders

DMSO for mitomycin or mitoxantrone leaksTopical dimethyl sulfoxide is the antidote for mitomycin C and mitoxantrone extravasation, and for anthracyclines when dexrazoxane is unavailable or contraindicated.

Irritant infiltration: cold, elevate, observeInfiltration of irritants or nonvesicants (electrolyte solutions, some antibiotics, propofol) usually needs no antidote: cold compress, elevation and monitoring; hyaluronidase may be used to speed absorption.

Red flags & don'ts

Avoid harm

Stop cold packs before dexrazoxane interactionGive dexrazoxane through a different vein, remove ice packs at least 15 minutes before each infusion so blood reaches the site, and do not use topical DMSO with dexrazoxane.

Infiltration or extravasation?

Commonly confused

What leaked	A nonvesicant solution or drug
Grade	Graded 1–4 by edema size and symptoms
Antidote	Usually none; hyaluronidase if needed
Compress	Usually cold, with elevation
Follow-up	Watch until edema resolves

More detail

Reference

Show 5 reference facts

Sodium thiosulfate is recommended for extravasation of > 20 mL of concentrated cisplatin (> 0.5 mg/mL) and for bendamustine.

Do not debride non-necrotic tissue after infiltration; surgical debridement, moist wound care or flap reconstruction is reserved for established, progressing necrosis.

Phentolamine's sympathetic (alpha) blockade reverses local vasoconstriction and produces visible hyperemia when given within 12 hours; hyaluronidase promotes dispersal and absorption of the leaked drug.

Antineoplastic extravasation occurs in about 0.01–6.5% of patients and is more common through peripheral IVs; the 2025 ONS/ASCO guideline is the first US antineoplastic extravasation guideline.

For paclitaxel or docetaxel extravasation the 2025 ONS/ASCO guideline conditionally suggests hyaluronidase with warm compresses; taxane leaks often cause less severe injury.

Pearl

Pressor leak → phentolamine; anthracycline → ice and dexrazoxane within 6 hours; vinca alkaloid → hyaluronidase plus moderate heat.

Sources · Liu H et al. Intraoperative peripheral intravenous complications in adults: a summary of evidence for prevention and management of infiltration/extravasation. Front Med (Lausanne) 2026 · ONS Voice (Oct 2025) — summary of the ONS/ASCO Management of Antineoplastic Extravasation guideline (Clin J Oncol Nurs, Oct 2025) · Levophed (norepinephrine bitartrate) prescribing information — DailyMed (emergency treatment of extravasation) · Totect (dexrazoxane) prescribing information, revised 11/2020 — FDA · MGH Patient Care Services — Nursing Management of Venous Access Devices: Complications and Troubleshooting (INS infiltration scale; rev. 2019) · Doxorubicin hydrochloride injection prescribing information (rev. 7/2024) — DailyMed (management of extravasation) · Vincristine sulfate injection prescribing information — DailyMed (hyaluronidase and moderate heat for extravasation) · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).