Extravasation injury as a complication of neonatal intensive care remains an important cause of iatrogenic morbidity and mortality. 92% of units surveyed reported having experienced a significant extravasation incident. While much of the focus and concern regarding EI centres around peripheral venous access, the occurrence of life-threatening central complications is high, with half the units in this survey reporting experience of cardiac tamponade, with some associated deaths. This highlights the importance of vigilance and monitoring in both central and peripheral IV access.
As the complexity of neonatal care increases, NICUs are increasingly using evidence-based practice protocols. This is particularly important in an environment where monitoring and management is provided by front-line nursing and medical staff at varying levels of training. Our survey reveals that approximately two thirds of Australian and New Zealand NICUs have protocols for the prevention and management of EI; however, as previously noted in the UK, considerable diversity exists between units regarding practice.
It is clear that a number of techniques are being employed for prevention and monitoring of EI. Regarding peripheral IV lines: More than three-quarters of units surveyed reported a policy of regular nursing observations and ensuring IV site visibility, as originally described by Millan [10
]. Over half the units have concentrated TPN preparations for exclusive use in central lines, with 15% disallowing peripheral TPN altogether. Based on many qualifying comments received to this question, it is clear most units take a cautious approach to peripheral TPN. The practice of peripheral dopamine infusion is similar, with the majority allowing this with significant qualifications and caution, and some disallowing it altogether. Education and identification of preparations posing risk is clearly an important preventative strategy. 50% of units currently identify and document preparations posing particular risk. Regarding central lines, it is well recognised these carry a risk of potentially serious harm [11
]. Nevertheless, it is possible to have a low rate of serious and life-threatening complications with strict adherence to safety criteria [12
In terms of treatment, while most agree on line removal, subsequent steps vary. Much of this diversity may be explained by the paucity of robust evidence in the literature. 38% currently use hyaluronidase. Hyaluronidase is an enzyme which breaks down constituents of the extracellular matrix, leading to increased diffusion and a subsequent decrease in concentration of the toxic infusate substance [13
]. The benefits of this in EI have been shown in animal studies and in a number of case reports in neonates [6
]. However, as hyaluronidase is generally used in conjunction with the multiple puncture and saline wash-out technique, it is unclear whether it adds anything over saline alone [17
Techniques such as multiple skin puncture and saline flush with or without hyaluronidase are invasive, and carry some morbidity. Accurate case selection is vital. Using a staging system (Table ) is used by over half of the units in this survey, and the practice is referenced in numerous previous papers [1
]. This allows protocols to be devised which guide treatment based on injury severity. For example, stage I and II injuries often do not require treatment, while stage III and IV are likely to require intervention [1
]. Another strategy is greater involvement of plastic surgical services in decision making around EI. This is now used by over a third of units, for the majority of their EIs. Whatever the method used, with increasing data on the benefits of these or similar treatment techniques, accurate and prompt assessment and treatment is essential (Table ).
Table 2 Staging of extravasation injuriesas adapted from Millan
While TPN would be the most implicated agent in EI, dopamine and other catecholamines, widely used as a treatment to support the maintenance of cardiac output and BP, are notorious for causing EI due to their vasoactive properties [3
]. The extravasation of dopamine leads to the activation of alpha-adrenoreceptors in the peripheral vasculature, [19
] resulting in vasoconstriction and subsequent tissue hypoxia [20
]. Various treatment regimes aim to prevent/interrupt this cascade, e.g. phentolamine [9
] and nitroglycerin ointment, [21
]. Phentolamine antagonises alpha-adrenergic receptors, preventing vasoconstriction and subsequent tissue necrosis, [19
] while nitroglycerin acts on vascular smooth muscle in arteries and veins, leading to vasodilation and increased perfusion of tissues [21
]. Despite 69% of the units administering vasoactive substances (e.g. dopamine) by peripheral venous access, only 25% use a specific antidote, such as phentolamine or nitroglycerin ointment, in the treatment of catecholamine-induced EI.
This is the first survey investigating prevention and management of extravasation injury in Australian and New Zealand neonatal intensive care units. Responses were obtained from senior clinicians with close to 100% response rate, ensuring that this survey provides an accurate and reliable picture of the current practice.