A puffy hand after a routine cannula… and suddenly the IV isn’t so innocent anymore.
3-year-old Noah arrives at the ED for a “pit-stop review” for a planned hospital-to-hospital transfer, with IV antibiotics running. On arrival, the team notes that his hand appears swollen and pale.
What is an extravasation injury?
Extravasation occurs when intravenous fluid or medication leaks out of a vein and into the surrounding tissues. Imagine it as: instead of flowing down the bloodstream’s ‘motorway’, the infusion detours into the soft tissue ‘suburbs’, where it can cause anything from mild swelling to tissue necrosis and compartment syndrome.
In children, small veins, wriggly limbs, and subcutaneous fat make this a particularly important problem to be aware of, one that isn’t always easy to pick up on.
Why does it happen?
Cannulas can leak for many reasons:
- Fragile veins
- Incorrectly sited cannula
- Movement of the limb
- High-pressure infusions
- Poorly secured lines
- Irritant medications
Not all extravasations are created equal. Risk depends on:
- What leaked (high, medium or low risk infusions)
- How much leaked (the percentage limb swelling can be used to estimate severity)
- Where it leaked (hands, feet and joints are at higher risk of complications)
- How long has it been leaking?
High-risk infusions such as vasoactive drugs, concentrated electrolytes, or certain antibiotics can turn a small leak into a big problem very quickly.
How can we identify extravasation injuries?
The limb may tell the story before the pump alarms:
- Swelling or puffiness
- Pain or irritability
- Blanching or erythema
- Coolness or tightness
- Reduced movement
- Loss of IV patency
In darker skin tones, swelling and tension may be the earliest clues. Always compare with the other limb. If the cannula looks suspicious, assume it is the problem until proven otherwise.
How can we treat extravasation injuries in the ED?
First things first- first aid considerations:
- Stop the infusion immediately
- Do not remove the cannula (yet)
- Aspirate any residual drug if possible
- Elevate the limb
- Apply warm or cold compresses depending on the drug extravasated (check Extravasation Guidelines on your local intranet, discuss with your local pharmacy or search the specific drug “summary of product characteristics”)
Second- think risk stratification:
- Low-risk infusions may only need observation and supportive care.
- Intermediate and high-risk injuries may require antidotes such as
- Phentolamine for vasoconstrictors
- Hyaluronidase to disperse infiltrated fluid
In some cases, surgical washout is needed to dilute and remove the offending agent before it causes tissue damage.
When do we refer for specialist support?
Time matters. Early referral is indicated in the following situations:
- High-risk or “red” infusions
- Evidence of skin compromise
- Increasing pain or tightness
- Any concern for compartment syndrome
- Swelling involving more than 30% of the limb (calculated by [Swelling maximum length/ Arm Length] x 100)
In the UK, practice commonly favours early referral to paediatric surgery if there is concern. Unlike some international settings, ED-based washout is not routinely performed, and theatre washout by surgical teams is often preferred.
Specialists may:
- Perform a saline washout procedure
- Monitor for evolving tissue injury
- Manage compartment syndrome
- Arrange plastic surgical follow-up if needed
The swelling was spotted early, with the transport team confirming that Noah’s hand appeared normal as they pulled into the hospital about 30 minutes ago. The infusion is stopped, the limb elevated, and a cold compress applied.
The drug, vancomycin, is identified as high-risk. The Paediatric Surgical Registrar is called. The child is accepted for urgent washout in theatre and recovers without skin loss or functional deficit.
Take-home points
Extravasation injuries range from mild to limb-threatening.
Risk depends on the drug, the volume and the location.
Early recognition and immediate first aid are essential.
High-risk injuries need prompt surgical discussion.
Clinical photos and knowing what specialists can do help you refer with confidence.
References
Billingham MJ, Mittal R. Peripheral venous extravasation injury. February 2023. BJA Education. Volume 23, Issue 2, p42-45 [Available from: Peripheral venous extravasation injury – BJA Education ]
Cambridge University Hospitals NHS Foundation Trust. Information on Extravasation (Paediatrics). [Online], UK, NHS, [Cited 2026 Feb], Available from: Information on Extravasation (Paediatrics) | CUH
Guy’s and St Thomas’ NHS Foundation Trust. Clinical Guidance: Paediatric Peripheral Extravasation Treatment Guideline. [Online]. Evelina London. 2019 January [Updated 2022 January; Cited 2026 February], Available from: Paediatric Peripheral Extravasation Treatment Guideline
NHS Scotland. Peripheral extravasation injury (Non-cancer) (Guidelines). Healthcare Improvement Scotland. 2025 Aug 28, [Cited 2026 Feb], Available from: Peripheral extravasation injury (Non-cancer) (Guidelines) | Right Decisions
NICE / BNF. Soft tissue disorders – extravasation, [Online], UK, BMJ Publishing Group LtD and Pharmaceuticals Press, [Cited 2026 Feb], Available from: Soft-tissue disorders | Treatment summaries | BNF | NICE Royal Children’s Hospital Melbourne. Peripheral extravasation injuries: Initial management and washout procedure. [Online], Melbourne, Australia. December 2023 [cited 2026 Feb], Available from: Clinical Practice Guidelines : Peripheral extravasation injuries: Initial management and washout procedure
