Extravasation of IV Amiodarone

Introduction

1. This guideline describes the appropriate steps to take following extravasation of peripheral Amiodarone Hydrochloride ONLY.
2. Many other drugs including calcium chloride, 50% dextrose, chemotherapeutics and parenteral nutritional products can cause damage to tissues if they extravasate, but the treatments may be different depending on their individual drug characteristics.
3. If you are looking for advice on extravasation of a different compound, contact the consultant in charge of your patient’s care or the on call Plastics SHO via the Glasgow Royal Infirmary switchboard on 0141 211 4000 (see below).

Suspect Extravasation if any of the Following

1. Patient reports pain, stinging or burning at the site of the cannula either during, or shortly after, drug administration
2. Patient reports, or you notice, swelling or changes to skin colour (this could include blanching, redness, bruising, blistering or blackening) around the infusion site
3. New neurovascular compromise of the limb distal to the infusion site including numbness or loss of peripheral pulses
4. You encounter, or an electronic drug delivery pump alerts you to, unexpected resistance to infusion of the drug
5. One of the early signs that extravasation may have occurred is pain around the infusion site.  If the patient has a reduced conscious level, is sedated or has sensory loss or vascular damage to the affected limb, extravasation injuries may not be picked up as quickly, so extra staff vigilance is required.

Immediate Treatment of Extravasation Injuries

1. Suspected extravasation injury should be treated as soon as it is recognised. Delayed treatment can worsen patient outcomes
2. Stop the infusion immediately. Attempt to aspirate back as much drug as possible from the cannula
3. Leave the cannula in situ
4. Elevate the affected limb to promote absorption of the drug into the lymphatic and vascular systems
5. Advice should be sought immediately from the Plastics team based at Glasgow Royal Infirmary. To do this, phone the GRI switchboard on 0141 211 4000 and ask the operator to page the on-call Plastics SHO for you.  You will need to stay on the line until the page is answered and the operator is able to connect you.

How Amiodarone Damages Tissues

1. Amiodarone is a vesicant drug which causes tissue necrosis by virtue of its low pH (3.5-4.5) and some of its excipients, polysorbate and benzyl alcohol.
2. Tissue necrosis can lead, in the worst-case scenario, to the need for extensive debridement or skin contractures, so if extravasation is suspected it should be acted on quickly.

Good Practice for Reducing Risk of Extravasation

1. First, consider: do you need to give amiodarone? Does it need to be given intravenously?
   

   Rhythm problem	Characteristics	Consider treatment with
   AF: atrial fibrillation with rapid ventricular rate, with or without bundle branch block Atrial Flutter***	Haemodynamically stable*	Beta blockers** OR Rate-limiting calcium channel blockers (verapamil or diltiazem) ± Digoxin are all approproiate alternative treatments (with better side effect profiles if selected for the right patients)
   	Haemodynamically unstable	DC Cardioversion can be considered in unwell patients with fast AF, even where they were known to have AF before their current illness
   VT: ventricular tachycardia	Non-sustained VT (NSVT), AND haemodynamically stable*	Can often be treated with Beta blockers OR Oral amiodarone as a rapid loading regime (400mg TDS for 7 days followed by 200mg OD thereafter as a maintenance dose if required)
   	Sustained VT, or NSVT with haemadynamic instability	IV Amiodarone OR DC Cardioversion as per ALS Adult Tachycardia Algorithm
   Unsure if VT or AF with bundle branch block	Treat as VT and seek senior advice
   Notes	* Unless a patient is haemodynamically unstable or their tachycardia causes chest pain, patients can usually tolerate a ventricular rate of around 150bpm for a few days, giving oral agents time to work (bisoprolol takes effect between 2-6 hours and digoxin takes >12 hours) ** Beta blockers can be a suitable treatment for AF with heart failure - use clinical judgement if concerned about hypotension in these patients *** All drug treatments listed for AF are approporiate to try in patients with atrial flutter. Flutter can be resistant to rate control, in which case inpatient cardioversion, either by amiodarone or with synchronised DC cardioversion may be considered if the patient is already anticoagulated. If cardioverting a haaemodynamically stable patient with amiodarone or DCCV, the patient should be on anticoagulation for at least 3 weeks unless onset of arrhythmia is <72hrs.

2. Select a large vein, avoiding veins that lie over joints, as patient movement may dislodge the cannula.
3. As per usual peripheral cannula insertion good practice, look for flashback to confirm cannula placement, flush with at least 10mL water for injections or 0.9% NaCl, and ensure the cannula site is visible i.e. not covered with wound dressings, bandages or blood pressure monitoring equipment.
4. If the patient is frail, was noted to have fragile veins when they were cannulated, or have a history of repeated failed cannulation attempts or tissued cannulas, they may be at higher risk of extravasation injury. Consider whether a central line or midline would be more appropriate for administration.
5. Inserting a midline is very similar to inserting an ultrasound-guided cannula. Speak to your senior or the on-call critical care/anaesthetics doctor if you need support in doing this procedure.

Links

1. CEACCP (2010) Extravasation injuries and accidental intra-arterial injection
2. European Society of Cardiology (2020) Guidelines for the diagnosis and management of atrial fibrillation
3. Russell & Saltissi (2005) Amiodarone induced skin necrosis (Heart)
4. Association of Anaesthetists of Great Britain & Ireland (2016) Safe Vascular Access

Content by Katie Percival, Jess Langley, Jenna McMinn & Chris Isles