You are administering medications to a patient through an intravenous (IV) line. Suddenly, you notice that the IV site is becoming red, swollen, and painful. You suspect extravasation, a potentially serious complication. Which of the following medications is most likely to cause severe tissue damage and necrosis if extravasation occurs?

Appeared in: NORCET 6 Prelims -2024

Explanation

Phenytoin is classified as a potent vesicant, a type of drug known to cause severe tissue damage and necrosis if it leaks from the vein.
The primary mechanism of injury is its extreme alkalinity, with a pH of about 12, which causes a direct chemical burn to the surrounding tissues.
A well-known, severe complication specific to phenytoin extravasation is 'Purple Glove Syndrome,' which involves significant pain, edema, and discoloration that can progress to necrosis.

Option A: Diazepam is classified as an irritant, not a vesicant. It can cause inflammation and pain at the IV site (phlebitis) but does not typically cause the extensive tissue death seen with vesicants.
Option B: While epinephrine is a vesicant, its mechanism of injury is vasoconstriction leading to tissue ischemia, not a direct chemical burn. Phenytoin's high pH makes it a classic example of a chemically destructive vesicant, often highlighted for its severe local effects.
Option D: Ranitidine is a non-vesicant medication. Infiltration of ranitidine is not associated with severe tissue damage or necrosis.

Clinical Relevance

Nursing practice connection: Use the key finding related to Identification of vesicant medications and the risks associated with extravasation to guide bedside assessment, documentation, and the next nursing action.
Nurses must be vigilant when administering any IV medication, but especially known vesicants. Always confirm IV line patency with a saline flush before and during administration. Patient education is key; instruct them to immediately report any pain, burning, or swelling at the IV site.
The choice of central vs. peripheral line is critical. Vesicants like phenytoin, if administered continuously or in high concentrations, should ideally be given through a central venous access device to minimize the risk of extravasation and severe tissue injury.
What if the extravasated drug was a vasoconstrictor like dopamine or norepinephrine? The immediate intervention would be different. The antidote phentolamine would be infiltrated into the site to cause vasodilation and restore blood flow, which is a different management strategy than for a chemical burn from phenytoin.

How to Approach the Question

First, identify the clinical problem presented in the stem: The signs (redness, swelling, pain) indicate an IV complication, specifically extravasation.
Next, understand the question's core task: Identify which of the four drugs is MOST likely to cause severe tissue damage (necrosis) upon extravasation.
This requires recalling or applying knowledge about drug properties, specifically the difference between irritants and vesicants.
Evaluate each option: Categorize Ranitidine as a non-vesicant and Diazepam as an irritant, eliminating them as causes of severe necrosis.
Compare the remaining two vesicants, Epinephrine and Phenytoin. Differentiate their mechanisms of injury. Epinephrine causes vasoconstrictive ischemia, while Phenytoin causes a direct chemical burn due to its high pH.
Conclude that Phenytoin is the most likely answer because its direct chemical destructive properties and associated 'Purple Glove Syndrome' are classic examples of severe extravasation injury taught in nursing.

Concept Tested & Keywords

Concept Tested: Identification of vesicant medications and the risks associated with extravasation.
Stem keywords: intravenous (IV) line, extravasation, red, swollen, and painful, severe tissue damage, necrosis
Lead-in keywords: most likely
Clinical cues: The signs of IV complication (red, swollen, painful) point directly to infiltration or extravasation, prompting the nurse to consider the properties of the infused drug.
Negative lead-in flag: false

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E6 Pharmacology Nursing Lilley 11e Part 3 p. 100-102

E6 Nursing Brunner Adult Health 3SA Vol 2 Part 3 p. 8-10

Practise the full NORCET 6 Prelims -2024

Attempt every question from this paper in a timed mock, then review the full solution for each one.