Extravasation Injury | Medical Algorithm

The severity of an infiltration or extravasation injury can be graded based on the clinical findings.

Parameters:

(1) skin appearance

(2) edema

(3) perfusion

(4) pain

(5) other findings

Skin	Edema	Perfusion	Pain	Grade
normal	none	normal	none	0
blanched	< 1 inch	cool to touch	variable	1
blanched	1 – 6 inches	cool to touch	variable	2
blanched, translucent	> 6 inches (gross)	cool to touch	mild to moderate; possibly numb	3
blanched, translucent	> 6 inches (gross); pitting	circulatory impairment	moderate to severe	4

The infiltration of any amount of blood product, irritant or vesicant is a Grade 4 injury.

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Grading Severity of Infiltration and Extravasation Injury