Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [257], C).
2. 2.Show
   Ascertain what emergency treatment has been carried out. For example, was hyaluronidase administered?
   To ensure that only required treatment is carried out; for example, if hyaluronidase has been given, no further dose would be administered as this could result in a sensitivity reaction. E
3. 3.Show
   Assemble all of the equipment necessary for the procedure.
   To ensure that time is not wasted and the procedure goes smoothly without any unnecessary interruptions. E
4. 4.Show
   Check all packaging before opening and preparing the equipment to be used.
   To maintain asepsis throughout and check that no equipment is damaged or out of date (Fraise and Bradley [98], E).
5. 5.Show
   Wash hands using bactericidal soap and water or an alcohol‐based handrub and dry.
   To minimize the risk of infection (DH [64], C).
6. 6.Show
   Place the patient's arm on a plastic‐backed towel.
   To prevent leakage of the flushed‐out solution and possible contamination of the area with cytotoxic drugs. E
7. 7.Show
   Apply a disposable gown and eye protection.
   To prevent contamination of the practitioner with cytotoxic drugs. E
8. 8.Show
   Open a pack, empty all equipment onto the pack and place a sterile dressing towel under the patient's arm.
   To create a sterile working area. E
9. 9.Show
   Wash hands using bactericidal soap and water.
   To minimize the risk of infection (DH [64], C; Fraise and Bradley [98], E).
10. 10.Show
    Apply sterile gloves.
    To minimize the risk of infection and prevent contamination of the nurse (DH [64], C; Fraise and Bradley [98], E).
11. 11.Show
    Clean the skin with 2% chlorhexidine and allow the area to dry.
    To maintain asepsis and remove skin flora (DH [64], C; Fraise and Bradley [98], E).

Procedure

1. 12.Show
   Draw up 1% lidocaine in a 10 mL syringe.
   To prepare for infiltration of the area. E
2. 13.Show
   Mix the hyaluronidase with sterile water in a separate 5 mL syringe.
   To ensure the drug is reconstituted correctly (BNF [25], C).
3. 14.Show
   Mark the area of extravasation with a sterile marker; this is where incisions will be made.
   To ensure the correct area is treated. E
4. 15.Show
   Using a 25 G needle, make a small bleb by inserting the needle intradermally and administering 0.1–2 mL of lidocaine slowly as if towards the points of a clock face. Allow it to take effect.
   To reduce any discomfort to the patient. E
5. 16.Show
   Then, using a 23 G needle, infiltrate the marked area with lidocaine subdermally as if towards the points of a clock face. Check with the patient what kind of sensation they can feel (e.g. sharp or dull) before proceeding.
   To ensure administration of anaesthetic to the area and to ensure the anaesthetic has taken effect. E
6. 17.Show
   Attach a 23 G needle to the syringe of hyaluronidase and infiltrate the anaesthetized area towards the points of a clock face.
   To facilitate the flush‐out by loosening the tissues. E
7. 18.Show
   Cut an opening in a transparent dressing that matches the size of the infiltrated area and apply it to the patient's skin.
   To protect the skin from the flushed‐out vesicant drugs. E
8. 19.Show
   Attach the administration set, three‐way tap and extension set to the bag of 0.9% sodium chloride and withdraw 20 mL via the tap.
   To prepare the syringe and to enable continued access without having to open the system. E
9. 20.Show
   Make at least four incisions around a clock face using a size 11 scalpel by inserting the blade straight down to a depth of no more than 0.5 cm. Make one further small incision to use for insertion of the cannula.
   To prepare the area for flushing. The number of incisions will depend on the size of the area to be treated. To reduce risk of damage to tendons and other anatomical structures (Gault [103], E).
10. 21.Show
    Gently press on the area.
    This alone may allow the fluid to escape (Gault [103], E).
11. 22.Show
    Insert the cannula through one of the incisions and push along tissues within the marked area.
    To free up tissues from the skin and to aid advancement of the cannula and flush (Gault [103], E).
12. 23.Show
    Remove the stylet and attach the extension set to the cannula.
    To facilitate the flushing. E
13. 24.Show
    Flush the 0.9% sodium chloride through – it will exit out of the other incision holes. Pat with a sterile gauze swab, massaging and milking the area at the same time. The area will become puffy and swollen – this is normal.
    To commence the flushing procedure. To assist with removal of saline (Gault [103], E).
14. 25.Show
    Draw up more 0.9% sodium chloride and repeat the procedure using a minimum of 100 mL (up to 500 mL) of 0.9% sodium chloride.
    To facilitate the flushing of the drug from the area (Gault [103], E).
15. 26.Show
    If saline does not flow out of one incision, it may be necessary to remove the cannula from the original incision and insert a new cannula into another one.
    To ensure all areas are flushed. E

Post‐procedure

1. 27.Show
   Remove the transparent dressing and clean and dry the area, although it will continue to leak.
   To promote patient comfort. E
2. 28.Show
   Apply a Mepitel dressing and a loose bandage (do not wrap tightly).
   To reduce the risk of infection and to prevent compression of the skin. E
3. 29.Show
   Elevate the limb so that the hand is level with the head whenever the patient is at rest.
   To aid reduction of oedema. E
4. 30.Show
   Discard waste in appropriate containers.
   To ensure safe disposal in the correct containers and avoid laceration or injury of other staff (EASHW [84], C; HWR [137], C).
5. 31.Show
   Document the procedure in the patient's medical and nursing notes and on the flush‐out technique form.
   To ensure adequate records are kept and enable continued care of the patient (NMC [257], C).
6. 32.Show
   Discuss with medical colleagues the prescribing of oral antibiotics (flucloxacillin is recommended to reduce skin pathogens) and if necessary analgesia.
   If the patient is neutropenic, they may be more at risk of infection. To minimize pain and discomfort. E
7. 33.Show
   Refer to a plastic surgeon if there are any problems during the procedure or if there are any skin problems.
   To ensure rapid access for further management. E
8. 34.Show
   Monitor and review within the first 24 hours. Have photographs taken if possible.
   To observe and document for any skin changes or infection and provide immediate treatment. E
9. 35.Show
   Change the dressing every 48 hours and ensure that it remains in situ for up to a week. The skin incisions will heal within 1–2 weeks.
   To reduce the risk of infection. E
10. 36.Show
    Ensure the patient knows when and how to make contact if they have any problems once at home. Arrange for the patient to return for dressing changes at the hospital or with the community nurse. Inform the patient to contact the hospital if:

    • the swelling does not reduce
    • they have ongoing severe pain
    • there is any tingling or numbness in the fingers or arm.
    To ensure the patient receives immediate treatment should there be any problems post‐procedure. E