Pre‐procedure

ActionRationale

1. 1.Show
   Explain the procedure and reason for performing it to the patient and gain written consent using pre‐prepared consent form.
   To ensure that the patient understands the procedure and gives their valid consent (NMC [178], 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 should be administered as this could result in a sensitivity reaction. E
3. 3.Show
   Assemble all 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   To maintain asepsis throughout and check that no equipment is damaged or out of date (Fraise and Bradley [77], E).
5. 5.Show
   Carefully wash hands using bactericidal soap and water or bactericidal alcohol handrub before commencement and dry.
   To minimize the risk of infection (DH [46], C).
6. 6.Show
   Place the patient's arm on the 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 disposable gown and eye protection.
   To prevent possible contamination of 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 [46], C; Fraise and Bradley [77], E).
10. 10.Show
    Apply sterile gloves.
    To minimize the risk of infection (DH [46], C; Fraise and Bradley [77], E) and prevent contamination of the nurse.
11. 11.Show
    Clean skin with 2% chlorhexidine and allow the area to dry.
    To maintain asepsis and remove skin flora (DH [46], C; Fraise and Bradley [77], E).

Procedure

1. 12.Show
   Draw up 1% lidocaine in 10 mL syringe and label.
   To prepare for infiltration of area. E
2. 13.Show
   Mix hyaluronidase with sterile water in a separate 5 mL syringe.
   To ensure drug is reconstituted correctly (Joint Formulary Committee 2018, C).
3. 14.Show
   Mark the area of extravasation with a sterile marker and indicate where the incisions will be made (Action figure 14).
   To ensure the correct area is treated. E
4. 15.Show
   Using a 25 G needle, make a small bleb at the lowest point of the marked area by inserting the needle intradermally and administering 0.1–2 mL of lidocaine slowly towards the four points of the compass. Allow it to take effect (Action figure 15).
   To reduce any discomfort to the patient. E
5. 16.Show
   Then, using a 23 G needle, infiltrate the marked area with lidocaine subdermally towards the four points of the compass. Check with the patient what kind of sensation they can feel, for example sharp or dull, before proceeding.
   To ensure administration of anaesthetic to area and to ensure anaesthetic has taken effect. E
6. 17.Show
   Attach a 23 G needle to the syringe of hyaluronidase and infiltrate the anaesthetized area at the four points of the compass.
   This will 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 to the patient's skin.
   To protect the skin from the flushed out cytotoxic 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 at the four points of the compass using a size 11 scalpel by inserting the blade straight down to a depth of no more than 0.5 cm and one small incision to use for insertion of the cannula 20 (Action figure 20).
   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 or other anatomical structures (Gault [82], E).
10. 21.Show
    Gently press on the area.
    This alone may allow the fluid to escape (Gault [82], E).
11. 22.Show
    Insert the cannula through one of the incisions and push along tissues within the marked area (Action figure 22).
    To free up tissues from skin and to aid advancement of cannula and flush (Gault [82], E).
12. 23.Show
    Remove the stylet, dispose of in the sharps bin 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 (24).
    To commence the flushing procedure. To assist with removal of the extravasated drug (Gault [82], 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 [82], E).
15. 26.Show
    If 0.9% sodium chloride 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 incision.
    To ensure all areas are flushed. E

Post‐procedure

1. 27.Show
   Clean and dry the area although it will continue to leak.
   To aid 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 until swelling has reduced.
   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. E
5. 31.Show
   Document in the patient's medical and nursing notes and on the flush‐out technique form.
   To ensure adequate records and enable continued care of the patient (NMC [178], C).
6. 32.Show
   Discuss with medical colleagues the prescribing of oral antibiotics (flucloxacillin is recommended for reducing 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 procedure or if there are any skin problems.
   To ensure rapid access for further management. E
8. 34.Show
   Have a photograph taken if possible.
   To observe and document for any skin changes. E
9. 35.Show
   Monitor and review within first 24 hours.
   To observe and document for any skin changes or infection and provide immediate treatment. E
10. 36.Show
    Dressing will need to be changed every 48 hours and should remain in situ for up to a week. The skin incisions will heal within 1–2 weeks.
    To prevent risk of infection. E
11. 37.Show
    Ensure the patient knows when and how to make contact if they have any problems once at home. Organize for the patient to return for dressing changes at the hospital or with the district nurses. Inform the patient to contact the hospital if:

    • the swelling does not reduce
    • they have 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