Type of Med 0-5 days 6-14 days 15 days-2 month >2 months Green PIV PIV Non-tunneled CVC (Midline***) Non-tunneled CVC (PICC***) Tunneled CVC Port Yellow PIV PIV Non-tunneled CVC (Midline ***) Non tunneled CVC (PICC ***) Tunneled CVC Port Red Non-tunneled CVC (PICC***) Non-tunneled CVC (PICC***) Non-tunneled CVC (PICC ***) Tunneled CVC Port Line Selection Table – RENAL (Nephrology) CKD/ESRD patients Venous Infusion Extravasation Risk This is an estimate of risk for phlebitis or local tissue injury due to extravasation from any intravenous infusion device. Risk derived from available evidence, CCHMC data and CCHMC expert opinion, subject to review and change as further evidence becomes available. For Treatment of Extravasation, Refer to CCHMC Policy P&T II-112 This does not apply in situations of emergency medical treatment. If a medication is not on this list, please refer to the CCHMC formulary or contact pharmacy (6-4291) for information Green + Lower Risk Aminophylline Amphotericin B Liposomal Ampicillin Ampicillin/Sulbactam Cefazolin Cefotaxime Ceftazidime Ceftriaxone Cefuroxime Clindamycin D5LR Dextrose < 10% Fentanyl Fosphenytoin Furosemide Gentamicin Heparin Imipenem IVIG Lactated Ringers Lipids Magnesium sulfate (bolus) Meropenem Methylprednisolone Piperacillin/tazobactam Normal saline Ticarcilllin Pentamidine Ticarcillin/clavulanate Piperacillin Tobramycin Yellow Intermediate Risk Acetazolamide Allopurinol Amikacin Amphotericin B (conventional) Arginine Ciprofloxacin Dextrose 10% to <12.5% Diazepam Erythromycin Ganciclovir Lorazepam Midazolam Morphine Ondansetron Nafcillin Non-Ionic Radiology Contrast Phenobarbital Phenytoin Potassium < 60 mEq/L TPN <950 mOsm/L Vancomycin Red Higher Risk Acyclovir Amiodarone Caffeine Citrate Calcium (all salt forms) Dextrose > 12.5% Doxycycline Esmolol Mannitol 20% & 25% Promethazine Potassium >60 mEq/L Sodium bicarbonate > 3% Sodium chloride > 3% TPN > 950 mOsm/L Vasopressors such as Dopamine Chemotherapy Drugs Extravasation treatment: Refer to policy P&T II-113 + NOTE: No intravenous infusate is “safe”. Gross extravasation, even of normal saline, may result in serious harm including compartment syndrome, causing ischemia and loss of tissue or permanent loss of limb function. Reviewed: January 30, 2017 © 2009 – 2013 Cincinnati Children’s Hospital Medical Center v. 2016 1007 *** this situation is intended for a) the rare CKD patient where is has been discussed & documented that he/she would not be considered a candidate for future Renal Replacement Therapy (i.e. dialysis, transplant), and/or b) extremely difficult access situations. Use of a midline or PICC in a pt with documented CKD stages 2-5 OR ESRD (KTX, HD, PD pt) requires a verbal discussion with the family of risks as well as verbal discussion & approval by the nephrology attending to the VAT team nurse
Drug Extravasation Risk and Line Guideline for Nephrology Patients
Guideline · Aug 2019 · 2 min read
In brief
In brief
Clinical guideline addressing intravenous line selection and drug extravasation prevention strategies specific to nephrology patient populations, likely covering risk assessment and safe administration protocols.
Written by the GCMD Library team from the guideline.
Line Selection for 0-5 Day Therapy Duration
For short-term infusions under 5 days, peripheral IV (PIV) access is recommended for green and yellow risk medications. Red (higher risk) medications require non-tunneled central venous catheters, specifically PICC lines, even for this brief duration due to extravasation risk.
Line Selection for 6-14 Day Therapy Duration
Therapy lasting 6-14 days continues to favor PIV for green and yellow risk medications. Red risk medications necessitate non-tunneled CVC (PICC) placement to minimize vascular complications during this intermediate timeframe.
Line Selection for 15 Days to 2 Months
For therapy extending 15 days to 2 months, midline catheters become an option for green and yellow risk medications, while PICC lines are preferred for non-tunneled access. Red risk medications require PICC placement, with tunneled CVCs or ports considered for longer durations within this range.
Line Selection for Therapy Over 2 Months
Extended therapy beyond 2 months warrants long-term access devices. PICC lines remain acceptable for all risk categories, but tunneled CVCs and implanted ports are preferred to reduce infection risk and improve patient quality of life during prolonged treatment.
Special Considerations for Renal CKD/ESRD Patients
Chronic kidney disease and end-stage renal disease patients require careful vascular access preservation for future dialysis or transplantation. Midline and PICC placement in CKD stages 2-5 or ESRD patients requires nephrology attending approval and documented family discussion of risks to preserve upper extremity veins.
Green (Lower Risk) Medications
Lower risk medications include common antibiotics (ampicillin, cephalosporins, aminoglycosides), standard IV fluids (normal saline, lactated Ringers, dextrose <10%), and routine medications like heparin and fentanyl. These agents pose minimal risk of tissue injury if extravasation occurs and are generally safe for peripheral administration.
Yellow (Intermediate Risk) Medications
Intermediate risk medications include vancomycin, certain antibiotics (nafcillin, erythromycin), sedatives (midazolam, lorazepam), and solutions with moderate osmolarity (dextrose 10-12.5%, TPN <950 mOsm/L). These agents require careful monitoring and may cause phlebitis or moderate tissue injury with extravasation, warranting consideration of central access for prolonged therapy.
Red (Higher Risk) Medications and Vesicants
Higher risk medications include vesicants and irritants such as vasopressors (dopamine), hypertonic solutions (>12.5% dextrose, >3% sodium chloride/bicarbonate), calcium salts, and all chemotherapy agents. Extravasation of these medications can cause severe tissue necrosis, compartment syndrome, and permanent limb dysfunction, necessitating central venous access and adherence to extravasation treatment protocols (P&T II-113).
Extravasation Risk and Safety Principles
No intravenous infusate is completely safe, as even normal saline extravasation can cause compartment syndrome and tissue loss. All IV sites require vigilant monitoring, and clinicians should refer to CCHMC formulary or pharmacy for unlisted medications. Emergency medical situations may necessitate deviation from these guidelines when immediate vascular access is critical.
Statements in this guideline
For nephrology patients requiring treatment 0-5 days, green-risk medications may be given via peripheral intravenous line, yellow-risk medications may be given via peripheral intravenous line, and red-risk medications require a non-tunneled central venous catheter such as a PICC.
For nephrology patients requiring treatment 6-14 days, green-risk medications may be given via peripheral intravenous line, yellow-risk medications may be given via peripheral intravenous line, and red-risk medications require a non-tunneled central venous catheter such as a PICC.
For nephrology patients requiring treatment 15 days to 2 months, green-risk medications may be given via non-tunneled central venous catheter or midline, yellow-risk medications may be given via non-tunneled central venous catheter or midline, and red-risk medications require a non-tunneled central venous catheter such as a PICC.
For nephrology patients requiring treatment greater than 2 months, green-risk medications may be given via non-tunneled central venous catheter, PICC, tunneled central venous catheter, or port; yellow-risk medications may be given via non-tunneled central venous catheter, PICC, tunneled central venous catheter, or port; and red-risk medications require a tunneled central venous catheter or port.
Use of a midline or PICC in a patient with documented chronic kidney disease stages 2-5 or end-stage renal disease requires a verbal discussion with the family of risks as well as verbal discussion and approval by the nephrology attending to the vascular access team nurse.
Midline or PICC use is intended for the rare chronic kidney disease patient where it has been discussed and documented that he or she would not be considered a candidate for future renal replacement therapy, or for extremely difficult access situations.
For treatment of extravasation, refer to CCHMC Policy P&T II-112.
Gross extravasation, even of normal saline, may result in serious harm including compartment syndrome, causing ischemia and loss of tissue or permanent loss of limb function.
For extravasation treatment of chemotherapy drugs, refer to policy P&T II-113.