Iron staining tips to avoid a claim

While iron staining claims² can be lower in value than other claims, the increasing volume is concerning – because many of the cases we review could have been avoided, or at least mitigated, by better processes.

I spoke to ACT General Practitioner Dr Gillian Riley for some practical advice on what doctors can do to avoid an adverse event while performing iron infusions.

Q1: How important is patient selection, and what clinical indications should you consider before proceeding with an iron infusion?

Ferinject (ferric carboxymaltose) is a suitable and effective preparation for patients with iron-deficiency anaemia who haven't had any improvement with, or haven't been able to tolerate, oral iron preparations.

At present, it’s PBS listed for this indication.³

Q2: How, and when, should you decline if a patient insists on an infusion against your clinical judgement?

It’s really important not to proceed unless you’re comfortable there will be clinical benefit, and that the patient is aware of (and comfortable with) the potential risks.

In this context particularly, there’s a lot of talk on social media that an iron infusion will be a panacea for fatigue, but unfortunately this is not always the case.

While an iron infusion is a low-risk procedure, it’s not a no-risk procedure. Judicious clinical judgement should always apply.

Q3: How do you manage patient consent, and what level of detail do you provide in relation to the potential for staining?

As part of my consent process, I inform patients that the risk of staining is somewhere around 1 per cent. Some data suggests that staining may fade, but it must be considered permanent and irreversible. Like tattoo removal, cosmetic recourse has its own uncertainty.

I tell my patients we will monitor for issues carefully, but we can make no guarantees with respect to staining. I then show my patients some photos sourced from a reputable online site. I find the use of images to be the most important step in the process. Most patients who are very concerned will decline at this point.

I spend quite a bit of time on the staining aspect, because I know this is the issue where a complaint is most likely to arise. I do this for every patient. In my experience, the patient you least expect is the one most likely to complain, so I feel everyone should have a clear, complete, and well-documented consent.

Q4: How important is the technique of cannulation?

There is a small amount of evidence that extravasation is reduced if using a vein not in a flexural site, so stay away from the wrist or antecubital fossa. I usually use the large veins in the forearm.

There is also evidence that the less vessel trauma, the better. We use a giving set and secure the cannula very well, infusing slowly – generally over 15-20 minutes. We use the smallest suitable cannula size (mostly a 20G; but a 22G is sometimes needed, in which case the infusion rate is slower).

The vessel should flush easily with 10 ml of saline, and flush easily again with 10 ml following. If a patient is hard to cannulate, I would usually abandon the attempt that day, as the chance of the iron leaking out due to vessel trauma may increase if you’ve put multiple holes into a venous system.

Q5: What warning signs should patients and medical staff be aware of as a sign of extravasation?

There isn’t an enormous amount of evidence, but there is one study where patients reported pain, swelling, and prickly and odd feelings at the cannulation site prior to extravasation. It’s important for patients to let you know if they feel anything like that. I also tell my patients to let me know if the cannula feels weird at all, and we will stop. Extravasation can also be painless.

Q6: Iron staining is one of the most common claims arising from infusions, but are there other risks doctors should be aware of?

The biggest risk is nausea at about 3 per cent, followed by hyperphosphatemia at around 2 per cent. There is around a 1 per cent risk of headache, hypertension, injection site reactions and dizziness; and a small, but possible, risk of anaphylaxis.

Pregnant women in the second and third trimester face a very small risk of foetal bradycardia and hypoxia, which is what occurs when mum experiences bradycardia. Pregnant women MUST be taken through the consent process very carefully for this and monitored closely.

We have a nurse monitoring our patients during the infusion, with the doctor in the room next door. We check and document BP, HR and O2 saturation at the commencement, during, and at the end of the infusion. If the patient is pregnant, we also check foetal HR.

Q7: What would be your number one tip for doctors doing iron infusions?

Make sure you’re doing it for the right reasons – and make sure you communicate really clearly with your patients!

References

1. mdanational.com.au/advice-and-support/library/blogs/2020/09/dont-let-iron-infusions-stain-your-reputation
2. mdanational.com.au/advice-and-support/library/articles-and-case-studies/2016/03/iron-infusion-skin-staining 
3. nps.org.au/radar/articles/ferric-carboxymaltose-ferinject-for-iron-deficiency-anaemia

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