3.3 Extravasation Management
The following procedures outline recommendations for the prevention and treatment of extravasation of chemotherapy agents. Chemotherapy should only be administered by an Association of Pediatric Hematology/Oncology Nurses (APHON) certified personnel with demonstrated knowledge of and clinical skills in the administration of chemotherapy. Maintain provider status as per APHON standards. Extravasation can occur with either peripheral intravenous (PIV) or central line intravenous administrations.
Definitions
Extravasation is the inadvertent leakage of vesicant drug or solution into the tissues surrounding an intravenous (IV) site.
Vesicant is an agent that can cause blistering or tissue necrosis when extravasated.
Irritant is an agent that can cause a local inflammatory reaction but does not cause tissue necrosis when extravasated.
None refers to an agent that is considered not to be a vesicant or an irritant.
Signs of extravasation include the following:
- Pain and/or burning in the infiltrated area
- Swelling near the IV injection site or along venous tract
- Erythema in the infiltrated area
- Poor or absent blood return from the IV catheter
- Increase in IV pump pressures
Signs of irritant or vesicant extravasation:
- Aching and tightness along vein
- Full length of vein may become erythematous and/or discolored
- Swelling unlikely
- Usually able to get blood return
Flare Reaction
- No pain
- Immediate blotches or streaks along vein which usually subside within 30 minutes with or without treatment
- Swelling unlikely, wheals may appear along vein line
- Usually able to get blood return
Signs and Symptoms Associated with Vesicant Extravasation, Venous Irritation and Flare Reaction
| SIGN/SYMPTOM | VESICANT | IRRITANT | FLARE |
| Pain | + | + | – |
| Swelling | + | – | – |
| Erythema | + | + | – |
| Pump pressure increase | + | – | – |
| Poor or absent blood return | + | +/- | – |
| Ulceration | + (delayed) | – | – |
Below is a list of antineoplastic vesicants and irritant drugs classified into the following categories:
(See Section ‘Guidelines for Management of Extravasation of Vesicant Antineoplastic Drugs’ below)
|
Vesicant |
Nonvesicant |
|
| Irritant | None | |
| Amsacrine | Arsenic trioxide | Aldesleukin |
| Busulfan | Bortezomib | Asparaginase |
| Carmustine | CISplatin | Bacillus Calmette–Guérin vaccine (BCG) |
| Dactinomycin | Dacarbazine | Bevacizumab |
| DAUNOrubicin (DAUNOmycin) | DOCEtaxel | Bleomycin |
| DOXOrubicin (Adriamycin) | Etoposide (VP-16) | Brentuximab |
| Epirubicin | Mesna (undiluted) | Buserelin |
| IDArubicin | MitoXANTRONE | CARBOplatin |
| Mechlorethamine (Nitrogen Mustard) | 1Oxaliplatin | Cladribine |
| Melphalan | 2PACLitaxel | Clodronate |
| Mitomycin | Teniposide (VM-26) | Cyclophosphamide |
| Streptozocin | Temozolomide | Cyproterone |
| VinBLAStine | Cytarabine | |
| VinCRIStine | Dexrazoxane | |
| Vindesine | Fludarabine | |
| Vinorelbine | Fluorouracil | |
| Gemcitabine | ||
| Ifosfamide | ||
| Interferon | ||
| Irinotecan | ||
| Leucovorin | ||
| Methotrexate | ||
| Pentostatin | ||
| Raltitrexed | ||
| RiTUXimab | ||
| Thiotepa | ||
| Topotecan | ||
| Trastuzumab | ||
| 1, 2 Treat like a vesicant | ||
| Adapted from the BCCA Cancer Drug Manual, BC Cancer Agency, November 2014
Adapted from Chemotherapy Extravasation guidelines LHSC, revision June 2015 |
||
Guidelines for Prevention of Extravasation
Vesicant antineoplastic agents should be administered by qualified personnel. Vesicant/irritant drugs should be administered via Central Venous Catheters (CVCs) whenever possible.
Consider the following measures to prevent extravasation:
- Anticipate the possibility of extravasation.
- Ensure extravasation treatment protocol and antidotes are readily available.
- Careful vein selection for PIVs.
- Minimize number of venipunctures in starting PIVs.
- Ensure good blood return from site prior to administration, during and upon completion. If infusion is less than one hour check for blood return every 15 min. If greater than one hour check site and blood return every hour.
- Ensure free flowing Intravenous fluids during administration of vesicant chemotherapy when applicable.
- Frequent monitoring if PIV/port needle sites or CVC site and monitor for increase in pump pressures.
Extravasation supplies should be available.
Starting a New PIV for Administration of Vesicant Drugs
Choose PIV site carefully. Choose the most distal position of a vein and in this order if possible:
- Dorsum of hand
- Forearm
- Wrist (potential damage to tendons and nerves should extravasation occur)
Avoid the antecubital fossa since this area is dense with tendons and nerves; damage here can result in loss of structure and function.
If first attempt is unsuccessful, select another site preferably in another limb. Avoid a distal point in the same vein because of the potential for extravasation “downstream”.
Guidelines for Management of Extravasation of Vesicant
The following guidelines are recommended for the management of extravasation. The medical team should be notified immediately and treatment must be individualized to each extravasation event.
*It is unclear whether injection of antidotes into area of extravasation is of benefit. Most small extravasations do not result in serious problems without the injection of antidotes.” (BCCA Cancer Drug Manual, BC Cancer Agency November 2014.)
| Important Steps | Key Points | |
| 1. | STOP the IV infusion. Do not remove the IV/port needle yet |
Click here to access the Flowchart available for quick reference. |
| 2. | Detach IV tubing/syringe from the IV/port needle. Attach a new syringe to the IV/port needle as close as possible to insertion site. Aspirate as much drug, blood and tissue fluid as possible. Remove the syringe. | |
| 3. | Notify the medical team of extravasation as soon as possible. | |
| 4. | REMOVE the original angiocatheter/port needle. | |
| 5 | Consult section ‘Antidotes and treatments of extravasation’ below. | |
| 6. | Continue as per table below for each drug. | |
| 7. | Administer analgesics as ordered. | Corticosteroid cream (e.g. hydrocortisone 1% cream) may reduce inflammation.
Silver Sulfadiazine cream, povidone iodine ointment or sterile dressings may also provide symptomatic relief or prevent secondary infection. |
| 8. | For PIVs, restart the IV at another site, preferably in the opposite limb or in the same limb proximal to the infiltrated area, if needed. For Port-a-catheter, re-access to heparin lock. |
|
| 9. | Immobilize the affected limb or area. Elevate the affected area to promote venous drainage and to reduce edema. | |
| 10. | Document the extravasation occurrence in the patient’s chart and complete your hospital Safety Report. Photo documentation may be helpful. Consent may be required. | |
| 11. | Consult Plastics upon Medical Doctor(MD) /Nurse Practitioners (NP) discretion and/or no improvement of site in 24 hours. | |
| 12. | Extravasation known: Return to clinic in 24-48 hours for assessment, then weekly for one month minimum. Extravasation suspected: Telephone call in 24 hours by nurse to assess and then in one week minimum. |
Provide Information to patient/ family with what to look for and when to call. The site should be observed daily by the patient and/or parent for one month as there may be delayed reaction. |
Guidelines for Management of Extravasation of Irritant Drugs
The following guidelines are recommended for the management of extravasation. The medical team should be notified immediately and treatment must be individualized to each patient. While the medical team may elect to use an antidote if one exists, or topical medications, it is important to realize that many patients recover fully with no drug treatment at all.
| Important Steps | Key Points | |
| 1. | Stop IV infusion. Do not remove angiocatheter/port needle yet. |
Click here to access the Flowchart available for quick reference. |
| 2. | Detach IV tubing/syringe from IV/port needle. Attach a new syringe to IV/port needle as close as possible to insertion site. Aspirate as much drug, blood, and tissue fluid as possible. Remove the syringe. | |
| 3. | Notify the medical team of extravasation as soon as possible. | |
| 4. | REMOVE the original angiocatheter/port needle. | |
| 5. | Continue as per table below for each drug. | |
| 6. | Administer analgesics as ordered. | Corticosteroid cream (e.g. hydrocortisone 1% cream) may reduce inflammation.
Silver Sulfadiazine cream, Povidone iodine ointment or sterile dressings may also provide symptomatic relief or prevent secondary infection. |
| 7. | For PIVs, restart the IV at another site, preferably in the opposite limb or in the same limb proximal to the infiltrated area, if needed. For Ports, re-access to heparin lock or re-establish IV. |
|
| 8. | Immobilize the affected limb or area. Elevate the affected area to promote venous drainage and to reduce edema. | |
| 9. | Document the extravasation of occurrence in the patient’s chart and complete your hospital safety report. Photo documentation may be helpful. Consent may be required. | |
| 10. | Consult Plastics upon MD or Nurse Practitioners discretion and/or no improvement of site in 24 hours. | |
| 11. | Extravasation known: Return to clinic in 24-48 hours for assessment, then weekly for one month minimum. Extravasation suspected: Telephone call in 24 hours by nurse to assess and then in one week minimum. |
Provide Information to patient/ family with what to look for and when to call. The site should be observed daily by the patient and/or parent for one month as there may be delayed reaction. Click here for sample documents. |
Antidotes and Treatments of Extravasation
| Compress Required | Actions | Rationale | |
| Amsacrine
Dactinomycin DAUNOmycin (DAUNOrubicin) DOXOrubicinEpirubicin IDArubicin Mitomycin |
COLD | 1. Remove the IV/port needle.
2. Apply 50% DMSO (Dimethyl sulfoxide) topical solution to an area twice that affected by extravasation (approximately 1.5 mL). 3. Allow DMSO to air dry. Do not cover and repeat QID for at least 7 days. 4. Elevate limb and apply gentle pressure to site. 5. Apply ice pack wrapped in towel or cold compresses to the extravasation site for 1 hr; continue cold compresses x 15-20 min, qid for 24-48 hrs. Care must be taken to avoid tissue injury from excessive cold. |
DMSO speeds up removal of the drug from the tissue and is a free-radical scavenger.
Air-drying is required as DMSO may cause blisters with occlusions. Cold compresses cause vasoconstriction and decrease fluid absorption. |
| VinBLAStine
VinCRIStine Vindesine Vinorelbine |
WARM | 1. Remove IV/port needle
2. MD to administer antidote*: hyaluronidase 1500 units dissolved in 1 mL of either sterile water for injection or normal saline injection infiltrated into affected area subcutaneous in a clockwise fashion in divided doses around the site ( as soon as possible after extravasation).14 3. Elevate limb and apply pressure to site 4. Apply warm compresses to extravasation site for 1 hr; continue warm compresses 15-20 min qid for 24-48 hrs. Care must be taken to avoid injury from excessive heat. |
Cooling may have adverse effect |
| Mechlorethamine (Nitrogen Mustard) | COLD | Administer antidote: 2 mLsodium thiosulfate 4% solution for each 1 mg of drug via same IV/Port needle or use 25 gauge needle to inject subcutaneously. (to prepare mix 1.6 ml sodium thiosulfate 25% solution with 8.4 mL sterile water for injection to give 10 mL of a 4 % solution.
1. Remove the IV/ Port needle 2. Elevate limb and apply gentle pressure to site 3. Apply ice pack wrapped in towel or cold compresses to the extravasation site for 1 hr; continue cold compresses for 15-20 min, QID for 24-48 hours. Care must be taken to avoid tissue injury from excessive cold |
|
| Busulfan
Carmustine DOCEtaxel Melphalan PACLitaxel Streptozocin |
COLD | 1. Remove IV/port needle.
2. Elevate limb and apply gentle pressure to site. 3. Apply ice pack wrapped in towel or cold compresses to the extravasation site. Continue cold compresses for 15 to 20 minutes QID for 24 to 48 hours. Care must be taken to avoid tissue injury from excessive cold. |
Cold compresses cause vasoconstriction and decrease fluid absorption |
| Adapted from the BCCA Cancer Drug Manual, BC Cancer Agency, November 2014. | |||
Supply of Antidotes
A supply of antidotes should be readily available and maintained in areas where chemotherapy is administered for easy access.
Hyaluronidase (See Antidote table above)* 1500 units’ injection is a Special Access Medication. A future use supply should be kept in the Pharmacy so that doses may be administered as soon as they are ordered. A Special Access request form must be submitted within 24 Hours.
NOTE: For drugs and antidotes not listed please consult Pharmacy. For non-vesicant/irritant antineoplastic drugs please refer to your hospital guidelines on the treatment for extravasation.
The superiority of dexrazoxane over DMSO has not been established. Dexrazoxane is not included in this policy and DMSO remains the standard of care for anthracycline extravasation. References are provided for a situation where dexrazoxane use may be deemed warranted.
References
- C. Cancer Agency Policy III-20, Extravasation of Chemotherapy, Prevention and Management of, Revised November 2014, Approved by Provincial Systemic Program Committee.
- Cancer Care Ontario, Appendix 2 – Extravasation of Chemotherapy (Revised October ) Retrieved from https://www.cancercare.on.ca/cms/one.aspx?portalId=1377&pageId=10760
- Fabian, B. Intravenous complications: Infiltration. Journal of Intravenous Nursing 2000; 23(4):229-31.
- Froland, K. Extravasation injuries. J WOCN 2007; 34 (3): 299-302.
- Hooke MC. Clinical nurse specialist and evidence-based practice: Managing anthracycline extravasation. Journal of Pediatric Oncology Nursing 2005; 22(5): 261-4.
- Kassner E. (2000). Evaluation and treatment of chemotherapy extravasation injuries. Journal of Pediatric Oncology Nursing 2000 Jul; 17(3):135-48.
- Kline, N. (2011) The Pediatric Chemotherapy and Biotherapy Curriculum, Third Edition, Association of Pediatric Hematology/Oncology Nurses.
- Langer SW, Sehested M, Jensen PB. Treatment of anthracycline extravasation with dexrazoxane. Clin Cancer Res; 2000; 6: 3680-86.
- Llinares ME, Bermudez M, Fuster JLet al. Toxicity to topical dimethyl sulfoxide in a pediatric patient with anthracycline extravasation. Pediatric Hematology and Oncology 2005;22(1):49-52.
- London Health Sciences Centre Formulary, Chemotherapy Extravasation Management Protocol. London, ON, Canada, Revised May 2011, Approved by Drugs and Therapeutics Committee.
- Mader I, Furst-Weger PR, Mader R, et al. Amsacrine. In: Mader I, ed. Extravasation of cytotoxic agents: Compendium for prevention and management. Vienna, Austria: Springer; 2003. p.59-60.
- Medication Extravasation, Treatment of, Clinical Standards Manual, Children’s Hospitals and Clinics, Minneapolis/St. Paul, Minnesota, Feb 11, 2005, page: E-105.1-105.6.
- Mouridsen HT, Langer SW, Buter J, et al. Treatment of anthracycline extravasation with Savene (dexrazoxane): results from two prospective clinical multicentre studies. Ann Oncol 2007; 18(3): 546-50.
- Olver IN, Aisner J, Hament A. et al. A prospective study of topical dimethyl sulfoxide for treating anthracycline extravasation. J Clin Oncol 1988; 6(11):1732-35.
- Perez Fidalgo JA, Garcia Fabregat L, Cervantes A, et al. Management of chemotherapy extravasation: ESMO-EONS Clinical Practice Guidelines. Ann Oncol 2012; 23(Suppl 7): vii167-73.
- Pizzo PA, Poplack DG (eds). Local treatment for chemotherapy extravasation. In: Principles and Practice of Pediatric Oncology, Table 44-7. Lippincott Williams & Wilkins, United States 2002.
- Polovich M, Whitford JM, Olsen M, eds Chemotherapy and Biotherapy Guidelines and Recommendations for Practice.,3rd ed. Pittsburg, PA: Oncology Nursing Society; 2009. p. 105-10.
- Sauerland, C, Engelking, C, Wickham, R, et al. Vesicant Extravasation Part 1: Mechanisms, Pathogenesis and Nursing Care to Reduce Risk. Oncol Nurs Forum 2006; 336(6) 1134 –41.
- Schulmeister, L. Preventing and managing vesicant chemotherapy extravasations. J Support Oncol 2010; 8(5): 212-15
- Schulmeister, L and Camp-Sorell, D: Chemotherapy extravasation from implanted ports. Oncol Nurs Forum 2000; 27: 531-38
Primary author Ms. Julie Dowler, Children’s Hospital, London Health Sciences Centre, London with input from Ms. Denise Reniers, Children’s Hospital, London Health Sciences Centre Ms. Mary Jo Decourcy, Children’s Hospital, London Health Sciences Centre, and Ms. Anne Chambers, Children’s Hospital, London Health Sciences Centre, London. Reviewed by POGO Satellite Manual Review Nursing Group, 2016 and the POGO Satellite Manual Review Pharmacy Working Group, 2016.