POGO

icon-facebook

Satellite Manual

3.2 Accidental Exposure/Spills

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:

  1. Anticipate the possibility of extravasation.
  2. Ensure extravasation treatment protocol and antidotes are readily available.
  3. Careful vein selection for PIVs.
  4. Minimize number of venipunctures in starting PIVs.
  5. 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.
  6. Ensure free flowing Intravenous fluids during administration of vesicant chemotherapy when applicable.
  7. 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:

  1. Dorsum of hand
  2. Forearm
  3. 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

  1. C. Cancer Agency Policy III-20, Extravasation of Chemotherapy, Prevention and Management of, Revised November 2014, Approved by Provincial Systemic Program Committee.
  2. Cancer Care Ontario, Appendix 2 – Extravasation of Chemotherapy (Revised October ) Retrieved from https://www.cancercare.on.ca/cms/one.aspx?portalId=1377&pageId=10760
  3. Fabian, B. Intravenous complications: Infiltration. Journal of Intravenous Nursing 2000; 23(4):229-31.
  4. Froland, K. Extravasation injuries. J WOCN 2007; 34 (3): 299-302.
  5. Hooke MC. Clinical nurse specialist and evidence-based practice: Managing anthracycline extravasation. Journal of Pediatric  Oncology  Nursing 2005; 22(5): 261-4.
  6. Kassner E. (2000). Evaluation and treatment of chemotherapy extravasation injuries. Journal of Pediatric Oncology Nursing 2000 Jul; 17(3):135-48.
  7. Kline, N. (2011) The Pediatric Chemotherapy and Biotherapy Curriculum, Third Edition, Association of Pediatric Hematology/Oncology Nurses.
  8. Langer SW, Sehested M, Jensen PB. Treatment of anthracycline extravasation with dexrazoxane. Clin Cancer Res; 2000; 6: 3680-86.
  9. 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.
  10. London Health Sciences Centre Formulary, Chemotherapy Extravasation Management Protocol. London, ON, Canada, Revised May 2011, Approved by Drugs and Therapeutics Committee.
  11. 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.
  12. 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.
  13. 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.
  14. 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.
  15. 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.
  16. 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.
  17. 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.
  18. 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.
  19. Schulmeister, L. Preventing and managing vesicant chemotherapy extravasations. J Support Oncol 2010; 8(5): 212-15
  20. 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.

3.3.1 Sample Extravasation Documenting Tool
Back to Top

In this Section

  • 1.1 History & Overview
  • 1.2 Acknowledgements
  • 1.3 Committees and Working Groups
  • 1.4 Satellite Manual Disclaimer
  • 2.1 Principles of Satellite Care
  • 2.2 Eligible Patients
    • 2.2.1 Children Eligible for Chemotherapy Administration in a Satellite Centre
    • 2.2.2 Children Not Eligible for Chemotherapy Administration in a Satellite Centre
    • 2.2.3 Children Eligible for the Management of Complications on a Satellite Centre
    • 2.2.4 Eligibility of Children Requiring Supportive Care
  • 2.3 Scope of Satellite Practice
    • 2.3.1 Implementation of Psychosocial Treatment Plan (Process for Communication)
    • 2.3.2 Limitations on Satellite Practice
  • 2.4 Advanced Satellite Practice
  • 3.1 Safe Handling, Administration and Disposal of Chemotherapy Agents
  • 3.2 Accidental Exposure/Spills
  • 3.3 Extravasation Management
    • 3.3.1 Sample Extravasation Documenting Tool
  • 3.4 Injecting SC Medication Via an Insuflon
  • 3.5 Chemotherapy Administration Reference List
  • 3.6 Central Venous Catheter Care
  • 3.7 Chemotherapy Quick Reference
    • 3.7.1 Rapid Hydration Document
    • 3.7.2 Provider Guide: Prevention and Management or Irinotecan induced Diarrhea
    • 3.7.3 Parent Handout: Prevention and Management of Irinotean induced diarrhea
    • 3.7.4 Capizzi Methotrexate
    • 3.7.5 Erwinia L-Asparaginase
  • 4.1 Management of Fever and Neutropenia
    • 4.1.1 Routine Order Sample Sheet
    • 4.1.2 Fever Cards (Sample)
    • 4.1.3 Criteria for low-risk designation. Risk categorization refers to risk of bacteremia and serious complications, including mortality.
  • 4.2 Pentamidine Administration
    • 4.2.1 Inhaled Pentamidine
    • 4.2.2 Intravenous Pentamidine
  • 4.3 Antiemetics
  • 4.4 Treatment of Varicella-Zoster Infections
  • 4.5 TPN Document
  • 4.6 Immunization of Children with Cancer
  • 4.7 Transfusion
  • 4.8 When to consult the Tertiary Centre
  • 5.1 Palliative Care Overview
  • 5.2 Communication
  • 5.3 Settings of Care
  • 5.4 Symptom Management
  • 5.5 End of Life
  • 5.6 When a Child Dies in the Satellite Centre
    • 5.6.1 Reconciling your grief
    • 5.6.2 Funeral arrangement checklist
    • 5.6.3 Helping Children who grieve
    • 5.6.4 Coping with the Holidays
    • 5.6.5 The grieve experience
  • 6.1 Goals and Objectives
  • 6.2 Participant Site Selection
    • 6.2.1 Tertiary Site Selection
    • 6.2.2 Community Site Selection
  • 6.3 POGO’s Roles
    • 6.3.1 PHIPA, Privacy and Research
  • 6.4 Funding
    • 6.4.1 Funding Support for Tertiary Activity
    • 6.4.2 Financial Support for Pediatric Oncology Community Activity
  • 6.5 Infrastructure and Formal Requirements
    • 6.5.1 Tertiary Partners’ Role in Provincial Pediatric Oncology Satellite Program
    • 6.5.2 Satellite Partners’ Role in Provincial Pediatric Oncology Satellite Program
  • 7.1 Preamble
  • 7.2 Investigator responsibilities
  • 7.3 Training Requirements
    • 7.3.1 General Training for Conduct of Research
    • 7.3.2 Protocol Specific Training
  • 7.4 Research Activites that may be completed in satellite centres under supervision of DSI
  • 7.5 Research Activities to be completed in Tertiary Centres Only
  • 7.6 Recognition and Reporting of Adverse Events (AEs)
  • 7.7 Data Transfer
  • 7.8 Pharmacy Drug Accountibility
  • 7.9 Site Inspections and Quality Assurance
  • 8.1 Pediatric Oncology Shared Care Initial Data Transfer Sheet
  • 8.2 Shuttle Sheet
  • 8.3 Psychosocial Communication Tool
  • 9.1 Satellite Readiness/ Preparedness Checklist
  • 9.2 Education Report for Tertiary Centres
  • 9.3 Education Report for Satellite Centres
  • 9.4 Vital Signs Report
  • 9.5 Self- Assessment
  • 9.6 Satellite Contact Form
  • 9.7 Annual Satellite Caseload Report
  • 9.8 POGO Provincial Satellite Program Annual Accounting Report
Back to table of contents
Search our Manual
Have a question?
Contact us at: satellite@pogo.ca
  • About Us
    • Diversity, Equity, Inclusion
    • Childhood Cancer Care Plan
    • Our Mission and Vision
    • Our Board
    • Our Partners
    • Our Donors
    • Privacy
    • History & Milestones
    • Reports
    • Newsroom
    • Job Opportunities
    • Accessibility
    • Staff List
  • Programs & Support
    • Patient Care Programs
    • Financial Assistance
    • Survivor Care
    • Cancer Resources
    • Childhood Cancer Resource Guide
    • Inspiring Stories
    • Clinical and Program Advisory Committees
  • Education
    • POGO AfterCare Education Day
    • POGO Multi-Disciplinary Symposium on Childhood Cancer
    • All Education Events & Conferences
  • Healthcare Practice
    • COVID-19 Updates
    • Pediatric Oncology Nursing
    • Clinical Practice Guidelines
    • Satellite Manual
  • Research & Data
    • 2020 POGO Surveillance Report
    • POGO Research Unit
    • POGONIS – Childhood Cancer Database
    • Data Reports
    • Data Requests
  • Get Involved
    • Pajamas and Pancakes
    • Birthday Parties for POGO
    • Events
    • Volunteer
  • Ways to Give
    • Donate
    • Gifts of Stock and Securities
    • Become a Corporate Partner
    • Gifts in Honour/Memory
    • Legacy Gifts
    • Shop Online/Earn Cash Back

©2020 Pediatric Oncology Group of Ontario

480 University Avenue, Suite 1014 | Toronto, Ontario, M5G 1V2, Canada | Charitable Registration Number: 871067245RR0001 | Contact Us
1-855-FOR POGO (367-7646) | Website Privacy Policy | Website Disclaimer | Satellite Manual Disclaimer |