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Extravasation

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Shared care information

If extravasation of vesicant chemotherapy occurs in a shared care centre then:

  • Contact the paediatric oncologist on call.
  • Refer to your local DHB extravasation protocol as well as the information listed below. This will have information on the drugs available in your institution and where they are located.

Extravasation of Chemotherapeutic Agents

If extravasation occurs, the local policy and procedure manual of extravasation MUST be consulted for full information. For further information please consult your local manual.

Background

Anti-cancer drugs can be divided into 5 categories:

Vesicants (Group A)

anthracyclines and related drugs - daunorubicin, doxorubicin, epirubicin, idarubicin, amsacrine
vinca alkaloids - vincristine, vinblastine, vindesine
some antitumour antibiotics - actinomycin D, mitomycin 
some alkylating agents - carmustine (BCNU), dacarbazine (DTIC), mustine.

Exfoliants (Group B)

Capable of causing inflammation and shedding of skin, but less likely to cause tissue death:

cisplatin
liposomal daunorubicin, liposomal doxorubicin 
mitozantrone 

Irritants (Group C)

Capable of causing inflammation and irritation, rarely proceeding to breakdown of the tissue:

Carboplatin
Epipodophyllotoxins - etoposide (VP16), teniposide (VM26). 
Bleomycin 
Dacarbazine 
Dexrazoxane 
Ifosfamide 
Thiotepa 

Inflammatory agents (Group D)

Capable of causing mild to moderate inflammation and flare in local tissues:

etoposide phosphate
methotrexate 

Non-vesicants (Group E)

Very rarely associated with local tissue necrosis:

asparaginase
some alkylating agents - cyclophosphamide, melphalan 
cytarabine 

Irritation and flare are local reactions and must be distinguished from extravasation in which the injected drug leaks into tissues surrounding the vein.

Irritants cause:

  • local inflammatory reaction
  • tenderness along vein with burning, tightness and erythema
  • intact blood return
  • short term injury that does not lead to tissue injury or necrosis.

Irritation can be minimised by further diluting the drug or slow intermittent injection into a continuous IV crystalloid infusion.

A flare is a local allergic reaction causing red blotches along the vein usually with itching.

Vesicants may cause:

  • Erythema and blistering
  • Symptoms may be delayed for up to 6 - 12 hours after drug extravasation. Complaints of pruritus are common.
  • Severe necrosis may occur which may be over weeks
  • Level of tissue damage depends on the vesicant potential of the drug, the volume and concentration infused, the site of infiltration, length of exposure and the immediate measures taken once extravasation occurs.

Children are at higher risk of extravasation if they:

  • have small or difficult veins
  • are obese
  • are receiving steroids (thins skin and endothelium).

Prevention of Extravasation

All staff involved in the administration of chemotherapy MUST be familiar with their local policy and procedure manual on extravasation of vesicant drugs.

  • All chemotherapy given via a central venous catheter is given by a nurse credentialed for chemotherapy administration according to hospital policy.
  • All chemotherapy given via a peripheral cannula is administered by a senior experienced chemotherapy accredited person.
  • Nurses and doctors should be aware of vesicant drugs and their risks.
  • Concentration of chemotherapy must not exceed manufacturers' recommendations.

Device used for infusion

Central venous catheter

  • Essential for the administration of any vesicant drug that is given by infusion. Extravasation can occur into the tissues surrounding the Port. The most common cause of extravasation associated with Ports is needle dislodgment or incorrectly placed Port needle. If the needle is not fully through the septum, fluid may leak back alongside the needle and into the tissues. Ensure that blood can be aspirated from the line and that there is no leakage from around the exit site. If blood cannot be aspirated follow the Central Venous Catheter Nursing Protocol.

Peripheral venous catheter
Acceptable for the bolus injection of vesicant drugs:

  • use a well-secured, freshly-inserted cannula, not a butterfly needle
  • check patency of vein using a saline flush before injection of chemotherapy
  • ensure that there is backflow of blood. If there is no backflow, do not proceed - resite cannula. However, backflow does not, in itself, guarantee that the bevel is entirely in the vein.
  • site tip of cannula away from joint. Extravasation over a joint can cause contractures with major functional consequences.
  • avoid the cubital fossa. Extravasation here is difficult to detect early and it is over a joint.
  • use dilute injections of chemotherapy eg vincristine 1mg/ml. The larger volume makes extravasation easier to detect and greater dilution means potentially less vesicant effect.
  • observe injection site constantly for signs of infiltration during infusion.
  • vein should be irrigated with saline after the drug is infused in order to flush the vein and avoid leakage of drug on withdrawal of the catheter.

Recognition of Extravasation

If extravasation occurs, the local policy and procedure manual of extravasation MUST be consulted for full information.

Any suspected extravasation must be discussed with the oncologist on call immediately.

  • Burning /stinging pain around the injection or infusion site.
  • Sudden onset of agitation in a young child
  • Occasionally there will be no pain initially only itching
  • A change at the infusion site:
    • Swelling
    • "solid" redness i.e., "sudden cellulitis"
    • blanching
    • fluid leakage out of injection site.
  • Resistance while giving drug
  • Specific to central venous catheters:
    • Pain/burning over chest wall, groin, peri-clavicular, neck or shoulder pain depending on site of port
    • Swelling at vein insertion site - usually in the neck
    • Swelling along subcutaneous tunnel.

Management

If extravasation occurs, the local policy and procedure manual of extravasation MUST be consulted for full information.

The components of an extravasation kit should be readily available in each hospital that administers vesicant chemotherapy (including by CVL).

If extravasation of a vesicant drug is suspected, notify the paediatric oncologist on call, and:

  1. Stop injection immediately. Do not remove the cannula/needle at this stage.
  2. Detach syringe or line containing remaining chemotherapy.
  3. Attach new syringe and aspirate as much fluid and blood as possible from the subcutaneous space.
  4. Remove cannula/needle while still aspirating.
  5. Apply appropriate pack:
    1. vincristine/vinblastine/vineralabine/paclitaxel/docitaxel/etoposide - apply a warm pack for 20 minutes qid.
    2. all other vesicants except oxaliplatin - apply a cold pack to the site for at least an hour then for 15 minutes qid
    3. oxaliplatin - do not apply hot or cold pack.
  6. Elevate limb.
  7. Keep patient nil by mouth.
  8. Administer analgesia IV as required.
  9. Administer antidote as recommended below:
    1. anthracyclines - consider IV dexrazoxane if available. This is administered via a large calibre vein in an extremity OTHER than the one that is affected by the extravasation.
    2. OR apply DMSO (do not use both). The person applying the DMSO should avoid contact, use double gloves and metal forceps to apply dressing.
      Cortico steroids worsen toxicity
    3. Vinca alkaloids - apply hyaluronidase (cortico steroids worsen toxicity)
    4. all other vesicants - apply 1% hydrocortisone cream dressings.
  10. Contact the on-call paediatric or plastic surgeon for consideration of soft tissue saline irrigation under anaesthetic.
  11. Complete incident form.
  12. Arrange for clinical photographs to be taken.
  13. Prescribe Augmentin IV/PO.

If extravasation of an irritant drug is suspected:

  1. Stop injection immediately. Do not remove the cannula/needle at this stage.
  2. Detach syringe or line containing remaining chemotherapy.
  3. Attach new syringe and aspirate as much fluid and blood as possible from the subcutaneous space.
  4. Remove cannula/needle.
  5. Inform medical staff.
  6. Give pain relief.
  7. Elevate limb and encourage movement.
  8. Cover with ice pack/cold compress for 1 hour and then observe site.
  9. Complete incident report form.
  10. After 1 hour, if erythema present then send home with topical corticosteroid dressing to be changed daily with regular review.
  11. If blistering/ulceration occurs, discuss with plastic surgeons.

References

  1. Doellman D, Hadaway L, Bowe-Geddes L, Franklin M, Le Donne J, Papke-O'Donnell LP, Pettit J, Schulmeister L, Stranz M. Infiltration and Extravasation- update on prevention and management. The Art and Science of Infusion Nursing (2009) , 32 (4) 203-211
  2. Auckland District Health Board (2012) intranet. Medications-Cytotoxic-Extravasation Policy 
  3. Canterbury District Health Board ( retrieved 29 May 2015) http://www.cdhb.health.nz/Hospitals-Services/Cancer-Blood-Services/Cytotoxic-Biotherapy/Documents/Management%20of%20Extravasation%20of%20Cytotoxic%20Drugs.pdf

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Document Control

  • Date last published: 30 July 2015
  • Document type: Clinical Guideline
  • Services responsible: National Child Cancer Network