Can you recognize the risk factors for vesicant extravasation?

Certain chemotherapy drugs have tissue-damaging properties and can cause progressive, persistent, and painful ulceration if administered incorrectly. The severity of the injury is related to whether the drug is a vesicant or irritant and whether the drug binds to DNA. Because the initial manifestations can be subtle, extravasation must be differentiated from other paravenous reactions, such as flare or recall reactions. Little evidence exists from human studies to guide the management of vesicant extravasation, and most recommendations remain empirical and controversial.

Risk factors for extravasation can be device, location, agent, patient, and clinician related (see Table 1).

Education can help minimize the risk of extravasation. All nurses who administer chemotherapy or monitor patients receiving continuous IV chemotherapy should complete a certified chemotherapy course and demonstrate essential knowledge and clinical skills. Competency includes risk identification, prevention and management of extravasation, peripheral IV and implanted venous access port (IVAP) skills, appropriate use of venous devices (e.g., peripheral IV, peripherally inserted central catheters, tunneled central venous catheters, IVAPs), and components of adequate documentation. In addition, strict institutional policies and procedures can reduce extravasation risk. Nurses should review the ONS Chemotherapy Guidelines and Recommendations for Practice (Polovich, White, & Kelleher, 2005) regarding recommendations and controversies. Nurses, physicians, and pharmacists must work together to implement systems to reduce the risks for vesicant injury. They also can argue for standardization of institutional practice and help develop practice guidelines if they are not in use.

Vesicant Chemotherapy Agents

* Cisplatin

* Daunorubicin

* Epirubicin

* Mechlorethamine

* Mitomycin

* Paclitaxel

* Vincristine

* Vinorelbine

* Dactinomycin

* Doxorubicin

* Idarubicin

* Melphalan

* Oxaliplatin

* Vinblastine

* Vindesine

Signs of Peripheral Extravasation

* Sudden swelling

* Palpable subcutaneous fluid

* Pain, stinging, or burning

* No (or loss of) blood return

* Fluid leaking at needle

Additional signs with tunneled central venous catheters and peripherally inserted central catheters include cough, pleural effusions, chest pain, and dyspnea.

Management of Extravasation

Strategies for managing extravasation have not been systematically tested in randomized clinical trials, but one drug, hyaluronidase (Vitrase[R], ISTA Pharmaceuticals, Irvine, CA), has been approved by the U.S. Food and Drug Administration for treatment. Hyaluronidase is recommended for extravasation caused by docetaxel, vinblastine, vincristine, and vinorelbine. Sodium thiosulfate is the only antidote currently recommended by ONS for extravasation of mechlorethamine or concentrated cisplatin. Other potentially useful antidotes include dimethyl sulfoxide, dexrazoxane, and growth factors. Corticosteroids no longer are believed to be useful in most cases, but dexamethasone may relieve inflammation after oxaliplatin extravasation. Other methods for managing extravasation include empirical comfort measures (e.g., heat or cold, limb elevation); surgical debridement; localization of anthracycline; removal of the agent by stab incisions, flushing with saline, and drain placement; or surveillance.

Treatment decisions are based on sequential judgments.

* If extravasation is suspected or confirmed, stop the infusion and determine the drug properties.

--If the drug is a vesicant, decide if necrosis is likely.

--If likely, consult a plastic surgeon who may use additional physical methods (e.g., stab incisions, drains, saline flush) to eliminate the agent within 24 hours.

--If not likely, watch for induration. If it develops, consult a plastic surgeon and possibly use surgical debridement.

* If not a vesicant, use only comfort measures.

References

Camp-Sorrell, D. (2004). Access device guidelines: Recommendations for nursing practice and education. Pittsburgh, PA: Oncology Nursing Society.

Hadaway, L. (2004). Preventing and managing peripheral extravasation. Nursing, 34, 66-68.

Luke, E. (2005). Mitoxantrone-induced extravasation. Oncology Nursing Forum, 32, 27-29.

Polovich, M., White, J., & Kelleher, L. (Eds.). (2005). Chemotherapy and biotherapy guidelines and recommendations for practice (2nd ed., pp. 68-84, 89). Pittsburgh, PA: Oncology Nursing Society.

Pamela Oestreicher, PhD, ONS Scientific Writer

RELATED ARTICLE: Key Definitions.

Extravasation: leakage of a drug or drug solution from a vein into surrounding tissue

Induration: the process of becoming or the state of being hard

Necrosis: tissue death

Vesicant: an agent that causes blistering tissue damage

Irritant: an agent that causes inflammation that includes soreness and redness

Flare: a localized, self-limiting hypersensitivity response, usually to anthracycline or mechlorethamine

Recall: a reaction in which tissue responds to an agent after a previous exposure; a delayed, local response

Table 1. Risk Factors for Extravasation

Note. Based on information from Camp-Sorrell, 2004; Hadaway,
2004; Luke, 2005.

Risk Factor               Examples

Device related            * Metal needles, large-gauge
                            catheters

Peripheral IV access      * Inadequately secured IV needle or catheter
                          * Undesirable IV site location (antecubital
                            fossa, dorsum of hand or wrist rather than
                            forearm)

Central venous catheter   * IV access device surgically placed in area
IV access                   prone to movement, poor ability to secure
                          * Inadequately secured needle in access
                            device
                          * Inappropriate needle length for access
                            device (i.e., too short to reach the back
                            of port body)
                          * Development of fibrin sheath at the tip of
                            the catheter
                          * Catheter or port separation, breakage, or
                            dislodgement
                          * Flushing with small-gauge syringe

Agent related             * Vesicant potential
                          * Volume infiltrated
                          * Drug concentration
                          * Repeated use of same vein for vesicant
                            administration

Patient related           * Age (very young or old)
                          * Impaired communication
                          * Compromised circulation
                          * Altered sensory perception
                          * Poor understanding of risk related to
                            anxiety and fear, cultural barriers, and
                            medications

Clinician related         * Lack of knowledge
                          * Lack of IV skills
                          * Unfamiliarity with central venous catheter
                            use and management
                          * Interruptions and distractions during drug
                            administration