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HEALTH SERVICES

CODE: E.9

NURSING PROCEDURE

TITLE: EXTRAVASATION OF CHEMOTHERAPY AGENTS (INFILTRATION) - MANAGEMENT

A. IMMEDIATE CARE

B. POST CARE

CATEGORY: RN – General

PURPOSE

Treat and minimize complications of tissue damage associated with extravasation of vesicant medications.

NURSING ALERT:

A vesicant is a medication that when extravasated can produce local tissue necrosis. (See Appendix A for list of medications)

An irritant is a medication that can produce a high incidence of phlebitis and pain at the injection site.

Signs and symptoms of extravasation may include:

Swelling (most common).

Stinging, burning or pain at the injection site.

IV flow rate that changes in quality, slows or stops.

Leaking around intravenous (IV) catheter or implanted access device/needle.

Sluggish blood return or lack blood return from IV site.

Erythema, inflammation or blanching at the IV site.

Induration.

Vesicle formation.

A. IMMEDIATE CARE EQUIPMENT

1. PPE (Personal Protective Equipment) 2. 3 mL luer lock syringe 3. Sterile gauze pad 4. Plastic backed pad 5. Alcohol swabs 6. Ice pack or dry heat

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CODE E.9

7. Indelible pen or marker 8. Antidote as per physicians order (i.e. Dimethyl Sulforide [DMSO]) 9. Assessment and management of extravasation flow sheet 10. Confidential Occurrence Report

PROCEDURE

1. Don PPE. 2. STOP infusion.

NOTE: Do not flush with IV fluid.

3. Leave IV catheter/IVAD needle in place.

4. Place plastic backed pad under affected site.

5. Disconnect IV tubing from device and attach 3 mL syringe to IV catheter hub or IVAD needle tubing. NOTE: Smaller syringes produce more pressure when flushing and less

pressure when withdrawing.

6. Aspirate as much drug as possible. NOTE: DO NOT remove IV or IVAD needle. 7. Assess site, measure and mark extravasated area with indelible ink.

8. Refer to appendix B for suggested management. 9. Notify physician.

10. Remove IV catheter/IVAD needle while continuing to aspirate from extravasation

site.

NOTE: DO NOT remove catheter/IVAD needle if antidote is ordered through catheter/IVAD needle.

11. Place a sterile gauze pad over insertion site and remove IV or IVAD needle allowing

site to bleed/leak into gauze. NOTE: DO NOT apply pressure manually to site, as this may cause further

tissue damage.

12. Secure clean gauze with paper tape if DMSO not ordered.

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CODE E.9

13. Dispose used items into hazardous waste.

14. Assess symptoms experienced by patient. (i.e. pain, reduced mobility).

15. Apply ice pack or heat. (Appendix B). 16. Elevate and rest affected extremity. 17. Document using assessment and management of extravasation flow sheet. (See

Appendix C). 18. Complete Confidential Occurrence Report. 19. Follow up with Post Care on Section B.

B. POST CARE EQUIPMENT 1. Non occlusive dressing as required, i.e. gauze pad 2. Paper tape as required 3. Normal Saline (N/S) as required 4. Dressing bundle as required

NOTE: Plastic surgeon may be consulted.

PROCEDURE

1. Elevate extremity for 24 - 48 hours post extravasation.

NOTE: After 24 - 48 hours, encourage use of extremity to prevent stiffness, neuropathy and pain.

2. Assess site q4-6h for 24 hours and document findings in notes. 3. Assess for pain and administer analgesics as ordered.

4. Assess dressing (if applicable) and change as ordered.

4.1 Change dressing cleansing with N/S and cover with gauze pad and secure with paper tape.

5. Remove initial gauze within 24 hours if gauze dressing in place.

6. Assess site and document using assessment and management of extravasation

record.

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CODE E.9

NOTE: Keep blisters intact if present. You may see:

Blistering in 3 to 5 days. Peeling and sloughing begins within 2 weeks following

extravasation. Tissue Necrosis is usually evident 2 to 3 weeks post

extravasation. 7. Coordinate follow up care and assessment if patient is discharged.

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HEALTH SERVICES

CODE E.9

REFERENCES: Alberta Health Services (2012). Extravasation, Management Of. BC Cancer Agency. (2014). Policy III-20. Prevention and Management of Extravasation

of Chemotherapy. European Society for Medical Oncology (2012). Management of Chemotherapy

Extravasation: ESMO-EONS Clinical Practice Guidelines. Oxford University Press.

Infusion Nurses Society. (2011). Infusion Nursing Standards of Practice. Journal of

Intravenous Nursing Supplement. 34(1S). NHS East Midlands. (2013). New Chemotherapy agents recently listed on extravasation

management guidelines. http://www.eastmidlinadscancernewtwork.nhs.uk/library/EMCNDC016612Extrav

sastionAdditionalDrugList2Sept13.pdf NHS the Christie. (2014)Management of Extravasation Policy.

http://www.christie.nhs.uk/media/447889/Extravsation%20Policy.pdf. Polovich M, Olsen M., LeFebvre, K.B. (2014) Infusion-Related Complications.

Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. 4th ed. Pittsburgh Pennsylvania: Oncology Nursing Society; 2014. P. 157 – 161.

Vacca, V.M. (2013). Time Critical Vesicant Extravasation. Nursing; 2013 pp 21-22. Written by: B. Beaurivage and L. Roland Date: November 25, 2002 Revised by: Jana Lowey, CNE, Lisa Roland, CNE Date: January 2016

Regina Qu’Appelle Health Region Health Services

Nursing Procedure Committee

Feb 4/16

Keywords: Extravasation Chemotherapy

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Appendix A

Classification of Cytotoxic and Non-Cytotoxic Drugs, Vesicants, Irritant, Non-Vesicant

Vesicant NONVESICANT

IRRITANT NONE

Amsacrine Busulfan

Carmustine Dactinomycin DAUNOrubicin DOXOrubicin

EPIrubicin IDArubicin

Melphalan Mannitol

mitoMYcin

vinBLAStine vinCRIStine vinorelbine

Radiographic contrast media (e.g. contrast

CT solution)

Arsenic trioxide Bendamustine

bortezomib CISplatin

Dacarbazine DOCEtaxel

DOXOrubicin, pegylated liposomal

Etoposides

Fluorouracil

Ifosfamide

Mesna (undiluted) mitoXANtrone OXALiplatin

PACLitaxel PACLitaxel-nab

(Abraxane®) Teniposide

Trastuzumab emtansine

(KADCYLA®)

Aldesleukin

Alemtuzumab Amifostine

Asparaginase Azacitidine

Bevacizumab

Bleomycin BRENtuximab-vedotin

CABAZitaxel

CARBOplatin Cetuximab Cladribine Clodronate

Cyclophosphadmide Cytarabine

Dexrazoxane eriBULin

fludarabine

Gemcitabine

Interferon Ipilimumab Irinotecan Leucovorin

Mesna (diluted)

Methotrexate

Pamidronate

Panitumumab Pembrolizumab

Pemetrexed Raltitrexed rituximab

temsirolimus

thiotepa Topotecan

Trastuzumab (HERCEPTIN®)

*Above chart is copied from Saskatchewan Cancer Agency Care Services Policy, and Procedure Manual. Assessment and Management of Infiltration/Extravasation NSG 603 March 2015*

The following list in NOT ALL INCLUSIVE. Various resources categorize drugs

differently.

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Appendix B

Extravasation Management As extravasations occur infrequently, ethical concerns prohibit large randomized trials. Current

management recommendations are based for the most part on anecdotal experience.

Note The following are suggested antidotes adapted from British Columbia Cancer Agency and Oncology Nursing Society. Reports are conflicting as to the benefits of these antidotes. Most small extravasations do not result in serious problems without injection of antidotes. Injection of specific antidotes should likely be restricted to larger extravasations (>1 – 2 mL).

A physician’s order must be obtained for these antidotes

Type of Extravasation Actions Comments

Anthracyclines (DAUNOrubicin, DOXOrubicin, EPIrubicin, IDArubicin)

Remove venipuncture needle. Apply ice pack for 30 – 60 minutes, then for 15 minutes 4x daily; discontinue ice pack at least 15 minutes prior to dexrazoxane therapy. Care must be taken to avoid tissue injury from excessive cold. Dexrazoxane If available and ordered by the physician Must be given as soon as possible and within 6 hours of the extravasation. Dose: recommended dose is based on patient’s BSA Day one: 1,000 mg/m

2

Max dose- 2,000mg Day two: 1,000 mg/m

2

Max dose- 2,000mg Day three: 500 mg/m

2

Max dose- 1,000mg Dose should be reduced by 50% if the creatinine clearance values < 40 mL/min Monitor CBC & liver enzymes If dexrazoxane unavailable or cannot be started within 6 hours Apply DMSO 50%-99% topical solution to an area double the size of the extravasated area Allow DMSO to air dry, do not cover and repeat every 8 hours for 7 days. Elevate limb and only apply gentle pressure to site. Begin within 10 min.

Causes local vasoconstriction and decreases fluid absorption for 24 hours (Day 1) only This will allow sufficient blood flow to the area. Infusion should be room temperature prior to administration Infuse over 1-2 hours in a large vein in an area other than the extravasation area (e.g. opposite arm) Day 2 and 3 should be given at approximately the same time (+/- 3 hours) as the 1

st dose.

May cause mylosuppression and may increase with concurrently administered chemotherapy agents. 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.

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Type of Extravasation Actions Comments

VinBLAStine

VinCRIStine

Vinorelbine

Etoposide Ifosfamide

Keep venipuncture needle if antidote ordered via needle/cannula.

Elevate limb and apply gentle pressure to site.

Apply warm compresses to extravasation site 15 to 20 minutes at least 4 X daily. Care must be taken to avoid tissue injury from excessive heat. Hyaluronidase (if ordered & available)

*if needle/cannula still in place : Following aspirating of drug, administer 1-6 mL hyaluronidase (150 units/mL) into existing IV line; the usual dose is 1 mL hyaluronidase for each 1 mL of extravasated drug

OR *If needle/cannula has been removed: subcutaneous inject clockwise 1-6 mL (150 units/mL) 1mL for every 1 mL of extravasated drug. OR 1 mL (150 units) as five separate injections of 0.2 mL each, each injected subcutaneously into the extravasated site using a separate 25 gauge or smaller needle. One time dose: 1mL (150 units) as five separate injections of 0.2 mL each, each injected subcutaneously into the extravasated site using a separate 25 gauge or smaller needle.

Cooling may have adverse effects For 24- 48 hours Hyaluronidase (Hyalase®) is available through Health Canada Special Access Programme

OXALiplatin Remove venipuncture needle.

Elevate limb and apply gentle pressure to site.

Apply warm compresses to extravasation site for 1 hour. Care must be taken to avoid tissue injury from excessive heat.

Early administration of high-dose oral dexamethasone (8 mg twice daily for up to 14 days)

Cooling may have adverse effect. Oral corticosteroids MAY be of benefit with an extravasation of a large amount of oxaliplatin.

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Type of Extravasation Actions Comments

Liposomal anthracyclines (DAUNOrubicin, DOXOrubicin)

Remove venipuncture needle.

Cold packs applied for 15-20 minutes at least 4 X daily

24 hours

MitoMYcin Remove venipuncture needle.

Cold packs applied for 15-20 minutes at least 4 X daily

DMSO – Apply DMSO 50% - 99% topical solution to an area double the size of the extravasated area

Allow DMSO to air dry, do not cover and repeat every 8 hours for 7 days. Elevate limb and only apply gentle pressure to site. Begin within 10 mins

24 hours

7 days

Taxanes

(DOCEtaxel, paclitaxel)

Remove venipuncture needle.

Cold packs applied for 15 – 20 minutes at least 4 X daily

Hyaluronidase

Administer 1-6 mL (150 units/mL) into existing IV line, and/or, if needle/cannula has been removed, inject 1 mL hyaluronidase for each 1 mL of extravasated drug.

24 hours

Use of hyaluronidase for taxane extravasation recommended in guidelines from the European Oncology Nurses Society (EONS) but not Oncology Nursing Society (ONS).

Recall skin reactions may occur despite administering through a different IV site (see Definitions)

Mannitol Remove venipuncture needle.

Cold packs applied for 15 – 20 minutes at least 4 X daily

Hyaluronidase

Administer multiple injections of 0.5-1 mL (15 units/mL) around the periphery of the extravasation.

24 hours

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Type of Extravasation Actions Comments

Bendamustine

CARBoplatin

CISplatin (>0.4 mg/mL)

Dacarbazine

Keep venipuncture needle if antidote ordered via needle/cannula.

Cold packs – FOLLOWING sodium thiosulfate antidote injection. 15 – 20 min at a time.

Sodium thiosulfate – subcutaneously

One time dose: Inject 2 mL for each mg thought to be extravasated. Inject subcutaneously into extravasated site using a separate 25 gauge or smaller needle.

If large volume CISplatin (e.g. greater than 20 mL) Inject 2 mL of a 1/6M (4%) sodium thiosulfate solution into existing IV line for each 100 mg of cisplatin extravasation. Inject 0.1 mL subcutaneous injections (clockwise) into the area around the extravasation.

6- 12 hours

Pharmacy Preparation

- Prepare 4% (1/6 Molar) solution:

- If using 10% sodium thiosulfate, mix 4 mL with 6 mL sterile water for injection.

- If using 25% sodium thiosulfate, Mix 1.6 mL with 8.4 mL sterile water for injection.

Non- vesicants/

non-irritants Remove venipuncture needle.

Elevate limb for 24-48 hours, after which patient is encouraged to resume normal activity.

Other agents Remove venipuncture needle.

Cold packs for 15-20 minutes at least 4 X daily

24 hours

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Type of Extravasation Actions Comments

Contrast Media Remove venipuncture needle.

Elevate limb to decrease capillary refill and promote resorption

Cold packs to help relieve pain at the site.

Warm packs improve absorption and blood flow.

Hyaluronidase – Subcutaneously

One time dose: 1 mL (150 units) as five separate injections, each injected subcutaneously into the extravasated site using a separate 25 gauge or smaller needle.

Surgical consult is recommended whenever severe extravasation is a concern.

The American College of Radiology recommends and immediate surgical consult for any patient who has 1 or more of the following signs and symptoms:

Increased swelling and pain after 2-4 hours

Altered tissue perfusion as evidenced by decreased capillary refill at any time after the extravasation

Change in sensation in the affected limb

Skin ulceration or blistering

Disperse and dilute. Research shows no clear treatment No evidence to support the exclusive use of either warm or cold packs Acute local inflammation peaks 24- 48 hours after the extravasation due to the hyperosmolarity of the contrast. Skin ulceration and tissue necrosis can occur as early as 6 hours after the occurrence. Surgical drainage should be performed within 6 hours of extravasation. Observe for 2-4 hours

*Extravasation and management chart copied with minimal changes from Saskatchewan Cancer Agency Care Services Policy, and Procedure Manual. Assessment and Management of Infiltration/Extravasation NSG 603 March 2015*

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Appendix C (Page 1)

Assessment and Management of Infiltration/Extravasation Flow Sheet

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Appendix C (Page 2)