Vesicant AdministrationSAFETY CONSIDERATIONS

Vesicant Chemotherapy

Vesicants: Agents capable of causing pain, sloughing of skin, and/or tissue necrosis when they leak outside of a vein or are inadvertently administered into the tissue

Extravasation: the process of leakage

DNA-binding vesicant

Non-DNA binding vesicant

NON-DNA BINDING VESICANTS

Vinca alkaloids (vincristine, vinblastine)Do not bind to DNA in healthy cells when they extravasate into tissueAre metabolized in the tissueWith heat, elevation, and hyaluronidaselocal injection (spreads vesicant throughout tissue for faster metabolism of the vesicant), these extravasations improve over a short period of time (days to weeks)

DNA-BINDING VESICANTS

Anthracyclines (doxorubicin, epirubicin, daunorubicin, idarubicin)

Bind to DNA in healthy cells when they extravasate into tissue

When not immediately treated with Totect® (dexrazoxane), remain in the tissue and invade adjacent healthy tissue

Left untreated, these extravasations become larger and deeper, and worsen over time (weeks to months)

Vesicant Extravasation Prevention Basics:Peripheral IVs

Insert a new IV for peripheral vesicants

Avoid hand, wrist, antecubital areas

Do not go below a recent venipuncture site (<24 hours)

Use a flexible catheter

Instruct the patient to avoid movement and report anychange in sensation at the IV site

Use care when applying topical anesthetics. Commonly used EMLA cream (lidocaine2.5% and prilocane 2.5%) has a duration of action of 4 hours or more, and its application may mask changes in sensation at the IV site that may signal a possible vesicant extravasation.

Dilate those veins! Wrap the forearm in a warmed blanket or apply a warm pack. Provide a squeeze ball or similar object and enlist the assistance of gravity by having patients dangle their arms.

Apply a transparent dressing. Since common symptoms of vesicant extravasation are swelling and redness, and discomfort may or may not be present, a transparent dressing helps secure the IV catheter while allowing visualization of the site.

Don’t blame the patient. Veins do not “roll” or “disappear.” They are sometimes pushed by the IV catheter or constrict. Always ensure a good, clean stick prior to vesicant administration.

Clinical Practice Tips

Vesicant Extravasation Prevention Basics:Central Lines

Insert non-coring needles of appropriate length (deeply implanted ports require longer needle length)

Verify placement and patency (check for a blood return)

Apply a transparent dressing and secure IV tubing

Instruct patients to report unusual tugging on IV tubing or any action that may increase the risk of needle dislodgment, such as applying or removing clothing

Ensure that the non-coring needle is securely and completely inserted.

DO NOT administer vesicant chemotherapy via an implanted port or central venous catheter that does not have a blood return but “flushes easily.” If a blood return is not immediately obtained:

1. Place the patient in a supine position and attempt to aspirate blood.2. If unsuccessful, use a 10 mL syringe containing 10 mL of normal saline and gently “push-

pull.” 3. If unsuccessful, use a 20 mL syringe containing 5-10 mL of normal saline and gently

“push-pull” (the larger syringe diameter exerts less pressure on the walls of the catheter).4. If unsuccessful, follow institutional policy and procedures (e.g. dye study, instillation of a

thrombolytic agent).A “good blood return” is generally defined as the ability to draw back 3 mL of blood in 3 seconds.

Beware of the Following Myths

“We can use the port even though there is no blood return. It was inserted yesterday so it’s brand new. There can’t be

anything wrong with it.”

A blood return was not obtained from the newly inserted implanted port, and a dye study was ordered. The catheter of the implanted port was inadvertently and unknowingly nicked during insertion and after removal, the tear in the catheter was evident.

Neither of these catheters produced a blood return. The dye study of patient 1 shows the catheter lying transversely instead of having its tip in the superior vena cava. The CT scan of patient 2 shows that the catheter tip is in the lung and a large right pleural effusion (from injection of contrast dye) is present.

Patient 1 Patient 2

“I know the needle is in the port. I felt the hard metal back of the bottom of the port.”

What the nurse felt was the metal ring surrounding the silicone port septum. This dye study shows the dye cascading off of the top of the port; the non-coring needle is on the port, not in the port.

“Although there is no blood return, the port must be alright to use. The premeds infused just fine.”

xxxxx

Over time, the patient’s implanted port catheter retracted until the tip was completely out of the venous system and was positioned in the subcutaneous tissue. All medications, including vesicant chemotherapy, were therefore infused subcutaneously and not intravenously. The patient has had multiple debridement procedures and required extensive physical therapy.

“We haven’t had a vesicant extravasation here in 8 years. Extravasations are something we just don’t have to worry about.”

Consider the number of patients at risk for extravasation, not how many extravasations occurred in the past.

Patients move around, and IV devices can break or malfunction.

Vesicant extravasations can occur despite best efforts to prevent them.

When in doubt, stop and assess the situation. Seek out colleagues to confer with.

It is always better to be safe than sorry.

References

Hahn, J. C., & Shafritz, A. B. (2012). Chemotherapy extravasation injuries. Journal of Hand Surgery, 37(2), 360-362.

Payne, A. S., & Savarese, D. M. F. (2013). Extravasation injury from chemotherapy and other non-neoplastic vesicants. UpToDate, http://www.uptodate.com/contents/extravasation-injury-from-chemotherapy-and-other-non-neoplastic-vesicants.

Schulmeister, L., & Pollack, C. V. (2011). Images in emergency medicine. Swollen hand. Anthracycline chemotherapy extravasation. Annals of Emergency Medicine, 57(4), 417, 422.

Schulmeister, L. (2011). Extravasation management: Clinical update. Seminars in Oncology Nursing, 27(1), 82-90.

Schulmeister, L. (2010). Preventing and managing vesicant chemotherapy extravasations. Journal of Supportive Oncology, 8(5), 212-215.