EXTRAVASATION

EXTRAVASATIONREPORTED BY:

CZARINA CIDSTAFF NURSE, IVIU

June 11, 2012

DEFINITION OF TERMS

• PHLEBITIS– The inflammation of a vein (not permanent)

• RECALL– A delayed local response at a prior administration

site. May have no evidence of extravasation on administration of medication but it may develop later on.

DEFINITION OF TERMS

• FLARE– An injection-site reaction (typically seen following

the first IV infusion of an anthracycline such as doxorubicin) which is localized to the area of injection or nearby. It may involve redness, itching and possibly hives. It is self-limiting and should not be treated as an extravasation reaction. It may be avoided with pretreatment of antihistamines (with an order from a physician).

DEFINITION OF TERMS

• EXTRAVASATION– considered an adverse event. – The leakage of a vesicant out of the vein upon

intravenous drug administration. – Extravasation is characterized by severe pain and

swelling at the site of administration.

MEDICATIONS

• The two main categories of medications to describe the local consequences of their extravasation are:– Vesicant

• Is an agent which has the potential to cause serious tissue destruction (i.e.necrosis). Injection of these medications may cause disruption of the endothelial lining with thrombosis.

– Irritant• Is a drug which has the potential to cause temporary irritation

(i.e. itching, redness, swelling) to surrounding tissues with or without an inflammatory reaction. These medications cause pain and discomfort along the venous pathway.

REACTIONS THAT CAN TAKE PLACE FOLLOWING MEDICATION ADMINISTRATION

• Local hypersensitivity reactions– Presentation

• Immediate burning, itching, erythema, ―flare/reaction along the length of the vein.

• Usually self-limited and subside within a few hours.• Treatment: administration of diphenhydramine before the next

course may reduce the severity or duration of reaction.

• Irritation of the vein (or phlebitis) reactions– Presentation

• Burning with administration of agent, ―tracking• Treatment: stopping therapy, removing the peripheral line, and

placing new IV line in other hand.

REACTIONS THAT CAN TAKE PLACE FOLLOWING MEDICATION ADMINISTRATION

• Extravastation– Localized, self-limiting inflammation (irritants) to full thickness

destruction and sloughing of the skin (vesicants).– Presentation: patients who experience an extravastation can show a

range of different signs or symptoms. Mild pain and swelling at the site of infiltration with marked edema and erythema, hyperpigmentation, induration, can also occur. Infiltration of a vesicant into tissue often produces a severe burning sensation that may persist for hours.

– Extravastation may ultimately lead to soft tissue ulcers and necrosis.– Initially, it may be impossible to distinguish a local irritant reaction

from a vesicant extravastation.– Treatment: once extravastation is suspected, therapy should be

stopped and extravastation procedures for agent should be utilized

POLICY

• All suspected or actual extravasation will be treated promptly to minimize any ill effects. Despite every precaution, extravasation may occasionally occur. Vesicants include antineoplastic as well as non-antineoplastic agents (including radiographic contrast agents).

RISK FACTORS

• Vascular disease• Advanced age• Vascular obstruction• Vascular ischemia• History of irradiation to area• Small vessel diameter• Venous spasms• Traumatic catheter• Needle insertion

SIGNS AND SYMPTOMS

• Pain or burning associated with drug administration at and around the IV catheter injection site

• Swelling, usually occurs immediately• Change in quality of infusion• May loose ability to obtain a blood return• May have blotchy redness around the IV catheter

injection site, may be delayed• May have local tingling and sensory deficits, often delayed• Ulceration develops insidiously usually 48 - 96 hours later

INFILTRATION / EXTRAVASATION GRADING SCALEAssess Vascular Access Device (VAD) as per management of peripheral intravenous catheter policy and follow the corresponding intervention guidelines

CLINICAL SYMPTOMS ACTIONSStage 1 Skin blanched

Edema <1 inch in any direction Cool to touch With or without pain

For All Stages:1. Stop

infusion/Establish alternative IV site.

2. Determine infusate3. Refer to Drug

Information / Pharmacy to determine if infusate is a vesicant

4. Elevate extremity5. Continue assessment

of site surrounding tissue PRN

Vesicant – refer to Stage 4 Nonvesicant – remove IV

Stage 2 Skin blanched Edema >1 inch Cool to touch With or without pain

Vesicant – refer to Stage 4 Non-vesicant-remove IV Notify primary service If tissue damage progresses, refer to Stage 3

or 4

Stage 3 Skin blanched, translucent Gross edema >6 inches in any direction Cool to touch Mild to moderate pain Possible numbness

Vesicant – refer to Stage 4 Non-vesicant-remove IV Call primary service for assessment and need

for plastic surgery consultant If tissue damage progresses, refer to Stage 4

Stage 4 Skin blanched, translucent Skin tight, leaking Skin discolored, bruised, swollen Gross edema >6 inches in any direction Circulatory impairment Moderate to severe pain Possible numbness Infiltration of any blood product, irritant,

vesicant Deep pitting tissue edema

Vesicant – refer to Stage 4 Non-vesicant-remove IV Notify primary service Notify plastic surgery and/or orthopedics for

assistance in determining further treatment

MANAGEMENT OF EXTRAVASATION OF VESICANT/IRRITANT AGENTS

1. Stop the procedure or process of the chemotherapeutic agent immediately.

2. Leave the needle in place. Do Not Remove Needle/Catheter (it may be used for administration of antidote/diluent and to prevent further needle sticks).

3. Put on gloves (if not already on).4. Attach syringe and attempt to aspirate any residual drug in the

needle, and suspected extravasation site. Administer a volume of sodium chloride for injection into existing needle/catheter equal to amount of fluid removed. Avoid unnecessary trauma. If unable to aspirate, IV should be removed to prevent further vesicant extravasation.

5. Refer to chart on the next page for specific antidote.


6. If an antidote is to be administered, use the same needle/catheter through which the vesicant drug extravasated.

7. All drugs except mechlorethamine (nitrogen mustard), remove needle/syringe.

8. Dispose of syringe and contents into biohazard container.9. Notify physician on call.10.Elevate area if possible.11.Apply cold pack if the extravasated drug is amsacrine, doxorubicin,

daunorubicin, or mechlorethamine. The ice pack should be applied for 15 minutes four times a day for 3 days. Refer to individual drug in the following table. The rationale for cold was vasoconstriction, thereby "containing" the drug at the site of extravasation and minimizing the size of the subsequent ulceration.


12.Apply hot pack if the extravasated drug is etoposide, teniposide, navelbine, vinblastine, vincristine, or vindesine. The warm, dry pack should be applied for 60 minutes, one time. Refer to individual drug in the list following. The rationale for heat was vasodilation, thereby "diluting" the drug and minimizing the size of the subsequent ulcer.

13.Complete Medication Error Report form.14.Documentation in patient's chart: date and time, needle size

and type, drug sequence, drug administration technique, approximate amount of drug extravasated, management, patient complaints, appearance of site, physician notification, and follow-up interventions, signature, return patient appointments.


15. The extravasation site should be evaluated by the physician as soon as possible after the extravasation and periodically thereafter as indicated by symptoms.

16. For inpatients, assess the site every day for pain, erythema, induration, or skin breakdown, and document assessment at least every shift (8-12 hours) for 48 hours. For outpatient, telephone contact should be made daily for 3 days to assess the site for pain, redness, and swelling weekly thereafter until the problem is resolved.

17. The physician should consult the Plastic Surgery service when pain and/or tissue breakdown occur.

MANAGEMENT OF NON-VESICANTS

1. Stop the administration of the drug.2. Remove the intravenous needle or catheter.3. Observe the site every eight hours for any

signs of tissue change (redness, swelling, or pain).

4. If area of infiltration is swollen, elevate the affected extremity for 24-48 hours or until the swelling subsides.

5. Document as for vesicant/irritant drug.

EXTRAVASATION KITShould contain the following:• Instructions for use.• List of contents.• List of cytotoxic drugs and their

antidotes.• Antidotes and instructions for use:

• DMSO (Dimethyl sulphoxide) topical solution.• Hyaluronidase.

• Swabs or swab sticks for applying DMSO.• 10ml syringes.• Water for injection.• Drawing up needles.• 25gage needles.• Spare gloves.• Alcohol wipes.• Access to icepacks and heat packs.

PREVENTION• Only qualified, chemotherapy-certified nurses should be allowed to administer

vesicants• Choose a large, intact vein with good blood flow• The digits, hands, and wrists should be avoided• Place the smallest gauge and shortest length catheter to accommodate the

infusion.• Monitor the venipuncture site closely• The IV infusion should be freely flowing. • The infusion should consist of a suitable carrier solution with an appropriately

diluted medicinal/chemotherapy drug inside.• After the IV infusion has finished, flush the cannula with the appropriate fluid.• Finally, depending on clinical circumstances, central line access may be most

appropriate for patients who require repeated administrations of vesicants and irritants.

THANK YOU!!!

Documents

EXTRAVASATION