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Chemotherapy extravasation

Vesicant chemotherapy extravasations have the potential to cause tissue necrosis, functional impairment, and permanent disfigurement.

Chemotherapy agents can be categorized by their vesicant potential: high risk vesicants, irritants and neutral.

Patients must be informed about the possibility of the extravagant decision injury when a known desiccant agent is being administered.

Patients should immediately report signs and symptoms of a vesicant extravasation.

Patients should report any change in sensation at or around the chemotherapy administration site.

Signs and symptoms of a vesicant extravasation include swelling, redness, leakage of fluid burning or stinging.

Blistering may occur immediately or within days following extravasation.

Subsequent changes include induration, discoloration and possibly tissue necrosis.

Weeks to months after extravasation ulceration may develop with invasion and destruction of deep structures such as tendons and joints.

Secondary infections of ulcerated tissue is common.

Scar formation at site of extravasation can lead to cosmetic and functional impairment.

Extravasation may lead to delay in therapy and infection.

Patients with small or fragile veins, deep veins, or damaged veins may require placement of a central venous catheter to prevent desiccant extravasation.

Patients with deep implanted ports are at risk for needle misplacement or dislodgement.

Flexible IV devices are recommended as rigid devices such as winged needles are more likely to pierce the vein and allow vesicant leakage.

Veins on the dorsum of the hand, at the wrist, and in the antecubital area have little subcutaneous tissue and if a desiccant extravasation occurs in these areas damaged to underlying tendons ligaments and nerves are likely.

Peripheral IV devices should be inserted with a clean stick approach, and started immediately prior to chemotherapy administration.

Peripheral IV devices that have been indwelling may produce vein trauma and increase the rate of the IV complications.

Vesicants should not be administered at an IV site below the site of a recent venipuncture.

Peripheral administration of vesicant chemotherapy should not be given via an infusion pump.

Risk factors include: chemotherapy vesicant properties, volume, concentration and duration of infusions, fragile veins, obesity lymph edema, obesity and patient impaired mentation.

Iatrogenic factors include inadequate staff training, poor infusion techniques, and improper intravenous catheters.

Only topical anesthetics with a short duration of action should be applied so as not to mask sensations that may signal an extravasation.

A blood return from an IV device should be obtained before administering of vesicant agent.

IV device sites should be assessed for swelling, tenderness,and leakage.

IV devices should be tested with normal saline or D5W fluids for integrity.

If a vesicant extravasation occurs the intravenous administration of the drug should be immediately discontinued, attempt to aspirate through the catheter, and topical heat or cooling should be applied.

Ice packs or cold gel packs is recommended for DNA-binding vesicant extravasations, such as anthracyclines and nitrogen mustard.

Docetaxel and paclitaxel extravasation’s can be treated with local cooling.

Local dry heat is indicated for non-DNA-binding vesicant extravasations such as with plant alkaloids.

Heat application is recommended for extravasation of oxaliplatinum as cold packs may precipitate or worsen neuropathy.

Local injection of sodium thiosulfate is recommended for nitrogen mustard extravasations.

Local injection of hyaluronidase is recommended for plant alkaloids extravasations.

Dexrazoxane is administered systemically for anthracycline extravasations.

Topical DMSO and subcutaneous hyaluronidase and saline infusion of tissues are considerations.

May require surgical intervention and wound care.

Wide excision of necrotizing tissues and skin grafting may be neede.

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