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Extravasation Management: Clinical Update
Abstract
To present a clinical update on the prevention, detection, and evidence-based management of vesicant chemotherapy extravasations.
Journal articles, published and unpublished case reports, personal experience.
In the 4 years that have elapsed since the publication of the original article, much more is known about vesicant chemotherapy extravasation, and effective evidence-based treatments now are available. The antidotes sodium thiosulfate for mechlorethamine extravasations and hyaluronidase for plant alkaloid extravasations are recommended by the manufacturers of these vesicants and cited in nursing guidelines. The anthracycline extravasation treatment dexrazoxane for injection, the first and only extravasation treatment with proven effectiveness, is now available as Totect (dexrazoxane; TopoTarget USA, Rockaway, NJ, USA) in the US and Savene (SpePharm, Amsterdam, The Netherlands) in Europe.
Nurses who administer vesicant chemotherapy agents need to be aware of the most current evidence (or lack of evidence) for various types of extravasation treatment. Well-informed nurses are patient advocates and instrumental in detecting, managing, and documenting extravasations. Most importantly, nurses play a key role in preventing vesicant chemotherapy extravasations.
... Alguns quimioterápicos podem ser tanto irritantes quanto vesicantes. (2) As drogas vesicantes ligantes ao DNA, quando se ligam aos ácidos nucleicos dos tecidos, geram radicais livres, inibem a síntese de proteínas e promovem a destruição progressiva, fazendo com que a lesão se torne mais profunda, extensa e dolorosa. O quimioterápico é retido no tecido durante longo tempo através de ligações de DNA. ...
... Estatisticamente, a incidência de extravasamento é baixa: estima-se que 0,01% a 6,5% de todas as administrações de medicamentos citotóxicos resultem em extravasamento. (2) ...
... Pessoas com doenças cutâneas generalizadas e com alterações patológicas dos tecidos também constituem grupo de risco (2) . ...
O extravasamento de drogas administradas por via intravenosa pode ocorrer em vários contextos clínicos, e está predominantemente associado a cateteres venosos periféricos. O objetivo foi identificar na literatura evidências científicas sobre prevenção e tratamento de lesões cutâneas provocadas por infiltração e extravasamentos de drogas quimioterápicas, buscando métodos que norteiam as condutas de enfermagem, no intuito de aperfeiçoar os cuidados assistenciais aos pacientes submetidos a punção venosa. Trata-se de estudo de revisão integrativa realizado no portal BVS, nas bases de dados PubMed, Lillacs, Medline e BDENF. Foram utilizados os seguintes critérios de inclusão: artigos publicados sem limite de datas, nos idiomas português, inglês e espanhol. A amostra foi composta por oito estudos desenvolvidos em diversos países. A intervenção em caso de extravasamento requer fundamentação teórica e prática atualizada, uma vez que medidas de segurança no processo de administração de agentes quimioterápicos devem ser conhecidas pelas equipes de enfermagem, sendo de sua responsabilidade. Neste sentido, é fundamental monitorar a qualidade da assistência, refletir sobre a prática clínica com base naquilo que é observado e reforçar a cultura de segurança do paciente. Como considerações finais, apesar de não existirem recomendações uniformes acerca da melhor estratégia a adotar no intuito de prevenir infiltração e extravasamento de drogas, o diagnóstico e tratamento adequados poderão prevenir sequelas a longo-prazo.
... 2) Non-vesicants and non-irritant These agents usually produce no local reaction at the injection site or to surrounding tissues upon extravasation. Occasionally, patients may notice mild inflammation and discomfort [1], [4], [13], [16]. ...
... Studies regarding the use of most antidotes are not all conclusive [1], [4], [8], [13], [15], [18]. ...
... Most authors recommend the implementation of management protocols detailing the specific measures to be taken, with the provision in each institution of an extravasation kit and a register for reporting infusion accidents [1], [2], [4]- [6], [12], [13], [17]. ...
Extravasation is defined as the leakage of fluid from a blood vessel into the surrounding area at the injection site. These accidents occur during injection for diagnostic or therapeutic purposes, carried out through the peripheral or central venous lines (Chemotherapy, metabolites, or contrast agent for radiographic examination). They can be the cause of skin necrosis able to progress to significant functional, cosmetic, and psychological sequelae. The saline washout technique is the emergency surgical treatment of choice for extravasations of certain products, allowing the elimination of the toxicant and the preservation of the skin. In the event of skin necrosis, covering techniques such as directed healing, grafts and flaps allow healing. The difficulty of the therapeutic management of these lesions and their unpredictable evolution, require prevention, by the development of protocols for the installation and monitoring of the venous catheters, and by the continuous training of the nursing staff to know the symptoms of extravasation, and their immediate management. The aim of this work is to present a review of the existing literature, allowing to know the diagnostic criteria, insist on the means of prevention, and propose a protocol of management.
... Data from well-designed controlled studies without randomization; "B": conservative degree of recommendation) [35,36]. ...
... A common dose is five 0.2 mL subcutaneous injections of hyaluronidase at a concentration of 150-100 IU [33,34]. It is recommended particularly for vinca-alkaloids, etoposide, and taxaneinduced extravasation and has level V-C evidence (Level V evidence: Evidence from systematic reviews of descriptive and qualitative experiments; "C": Suggestion with limited power) [21,35,36]. ...
... In the case of anthracycline extravasation, the combination of DMSO and cooling is frequently recommended as the first line treatment, particularly when dexrazoxane is not practicable [4,23]. Level IV-B evidence (Evidence Level IV: Strongly constructed case-control and cohort studies; "B": cautious recommendation strength) [35,36]. ...
Chemotherapy is a category of medicines that are utilized to kill and eradicate immediately the abnormally growing cells in the body. It is commonly utilized to treat cancer because cancer cells grow and divide at a faster rate than other cells. Extravasation is the mechanism by which any liquid (fluid or drug) accidentally enters the surrounding tissue. Extravasation in cancer treatment indicates the unintentional chemotherapy infiltration into the subdermal tissues or subcutaneous enclosing the intravenous or intra-arterial location of administration. Extravasated agents are categorized as vesicants, exfoliants, irritants, inflammators, and neutrals. Based on their potential for causing harm, management of chemotherapy-related extravasation includes both non-pharmacological treatment and pharmacological treatment.
... The extravasation of irritants can cause an inflammatory reaction, accompanied by warmth, erythema, and tenderness in the extravasated area [22,23]. Extravasation of TPN is most commonly reported in newborns in the intensive care setting [24]; there are few adult case reports and the vast majority of reports were published more than a decade ago [6,15,[24][25][26][27]. ...
... The solution is often hyperosmolar (>1000 mOsm/L) to the serum (285 mOsm/L) [22]. Although the exact mechanism underlying the tissue toxicity caused by extravasated TPN is not clear, it has been suggested that it is related to the hyperosmolarity, acidic pH, and ion content of the PN [6,22,23]. Treatment should ideally include early recognition of TPN extravasation, with immediate discontinuation of the infusion [6,22,23]. When extravasation does occur, it is important to recognize and treat it promptly [22,23,25]. ...
... Although the exact mechanism underlying the tissue toxicity caused by extravasated TPN is not clear, it has been suggested that it is related to the hyperosmolarity, acidic pH, and ion content of the PN [6,22,23]. Treatment should ideally include early recognition of TPN extravasation, with immediate discontinuation of the infusion [6,22,23]. When extravasation does occur, it is important to recognize and treat it promptly [22,23,25]. ...
Central venous catheterization is a preferred method for intensive care patients who require total parenteral nutrition (TPN). TPN can cause tissue damage due to osmotic effects and the presence of ions. We report a case of TPN extravasation into the pleural cavity due to a shift in position of a subclavian central vein catheter. In this report, we discuss the importance of serial follow up of chest X-ray examination in patients with central vein catheterization.
... Svaka ekstravazacija rezultira oštećenjem tkiva, a u zavisnosti od vrste i osobine aplikovane supstance, stepen oštećenja tkiva kreće se od vrlo blage kožne reakcije do veoma ozbiljnog oštećenja tkiva (nekroza) [1,2], pri čemu se simptomi ne moraju ispoljiti odmah, već i nakon nekoliko dana ili nedelja od akcidenta [1,4]. Iz tog razloga, ova komplikacija zahteva posebnu pažnju svih zdravstvenih radnika uključenih u zbrinjavanje onkoloških pacijenata, a najznačajnije su intervencije koje preduzimaju medicinske sestre poput prevencije, prepoznavanja, tretmana i dokumentovanja ekstravazacije citotoksičnih agenasa [1][2][3][4][5][6][7][8][9][10][11]. ...
... Faktore rizika za ekstravazaciju citostatika možemo podeliti u četiri grupe: 1) Endogeni faktori -tanke, fragilne, sklerotične vene pacijenta, limfedem, opstrukcije venae cavae, pojedine bolesti ili stanja koja dovode do smanjene osetljivosti na dodir/bol (diabetes mellitus, ozračena regija, pareza), Syndroma Raynaud [1,2,5,7,10], poremećaji hemostaze [2,7,10]; 2) Egzogeni faktori -neadekvatan izbor vrste i promera kanile [7,8,10], plasiranje kanile na nepogodno mesto [1,7,8,10], aplikacija medikamenta pod velikim pritiskom [1,7], neadekvatna zaštita i fiksacija kanile, nepravilno plasiran intravaskularni kateter/port-a-cath, kao i njihovo oštećenje [2]; 3) Faktori koji onemogućavaju rano prepoznavanje simptoma ekstravazacije -otežana komunikacija i/ili nemogućnost pacijenta da prijavi osoblju bilo kakvu nelagodnost (konfuznost, sedacija, pacijenti sa oštećenim vidom/sluhom), poremećaji senzibiliteta [1,2,5,7,8]; 4) Karakteristike samog citostatika -prema EONS vodiču za ekstravazaciju citostatika u odnosu na potencijal oštećenja tkiva koje izazivaju u slučaju ekstravazacije, citotoksični agensi se mogu podeliti u tri grupe: nevezikanti, iritanti i vezikanti (Tabela 1) [1,3,4,7]; dok nešto novija podela ustaljena u Velikoj Britaniji svrstava citotoksične agense u sledećih pet kategorija (Tabela 2) [6]: • neutralni agensi -u slučaju ekstravazacije ne izazivaju inflamatornu reakciju niti oštećenje tkiva [6]; • inflamatorni agensi -inflamacija tkiva praćena je osećajem povremenog i intenzivnog peckanja [4,6]; • iritanti -lokalno izazivaju osećaj nelagodnosti, bola, toplote i "žarenja" zahvaćene regije. Prisutni su eritem i hiperpigmentacija. ...
... Faktore rizika za ekstravazaciju citostatika možemo podeliti u četiri grupe: 1) Endogeni faktori -tanke, fragilne, sklerotične vene pacijenta, limfedem, opstrukcije venae cavae, pojedine bolesti ili stanja koja dovode do smanjene osetljivosti na dodir/bol (diabetes mellitus, ozračena regija, pareza), Syndroma Raynaud [1,2,5,7,10], poremećaji hemostaze [2,7,10]; 2) Egzogeni faktori -neadekvatan izbor vrste i promera kanile [7,8,10], plasiranje kanile na nepogodno mesto [1,7,8,10], aplikacija medikamenta pod velikim pritiskom [1,7], neadekvatna zaštita i fiksacija kanile, nepravilno plasiran intravaskularni kateter/port-a-cath, kao i njihovo oštećenje [2]; 3) Faktori koji onemogućavaju rano prepoznavanje simptoma ekstravazacije -otežana komunikacija i/ili nemogućnost pacijenta da prijavi osoblju bilo kakvu nelagodnost (konfuznost, sedacija, pacijenti sa oštećenim vidom/sluhom), poremećaji senzibiliteta [1,2,5,7,8]; 4) Karakteristike samog citostatika -prema EONS vodiču za ekstravazaciju citostatika u odnosu na potencijal oštećenja tkiva koje izazivaju u slučaju ekstravazacije, citotoksični agensi se mogu podeliti u tri grupe: nevezikanti, iritanti i vezikanti (Tabela 1) [1,3,4,7]; dok nešto novija podela ustaljena u Velikoj Britaniji svrstava citotoksične agense u sledećih pet kategorija (Tabela 2) [6]: • neutralni agensi -u slučaju ekstravazacije ne izazivaju inflamatornu reakciju niti oštećenje tkiva [6]; • inflamatorni agensi -inflamacija tkiva praćena je osećajem povremenog i intenzivnog peckanja [4,6]; • iritanti -lokalno izazivaju osećaj nelagodnosti, bola, toplote i "žarenja" zahvaćene regije. Prisutni su eritem i hiperpigmentacija. ...
As a potential complication of a systemic administration of cytotoxic agents, extravasation requires particular caution of all health practitioners involved in treatments of oncological patients. In the light of the fact that more than 100.000 doses of chemotherapy are indicated worldwide and more than 1.000.000 intravenous infusion of cytostatic drugs are administered on daily bases, it is upsetting that in the case of cytostatic administration through peripheral intravenous cannulas extravasation occurs in 0,5 to 6% of oncological patients, while in the case of administration through central venous lines it occurs in 6% of the cases. Each extravasation results in tissue damage and depending on type and features of the administered substance can be manifested in different forms, from skin reaction to tissue necrosis. By highlighting the multiple significance of documenting and accident reporting, the authors state the necessary elements and propose the form of a nurse documenting list for the cases of extravasation of cytostatic agents. A nurse must document the following data on an accident: patient's name and surname, date of birth, name of the clinics, primary oncological diagnosis, date and time of extravasation, name of the cytotoxic drug, symptoms and signs of extravasation and the measures undertaken. The accurate documenting and reporting of accidents are legally binding for health practitioners, particularly nurses, as a result of the need to map the risk factors of their occurrence, to assess compliance of the standard nursing procedures in administration of cytostatic therapy, to follow up the course of the management of complications, outcomes and the undertaken measures but also to improve the existing and develop new preventive strategies.
... Estudos apontam que os extravasamentos ocorrem principalmente em veia periférica na fossa cubital, antebraço, e dorso da mão (14)(15) . Esses dois últimos locais proporcionam mais danos quando ocorre o extravasamento, pois apresentam menos tecido adiposo e muscular, assim, causam maior comprometimento de nervos e tendões, como apontado por uma especialista norte-americana (16) . ...
... Desse modo, o paciente encontra-se mais propenso à medida que apresenta disfunção endotelial (por avanço da idade, diabetes mellitus, hipertensão, dislipidemia, aterosclerose, insuficiência renal crônica), em casos de radioterapias prévias, fluxo sanguíneo comprometido, infusão de alta pressão (pediatra ou percepção sensorial alterada), pacientes incapazes de descrever a dor (pediatria, percepção sensorial comprometida), e devido à inexperiência da equipe (17) . Nesse contexto, protocolos, Norte-americanos e Europeus, descrevem outras características da rede venosa que favorecem maior risco, como a diminuição da elasticidade, por fragilidade e em veias de pequeno calibre, obesidade, múltiplas punções anteriores, presença de doença de pele disseminada e movimentação do paciente durante a infusão (16)(17)(18) . ...
... Estudos de casos (21)(22)(23)(24)(25)(26) , trabalho retrospectivo (14) , especialista (16) e revisão de literatura (27) , concordam que ações imediatas podem retardar complicações frente à ocorrência do extravasamento. Sendo necessário cessar a infusão imediatamente a suspeita ou confirmação, identificar o antineoplásico, estimar a quantidade extravasada, mensurar e registrar a área com foto. ...
Objetivo: descrever padrões de cuidados em prevenção e tratamento de extravasamento de antineoplásicos baseado
em evidências clínicas. Métodos: revisão integrativa da literatura realizada nas bases de dados Medline/PuBMed, CINAHL, LILACS e Science Direct. Resultados: foram localizados 30 estudos em inglês e espanhol, entre 2005 a 2015.
Os temas predominantes quanto ao extravasamento são fatores de risco, medidas de prevenção e tratamento, como
o uso de compressas e antídotos, estes foram organizados em quadros e classificados quanto ao nível de evidência e
grau de recomendação. Conclusão: a prevenção é a principal estratégia. Ressalta-se a importância de implementação de
protocolo assistencial.
Descritores: Antineoplásicos; Extravasamento de Materiais Terapêuticos e Diagnósticos; Enfermagem.
ABSTRACT
Objective: to describe patterns of care in the prevention and treatment of clinical evidence based antineoplastic extravasation. Methods: integrative literature review carried out in Medline/PuBMed, CINAHL, LILACS and Science Direct
databases. Results: 30 studies were conducted in english and spanish between 2005 and 2015. The predominant themes
regarding extravasation are risk factors, prevention and treatment measures, such as the use of compresses and antidotes, these were organized in tables and classified as level of evidence and degree of recommendation. Conclusion:
prevention is the main strategy. It is important to emphasize the importance of implementing a care protocol.
Descriptors: Antineoplastic Agents; Extravasation of Diagnostic and Therapeutic Materials; Nursing.
... While the incidence of cytotoxic vesicant drug extravasation is low (0.1% to 6.5%), the natural course is unpredictable and initial clinical symptoms are non-specific and difficult to identify. 7,8 Nonetheless, these incidents must be detected early (within six hours) because medical management and surgical treatment are urgent. [8][9][10][11][12] Among these incidents, the literature reported a low rate (0.25%) of extravasations evolving towards severe necrosis and extensive soft-tissue destruction requiring further reconstruction surgeries. ...
... 7,8 Nonetheless, these incidents must be detected early (within six hours) because medical management and surgical treatment are urgent. [8][9][10][11][12] Among these incidents, the literature reported a low rate (0.25%) of extravasations evolving towards severe necrosis and extensive soft-tissue destruction requiring further reconstruction surgeries. The severity of the damage depends on the volume, concentration and toxicity of the substance. ...
... Numerous strategies have been reported in adults. 8,[11][12][13][14][15][16][17] Two types of treatment predominate: conservative management (local topic application, antidotes) and saline washout. 11,15,16 However, there is a lack of evidence regarding the superiority of one technique above the other in recent literature. ...
Purpose
Extravasation of cytotoxic vesicant drugs is a surgical emergency (within six hours) since this incident can lead to severe skin and soft-tissue damage. Outcomes after the saline washout procedure have been extensively described in adults, but rarely in children. The aim of this study was to evaluate the outcome of early saline washout procedure for upper limb cytotoxic drug extravasation in children.
Methods
All consecutive children with vesicant drug extravasation were retrospectively reviewed. The saline washout procedure was performed. Cosmetic aspect, residual pain and range of movement were analyzed as well as time to surgery and chemotherapy resumption at last follow-up.
Results
Between 2014 and 2018, 13 cytotoxic vesicant drug extravasations occurred (mean age 8 years (sem 5)), including 11 treated by the saline washout procedure. At mean follow-up of 11 months (sem 7), the patients had no or low pain and ranges of movement were fully conserved. Two patients (one within the six hours’ delay) had soft-tissue necrosis leading to extensive reconstructive surgery.
Conclusion
The saline washout procedure is safe and easy and significantly reduces the incidence of extensive skin damage. Early referral to a specialized department is essential. However, the key parameter remains prevention by educating medical staff and nurses about these injuries and by training them for early and urgent management.
Level of Evidence
IV
... Therefore, cytotoxic agents are classified into three groups based on the extent of damage reported in case reports and animal experiments: vesicants, irritants, and non-tissue-damaging agents. [1][2][3] As guidelines for extravasation of cytotoxic agents have been issued, 4,5) preferential use of the central venous route to prevent extravasation, consideration for the fragility of the vessel and the site of puncture, and careful monitoring by specialized nurses according to the severity and initial treatment have been widely implemented, resulting in a decrease in the frequency of extravasation of cytotoxic agents. 3) In contrast, noncytotoxic agents are routinely used in various hospitals. ...
... The incidence of extravasation is 23-78% in neonates and 11-28% in children 63) for all agents as well as 0.5-6.5% in adults for cytotoxic agents. 4) Children are particularly vulnerable to extravasation because of their small and fragile veins, capillary leakage, flexible subcutaneous tissue, inability to pay attention to infusion leaks, and inability to express abnormality, leading to serious complications. 64) The puncture site is important, and administration from veins such as the dorsum of the hand and movable parts near joints should be avoided; however, if administration from these sites is unavoidable, leakage should be carefully considered. ...
Extravasations are common manifestations of iatrogenic injuries associated with intravenous therapy. Cytotoxic agents are already subject to a relatively well-defined management strategy in healthcare institutions and classified into three groups according to the extent of damage from extravasation: vesicants, irritants, and non-tissue-damaging agents. Therefore, careful monitoring and initial treatment according to the severity of the skin injury decreases the incidence of extravasation injury. In contrast, high osmolarity, acidic or alkaline, and/or vasoconstrictive activity have all been suggested as possible causes of tissue injury due to the extravasation of noncytotoxic agents. However, the severity of the injuries has not been classified. Therefore, due to a lack of awareness, case reports of severe extravasation injury caused by noncytotoxic agents are increasing. In this paper, we review case reports and animal experiments and classify the severity of extravasation injury by noncytotoxic agents into three categories. Parallel to cytotoxic agents, the classification provides appropriate warning of possible injury severity, helping medical personnel better understand the severity of tissue damage and prevent injury severity during extravasation.
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... Este fármaco modifica la permeabilidad de los tejidos al hidrolizar el ácido hialurónico, favoreciendo la reabsorción de líquidos y disminuyendo el edema. La Oncology Nursing Society (ONS) recomienda esa enzima como antídoto e indica la aplicación subcutánea de 1,0 ml de 150 UI/ml en el área de extravasación (1,(6)(7)(8) . Después de diez minutos de la aplicación, se puede observar que la difusión del líquido extravasado en el área tratada es de 3 a 5 veces más que en un área no tratada. ...
... Después de diez minutos de la aplicación, se puede observar que la difusión del líquido extravasado en el área tratada es de 3 a 5 veces más que en un área no tratada. La permeabilidad del tejido se restaura de 24 a 48 horas después de la aplicación del antídoto (2,7,9) . ...
Resumen Objetivo: investigar el efecto del uso de diferentes agentes (hialuronidasa tópica, fotobiomodulación y la combinación de fotobiomodulación y hialuronidasa tópica) en la prevención de la formación de lesiones causadas por la extravasación de doxorrubicina y en la reducción de las lesiones formadas por la extravasación de ese fármaco. Método: estudio experimental con 60 ratas Wistar, distribuidos aleatoriamente en cuatro grupos de 15 animales. Grupo 1 (Control); Grupo 2 (Hialuronidasa); Grupo 3 (Fotobiomodulación) y Grupo 4 (Hialuronidasa + Fotobiomodulación). La herida se indujo aplicando 1 mg de doxorrubicina por vía subcutánea en el lomo de los animales. La concentración de hialuronidasa tópica fue de 65 unidades de turbidez/g, la energía utilizada fue de 1 joule de láser rojo de 100 mW por centímetro cuadrado. En la evaluación macroscópica cada dos días durante 28 días se observaron las siguientes variables: piel intacta, presencia de flictena, hiperemia, exudado, sangrado, edema, costra, descamación y tejido de granulación. Resultados: los animales de los grupos con fotobiomodulación obtuvieron mejores resultados en la evaluación de las variables: sangrado, hiperemia, exudado, piel intacta y edema. Conclusión: se demostró que la combinación de fotobiomodulación y hialuronidasa tópica fue eficaz para reducir los efectos locales y ayudó en el proceso de cicatrización de heridas y que la FBM por sí sola previno la aparición de lesiones.
... This medication modifies tissue permeability by hyaluronic acid hydrolysis, promoting reabsorption of fluids and reducing the edema. This enzyme is an antidote recommended by the Oncology Nursing Society (ONS), which 1.0 ml subcutaneous application of 150 UI/ml to the extravasation area (1,(6)(7)(8) . After ten minutes since application, an increase in diffusion of the overflowed liquid can be seen in an area from 3 to 5 times greater than in an untreated area. ...
... Tissue permeability is restored from 24 to 48 hours after applying the antidote (2,7,9) . Photobiomodulation (PBM) consists in irradiating nonionizing light and is classified according to its wavelength into visible red (622-780 nm) or infrared (780-1,500 nm). ...
Objective:
to investigate the effect of using different agents (topical hyaluronidase, photobiomodulation, and the association of photobiomodulation with topical hyaluronidase) in preventing the formation of lesions caused by doxorubicin extravasation, as well as in the reduction of lesions formed by extravasation of this drug.
Method:
a quasi-experimental study conducted with 60 Wistar rats, randomized into four groups with 15 animals each. Group 1 (Control); Group 2 (Hyaluronidase); Group 3 (Photobiomodulation); and Group 4 (Hyaluronidase + Photobiomodulation). A wound was induced by applying 1 mg of doxorubicin to the subcutaneous tissue of the back of the animals. The concentration of topical hyaluronidase was 65 turbidity units/g and the energy employed was 1 joule of 100 mW red laser per square centimeter. With macroscopic evaluation every two days for 28 days, the following variables were observed: skin integrity, presence of blisters, hyperemia, exudate, bleeding, edema, crust, peeling and granulation tissue.
Results:
the animals from the groups subjected to photobiomodulation obtained better results in the assessment of the following variables: bleeding, hyperemia, exudate, intact skin and edema.
Conclusion:
it was evidenced that the association of photobiomodulation with topical hyaluronidase was effective in reducing the local effects and assisted in the wound healing process, and that PBM alone was able to prevent appearance of lesions.
... For scoring of the IIERAT for the three categories of mild, moderate and severe risk, the median value was calculated by subtracting the minimum score of 11 from maximum score of 33 and dividing it by 3, which was approximately 7. Then, this value was added into the minimum score to get the range of scores in each level-Low risk (11)(12)(13)(14)(15)(16)(17)(18), Moderate risk (19)(20)(21)(22)(23)(24)(25)(26) and Severe risk (27)(28)(29)(30)(31)(32)(33). Content validity index for each item in the tool was found to be 1. ...
... This is because small and or fragile veins are more prone to cause infiltration [26]. Similar to our results, Schulmeister [27] also found that sterile, transparent dressings should be used by clinicians to protect the site from extrinsic contamination, and visual assessment in pediatric patients for redness, tenderness, swelling, numbness, or tingling on a regular basis. ...
Objective:
To develop and validate a new tool viz., Intravenous Infiltration and Extravasation Risk Assessment Tool (IIEART) for assessing risk of fluid extravasation in children.
Participants:
120 children (aged 2-18 year) undergoing peripheral intravenous cannulation were recruited from four hospitals of Haryana to determine the IIEART scale's psychometric properties.
Methods:
The tool was developed under four phases with Modified Delphi rounds among nine experts. After experts' confirmation of final draft, the reliability and validity of the tool was ascertained.
Results:
The final IIERAT with 11 items showed good internal consistency (α=0.81) with inter-rater reliability of (κ=0.88). To calculate predictive validity, sensitivity and specificity were assessed for 3 consecutive days from the day of cannulation. At a score >21, the sensitivity was 100% and specificity was 100% with area under curve of 1.000 (95% CI) on second day of cannulation.
Conclusion:
The IIEART developed was found to be valid and reliable and can be used by health care personnel to predict pediatric patients at risk for intravenous infiltration and extravasation.
... They can be summed up into four categories: patient-specific (e.g., cardiovascular disease, obesity), health care-specific (e.g., time pressure, establishment of intravenous access), procedurespecific (e.g., volume and duration of infusion, quality of equipment) and substance-specific (e.g., chemical properties, time of exposure) (Larson, 1982;Boschi and Rostagno, 2012;Pérez Fidalgo et al., 2012;de Wit et al., 2013;Reynolds et al., 2014). Timely identification of these potential risk factors is crucial to successfully prevent or minimize the risk for extravasation injuries (Goolsby and Lombardo, 2006;Schulmeister, 2011). ...
... This way lesions become larger, deeper, and more painful, and the extravasation damage may become chronic (Ener et al., 2004). DNA non-binders are metabolized and neutralized quicker and this way they may cause only mild-to moderate lesions that heal in a significantly shorter time (Schulmeister, 2011;Onesti et al., 2017). Irritant substances may cause local pain, with or without inflammation and, e.g., through irritation of the venous vessels may cause vasospasm leading to a venous flow obstruction, which may raise the risk of extravasation due to the resulting increased hydrostatic pressure. ...
Background: Extravasation during chemotherapy administration can lead to dangerous adverse effects ranging from pain to tissue necrosis. Evidence-based data about prevention and treatment of extravasation injuries of some clinically used compounds still remains elusive. This work aimed to investigate, in a preclinical mouse model, the effects of extravasation of two chemotherapeutic agents, nanoliposomal irinotecan (nal-Iri) and trabectedin. In addition, we aimed to study treatment options for injuries induced by extravasation of these substances.
Methods: Mice were subcutaneously injected with nal-Iri or trabectedin applied in clinically used concentration. Doxorubicin was used as a positive control. In subsequently performed experiments, hyaluronidase, DMSO and tacrolimus were tested as potential treatments against extravasation-induced injuries by trabectedin. Systemic effects were analyzed by observation and documentation of the health status of mice and local reactions were measured and graded. In addition, hematoxylin-eosin stained histological sections of the treated skin areas were analyzed.
Results: Of the two tested substances, only trabectedin showed vesicant effects. Subcutaneous injection of trabectedin caused erythema formation in mice by day two that was progressing to skin ulcerations by day five. Furthermore, we found that topical treatment of mice with tacrolimus or DMSO reduced the vesicant effects of trabectedin. The results observed in vivo were supported microscopically by the analysis of histological sections.
Conclusions: We recommend classifying trabectedin as a vesicant agent and nal-Iri as a non-vesicant agent. Furthermore, our results obtained in a preclinical model suggest that tacrolimus and DMSO might be suitable treatment options of trabectedin extravasations, a finding that might be further utilized in clinical studies.
... Multiple unsuccessful attempts at venipuncture may limit future peripheral vein access (3,(10)(11)(12). In addition, there is a risk of increased peripheral chemotherapy extravasation in veins that had had multiple cannulation attempts, with incidence reported in the literature from 0.08% to 6.5% (13,14) . Although the incidence is low, the devastating long-term effects of chemotherapy extravasation on the patient can result in significant pain, tissue necrosis, and loss of function at the site of injury (13) . ...
... In addition, there is a risk of increased peripheral chemotherapy extravasation in veins that had had multiple cannulation attempts, with incidence reported in the literature from 0.08% to 6.5% (13,14) . Although the incidence is low, the devastating long-term effects of chemotherapy extravasation on the patient can result in significant pain, tissue necrosis, and loss of function at the site of injury (13) . Therefore, superficial veins of the forearm are preferable for the venipuncture, with smaller risk of injury given that they are far from articulations. ...
This study aimed to assess over time alterations of a peripheral vein used for chemotherapy infusion in patients with breast cancer. It is a prospective observational study which included patients who were scheduled to receive peripheral infusion of chemotherapy. These patients had the first peripheral vein used for infusion evaluated in five moments: before the venipuncture, after device removal at the end of the first chemotherapy infusion, and on days 21, 42, and 63 after the first infusion. The primary outcome was the caliber of the vein, measured in millimeters with a Veinlite LEDX® transilluminator and a tape measure. Fifty-nine women receiving doxorubicin and docetaxel for the first time were enrolled to the study. The caliber size varied from 2 to 4 millimeters at baseline, and decreased overtime. During the follow-up period, peripheral veins of 35 women (59.3%) were measured at 0 mm at day 63. The remaining 24 women (40.7%) had some recovery, but for 15 of them (62.5%) the vein became a palpable cord. The feasibility of using a peripheral vein to perform chemotherapy decreased as the treatment progresses.
Este estudio tuvo como objetivo evaluar las alteraciones en el tiempo de una vena periférica utilizada para la infusión de quimioterapia en pacientes con cáncer de mama. Es un estudio observacional prospectivo que incluyó pacientes que estaban programados para recibir infusión periférica de quimioterapia. A estos pacientes se les evaluó la primera vena periférica utilizada para la infusión en cinco momentos: antes de la venopunción, después de la extracción del dispositivo al final de la primera infusión de quimioterapia y los días 21, 42 y 63 después de la primera infusión. El resultado primario fue el calibre de la vena, medido en milímetros con un transiluminador Veinlite LEDX® y una cinta métrica. Se inscribieron en el estudio 59 mujeres que recibieron doxorrubicina y docetaxel por primera vez. El tamaño del calibre varió de 2 a 4 milímetros en la línea de base y disminuyó con el tiempo. Durante el período de seguimiento, las venas periféricas de 35 mujeres (59,3%) se midieron a 0 mm el día 63. Las 24 mujeres restantes (40,7%) tuvieron cierta recuperación, pero para 15 de ellas (62,5%) la vena se convirtió en un cordón palpable. La viabilidad de utilizar una vena periférica para realizar quimioterapia disminuyó a medida que avanzaba el tratamiento.
Este estudo teve como objetivo avaliar as alterações ao longo do tempo de uma veia periférica utilizada para infusão de quimioterapia em pacientes com câncer de mama. Trata-se de um estudo observacional prospectivo que incluiu pacientes que tinham indicação de receber infusão periférica de quimioterapia. A primeira veia periférica utilizada para infusão de quimioterapia nessas pacientes foi avaliada em cinco momentos: antes da punção venosa, após a retirada do dispositivo ao final da primeira infusão de quimioterapia e nos dias 21, 42 e 63 após a primeira infusão. O desfecho primário foi o calibre da veia, mensurado em milímetros com um iluminador transdérmico chamado Veinlite LEDX® e uma fita métrica. Cinquenta e nove mulheres que receberam doxorrubicina e docetaxel pela primeira vez foram incluídas no estudo. O tamanho do calibre variou de 2 a 4 milímetros no início do estudo e diminuiu com o tempo. Durante o período de acompanhamento, as veias periféricas de 35 mulheres (59,3%) foram medidas a 0 mm no dia 63. As 24 mulheres restantes (40,7%) tiveram alguma recuperação, mas para 15 delas (62,5%) a veia tornou-se um cordão palpável. A viabilidade do uso de uma veia periférica para a realização da quimioterapia diminuiu com o avanço do tratamento.
... Bu doğrultuda hemşirelik bakımında bir yaşam kalitesi indikatörü olarak görülen ve oluşmaması önerilen ekstravazasyona yönelik YBÜ'de çalışan hemşirelerin bilgi düzeyinin belirlenmesi oldukça önemlidir. 21,22 Literatür taramasında YBÜ'de çalışan hemşirelere yönelik herhangi bir araştırmaya rastlanılmamıştır. Dolayısıyla bu çalışma YBÜ'de çalışan hemşirelerin ekstravazasyona yönelik bilgi düzeyini belirlemek amacıyla planlandı. ...
... Hemşirelik bakımında bir yaşam kalitesi indikatörü olarak görülen ve oluşmaması önerilen ekstravazasyonun yönetiminden sorumlu hemşirelerin, dokuda ekstravazasyona neden olabilecek ilaçları bilmesi, ekstravazasyon oluşmaması için önlem alması, ekstravazasyon oluşması durumunda erken tanılaması ve yönetmesi oldukça önemlidir. 21,22 Çalışmamızda YBÜ'de çalışan hemşirelerin çalıştıkları süre içerisinde %76,3'ünün ekstravazasyonla karşılaştığı belirlenmiştir. Literatürde ilaca ve hastaya bağlı oluşan ekstravazasyon insidansının erişkin hastalarda nonvezikan ilaçlarda %0,1-6 oranında iken, pediatrik hastalarda ise %11 olduğu bildirilmektedir. ...
... The way in which chemotherapy extravasation is managed depends upon various factors: the category of the extravasated drug, the site and volume of extravasation, local expertise and historical practices within institutions. Taking these factors into account, the optimal strategy may then be chosen from among the following: the conservative strategy of 'watch and wait', surgical intervention, topical application of ice or heat, and the use of various antidotes or saline wash-out technique (26,(36)(37)(38). ...
... Despite this treatment, they had extensive necrosis in the following days, delaying chemotherapy. Our results confirmed that the outcome of an ineffectively managed extravasation can be potentially devastating (13,33,37,40), with long term consequencessuch as the need for reconstructive surgery -sometimes more debilitating for the patient than their primary disease (22). However, these poor results can be explained by the delay between the extravasation occurring and the administration of the antidote, and does not reflect the known effectiveness of antidotes. ...
Background
Totally implanted venous access is widely used in chemotherapy administration. With over 1 million intravenous chemotherapy infusions given worldwide each day, complications are frequent. Accidental cases of extravasation in the presence of a catheter are rare yet very serious and may require discontinuation of chemotherapy. The aim of this study was to evaluate the feasibility and efficacy of the subcutaneous wash-out technique for chemotherapy extravasation treatment.
Methods
We retrospectively reviewed the medical charts of patients who had received chemotherapy and sustained extravasation in our hospital between October 2013 and October 2016. Subcutaneous wash-out treatments were carried out exclusively, without the application of antidotes or the use of specific antidotes.
Results
We documented seven cases of chemotherapy extravasation. Two cases were treated with antidotes and suffered necrosis in the following weeks. The five patients treated using subcutaneous wash-out had no necrosis and had a steady decrease in the inflammatory reaction of the cutaneous and subcutaneous soft tissues. For these five patients, chemotherapy was restarted within 1 month following extravasation.
Conclusion
This study would argue for the feasibility and effectiveness of subcutaneous wash-out in the treatment of chemotherapy extravasations.
... Common 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 The way in which chemotherapy extravasation is managed depends upon various factors: the category of the extravasated drug, the site and volume of extravasation, local expertise and historical practices within institutions. Taking these factors into account, the optimal strategy may then be chosen from among the following: the conservative strategy of 'watch and wait', surgical intervention, topical application of ice or heat, and the use of various antidotes or saline wash-out technique (26,(35)(36)(37). ...
... Despite this treatment, they had extensive necrosis in the following days, delaying chemotherapy. Our results confirmed that the outcome of an ineffectively managed extravasation can be potentially devastating (13,32,36,39), with long term consequencessuch as the need for reconstructive surgery -sometimes more debilitating for the patient than their primary disease (22). The poor results obtained from treatment with antidotes contrast strongly with the results of saline wash-out. ...
Background and aim of the work: Totally implanted venous access is widely used in chemotherapy administration. With over one million intravenous chemotherapy infusions given worldwide each day, complications are frequent. Accidental cases of extravasation in the presence of a catheter are rare yet very serious and may require discontinuation of chemotherapy. The aim of this study was to evaluate the feasibility and efficacy of the subcutaneous wash-out technique for chemotherapy extravasation treatment. Methods: We retrospectively reviewed the medical charts of patients who had received chemotherapy and sustained extravasation in our hospital between October 2013 and October 2016. Treatments were carried out exclusively using subcutaneous wash-out, without the application of antidotes or the use of specific antidotes. Results: We documented 7 cases of chemotherapy extravasation. Two cases were treated with antidotes and suffered necrosis in the following weeks. The 5 patients treated using subcutaneous wash-out had no necrosis and had a steady decrease in the inflammatory reaction of the cutaneous and subcutaneous soft tissues. For these 5 patients, chemotherapy was restarted within one month following extravasation. Conclusions: This study validates the feasibility and effectiveness of subcutaneous wash-out in the treatment of chemotherapy extravasations.
... However, the success rate of this procedure is highly dependent on the experience of the practitioner and the patients' features, often leading to an adverse event known as extravasation. 36,69 In this article, an overview of the extravasation mechanism and of the potential issues the patients might experience as a result of such an incident were represented. Many studies in the literature report that, to date, visual inspection of the cannulation site by physicians and nurses is the most common method used to detect extravasation. ...
Peripheral intravenous catheters are administered for various purposes, such as blood sampling or the infusion of contrast agents and drugs. Extravasation happens when the catheter is unintentionally directed outside of the vein due to movement of the intravascular catheter, enhanced vascular permeability, or occlusion of the upstream vein. In this article, extravasation and its mechanism are discussed. Subsequently, the sensorized devices (e.g., single sensor and multimodal detection) to identify the extravasation phenomena are highlighted. In this review article, we have shed light on both physiological and engineering points of view of extravasation and its detection approaches. This review provides an overview on the most recent and relevant technologies that can help in the early detection of extravasation.
... Como citar este artigo Freitas (2,7,9) . ...
Resumo Objetivo: investigar o efeito do uso de diferentes agentes (hialuronidase tópica, fotobiomodulação e da associação da fotobiomodulação com a hialuronidase tópica) na prevenção de formação de lesões causadas por extravasamento de doxorrubicina bem como na diminuição de lesões formadas pelo extravasamento desta droga. Método: estudo experimental com 60 ratos Wistar, randomizados em quatro grupos de 15 animais. Grupo 1 (Controle); Grupo 2 (Hialuronidase); Grupo 3 (Fotobiomodulação) e Grupo 4 (Hialuronidase + Fotobiomodulação). Induziu-se ferida aplicando 1 mg de doxorrubicina no subcutâneo do dorso dos animais. A concentração da hialuronidase tópica foi de 65 unidades de turbidez/g, a energia empregada foi de 1 joule de laser vermelho 100 mW por centímetro quadrado. Com avaliação macroscópica a cada dois dias por 28 dias, observou-se as variáveis: integridade da pele, presença de flictema, hiperemia, exsudato, sangramento, edema, crosta, descamação e tecido de granulação. Resultados: os animais dos grupos com fotobiomodulação obtiveram melhores resultados na avaliação das variáveis: sangramento, hiperemia, exsudato, pele íntegra e edema. Conclusão: evidenciou-se que a associação da fotobiomodulação com a hialuronidase tópica foi eficaz na diminuição dos efeitos locais e auxiliou no processo de cicatrização da ferida e que a FBM isolada foi capaz de prevenir o aparecimento de lesões.
... Although this technique was recommended to be performed immediately after extravasation, the exact time frame is still unknown. Gault et al. felt that saline washout was most effective if undertaken within 1 h of drug extravasation, with no further studies to either support or refute this statement [22], whereas the protocol published by Dougherty and Oakley advocated referral for washout within 2 h of the incident [23]; Schulmeister advocated an ideal timeframe within 6 h of extravasation [24]; Steiert et al., reported maximum time to washout as 14 h [25]. Although SCWO (with or without liposuc-tion) can be successful in delayed presentations of more than 24 h, it is preferable to undertake it within 24 h [26]. ...
Chemotherapy extravasation can cause severe harm. There is a lack of evidence-based standardization on the surgical management of such injuries beyond the immediate stage. In an algorithm connecting presentation time post-injury with surgical treatment could help standardize future treatment. This study prospectively validated a preset standardized surgical algorithm based on presentation time in a consecutive series between October 2017 and October 2020. Chemotherapeutic agent, site and extent of injury, type of surgery and outcome at a minimum of 6 months’ follow-up were collected. Seven thousand six hundred twelve individuals received chemotherapy during that period; 15 patients suffered extravasation injuries, 2 of whom were referred from outside our hospital. This algorithm distinguished: A) beyond the immediate stage and up to 2 days, treated with saline subcutaneous washout (SCWO) and vacuum-assisted closure (VAC) dressing; B) 2 to 5 days, open surgical decompression and VAC dressing; C) 5 to 10 days, non-operative management with surveillance; and D) more than 10 days, radical necrotic excision with or without VAC dressing and tissue reconstruction. In 2 patients in Group A and 3 patients in Group B, all vesicant symptoms resolved. Five of the 6 patients in Group C (3 vesicant, 3 non-vesicant) did not progress into necrosis or infection, and 1 case of vesicant extravasation progressed to a localized ulcer beyond this period and, as surgery was refused, led to a chronic ulcer with stiffness; 2 cases of non-vesicant extravasation developed a recall phenomenon but resolved after the third cycle. Of the 4 patients in Group D, all vesicant, 2 were treated with no complications, 1 had complex regional pain syndrome (CRPS) due to late presentation, and 1, referred with necrotizing fasciitis, underwent above-elbow amputation but died due to septic shock. This study demonstrated a uniform surgical approach in a series of 15 cases; larger studies are still needed to validate the efficacy of this protocol in reducing morbidity.
... Although this technique was recommended to be performed immediately after extravasation, the exact time frame is still unknown. Gault et al. felt that saline washout was most effective if undertaken within 1 h of drug extravasation, with no further studies to either support or refute this statement [22], whereas the protocol published by Dougherty and Oakley advocated referral for washout within 2 h of the incident [23]; Schulmeister advocated an ideal timeframe within 6 h of extravasation [24]; Steiert et al., reported maximum time to washout as 14 h [25]. Although SCWO (with or without liposuction) can be successful in delayed presentations of more than 24 h, it is preferable to undertake it within 24 h [26]. ...
Chemotherapy extravasation can cause severe harm. There is a lack of evidence-based standardization on the surgical management of such injuries beyond the immediate stage. In an algorithm connecting presentation time post-injury with surgical treatment could help standardize future treatment. This study prospectively validated a preset standardized surgical algorithm based on presentation time in a consecutive series between October 2017 and October 2020. Chemotherapeutic agent, site and extent of injury, type of surgery and outcome at a minimum of 6 months’ follow-up were collected. Seven thousand six hundred twelve individuals received chemotherapy during that period; 15 patients suffered extravasation injuries, 2 of whom were referred from outside our hospital. This algorithm distinguished: A) beyond the immediate stage and up to 2 days, treated with saline subcutaneous washout (SCWO) and vacuum-assisted closure (VAC) dressing; B) 2 to 5 days, open surgical decompression and VAC dressing; C) 5 to 10 days, non-operative management with surveillance; and D) more than 10 days, radical necrotic excision with or without VAC dressing and tissue reconstruction. In 2 patients in Group A and 3 patients in Group B, all vesicant symptoms resolved. Five of the 6 patients in Group C (3 vesicant, 3 non-vesicant) did not progress into necrosis or infection, and 1 case of vesicant extravasation progressed to a localized ulcer beyond this period and, as surgery was refused, led to a chronic ulcer with stiffness; 2 cases of non-vesicant extravasation developed a recall phenomenon but resolved after the third cycle. Of the 4 patients in Group D, all vesicant, 2 were treated with no complications, 1 had complex regional pain syndrome (CRPS) due to late presentation, and 1, referred with necrotizing fasciitis, underwent above-elbow amputation but died due to septic shock. This study demonstrated a uniform surgical approach in a series of 15 cases; larger studies are still needed to validate the efficacy of this protocol in reducing morbidity.
Level of evidence
IV
... Today the incidence of extravasation is between 0.01% and 7%. 1,2,[16][17][18][19] This wide gap shows as this iatrogenic damage is often unrecognized and/or not signaled, furthermore, the absence of a centralized reporting mechanism of chemotherapy extravasation events determined the scant of data. The true incidence rate is probably closer to the lower end of reported ranges. ...
Extravasation is defined as the iatrogenic injury due to fluid/drug extravasation from the vessel occurring during the infusion therapy; it may result in serious damage to patients, with irreversible local injuries and disability. If treatment is delayed, surgical debridement, skin grafting, and even amputation may be the unfortunate consequences of such an injury. Evidence-based standardization on extravasation management is lacking, and many institutions do not practice adequate procedures to prevent the most severe damages. Numerous treatments have been proposed in literature. For chemotherapy extravasation, the antidotes to neutralize the vesicant solutions have been discussed controversially and are not considered standard methods for treatment, especially when polychemotherapy is administered and the identification of the causative drug is not possible. In neonatal intensive care units, extravasation is one of the most common injuries occurring in premature infants and critically ill newborns as a complication of infusion therapy. Preterm infants have immature and fragile skin, which is easily damaged. These tiny patients require especially effective pressure-sensitive equipment for the early detection of extravasation of intravenous fluids, and an invasive treatment should be avoided, whenever possible. We describe a therapeutic protocol consisting of local infiltration of saline solution. This technique aims to dilute rapidly the extravasated drug/fluid, thus reducing its harmful effects. This method is easy to use and always reproducible even when the drug is not known or when it is administrated in combination with other drugs. It is possible to perform it in the ambulatory care setting, and it represents a standard method.
... In between lies the irritant drugs that can cause pain along the administration route or extravasation site with or without inflammation, however causing ulceration only if in significant quantities [3,4]. Consequences of drug infiltration or extravasation may be varied; from minor discomfort, pain, and swelling to widespread inflammation or stubborn ulceration [5]. ...
Introduction: Extravasation injuries are one of the most feared complications of intravenous drug administration. The most common drugs associated with extravasation injury include chemotherapy agents and contrast media. Natural course of vesicant extravasation is discomfort, pain, swelling, inflammation, and ultimately skin ulceration. While diligence is the principle approach in prevention, immediate bed-side measures are as important in controlling the extent of tissue damage. Various options, either medical or interventional are next steps in treatment of the condition including
antidotes, volume dilution, flushing, suction, hyperbaric oxygen therapy, and surgery.
Materials and methods: 12 male Wistar albino rats were divided into two groups; one group
received fat injections following subdermal doxorubicin infiltration in their right thighs, while other group received saline injection following subdermal doxorubicin infiltration in their right thighs for dilution. Left thighs of both groups were left untreated following subdermal doxorubicin infiltration. Total area of necrosis, as well as resultant epidermal thicknesses were assessed. Histological analyses were conducted using modified Verhofstad scoring system for comparison.
Results: Mean necrotic area was significantly smaller in the fat injection group compared to other groups. Median Verhofstad score was lesser in the fat injection group as well. Median epidermal thickness, on the other hand, was greater in the fat injection group.
Conclusion: Injection of fat grafts following vesicant extravasation might be beneficial in preventing the progression of tissue damage, if employed early.
... venous damage (cytotoxic drugs), direct vasoconstriction, or by exposing cells to osmotic stress or a nonphysiologic pH [4,[11][12][13]. While oncology drug properties and their influence in VAD selection have been widely documented [14][15][16][17][18], there is limited data available regarding nononcologic drugs. ...
Background
Intravenous drug administration is associated with potential complications, such as phlebitis. The physiochemical characteristics of the infusate play a very important role in some of these problems.AimThe aim of this study was to standardize the dilutions of intravenous drugs most commonly used in hospitalized adult patients and to characterize their pH, osmolarity and cytotoxic nature to better guide the selection of the most appropriate vascular access.Methods
The project was conducted in three phases: (i) standardization of intravenous therapy, which was conducted using a modified double-round Delphi method; (ii) characterization of the dilutions agreed on in the previous phase by means of determining the osmolarity and pH of each of the agreed concentrations, and recording the vesicant nature based on the information in literature; and (iii) algorithm proposal for selecting the most appropriate vascular access, taking into account the information gathered in the previous phases.ResultsIn total, 112 drugs were standardized and 307 different admixtures were assessed for pH, osmolarity and vesicant nature. Of these, 123 admixtures (40%), had osmolarity values >600 mOsm/L, pH < 4 or > 9, or were classified as vesicants. In these cases, selection of the most suitable route of infusion and vascular access device is crucial to minimize the risk of phlebitis-type complications.Conclusions
Increasing safety of intravenous therapy should be a priority in the healthcare settings. Knowing the characteristics of drugs to assess the risk involved in their administration related to their physicochemical nature may be useful to guide decision making regarding the most appropriate vascular access and devices.
... ISAEs occur when drugs leak outside the vein, causing symptoms such as infusion site pain, erythema, swelling, and/or phlebitis to the site. The administration of irritant drugs can cause temporary aching, tightness, and phlebitis along the vein or at the injection site with or without a local inflammatory reaction; with vesicant drugs, there can be blistering and tissue necrosis requiring wound debridement, skin grafting, or other surgical intervention (Schulmeister, 2011). ...
Background:
Studies report a wide range of incidence and severity of infusion site adverse events (ISAEs) following fosaprepitant administration.
Objectives:
The purposes of this study were (a) to determine the incidence of suspected extravasation in patients with cancer receiving fosaprepitant infusions with chemotherapy and (b) to determine whether the documented signs, symptoms, and management strategies aligned with the diagnostic criteria for extravasation versus non-extravasation ISAEs.
Methods:
Electronic health records were used to identify patients who received fosaprepitant infusion with chemotherapy and had documentation for suspected extravasation. Chart reviews were conducted for a sample of patients to determine whether documentation was consistent with extravasation.
Findings:
About 3% (n = 460 of 15,667) of patients who received fosaprepitant had documentation for suspected extravasation. Among a random sample of patients (N = 110) with suspected extravasation, 6% (n = 6) had documentation consistent with extravasation.
... Moreover, recent studies have identified alarmingly high rates of PIV failure (resulting from occlusion, infiltration, dislodgement, phlebitis, and infection) in medical and surgical care populations (33-69%) [7,8]. However, similar outcome rates have yet to be confirmed in cancer-specific populations as, traditionally, PIV studies in cancer populations have focused upon the incidence and treatment of vesicant extravasation injuries, specifically [9,10]; to date, there have been no prospective studies which have reported the incidence of all-cause PIV failure. ...
Purpose:
To identify modifiable and non-modifiable risk factors for peripheral intravenous catheter (PIV) failure among patients requiring intravenous treatment for oncology and haematology conditions.
Methods:
A single-centre prospective cohort study was conducted between October 2017 and February 2019. Adult in-patients requiring a PIV for therapy were prospectively recruited from two cancer units at a tertiary hospital in Queensland, Australia. The primary outcome was a composite of complications leading to PIV failure (local and bloodstream infection; occlusion; infiltration/extravasation; leakage; dislodgement; and/or phlebitis). Secondary outcomes were (i) PIV dwell time; (ii) insertion and (iii) failure of a CVAD; (iv) adverse events; (v) length of hospital stay. Outcomes were investigated using Bayesian multivariable linear regression modelling and survival analysis.
Results:
Of 200 participants, 396 PIVs were included. PIV failure incidence was 34.9%; the most common failure type was occlusion/infiltration (n = 74, 18.7%), then dislodgement (n = 33, 8.3%), and phlebitis (n = 30, 7.6%). While several patient and treatment risk factors were significant in univariable modelling, in the final multivariable model, only the use of non-sterile tape (external to the primary dressing) was significantly associated with decreased PIV dislodgement (hazard ratio 0.06, 95% confidence interval 0.01, 0.48; p = 0.008).
Conclusion:
PIV failure rates among patients receiving cancer treatment are high, the sequelae of which may include delayed treatment and infection. Larger studies on risk factors and interventions to prevent PIV failure in this population are needed; however, the use of secondary securements (such as non-sterile tape) to provide further securement to the primary PIV dressing is particularly important.
Trial registration:
Study methods were registered prospectively with the Australian New Zealand Clinical Trials Registry on the 27th March 2017 (ACTRN12617000438358); https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372191&isReview=true.
... More generally, the application of cold packs limits the diffusion of the product and reduces persistent chemical activity. [36][37][38] Warm compresses increase local blood flow, and distribution and absorption of the product, and thus, the local concentration of the extravasated product decreases. 37,38 In the case of a product that has not been subject to any specific management recommendation, the action must be assessed on a case-by-case basis, using a multidisciplinary approach involving the nurse, pharmacist, doctor, and surgeon. ...
Objective: Commonly used drugs may be dangerous in case of extravasation. The lack of information from health care teams can lead to delays in both diagnosis and treatments. This review aims at alerting health care professionals about drugs and risk factors for extravasation and outlines recommendations for the diagnosis and treatment of extravasation. Data Source: A literature search of MEDLINE/PubMed, Scopus, the Cochrane Library, and Google Scholar was performed from 2000 to December 2019 using the following terms: extravasation, central venous line, peripheral venous line, irritant, and vesicant. Study Selection and Data Extraction: Overall, 140 articles dealing with drug extravasation were considered potentially relevant. Each article was critically appraised independently by 2 authors, leading to the inclusion of 80 relevant studies, guidelines, and reviews. Articles discussing incidents of extravasation in the neonatal and pediatric population of patients were excluded. Data Synthesis: Training of health care teams and writing care protocols are important for an optimal management of extravasations. A prompt consultation should be achieved by a specialist surgeon. The surgical procedure, if necessary, will consist of wound debridement followed by an abundant lavage. Relevance to Patient Care and Clinical Practice: This review discusses the management of drug extravasations according to their mechanism(s) of toxicity on tissues. It highlights the importance of a close monitoring of patients and the training of health care teams likely to face this type of adverse event. Conclusions: Extravasations still contribute to significant morbidity and mortality. A good knowledge of risk factors and the implementation of easily and quickly accessible standardized care protocols are 2 key elements in both prevention and treatment of extravasations.
... Since its introduction in 1975, DOX has been used in rituximab plus cyclophosphamide, DOX, vincristine, and prednisolone therapy [1], adriamycin, bleomycin, vinblastine and dacarbazine therapy, and modified cyclophosphamide, vincristine, doxorubicin and methotrexate therapy for lymphomas. The reported frequency of extravasation of infused anticancer drugs is 0.01-6.5% in Europe and America [2]. DOX is classified in a vesicant drug that can cause serious injury to skin tissue when it leaks out of blood vessels. ...
In the present study, we investigated a part of the mechanism responsible for the effects of hot and cold compresses for extravasation of doxorubicin. We injected 20 μl of doxorubicin (DOX) (1 μg/μl) subcutaneously into the dorsal area in mice and observed the resulting skin lesions macroscopically and histologically from day 1 to day 14 thereafter in groups treated with a cold pack (18-20°C) and a hot pack (38-40°C) or left untreated (control). Immunofluorescence and RT-PCR for C5a receptor (CD88), interleukin-8 receptor (IL-8RA), and transient receptor potential cation channel subfamily V member 1 (TRPV1) were also performed. Macroscopic observation showed that the area of the skin lesion was significantly smaller in the cold group than in the control group, but was significantly larger in the hot group. The neutrophil count in the lesion was significantly higher in the hot group than in the cold (3 hrs) and control groups. The numbers of inflammatory cells expressing CD88 and IL-8RA were significantly lower in the cold group than that in the other groups at almost time points and in the hot groups at later time points, respectively. The number of nerve fascicles expressing TRPV1 was higher in the hot group than in the cold group on days 1, 3 and 14. mRNA for CD88, IL-8RA and TRPV1 was detectable by reverse transcription-polymerase chain reaction in both the cold and hot pack groups. Consequently, these results suggested that the cold pack for the extravasation of DOX might reduce inflammation.
... Specifically, in the context of cancer therapy, extravasation refers to the inadvertent infiltration of chemotherapy agents into the subcutaneous or subdermal tissues surrounding an intravenous or intra-arterial administration site (2). Such inadvertent infiltration of vesicant anticancer agents (e.g., taxanes) can cause adverse events such as tissue necrosis or induration in the region of catheter placement (3)(4)(5). The reported incidence of extravasation varies greatly because there is no shared register of chemotherapy extravasation events; however, several studies have been published, most of which have reported that the incidence of extravasation is greater with paclitaxel than ...
Paclitaxel, a taxane, is frequently administered intravenously as an anticancer agent. When a peripheral intravenous catheter is used for paclitaxel infusion, clinical nurses often observe signs such as slight swelling at the catheter placement site, lack of blood return, and difficulty in continuing the infusion. However, the cause(s) of such phenomena at the puncture site has not yet been elucidated. The aim of this study was to obtain ultrasonography images of subcutaneous tissues and veins of patients undergoing paclitaxel and carboplatin chemotherapy and compare ultrasonography images taken immediately before catheter removal with those of patients receiving other types of taxanes. We studied 24 patients receiving chemotherapy, including seven receiving paclitaxel and carboplatin chemotherapy, through a peripheral intravenous catheter in a chemotherapy unit for outpatients of a university hospital in Japan. Ultrasonography images of venipuncture sites were obtained before catheter insertion and immediately before catheter removal. We observed subcutaneous edema in the absence of visible manifestations at the puncture sites of all patients undergoing paclitaxel and carboplatin chemotherapy, but not in any patients receiving other types of taxanes. When vesicant agents and vehicles have caused subclinical subcutaneous edema, clinical nurses may detect early slight extravasation by using ultrasonography.
... Moreover, vein stenosis caused by fibrosis in the perivascular tissue is a clinical challenge in patients who required recurrent administration of anticancer drugs through a peripheral vein catheter because of catheter placement difficulty. Typically, nonvesicant drugs are known not to impair or destroy the surrounding tissues [8,9] ; measurement of nonvesicant drug extravasation might not be included in the current extravasation management practice. These events are not managed like that of vesicant or irritant drug extravasation. ...
Rationale:
Induration may occur after an anticancer drug extravasation in patients who recurrently receive chemotherapy because of reduced choice of an appropriate vein for inserting a peripheral intravenous catheter, resulting in catheter placement difficulty. Although induration affects treatment, its size, shape, or hardness remains unclear in the conventional observation method using palpation and inspection. Here, we report our observation results in using ultrasonography to assess the induration that occurred after an anticancer drug extravasation as a new assessment method.
Patient concerns:
A 58-year-old woman with cervical cancer who complained of pain during the administration of a nonvesicant anticancer drug via a peripheral intravenous catheter. The medical staff's examination showed a swollen site; therefore, the catheter was replaced.
Diagnosis:
Induration occurred on the site after an extravasation. Over 6 months later, pigmentation and induration, which can easily be confirmed through palpation, persisted.
Interventions:
The subcutaneous tissue in the induration site was observed using ultrasonography (B-mode and elastography).
Outcomes:
The subcutaneous tissue might have degenerated the tissues surrounding the vein, making it thinner. Moreover, the hardness of the subcutaneous tissue was approximately 7 times than that of the surrounding tissues.
Lessons:
Induration that affects the vein form and its surrounding tissues should be prevented, and ultrasonography is an effective method to objectively observe the site where extravasation occurred.
Objective To describe the risk factors of extravasation, its impact on the pharmacokinetics of non-cytotoxic drugs, and management of extravasation in older individuals. Extravasation occurs when vesicants leak from blood vessels into surrounding tissue causing severe injury such as tissue necrosis while infiltration is caused by leakage of an irritant that causes injury but does not lead to tissue necrosis. Extravasation occurs in approximately 0.01% to 6% of patients, particularly with cytotoxic agents. However, there is limited documentation about extravasation of non-cytotoxic agents, particularly in older people. Data Sources A literature search of Pubmed and Medline was performed using the following search items: "extravasation," "infiltration," "elderly," and "non-cytotoxic drugs," as well as a combination of these terms. Conclusion It is important to recognize, identify, and manage extravasation early since it can have deleterious consequences for older people. It is more important to prevent extravasation than manage it using standardized evidence-based protocols, and this can be implemented in the nursing facility and acute care setting.
Chemotherapy extravasation remains an accidental complication of chemotherapy administration and may result in serious damage to patients. Since patients are the first to feel any symptoms of possible extravasation and are relied upon to report them, their education is a crucial step in chemotherapy extravasation prevention and treatment. Aim: This study aimed to evaluate the impact of implementing interventional guidelines on eliminating extravasation events for patients receiving chemotherapy. Design: Quasi experimental research design was utilized. Setting: The study was conducted at the inpatient and outpatient departments at Oncology Hospital at Mansoura University Hospitals. Subjects: A purposive sample of (60) patients receiving chemotherapy was randomly divided into two groups with equal size (control and study). Tools: Three tools were used to collect the data and achieve the aim of the study as follows: Tool I: Structured Interview Questionnaire. Tool II: Factors contributing to venous extravasation questionnaire. Tool III: Extravasation assessment questionnaire. Results: There was an inverse relationship between patients' knowledge and the occurrence of extravasation, this was reflected in the fact that when patients' information increased, the extravasation occurrence in the study group was decreased at r =-0.468 and P 0.009, than that occur in the control group at r = 0.205 and P 0.276. Conclusion: The study concluded that; there were a numerous factors that can eliminates extravasation occurrence, which include improving patients' knowledge, appropriate; venous assessment, cannula size, cannula site, and efficient cannula secure, that can reduce the rate of extravasation. Recommendation: The current study recommended that Standardized teaching guidelines should be applied in Arabic, updated, colored booklet and be available at inpatients and outpatient for patients undergoing chemotherapy in order to help eliminating extravasation occurrence.
Introduction
Extravasation is a potentially severe complication of intravenous administration of antineoplastic drugs. The limited data makes it difficult to develop an optimal management scheme. The objective of this study is to describe the clinical practice in the extravasation management of antineoplastic agents in Spanish centers.
Methods
An online survey was distributed to oncology pharmacists using the email distribution list of the Spanish Society of Hospital Pharmacists. Respondents were surveyed on the standard operational protocol (SOP) of extravasation, tissue damage risk classification, and specific measures of extravasation management.
Results
A total of 68 surveys were completed. A specific extravasation SOP was available in 82.4% centers. The pharmacist participates in the authorship (100%) and actively collaborates in extravasation management (76.5%). A tissue damage risk classification based on the three categories was mostly adopted (48.2%) and 73.2% applied specific criteria based on concentration and/or extravasated volume. Extravasation management was mainly performed with the application of physical measures and/or antidotes (91.2%). High variability in the choices of pharmacological and/or physical measures recommended is outstanding.
Conclusion
The results of this study highlight the involvement of Spanish pharmacists in extravasation management, the application of physical measures and/or pharmacological measures as the method of choice in extravasation management, as well as the existing discrepancies in tissue damage risk classification and management recommendations
Chemotherapy extravasation remains an accidental complication of chemotherapy administration and may result in serious damage to patients. Since patients are the first to feel any symptoms of possible extravasation and are relied upon to report them, their education is a crucial step in chemotherapy extravasation prevention and treatment. Aim: This study aimed to evaluate the impact of implementing interventional guidelines on eliminating extravasation events for patients receiving chemotherapy. Design: Quasi experimental research design was utilized. Setting: The study was conducted at the inpatient and outpatient departments at Oncology Hospital at Mansoura University Hospitals. Subjects: A purposive sample of (60) patients receiving chemotherapy was randomly divided into two groups with equal size (control and study). Tools: Three tools were used to collect the data and achieve the aim of the study as follows: Tool I: Structured Interview Questionnaire. Tool II: Factors contributing to venous extravasation questionnaire. Tool III: Extravasation assessment questionnaire. Results: There was an inverse relationship between patients' knowledge and the occurrence of extravasation, this was reflected in the fact that when patients' information increased, the extravasation occurrence in the study group was decreased at r =-0.468 and P 0.009, than that occur in the control group at r = 0.205 and P 0.276. Conclusion: The study concluded that; there were a numerous factors that can eliminates extravasation occurrence, which include improving patients' knowledge, appropriate; venous assessment, cannula size, cannula site, and efficient cannula secure, that can reduce the rate of extravasation. Recommendation: The current study recommended that Standardized teaching guidelines should be applied in Arabic, updated, colored booklet and be available at inpatients and outpatient for patients undergoing chemotherapy in order to help eliminating extravasation occurrence.
We developed a flow and pressure measurement device for detection of extravasation by intravenous injection of anticancer drugs at an early stage. Intravenous injection of a drug solution using a syringe pump enables a low‐speed and highly accurate drug‐administration rate. However, because the syringe pump forcibly delivers the drug solution, the drug solution is administrated at a constant administration rate regardless of the leakage of the drug solution to the outside of the blood vessel (extravasation) due to the indwelling needle coming out of the blood vessel. The proposed device is integrated into a flow‐channel structure consisting of a PDMS layer in which a MEMS thermal‐flow sensor formed on thin polyimide film and a pressure sensor are stacked on a plastic plate as a substrate. Therefore, it is possible to measure both the drug‐administration rate and injection pressure. Early detection of extravasation can be achieved by identifying the state of needle‐puncture based on changes in injection pressure. Then, the amount of leaked drug after leak occurs can be accurately measured with a flow sensor. We evaluated the flow and pressure detection function of the proposed device and confirmed that it is possible to detect extravasation early through an experiment involving a piece of raw chicken simulating human skin and flesh. © 2022 Institute of Electrical Engineers of Japan. Published by Wiley Periodicals LLC.
Diversos fármacos têm o potencial de causar danos nos tecidos se ocorrer extravasamento.
A gravidade do extravasamento e a dimensão da lesão estão dependentes de inúmeros fatores, tais como a dose do medicamento, a sua concentração, local de administração e tempo de exposição ao mesmo. A prevenção é a forma mais eficaz de gestão do extravasamento. Perante a ocorrência de extravasamento torna-se crucial adotar um conjunto de medidas/protocolo atempados e adequados com o intuito de prevenir sequelas a longo prazo. As lesões por extravasamento, não relacionadas com a administração de quimioterapia (QT), mais frequentemente reportadas são causadas por soluções hiperosmolares e agentes vasopressores. A hialuronidase é o antídoto dos fármacos hiperosmolares sendo a sua administração fundamental na prevenção de danos nos tecidos decorrentes do extravasamento. Importa, assim, conhecer os princípios gerais que devem nortear a abordagem desta forma de iatrogenia.
Accidental chemotherapy extravasation exacerbates the side effects of anticancer drugs. Therefore, drug-delivery nanocarriers should be designed to avoid persistent drug release at off-target sites and promote burst drug release at on-target. Considering these requirements, poly(allylamine)-co-poly(allylurea) (PAU), a ureido-derivatized temperature responsive polymer with upper critical solution temperature (UCSTs), is an ideal material. This report describes the fabrication, characterization, and in vitro cellular toxicity of PAU polymer-grafted magnetic mesoporous silica nanoparticles as drug-delivery nanocarriers. A UCST of 43 °C and an ultranarrow transition temperature range of 39–43 °C was realized, ensuring that the nanocarriers suppressed undesirable leakage to below 10 % of the drug loading for 8 h in the absence of a thermal stimulus. A drug release burst of up to 75 % of the drug loading was achieved within 30 min after the stimulus, reducing the viability of the in vitro cancer cells to 12 %. Therefore, the ureido-derivatized polymer is one of the most suitable gatekeepers for drug-delivery nanocarriers.
Aim:
We aimed to reveal detailed descriptive data on peripheral intravenous catheter (PIVC) failure related to insertion timing during the treatment cycle, in patients with lymphoma, leukemia, and myeloma.
Methods:
We conducted a prospective descriptive study to investigate the incidence of PIVC failure, defined as PIVC removal prior to completing infusion therapy. This was judged by ward nurses for adult patients requiring PIVC insertion for chemotherapy. A research nurse confirmed the timing and determined the causes of PIVC failure using ultrasonographic imaging. Descriptive data were collected in the hematology and oncology ward of a tertiary hospital in Japan.
Results:
We recruited 85 patients (with 303 PIVCs), and analyzed 67 patients (with 280 PIVCs). Of these, 118 PIVCs (42%) were inserted during the chemotherapeutic dosing period of the treatment cycle, and 106 (38%), during the rest period. The incidence of cumulative PIVC failure was 43.2% of all analyzed PIVCs (89.97 per 1,000 PIVC days). Of the PIVCs in patients with lymphoma, those inserted during the dosing period were less likely to show PIVC failure (32% vs. 57%, p < .001). Conversely, those inserted after the treatment cycle were more likely to show PIVC failure (22% vs. 7%, p = .002).
Conclusion:
This study demonstrated that the incidence of PIVC failure in patients with hematological malignancies was unacceptably high. Conceivably, the incidence of PIVC failure varies by the onset time of side effects in the treatment cycle. This should be considered when using PIVCs and selecting optimal vascular access devices for patients with hematological malignancies.
Background
Vascular access devices (VADs) are essential for delivery of intravenous therapies. There are notable gaps in the literature regarding a focus on patient experience and meaning-making related to living with a VAD, specifically a central venous access device (CVAD).
Aims
To explore how patients make sense of living with a CVAD.
Methods
This study followed an interpretive phenomenological analysis (IPA) approach. Purposive sampling was used to identify 11 cancer patients who had a CVAD in situ. One-to-one semi-structured interviews were performed. Interviews were digitally recorded, transcribed and analysed by the lead author.
Findings
Four superordinate themes were identified: the self under attack; being rescued/being robbed; protection of others/protection of self; bewilderment and dismay at lack of staff competence.
Conclusion
Having a CVAD affects the psychological, social, and personal self and impacts on self-esteem and self-image. Despite this, CVADs are accepted by patients and are eventually ‘embodied’ by them.
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Background:
Vascular access devices (VADs) are essential for delivery of intravenous therapies. There are notable gaps in the literature regarding a focus on patient experience and meaning-making related to living with a VAD, specifically a central venous access device (CVAD).
Aims:
To explore how patients make sense of living with a CVAD.
Methods:
This study followed an interpretive phenomenological analysis (IPA) approach. Purposive sampling was used to identify 11 cancer patients who had a CVAD in situ. One-to-one semi-structured interviews were performed. Interviews were digitally recorded, transcribed and analysed by the lead author.
Findings:
Four superordinate themes were identified: the self under attack; being rescued/being robbed; protection of others/protection of self; bewilderment and dismay at lack of staff competence.
Conclusion:
Having a CVAD affects the psychological, social, and personal self and impacts on self-esteem and self-image. Despite this, CVADs are accepted by patients and are eventually 'embodied' by them.
Infusion liquid extravasation occurs in up to 6% of all intensive care patients and up to 78% for neonates. Currently, emerging extravasation cannot be detected. An impulse-oscillometric method to detect the onset of extravasation is tested and evaluated in vitro.
A pinch valve compresses the infusion line, an impulse is formed, and the pressure response is recorded at the peripheral vein catheter. The response of this catheter-sensor-system is analysed by measuring the transient-step response (n = 10) for an opened and closed pinch valve. Trials utilising porcine shanks (n = 15) are performed with venous and extravasational catheter placement. The fundamental frequency, maximum amplitude, damping and decay constant of the pressure response are tested for differences between venous and extravasational placement.
The response of the catheter-sensor-system shows no significant differences between an opened or closed pinch valve. The maximum amplitude, frequency, damping and decay constant of the pressure response differ highly significant for venous and extravasational catheter placement (p < .001). The parameters also differ depending on the presence of infusion liquid flow (p < .001).
The method enables the detection of the onset of extravasation. Further tests are performed to investigate the relationships between impulse response and hydraulic impedance.
Calcinosis cutis (CC) is defined as the deposition of calcium salts on the skin and subcutaneous tissue. It is associated with different conditions, including some autoimmune diseases, and it can generate significant inflammation, pain, and functional impairment. Different therapies have been tried with limited results. Intralesional sodium thiosulfate seems a promising therapeutic option. We report a patient with diffuse systemic sclerosis who presented with two symmetrical plaques on both axillae, which caused pain and skin retraction. The clinical diagnosis was consistent with CC, which was confirmed by skin biopsy and ultrasound. The patient was treated with a 250 mg/ml solution of sodium thiosulfate injected into the plaques. Complete resolution was achieved after three monthly sessions. The only reported adverse effect was a transient burning sensation during the injections. Given its effectiveness and safety, we believe that intralesional sodium thiosulfate could become a valid first-line option for the treatment of CC.
Drug reactions resulting from chemotherapy agents are common and frequently affect the skin. Though often benign, a select few of these cutaneous reactions may necessitate immediate changes to the antineoplastic regimens. Given the diversity of chemotherapeutic skin reactions and their complex implications on patient management, an organized conceptual schema is imperative for proper patient care. This review evaluates a number of commonly seen chemotherapy-induced skin toxicities organized by pathogenic mechanism and drug class, providing a framework for the identification and categorization of adverse events to prevent under-recognition. Broadly, groupings of these reactions include: direct cytotoxicity and/or drug accumulation, immunologic hypersensitivity, and aberrant molecular signaling.
Background/Objective
Blood pressure optimization and maintenance of cerebral and spinal perfusion pressure are mainstays in the treatment of a neurocritically ill patient. Traditionally, central venous access has been required for vasopressor administration, with risk of inherent complications. The authors have previously reported pilot data on the safety of peripheral administration of phenylephrine in a neurocritical care unit. In this follow-up, we report the safety, feasibility, and potential efficacy of peripheral administration of low-concentration phenylephrine in a more robust cohort.
Methods
A retrospective chart review was conducted on all consecutive patients who received peripheral phenylephrine in a tertiary care hospital neurocritical care unit.
Results
A cohort of 125 patients were identified and included in the final analysis. The average age was 59.3 years, with an average intensive care unit (ICU) length of stay of 7.61 days. The most common indication for phenylephrine use was spinal perfusion (both with/without neurogenic shock) in 38.4% of cases, followed by postsurgical/anesthesia resuscitation in 16.8% of cases; 25.6% of patients in our cohort required escalation to central venous access (central venous catheter + peripherally inserted central catheter). A total of 2880 patient-hours were recorded with peripheral phenylephrine infusion, of which 73.9% were at goal blood pressure (either systolic or mean arterial pressure). Only one major complication of thrombophlebitis and 8 minor complications were recorded.
Conclusions
Protocol-driven peripheral administration of lower concentration phenylephrine in an ICU setting is safe and feasible. This strategy is potentially effective at achieving hemodynamic targets in the majority of patients avoiding the need for central venous access.
Abstract [en]
Central venous catheters (CVC) are vital for patients receiving chemotherapy not compatible with peripheral infusion. Thousands of centrally and peripherally inserted central venous catheters are inserted into patients with cancer each year. All types of intravascular catheters are associated with complications. These complications may be divided into infectious, thrombotic, mechanical and occlusive events. All of these events have the potential to harm patients and cause additional expense for the health-care system. Furthermore, the above-mentioned complications are largely avoidable through proper patient selection, insertion technique, hygiene precautions and catheter maintenance.
Catheter-related infections and deep venous thrombosis are the two most common and feared CVC related complications. Infection in a catheter can cause lifethreatening bacteraemia, and thrombosis can lead to pulmonary embolisation, post-thrombotic syndrome and stenosis of the vessel affected. Many studies describing methods to minimise infectious complications associated with central venous catheters have been carried out. These methods appear to have been implemented in most modern advanced healthcare facilities resulting in a continual decrease in catheter-related infections over the last two decades. New implantation techniques, fewer infections and better catheter materials are likely to have contributed to the reduction in the incidence of catheter-related deep venous thrombosis (CR-DVT). Peripherally inserted central venous catheters (PICC) and subcutaneously implanted vascular access ports (PORT) are two very commonly used catheter devices for delivery of chemotherapy. International guidelines are unclear as to which device to choose due to the paucity of controlled trials.
The aim of this thesis was to study complications related to central venous access devices used over long periods of time, usually for the delivery of chemotherapy. Vascular access in cancer patients – clinical implications We prospectively studied PORT complications (Study 1) over a six-month follow- up period. In Study 2, we assessed the number of common CVC-related micro- organisms that are transferred across PORT membrane contaminated by a controlled suspension of micro-organisms when a non-coring access needle is inserted using two different techniques. In the largest randomised controlled trial published on this topic (Study 3), we compared PICC with PORT regarding CRDVT and other catheter-related complications. The economic implications of using PICC or PORT were assessed from health-care system´s perspective (Study 4), using data on adverse events and clinical factors (implantation, treatments and dwell-time) from Study 3.
Chemotherapy against various forms of cancer is very common. Implantation of PORT is one of the ten most common surgical procedures in Sweden according to the Swedish Perioperative Register. Hence, the topic in this thesis may be clinically relevant to many patients and their health care providers.
We found that the incidence of catheter-related blood stream infection was very low in the cohorts studied. In general, PICCs are associated with significantly more CR-DVTs and adverse events than PORTs. The cost to the health-care system when using PICC is higher than for PORT when complications are included. Given the choice, patients about to commence chemotherapy appear to prefer PORT to PICC. PORT implantation is more painful than PICC insertion, but PICC appears to influence activities of daily life more than PORT.
Although the arrival of new chemotherapy drugs and combinations has brought progress in terms of cancer patient survival, they entail many adverse effects that can compromise treatment, and hence prognosis, of the disease. Cytostatic agents can cause dermatological toxicity, among other side effects. The most familiar adverse effect of chemotherapy is alopecia. Although not serious, this changes the outward appearance of cancer patients. Other adverse effects include hypersensitivity and photosensitivity reactions, hand-foot syndrome, epidermal necrolysis, recall reactions, scleroderma-like reactions, Raynaud's phenomenon, eccrine squamous syringometaplasia, neutrophilic eccrine hidradenitis, nail abnormalities, pigmentation changes and extravasation injuries. Onset of these adverse effects often causes dose reduction and/or delayed treatment, which can affect patient survival and quality of life. It is therefore important to prevent their occurrence and treat them promptly, which requires cooperation between medical oncologists and dermatologists. This article reviews chemotherapy-associated dermatological toxicity, along with its diagnosis and therapeutic management.
Resumen
A pesar del avance que ha supuesto en la supervivencia de los pacientes oncológicos, la aparición de nuevos agentes quimioterápicos y nuevas combinaciones, estos han traído consigo numerosos efectos adversos que pueden llegar a comprometer el tratamiento y, por consiguiente, el pronóstico de la enfermedad. Entre otros efectos secundarios los citostáticos pueden causar toxicidad dermatológica. El efecto adverso más conocido de la quimioterapia es la alopecia que, aunque no es grave, altera la apariencia externa de los pacientes con cáncer. Otros efectos adversos que pueden observarse son las reacciones de hipersensibilidad y fotosensibilidad, el síndrome mano-pie, la necrólisis epidérmica, las reacciones de reactivación, las reacciones esclerodermiformes, el fenómeno de Raynaud, la siringometaplasia escamosa ecrina, la hidradenitis neutrofílica ecrina, las alteraciones ungueales, las alteraciones en la pigmentación y las lesiones por extravasación. La aparición de estos efectos adversos produce en muchas ocasiones una reducción de dosis y/o retraso del tratamiento, lo que puede afectar a la supervivencia y a la calidad de vida del paciente. Por ello, es importante prevenir su aparición e instaurar un tratamiento temprano, para lo que se hace imprescindible la colaboración entre oncólogos médicos y dermatólogos. En este artículo se revisa la toxicidad dermatológica asociada con la quimioterapia, así como su diagnóstico y abordaje terapéutico.
Salivary gland tumors are rare, clinically diverse neoplasms that represent less than 1% of all malignancies. In locoregional recurrent or metastatic disease, systemic therapy is the standard approach. While numerous small phase II studies have evaluated the activity of cytotoxic agents, either alone or in combination, the response rates are generally modest with objective response rates ranging from 15%–50%. Duration of response is cited in the range of 6–9 months. Given this, further evaluation of novel therapies is mandatory in these diseases. With the emergence of molecular targeted therapy, these tumors become optimal candidates for trials of investigational drugs and established drugs for new indications. Of note, given the often indolent nature of disease, only patients with progressive disease should be enrolled and treated on these clinical trials. Study designs must incorporate stringent inclusion criteria to enable accurate reporting of disease response and stabilization. With dedication and co-operation, patients with these rare neoplasms can be accrued to clinical trials and the establishment of new treatment guidelines will be forthcoming.
Standardization of care can reduce the risk of errors, increase efficiency, and provide a framework for best practice. In 2008, the American Society of Clinical Oncology (ASCO) and the Oncology Nursing Society (ONS) invited a broad range of stakeholders to create a set of standards for the administration of chemotherapy to adult patients in the outpatient setting. At the close of a full-day structured workshop, 64 draft standards were proposed. After a formal process of electronic voting and conference calls, 29 draft standards were eliminated, resulting in a final list of 35 draft measures. The proposed set of standards was posted for 6 weeks of open public comment. Three hundred twenty-two comments were reviewed by the Steering Group and used as the basis for final editing to a final set of standards. The final list includes 31 standards encompassing seven domains, which include the following: review of clinical information and selection of a treatment regimen; treatment planning and informed consent; ordering of treatment; drug preparation; assessment of treatment compliance; administration and monitoring; assessment of response and toxicity monitoring. Adherence to ASCO and ONS standards for safe chemotherapy administration should be a goal of all providers of adult cancer care.
An 81-year-old woman with metastatic leiomyosarcoma reported pain over her central venous access device (CVAD) site during her fifth cycle of trabectedin administered by outpatient 24-hour infusion. On deaccessing and flushing of her CVAD, she noted increased pain. Six days later, she developed a cluster of small, intact blisters over the CVAD site and erythema, ecchymosis, and tenderness extending to the upper breast and axilla (Fig 1) Computed tomogra-phy showed fat stranding around her CVAD but no drainable collection. She was managed expectantly. The CVAD was removed. Over the following week, she developed increased pain and skin erythema. She was then taken to surgery for chest wall debridement. On exploration , a large area of necrotic dermis, fat necrosis, adipose, and muscle was encountered with no evidence of purulence. Debridement of a 15-cm 8-cm area that included skin, subcutaneous tissue (Fig 2), and a portion of the pectoral muscle followed. Pathology showed acute and chronic inflammation and necrosis. Cultures were negative.
An accidental extravasation of anthracycline-containing chemotherapy is a feared complication that may lead to necrosis and severe tissue destruction. For four decades, much effort has been done to prevent and treat this devastating condition. Savene has recently been proved to be very effective, and is the only approved treatment against anthracyline extravasation. It is thus now widely recommended. The present article represents a comprehensive review of, and historical insight to, the experimental and clinical studies of surgical and non-surgical treatments of extravasation during forty years of clinical anthracycline treatment.
Oncology nurses and pharmacists often are given the responsibility of developing or updating institutional policies to manage vesicant chemotherapy extravasations. Antidote and treatment recommendations of vesicant chemotherapy manufacturers, antidotes and treatments approved by the U.S. Food and Drug Administration (FDA), and guidelines and recommendations made by professional oncology organizations are useful resources in this process. This article describes manufacturers' recommendations, lists antidotes and treatments approved by the FDA, and reviews published guidelines and recommendations. Available antidote and treatment formulations and their preparation and administration also are discussed.
Recently, we have shown that dexrazoxane (ICRF-187) is an effective antidote against accidental extravasation of anthracyclines. Thus, it inhibits the lesions induced by subcutaneous (s.c.) daunorubicin, idarubicin, and doxorubicin in mice and has proven to be successful clinically as well. Dexrazoxane is a potent metal ion chelator as well as being a catalytic inhibitor of DNA topoisomerase II. However, the mechanism behind the protection against anthracycline extravasation is not known.
Mice were injected s.c. with daunorubicin or doxorubicin. Systemic N-acetylcysteine, alfa-tocoferol, amifostine, merbarone, aclarubicin, ADR-925, and EDTA were administered i.p. immediately hereafter or as a triple-treatment over six hours. Intralesional (i.l.) adjuvants were injected immediately after and into the same area as the anthracycline. The frequency, duration, and sizes of wounds were observed until complete healing of all wounds.
Triple-treatment with systemic dexrazoxane was superior to single dosage and completely prevented lesions after s.c. daunorubicin and doxorubicin. Low-dose i.l. dexrazoxane was effective in protecting as well. In contrast, none of the other seven adjuvants was effective. Protection was not achieved with local cooling, however, topical ice did not impair the efficacy of dexrazoxane.
Dexrazoxane is extremely effective and apparently quite specific in protecting against lesions after s.c. doxorubicin and daunorubicin.
To review the literature, synthesize current recommendations, and discuss remaining controversies regarding vesicant extravasation management.
Published evidence-based reports, clinical articles, and anecdotal case reports about antineoplastic and nonantineoplastic vesicant agent management.
Prevention of vesicant extravasation sequelae requires knowledge about vesicant extravasation manifestations and differentiation of vesicant extravasation from other local IV site reactions. When evidence is weak or missing, logical application of data-based or empirical management strategies is critical. Actions may include timely administration of subcutaneous or topical antidotes, comfort measures, and surgical interventions to minimize the extent of tissue damage and morbidity should extravasation occur.
Vesicant extravasation and sequelae constitute a complex patient problem. Clinicians should strive to prevent extravasation or seek to minimize injury should it occur. To this end, clinicians must demonstrate awareness of its risks and use specialized knowledge when administering vesicant agents.
Nurses who administer vesicant agents should understand the nursing and collaborative actions that should be taken to minimize patient morbidity, pain, and disability.
To review the literature regarding the incidence, current practice, guideline recommendations, nursing management, and knowledge gaps relevant to vesicant extravasation.
Published research articles, books, case reports, and national guidelines.
Vesicant extravasation is a relatively rare but significant complication of chemotherapy administration. Extravasation may have a range of consequences that can cause serious physical and quality-of-life effects. Knowledge of risk factors and preventive measures can reduce patient risk. Data-based and empirical management strategies such as immediate local measures (agent withdrawal, comfort measures, and medical interventions) may minimize risk for extravasation, as well as lead to timely recognition and management and decreased morbidity should extravasation occur.
Vesicant extravasation and sequelae constitute a complex patient problem that clinicians should strive to prevent or to minimize injury should it occur. To this end, clinicians must demonstrate awareness of risks and use specialized knowledge while administering vesicant agents.
Only nurses knowledgeable about extravasation and skilled in associated techniques should assume responsibility for vesicant administration.
The purpose of this study was to assess the efficacy and tolerability of i.v. dexrazoxane [Savene (EU), Totect (US)] as acute antidote in biopsy-verified anthracycline extravasation.
Two prospective, open-label, single-arm, multicentre studies in patients with anthracycline extravasation were carried out. Patients with fluorescence-positive tissue biopsies were treated with a 3-day schedule of i.v. dexrazoxane (1000, 1000, and 500 mg/m(2)) starting no later than 6 h after the incident. Patients were assessed for efficacy (the possible need for surgical resection) and toxicity during the treatment period and regularly for the next 3 months.
In 53 of 54 (98.2%) patients assessable for efficacy, the treatment prevented surgery-requiring necrosis. One patient (1.8%) required surgical debridement. Thirty-eight patients (71%) were able to continue their scheduled chemotherapy without postponement. Twenty-two patients (41%) experienced hospitalisation due to the extravasation. Mild pain (10 patients; 19%) and mild sensory disturbances (nine patients; 17%) were the most frequent sequelae. Haematologic toxicity was common as expected from the fact that the extravasation occurred during a chemotherapy course. Other toxic effects were transient elevation of alanine aminotransferases, nausea, and local pain at the dexrazoxane injection site.
Dexrazoxane proved to be an effective and well-tolerated acute treatment with only one out of 54 assessable patients requiring surgical resection (1.8%).
Dexrazoxane has been in clinical use for more than 25 years for prevention of cardiotoxicity in anthracycline based anticancer therapy. However, we discovered another property of the compound, i.e. the ability to prevent the devastating tissue necrosis after accidental extravasation of anthracyclines. The preclinical and clinical studies leading to the clinical implementation of Savene (TM) (dexrazoxane) as the first and only proven antidote in anthracycline extravasation are described in short.
Systemic intravenous chemotherapeutic agents can cause multiple emergency situations including acute and chronic local and systemic reactions. Amongst them, drug extravasation is one of the most devastating complications, as many drugs can cause varying degrees of local tissue injury when extravasated. Although it is difficult to give an accurate measurement, the incidence of extravasation of systemic infusional chemotherapeutic agents has been reported to occur in 0.1-6.5% of cases. Since most extravasations can be prevented with the systematic implementation of careful administration techniques, guidelines have been published for the administration of vesicant drugs. The proper maintenance of intravenous lines, application of local cooling or warming for certain extravasations, and the use of antidotes to prevent the local toxic action of the extravasated drugs are the basis of medical management. The specific antidotes for certain chemotherapeutic agents are also discussed in this article.
Vesicant chemotherapy agents can cause varying degrees of tissue necrosis when they extravasate from the vein or are inadvertently administered into the tissue. Deoxyribonucleic acid (DNA) binding vesicants, such as anthracyclines, bind to the DNA of healthy tissue. Left untreated, these injuries progress over time and often require surgical intervention. Evidence-based treatment is topical cooling and administration of Savene (dexrazoxane). Non-DNA binding agents, such as plant alkaloids, usually remain localised and are metabolised in the tissue. Local heat application is recommended. To help prevent or treat extravasation injuries, oncology nurses should be aware of current guidelines for vesicant chemotherapy extravasation management, and be prepared to implement new antidotes and treatments in their clinical practice.
Extravasation is a potentially harmful complication of vesicant chemotherapy administration. Although nurses strive to prevent extravasations from occurring, they cannot always be prevented. Vesicant chemotherapy extravasations must be promptly detected and appropriately treated in order to reduce the severity of tissue destruction that occurs when vesicants inadvertently enter the tissue. Recently approved treatments have demonstrated safety and efficacy, and have enabled patients to maintain their skin integrity and adhere to their planned chemotherapy treatment schedules. Nurses need to be knowledgeable about advances in extravasation management so that they can provide optimal care to patients receiving vesicant chemotherapy.
In addition to their therapeutic effects on malignant cells, cytotoxic agents have the potential of causing destruction of healthy, normal cells. Extravasation of the drug can produce extensive necrosis of the skin and subcutaneous tissue. Management of these extravasational effects differs from one centre to another and prevention is usually strongly emphasized. We analyzed our management of 12 patients referred to us over five years with extravasation of cytotoxic drugs and reviewed the literature for different approaches with regard to prophylaxis and management of extravasational effects.
This study was done in the department of plastic surgery of a medical college. Five years of retrospective data were studied of patients referred to our department with extravasation of cytotoxic drugs.
We managed 12 cases referred to our department with extravasation of cytotoxic drugs. Mitomycin C was used in seven cases (58.33%), vincristine in two cases (16.66%), 5-Florouracil in another two cases while doxorubicin was responsible for extravasational side effects in one case (8.33%). The size of necrosis ranged from 3.75 cm(2) to 25 cm(2) with average size of 9.6 cm(2). In terms of the area involved, the dorsum of the hand was involved in five cases (41.66%), the wrist in another five cases (41.66%), and the cubital fossa in the remaining two cases (16.66%). All cases were treated with daily debridement of necrotic tissue, saline dressing, and split skin grafting.
Extravasation of cytotoxic drugs further increases the suffering of cancer patients. This catastrophe can only be avoided by vigilance and immediate application of antidotes. Once the local toxicity of the drugs takes effect, morbidity is unavoidable.
Infiltration and extravasation are risks of intravenous administration therapy involving unintended leakage of solution into the surrounding tissue. Consequences range from local irritation to amputation. While immediate action using appropriate measures (ie, dilution, extraction, antidotes, and supportive treatments) can decrease the need for surgical intervention, many injuries may be prevented by following established policy and procedures. However, timely surgical intervention, when necessary, can prevent more serious adverse outcomes. Clinicians should be prepared to act promptly when an event occurs. Thorough incident documentation helps determine whether infusion care meets the standard of practice and is a keystone to medicolegal defense.
A 63-year-old woman with a diagnosis of infiltrative ductal carcinoma of the breast (stage T2N1M0[IIB], according to the tumor–node–metastasis staging system) that was estrogen receptor–negative and HER2-negative was referred for adjuvant chemotherapy after undergoing modified radical mastectomy and axillary lymph-node dissection. Epirubicin, at a dose of 90 mg per square meter of body-surface area, was infused at 21-day intervals, along with fluorouracil and cyclophosphamide. During the third period of administration, the patient reported having excruciating pain in the left wrist, near the intravenous-catheter site (arrow). The infusion was stopped, and a diagnosis of extravasation of epirubicin was made. Physical examination . . .
An infrequent, but potential complication of chemotherapy is vesicant chemotherapy extravasation. Vesicants have the potential to cause blistering and ulceration when they extravasate from the vein or are inadvertently administered into the tissue. In 2007, the European Oncology Nursing Society published guidelines for extravasation prevention, detection, and management. Recommended management includes topical heating for plant alkaloid extravasations and topical cooling for anthracycline and other antitumor antibiotic vesicants. For treatment of antracycline extravasations topical dimethylsulfoxide (DMSO), sodium thiosulfate, and hyaluronidase have been described in the literature but due to lack of evidence to support their use as vesicant extravasation antidotes, it is recommended that these agents are studied further. Furthermore, Savene (dexrazoxane) is the only registered drug for the treatment of antracycline extravasation. Nurses need to be aware of current evidence-based guidelines for detecting and managing vesicant extravasations and need to be prepared to administer evidence-based treatment.
Extravasation of Adriamycin from an intravenous needle or catheter can produce a progressive skin necrosis and deep painful ulceration. The pathological changes which result in this ulceration were studied in a rabbit model. The earliest changes include vascular obliteration and necrobiosis of collagen. At no point were inflammatory cells found to play a primary role.
The highly vesicant nature of the alkylating anticancer agent mechlorethamine (HN2, or nitrogen mustard) requires careful i.v. technique during its administration. Skin toxicity due to HN2 extravasation is severe and typically prolonged over several months. Mouse skin toxicity studies were carried out to find a local antidote to decrease the severity of tissue damage by this agent. Intradermal (i.d.) HN2 (0.005-0.5 mg) caused dose-dependent skin ulcers in the mouse. Isotonic sodium thiosulfate Na2S2O3 (0.167 M) or hypertonic (0.34 M) Na2S2O3 (0.05 ml) given immediately after HN2 significantly reduced the mean HN2 ulceration area and the total time of ulceration. Ineffective local HN2 antidotes included hyaluronidase, hydrocortisone, and sodium chloride, all given i.d. Topical applications of DMSO, cold, and heat were also ineffective. Sodium thiosulfate is believed to chemically neutralize reactive mechlorethamine-alkylating species and thus decrease skin toxicity. Thiosulfate dosing studies showed that a molar excess of at least 200:1 (Na2S2O3:HN2) was required for significant antidotal activity. If thiosulfate treatment was delayed 4-24 h after HN2, no antidotal effects were obtained. We conclude that sodium thiosulfate can decrease the severity of local tissue damage caused by HN2. It should be considered the antidote of choice in the setting of clinical HN2 extravasations.
Twenty patients with extravasation of anthracyclines were treated on a single-arm pilot study with topical 99% dimethyl sulfoxide (DMSO) and observed for 3 months with regular examinations and photographs. DMSO was applied to approximately twice the area affected by the extravasation and allowed to air dry. This was repeated every six hours for 14 days. The initial signs of extravasation included swelling in 17 patients, erythema in 15, and pain in 12. The median area of damage was 8.25 cm2 and a median of 25 minutes elapsed between extravasation and application of DMSO with one patient not treated until seven days postextravasation. Sixteen patients were observed for 3 months, two died of disease earlier after receiving 2 weeks of DMSO and three days of DMSO, respectively, and two were lost to follow-up having received one day and five days of DMSO. In no patient did extravasation progress to ulceration or require surgical intervention, suggesting with 95% confidence a true ulceration rate of between 1% and 17%. At 3 months there was no sign of residual damage in six patients, while a pigmented indurated area remained in ten. Two patients had a recall reaction with increased pain at the extravasation site when further intravenous (IV) doxorubicin was administered. The only toxicities of DMSO included a burning feeling on application subsequently associated with itch, erythema, and mild scaling. Blisters occurred in four patients. Six patients reported a characteristic breath odor associated with DMSO. Topical DMSO appears to be a safe and effective treatment for anthracycline extravasation.
Review of 175 patients sustaining extravasation of an antitumor agent showed that most (89 percent) can be managed immediately with intermittent application of ice (15 minutes four times daily for 3 days) and close wound observation. We consider pain, usually associated with varying degrees of skin involvement, to be the only indication for surgery. Such a procedure should consist of wide, three-dimensional excision of all involved tissue, temporary coverage with a biologic dressing, and simultaneous harvesting and storage of a split-thickness skin graft. Once the wound is clean, delayed application of the graft is performed (usually at 2 to 3 days). Not only will this result in immediate pain relief and provide safe wound coverage, but it also will not interrupt the patient's chemotherapy schedule. Most patients were able to be restarted on their chemotherapy shortly after surgery, and none demonstrated a "recall phenomenon."
The pathophysiology and mechanisms of toxicity of anthracycline-induced skin damage are reviewed, and the various available therapeutic interventions are discussed.
Skin ulcers caused by the vesicant antineoplastic agents doxorubicin hydrochloride and daunorubicin hydrochloride begin slowly, and the extent of the tissue damage produced is often underestimated. Within a week, untreated infiltrations of these agents can advance to serious indurations and ulcerations, causing extensive damage to underlying structures such as tendons and bones. Two theories have been proposed to explain the mechanism of action of anthrocycline-induced tissue damage; one holds that doxorubicin-DNA complexes form causing cell death, and the other holds that these agents are reduced to free radicals that can cause cell-membrane damage.
Nonpharmacologic treatment of extravasation consists of stopping the infusion at the first sign of a problem and attempting to aspirate fluid and drug back through the same needle. The application of ice packs for the next 24-72 hours is recommended. A variety of pharmacologic approaches have been evaluated to ameliorate tissue damage. Corticosteroids, sodium bicarbonate, beta-adrenergic agents, and dimethyl sulfoxide have been used with some success. Patients who do not respond to initial conservative treatments should be referred to a plastic surgeon for skin grafting and reconstruction.
The best treatment for anthracycline toxicity is prevention.
This experimental study in the rabbit establishes a reliable model for the production of skin necrosis analogous to intravenous extravasation injuries in humans. The effectiveness of hyaluronidase in reducing the extent of tissue injury is examined, using several different toxic agents.
Infiltration of antitumor agents into subcutaneous tissues may either result in a local area of self-resolving inflammation, or progress to full-thickness loss of skin and underlying vital structures. The immediate treatment of 50 extravasations occurring over a 20-month period resulted in our developing a protocol of appropriate care. Once extravasation is suspected, the intravenous line is removed, ice is applied intermittently for three days, and the wound is observed closely. No drugs are even given locally. If local pain persists or skin changes progress, the area of involvement is debrided and, a skin graft is applied two to three days later. As a result of this conservative approach, only 12 of 50 patients have required surgery. This method of treatment has minimized patient mortality, hospitalizations, and loss of synchronization of chemotherapy.
To evaluate the activity and tolerability of dimethylsulfoxide (DMSO) in the prevention of soft tissue toxicity after extravasation of cytotoxic drugs.
From June 1991 to December 1994, all patients who had an extravasation during intravenous (IV) infusion of cytotoxic drugs in our institution were considered for an open, prospective study of preventive treatment with 99% DMSO, applied topically on the extravasation site every 8 hours for 7 days. Intermittent local cooling (for 1 hour three times daily) on the first 3 days was also used.
One hundred forty-four patients with extravasations of doxorubicin (n = 11), epirubicin (n = 46), mitomycin (n = 5), mitoxantrone (n = 13), cisplatin (n = 44), carboplatin (n = 6), ifosfamide (n = 14), and fluorouracil (n = 5) entered the study; 127 were assessable. Only one patient suffered an ulceration. The treatment was well tolerated, with mild local burning and a characteristic breath odor being the only side effects of DMSO application, even in cases in which treatment continued for up to 6 weeks to obtain remission of the symptoms of extravasation.
Topical DMSO is an effective and safe antidote that may be used with local cooling after extravasations of vesicant drugs other than those drugs for which standard interventions are defined.
We discuss our experience with antineoplastic drug extravasation. Between December 1988 and December 1990, 40 patients with cytostatic extravasation with lesions of varying seriousness were observed. In these patients, whenever possible, depending on the amount of time that elapsed since the accident and on the severity of the lesion, conservative therapy was done. The procedure consisted of local injection of a considerable amount of saline solution (20-90 ml, depending on the site of extravasation) and topical occlusive applications of corticosteroids locally. In all patients this was sufficient to avoid tissue necrosis. Treatment of a few patients deviated from these procedures because surgery was performed that ranged from the simple excision of infiltrated tissue to a more complex procedure of free flaps. On the basis of our experience, we discuss the role of early surgery when preventive measures and drug therapy are insufficient because of drug effects at the tissue level. In this series we did not perform early surgery.
Skin necrosis is a recognized potential consequence of an inadvertent extravasation of Vinca alkaloids in the surrounding tissues during i.v. administration. Experimental studies suggest that hyaluronidase, an enzyme that degrades hyaluronic acid and improves the absorption of locally injected drugs, can reduce the risk of progressing to skin necrosis. On this basis, we used this enzyme as a local treatment after extravasations of Vinca alkaloids in seven patients. No patient suffered from subsequent skin necrosis. To the best of our knowledge, this is the first clinical report confirming the positive findings of experimental studies on the effectiveness of this antidote.
The leakage of cytotoxic drugs, intravenous nutrition, solutions of calcium, potassium, bicarbonate and even 10% dextrose outside the vein into which they are delivered is known not only to cause skin necrosis but also to precipitate significant scarring around tendons, nerves and joints. In this review of 96 patients with extravasation injuries seen between 1987 and 1992 at St Thomas' Hospital, Mount Vernon Hospital and The Hospital for Sick Children, Great Ormond Street, several patients required extensive reconstruction and in some, despite this, extravasation injury has rendered a limb virtually useless. Two techniques, liposuction and saline flushout, are described to remove extravasated material while conserving the overlying skin. Analysis of flushout material confirmed that the extravasated material was actually being removed. Forty four of the study group in whom noxious materials were known to have extravasated underwent such early treatment. The results in this group were quite striking--the majority (86%) healed without any soft tissue loss at all. The early referral and treatment of extravasation injuries is, therefore, recommended.
This case report is presented to assess safety and efficiency of early suction and saline washout of extravasated cytotoxic drugs.
Through multiple small skin incisions, the area of extravasation is first suctioned and subsequently extensively washed out with saline. Incisions are left open and the arm is elevated for 24 hours.
A complete healing was obtained in five days without any skin or soft tissue loss. No additional treatment was needed.
Early referral and surgical treatment by suction and washout is a safe and reliable treatment protocol for major cytotoxic drug extravasation injuries.
To describe the four primary causes of extravasation from implanted ports.
Journal articles, textbooks, medical records, depositions, serial photographs, and the authors' personal experiences.
Extravasation from ports can occur by four major mechanisms: incomplete needle placement and needle dislodgment, thrombus or fibrin sheath formation, perforation of the superior vena cava, and catheter fracture. The degree of tissue injury can vary but may be severe enough to require that a simple mastectomy be performed to manage chest wall necrosis.
Extravasation is a known risk of chemotherapy administration via implanted ports. Vesicants should be administered only after a blood return has been obtained and the needle inserted into the port septum has been adequately secured.
Extravasation of vesicant drugs from ports can cause tissue necrosis and may prompt litigation. Risk-management strategies include careful assessment and use of ports, comprehensive patient teaching about the risk of extravasation and measures to decrease the likelihood of needle dislodgment, and development of extravasation-management policies that address port extravasations.