Extravasation

Extravasation Is….

• Infiltration, tissuing, displacement……………….. - at the end of the day they are all the same injury • The inadvertent administration of a cytotoxic drug, targeted therapy or iodinated contrast agent into the surrounding tissues, rather than into the vascular pathway as intended.

• Vesicant extravasation is an oncological / parenteral therapy emergency.

If we don’t take them seriously

Late PresentationVinorelbine Extravasation..

Anthracycline Extravasation (? Incomplete washout ? ) 9 weeks after the event

Day 1 Day 7 Day 30

Often Difficult to Diagnose

• Extravasation?

• Flare reaction?

Flare reaction

• Flare reaction – red streak, flushing along the vein • Caused by an inflammatory response • Does not cause pain, although does cause ‘itching’ • Usually the area is red and ‘blotchy’ (like nettle rash) • Occurs in 3 – 6% of patients • Often associated with Doxorubicin • Responds to topical steroids • Usually resolves in over 85% of patients within 45 minutes

Recognising an extravasation

1. Visual assessment Initial Redness/erythema Swelling/oedema Later Inflammation Induration Exfoliation Blistering 2. Patient reporting Pain, discomfort Burning, stinging 3. The infusion – warning signs!

The device alarms!

Increased resistance when administering drugs – BACK FLOW Infusion becomes slow or sluggish

Schulmeister 2011, Doherty 2010

The Nature of Extravasation Injuries Has Changed

• The most important development in the prevention and management of extravasation is ‘

the Chemotherapy Trained nurse ’.

• This has led to earlier detection of smaller volume extravasations, and a greater appreciation of the hazard and nature of the risk.

• This has diminished the potential consequences of the injury and altered the intervention / observation dynamic.

• The average volume of drug extravasated in 1985 was 11.6mls, in 1995 - 7.2mls and in 2005 - 3.1mls (www.extravasation.org.uk)

Extravasation Rate

• Statistics show that extravasations occur in 0.5% - 6.5% of cytotoxic administrations (Albanell and Baselga 2000) • Between 0.5% - 6% of cytotoxic drug administrations will result in an extravasation. (Dougherty and Oakley 2011)

How quickly should a vesicant extravasation be washed out?

•

Ideally within 6 hours

(Giunta 2004)

Surgical Intervention – The ‘Saline Wash Out Technique’

Gault 1993

Documentation!!!

• Need a complete history of the extravasation event with diagrams and photographs in the patient’s notes, including the planned follow-up for the patient.

• Follow up – what was the outcome?!

• PHOTOGRAPHIC EVIDENCE

Alternative to SWOT?

Antidotes…… Anthracyclines

Topical DMSO, corticosteroids

Mechlorethamine and Bendamustine

Sodium Thiosulphate (injected locally)

Vinca-Alkaloids

Hyaluronidase (inj localy)

Taxanes

Hyaluronidase

Schulmeister 2011, Doherty 2010, EONS 2007

Dexrasoxane (Savene)

• • • • Only antidote licensed for anthracycline extravasation Given as a peripheral infusion within 6 hours of extravasation, then again at day 2 and 3.

The anthracycline (full dose) then has to be re given at day 4.

Cost– around £6,000 per treatment ‘package’.

How can we help to minimize the risk of extravasation?

• • • • • • • • • Do not site cannula in ACF or over bony prominences Avoid multiple venepuncture!

Avoid small fragile veins!

Always cannulate distal to previous cannulation Take time when cannulating (view the whole arm!) Use a cannula placed specifically for purpose Vesicant first (if possible) Use a heat pad during administration Refer for a CVC before problems arise!!

Litigation?

•

£22.5k compensation - woman left scarred after chemotherapy drugs leaked from a port catheter site during treatment for breast cancer

Remember

• Extravasation is just one hazard of IV chemotherapy – not directly life threatening, but certainly has one of the most serious long term consequences.

References..

National Extravasation Service www.extravasation.org.uk

(2007) Dougherty Extravasation: Prevention, recognition and Management Nursing Standard (2010) Vol 24, no 52, p 48-55 European Oncology Nursing Society (EONS) Extravasation Guidelines Implementation Toolkit (2007) http://www.cancernurse.eu/documents/EONSClinicalGuidelinesSection6-en.pdf

Gault D T Extravasation Injuries British Journal of Plastic Surgery (1993) Vol: 46, no 2, p 91 – 96 Schulmeister L Extravasation Management: Clinical Update Seminars in Oncology Nursing (2011) Vol 27, no1, p 82 – 90 Giunta R Early sub cutaneous washout in acute extravasations Ann Onc (2004) 15, p1146