Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [257], C).
2. 2.Show
   Wash hands with bactericidal soap and water or an alcohol‐based handrub.
   To minimize the risk of infection (DH [64], C; Fraise and Bradley [98], E).

Procedure

1. 3.Show
   Stop the injection or infusion immediately, leaving the cannula in place.
   To minimize local injury. To allow aspiration of the drug to be attempted (Polovich et al. [287], C; RCN [295], C).
2. 4.Show
   Aspirate any residual drug from the device and suspected extravasation site.
   To minimize local injury by removing as much drug as possible (but only attempt if appropriate). Subsequent damage is related to the volume of the extravasation, in addition to other factors (Polovich et al. [287], C; RCN [295], C).
3. 5.Show
   Consider removing the cannula.
   Some sources recommend doing this to prevent the device from being used for antidote administration (Rudolph and Larson [319], E). Others state that the cannula may be used to instil antidote to the affected tissue (Kassner [150], E; Stanley [340], E; Weinstein and Hagle [363], E).
4. 6.Show
   Consider contacting the extravasation team and whether the flush‐out technique would be appropriate (see Figure 15.42).
   Flush‐out is most effective if undertaken as soon as extravasation is suspected (Dionyssiou et al. [71], E).
5. 7.Show
   Collect an extravasation pack and take it to the patient.
   It contains all the equipment necessary for managing extravasation (Dougherty [79], E; Stanley [340], E).
6. 8.Show
   Either:
    
   For Group A drugs (see Table 15.15):
    
   • Draw up 1500 international units of hyaluronidase in 1 mL sterile water for injection and inject volumes of 0.1–0.2 mL subcutaneously at points of the clock around the circumference of the area of extravasation.
   This is the recommended agent for Group A drugs. The warm pack speeds up absorption of the drug by the tissues (Polovich et al. [287], Weinstein and Hagle [363], E).
   • Apply warm pack.
    
   Or:
    
   For Group B drugs (see Table 15.15) (except those listed below):
    
   • Apply cold pack or ice instantly.
   To localize the area of extravasation, slow cell metabolism and decrease the area of tissue destruction. To reduce local pain (Polovich et al. [287], C).
   Or:
    
   If extravasation is with any of the following category B drugs: mitomycin C, doxorubicin, idarubicin, epirubicin, actinomycin D:
    
   • Draw around the area of extravasation with an indelible pen.
    
   • Put on gloves.
    
   • Apply a thin layer of DMSO topically to the marked area using the small plastic spatula in the lid of the bottle. Allow it to dry.
   DMSO is the recommended agent for these anthracyclines and helps to reduce local tissue damage (Bertelli [23], E, Pérez Fidalgo et al. [280], C).
   • Apply gauze.
    
   • This should be applied within 10–25 minutes.
    
   Or:
    
   If extravasation of doxorubicin, epirubicin, idarubicin or daunorubicin occurs (i.e. 5 mL or more peripherally or any volume from a central venous access device) then stop use of the cold pack, do not apply DMSO and contact a member of the extravasation team to advise on use of dexrazoxane.
   Cooling and DMSO interfere with the efficacy of dexrazaxone and it should be administered as soon as possible after extravasation of these drugs (El‐Saghir et al. [87], E; Langer et al. [165], E).
7. 9.Show
   Where possible, elevate the extremity and/or encourage movement.
   To minimize swelling and prevent adhesion of the damaged area to underlying tissue, which could result in restriction of movement (Buter et al. [36], E).

Post‐procedure

1. 10.Show
   Inform a member of the medical staff at the earliest opportunity and administer any other prescribed antidotes, for example dexrazoxane.
   To enable actions differing from agreed policy to be taken if considered in the best interests of the patient. To notify the doctor of the need to prescribe any other drugs. E
2. 11.Show
   Apply hydrocortisone cream 1% twice daily, and instruct the patient on how to do this. Continue as long as erythema persists.
   To reduce local inflammation and promote patient comfort (Stanley [340], E).
3. 12.Show
   Where appropriate, apply DMSO every 2 hours on day 1 and then every 6 hours for up to 7 days (patients will need to have this prescribed as a ‘to take out’ (TTO) and continue treatment at home where necessary).
   To help reduce local tissue damage (Bertelli [23], E).
4. 13.Show
   Heat packs (for Group A drugs) should be reapplied after initial management for 2–4 hours. Cold packs (for Group B drugs) should be applied for 15–20 minutes, 3–4 times a day for up to 3 days.
   To localize the steroid effect in the area of extravasation. To reduce local pain and promote patient comfort (Bertelli [23], E).
5. 14.Show
   Provide analgesia as required.
   To promote patient comfort. To encourage movement of the limb as advised. E
6. 15.Show
   Dispose of waste in appropriate containers.
   To ensure safe disposal and avoid laceration or injury to other staff (EASHW [84], C; HWR [137], C).
7. 16.Show
   Document the following details, in duplicate, on the form provided:
    
   1. patient's name/number
    

   b.

   ward/unit

    

   c.	date and time

    

   d.	signs and symptoms

    

   e.	cannulation site (on diagram)

    

   f.	drug sequence

    

   g.	drug administration technique, i.e. bolus or infusion

    

   h.	approximate amount of the drug extravasated

    

   i.	diameter, length and width of extravasation area

    

   j.	appearance of the area

    

   k.	step‐by‐step management with date and time of each step performed and medical officer notification

   To provide an immediate and full record of all details of the incident that may be referred to if necessary. To provide a baseline for future observation and monitoring of the patient's condition. To comply with professional guidelines (RCN [295], C; RPS [317], C; Schulmeister [329], E; Weinstein and Hagle [363], E).

   l.	patient's complaints, comments and statements

    

   m.	indication that the patient information sheet has been given to the patient

    

   n.	follow‐up actions required over subsequent days

    

   o.	whether photograph was taken

    

   p.	if required, when patient referred to plastic surgeon

    

   q.	signature of the nurse.

    
8. 17.Show
   Explain to the patient that the site may remain sore for several days.
   To reduce anxiety and ensure continued co‐operation. E
9. 18.Show
   As part of the follow‐up, all patients should receive written information explaining what has occurred, what management has been carried out, what they need to look for at the site and when to report any changes. For example, increased discomfort, peeling or blistering of the skin should be reported immediately.
   To detect any changes as early as possible and allow for a review of future management. This may include referral to a plastic surgeon (Gault and Challands [104], E; Polovich et al. [287], C; RCN [295], C).
10. 19.Show
    Observe the area regularly for erythema, induration, blistering or necrosis. Where appropriate, take photographs. Inpatients: monitor daily.
    To detect any changes at the earliest possible moment (RCN [295], C).
11. 20.Show
    If blistering or tissue breakdown occurs, begin dressing techniques and seek advice regarding wound management.
    To minimize the risk of a superimposed infection and increase healing (Naylor [224], E).
12. 21.Show
    Depending on size of lesion, degree of pain and type of drug, consider referral to plastic surgeon.
    To prevent further pain and other complications, as chemically induced ulcers rarely heal spontaneously (Dougherty [79], E; Polovich et al. [287], C).