Chapter 15: Medicines optimization: ensuring quality and safety
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Related theory
It is important to recognize and distinguish extravasation and infiltration from flare reaction. Flare reaction is a not uncommon transient painless skin‐streaking erythema that looks like urticaria with skin elevation; it may occur with anthracycline administration (Kreidieh et al. [161], Polovich et al. [287]). It is caused by a venous inflammatory response to histamine release. It can involve itching, burning and potentially pain, which usually resolve in 1–2 hours (Kreidieh et al. [161]). Slowing infusion rates may be helpful, but flare reaction responds well within a few minutes to the application of a topical steroid (Schulmeister [329], Weinstein and Hagle [363]).
The extent of tissue damage following extravasation of vesicant drugs depends on a number of factors:
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Whether the drugs bind to DNA or not:
- DNA‐binding vesicants (e.g. doxorubicin and epirubicin) bind to nucleic acids in the DNA of healthy cells, resulting in cell death. There is then cellular uptake of extracellular substances and this sets up a continuing cycle of tissue damage as the DNA‐binding vesicant is retained and recirculated in the tissue, sometimes for a prolonged period of time (Goolsby and Lombardo [107], Polovich et al. [287], Schulmeister [329]).
- Non‐DNA‐binding vesicants (e.g. paclitaxel and vinca alkaloids) have an indirect rather than a direct effect on the cells. They are eventually metabolized in the tissue and then neutralized (more easily than DNA‐binding vesicants) (Polovich et al. [287]).
- The concentration and amount of vesicant drug in the tissue.
- The location of the extravasation, for example hand or arm.
- Patient factors: certain patient groups are more susceptible, such as neonates, the elderly, those with malnourishment, those with several co‐morbidities and those with cancer (Doornaert et al. [73], Polovich et al. [287], Schulmeister [329]).
