Procedure

ActionRationale

1. 1.Show
   Stop 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. [194], C; RCN [201], C).
2. 2.Show
   If an infusion, wash hands and apply gloves. Then disconnect infusion, clean needle free connector and connect a syringe.
   To gain access to the cannula to aspirate drug. E
3. 3.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 (INS [112], C; Polovich et al. [194], C; RCN [201], C).
4. 4.Show
   Remove the cannula.
   To prevent the device from being used for antidote administration (INS [112], C; Rudolph and Larson [214], E).
5. 5.Show
   Consider contacting the extravasation team to find out if the flush‐out technique would be appropriate (see Figure 23.6).
   Flush‐out is most effective if undertaken as soon as extravasation is suspected (Gault [82], E).
6. 6.Show
   Collect the extravasation pack and take it to the patient.
   It contains all the equipment necessary for managing extravasation (Dougherty [59], E; Stanley [239], E).
7. 7.Show
   Either:
    
   For Group A drugs:

   • Draw up hyaluronidase 1500 IU in 1 mL water for injection and inject volumes of 0.1–0.2 mL subcutaneously at points of the compass around the circumference of the area of extravasation.
   • Apply warm pack.
   This is the recommended agent for Group A drugs. The warm pack speeds up absorption of the drug by the tissues (Bertelli [12], E).
   Or:
    
   For Group B drugs (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. [194], C).
   Or:
    
   If extravasation is with any of the following Group B drugs: mitomycin C, doxorubicin, idarubicin, epirubicin, actinomycin D, then:

   • Draw around the area of extravasation with indelible pen.
   • Put on gloves.
   • Apply a thin layer of dimethyl sulfoxide (DMSO) topically to the marked area using the small plastic spatula in lid of the bottle. Allow it to dry.
   • Apply gauze.
   • This should be applied within 10–25 minutes.
   DMSO is the recommended agent for these anthracyclines and helps to reduce local tissue damage (Bertelli [12], E).
   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 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 dexrazoxane and it should be administered as soon as possible after extravasation (El Saghir et al. [70], Langer et al. [129]).
8. 8.Show
   Where possible, elevate the extremity and/or encourage movement.
   To minimize swelling and to prevent adhesion of damaged area to underlying tissue, which could result in restriction of movement or neuropathy (Wilkes [268], E).

Post‐procedure

1. 9.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. 10.Show
   Apply hydrocortisone cream 1% twice daily, and instruct the patient how to do this. Continue as long as erythema persists.
   To reduce local inflammation and promote patient comfort (Stanley [239], E).
3. 11.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 [12], E).
4. 12.Show
   Heat packs (Group A drugs) should be reapplied after initial management for 2–4 hours. Cold packs (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 [12], E; Wilkes [268], E).
5. 13.Show
   Provide analgesia as required.
   To promote patient comfort. To encourage movement of the limb as advised. E
6. 14.Show
   Arrange to have a photograph of the area taken.
   To have a baseline photograph of the area for later comparison. E
7. 15.Show
   Document the following details, in duplicate, on the form provided.

   1. Patient's name/number.
   2. Ward/unit.
   3. Date, time.
   4. Signs and symptoms.
   5. Cannulation site (on diagram).
   6. Drug sequence.
   7. Drug administration technique, that is, ‘bolus’ or infusion.
   8. Approximate amount of the drug extravasated.
   9. Diameter, length and width of the extravasation area.
   10. Appearance of the area.
   11. Step‐by‐step management with date and time of each step performed and medical officer notification.
   12. Patient's complaints, comments, statements.
   13. Indication that the patient information sheet has been given to the patient.
   14. Follow‐up section.
   15. Whether photograph was taken.
   16. If required, when patient referred to plastic surgeon.
   17. Signature of the nurse.
   To provide an immediate full record of all details of the incident that can be referred to if necessary. To provide a baseline for future observation and monitoring of patient's condition. To comply with NMC guidelines (INS [112], C; NMC [178], C; RCN [201], C; Schulmeister [224], E; Weinstein and Hagle [265], E).
8. 16.Show
   Explain to the patient that the site may remain sore for several days.
   To reduce anxiety and ensure continued co‐operation. P, E
9. 17.Show
   Observe the area regularly for erythema, induration, blistering or necrosis. Inpatients: monitor daily. Where appropriate, take further photographs.
   To detect any changes at the earliest possible moment (RCN [201], C).
10. 18.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 sterile increase healing (Naylor [171], E).
11. 19.Show
    Depending on size of lesion, degree of pain, type of drug, refer to plastic surgeon.
    To prevent further pain or other complications as chemically induced ulcers rarely heal spontaneously (Dougherty [56], E; Polovich et al. [194], C).
12. 20.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 [83], E; Polovich et al. [194], C; RCN [201], C).