Chapter 23: Administration of systemic anticancer therapies
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Source: Adapted from Mayo ([150]), Polovich et al. ([192]), Schulmeister ([224]).Source: Boulanger et al. [19], INS [112], Polovich et al. [194], Sauerland et al. [218].Source: Adapted from Weinstein and Hagle ([265]), Wilkes ([268]).
Note: one or more of the above may be present. If extravasation is suspected or confirmed, the injection or infusion must be stopped immediately and action must be taken (INS [112], Polovich et al. [194], Weinstein and Hagle [265]).
Extravasation
Definition
Extravasation literally means ‘leaking into the tissues’; in relation to vesicants it describes a process that requires immediate action if local tissue damage is to be prevented (INS [112], Polovich et al. [194], Schulmeister [224]). A vesicant is any solution or medication (DNA or non‐DNA binding) that causes the formation of blisters with subsequent tissue necrosis (INS [112], Polovich et al. [194]).
Related theory
It is important to recognize and distinguish extravasation from an infiltration or flare reaction.
Infiltration refers to the leakage of non‐vesicant solutions/medications into the surrounding tissues (INS [112]). It generally does not cause tissue necrosis but can result in long‐term injury due to local inflammatory reactions or compression of the surrounding tissues (if a large volume infiltrates) which is known as compartment syndrome (Dougherty and Lister [63], RCN [201]). Flare reaction is a local inflammatory reaction to an agent manifested by red tracking along the vein or red blotches but without pain (although the area may feel itchy) (Polovich et al. [194], Wilkes [268]). It occurs in 3–6% of patients (How and Brown [102]). It is caused by a venous inflammatory response to histamine release, is characterized by redness and blotchiness and may result in the formation of small wheals, having a similar appearance to a nettle rash. It usually subsides in 30–60 minutes, with 86% resolving within 45 minutes (How and Brown [102]). Slowing the infusion rate may be helpful but it responds well within a few minutes to the application of a topical steroid (Schulmeister [224], Weinstein and Hagle [265]).
Tissue damage following extravasation of vesicant drugs occurs for many reasons (Polovich et al. [194], Schulmeister [224]):
- Whether the drugs bind to DNA or not:
- DNA‐binding vesicants (e.g. doxorubicin, 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 (Goolsby and Lombardo [88], Polovich et al. [194], Schulmeister [224]).
- Non‐DNA binding vesicants (e.g. paclitaxel, 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. [194]).
- The concentration and amount of vesicant drug in the tissue.
- The location of the extravasation, for example hand, arm.
- Patient factors, for example older age, co‐morbidities.
Evidence‐based approaches
Extravasation is a well‐recognized complication of intravenous (IV) chemotherapy administration, but in general is a condition that is often underdiagnosed, undertreated and under‐reported (Stanley [239]). The incidence of extravasation is estimated to be between 0.5% and 6.0% of all cytotoxic drug administrations (Goolsby and Lombardo [88], Kassner [118], Khan and Holmes [126], Lawson [132], Masoorli [146]), with some estimates for peripheral extravasation between 23% and 25% (Roth [212]). CVADs have decreased the incidence of extravasation but it can still occur and the incidence is estimated to be up to 6% with ports (Masoorli [146]). However, whilst the incidence is lower, the severity of the injuries is far greater as detection tends to occur later (Kassner [118], Polovich et al. [194], Stanley [239]). Even when practitioners have many years of experience, extravasation of vesicant agents can occur and is an extremely stressful event, but is not in itself an act of negligence (Weinstein and Hagle [265]). Early detection and treatment are crucial if the consequences of an untreated or poorly managed extravasation are to be avoided (see Box 23.6 and Figure 23.4). These may include (Polovich et al. [194]):
- blistering (typically occurs 1–2 weeks post extravasation)
- peeling and sloughing of the skin (about 2 weeks post extravasation)
- tissue necrosis (2–3 weeks post extravasation) with resulting pain
- damage to tendons, nerves and joints
- functional and sensory impairment of affected area such as limb disfigurement
- loss of limb or breast.
Figure 23.4 Extravasation. Source: Dougherty and Lister ([62]).
Box 23.6
Considerations for the prevention of extravasation
- Monitoring the site.
- Location of the device.
- Patients at risk.
- Sequence of drugs.
- Types of devices.
- Method of administration.
- Skill of practitioner.
- Informing the patient.
These can all result in possible hospitalization and plastic surgery, delay in the treatment of disease and psychological distress for the patient.
Before administration of any vesicant drug, the nurse should know which agents are capable of producing tissue necrosis. Damage is usually caused because of the ability to bind to DNA, pH, osmolarity or vasoconstrictive nature of the drugs (Box 23.7). Drugs should not be reconstituted to give solutions that are higher in concentration than is recommended by the manufacturer, and the method of administration should be checked, for example infusion or injection. If there is any doubt, the drug data sheet should be consulted or the pharmacy department should be consulted if the information is insufficient, regarding action to take if a vesicant drug extravasates. Consideration should be given to the management of mixed vesicant drug extravasation in terms of which drug to treat with which antidote. For example, if drug A and drug B were in the same infusion and they required different antidotes but if drug A would cause more damage than drug B, the correct action would be to use antidote for drug A (How and Brown [102]).
Possible causes of extravasation are shown in Box [178].
Box 23.7
Examples of vesicant cytotoxic drugs in common use
Group A drugs
- Vinca alkaloids:
- Vinblastine
- Vindesine
- Vinorelbine
- Vincristine
- Vinflunine
- Paclitaxel
Group B drugs
- Amsacrine
- Carmustine (concentrated solution)
- Dacarbazine (concentrated solution)
- Dactinomycin
- Daunorubicin
- Doxorubicin
- Epirubicin
- Idarubicin
- Amrubicin
- Actinomycin D
- Mitomycin C
- Mechlorethamine
- Streptozocin
Box 23.8
Possible causes of extravasation
Peripheral devices
- Vein wall puncture or trauma.
- Dislodgement of the cannula from the vein.
- Administration of a vesicant in a vein below a recent venepuncture or cannulation site (<24 hours).
Central venous access devices
- Perforation of the vein.
- Catheter leakage, rupture or fracture.
- Separation of the catheter from the portal body of an implanted port.
- Incomplete insertion of needle into an implanted port.
- Needle dislodgement from an implanted port.
- Fibrin sheath – leading to backflow of drug along the catheter from the insertion site.
Methods for preventing extravasation
The nurse's focus should be on safe intravenous technique and implementing strategies to minimize risk (Weinstein and Hagle [265]). These include the following strategies.
Patients at risk
Patients who are at increased risk of extravasation (Box 23.9) should be observed more closely.
Box 23.9
Patients at risk of extravasation
- Infants and young children.
- Elderly patients.
- Those who are unable to communicate, for example sedated, unconscious, confused, language issues.
- Those with chronic diseases, for example cancer, peripheral vascular disease, superior vena cava (SVC) syndrome, lymphoedema.
- Those on medications: anticoagulants, steroids.
- Those who have undergone repeated intravenous cannulation/ venepuncture.
- Those with fragile veins or who are thrombocytopenic.
Types of devices
The use of steel needles is associated with a greater risk of extravasation and should be discouraged; a plastic cannula should be used instead (INS [112], Polovich et al. [194], Rodrigues et al, [205], Sauerland et al. [218]). Vesicants should be given via a newly established cannula wherever possible (Dougherty [59], Goolsby and Lombardo [88]) and consideration should be given to changing the cannula site after 24 hours (Wilkes [268]). However, if the fluid runs freely, there is good blood return and there are no signs of erythema, pain or swelling at the site, there is no reason to inflict a second cannulation on the patient (Weinstein and Hagle [265]). Consideration should be given to a CVAD if peripheral access is difficult and a decision‐making tool such as the one in Figure 23.3 (vessel health and preservation [VHP]) can assist with this (Hallam et al. [93]).
Location of the device
The most appropriate site for the location of a peripheral cannula is the forearm (INS [112], Schrijvers [222], Weinstein and Hagle [265]). However, a large straight vein over the dorsum of the hand is preferable to a smaller vein in the forearm (Weinstein and Hagle [265]). Siting over joints should be avoided as tissue damage in this area may limit joint movement in the future. It is also recommended that the antecubital fossa should never be used for the administration of vesicants because of the risk of damage to local structures such as nerves and tendons (Gabriel [80], Weinstein and Hagle [265]). Avoid venepuncture sites in limbs with impaired circulation, sclerosis, thrombosis or scar formation. Also avoid cannulation below a recent venepuncture site (Goolsby and Lombardo [88]).
Sequence of drugs
Following the administration of any antiemetics, when administration of the cytotoxic drugs commences, vesicants should be given first (Goolsby and Lombardo [88], Wilkes [268]). Box 23.10 outlines the reasons for this (Weinstein and Hagle [265]).
Box 23.10
Drug sequencing – rationale for administering vesicant drugs first or last
Vesicants first
- Vascular integrity decreases over time.
- Vein is most stable and least irritated at start of treatment.
- Initial assessment of vein patency is most accurate.
- Patient's awareness of changes more acute.
Vesicants last
- Vesicants are irritating and increase vein fragility.
- Venous spasm may occur and mask signs of extravasation.
Methods of administration
Many vesicants must be given as a slow bolus injection, often via the side arm of a fast‐running intravenous infusion of a compatible solution, for example doxorubicin or epirubicin via an infusion of 0.9% sodium chloride. If repeated infusions are to be given then a CVAD may be more appropriate (Stanley [239], Weinstein and Hagle [265]).
Monitoring the site and early recognition of extravasation
Confirm venous patency by flushing with 0.9% sodium chloride solution with at least 5–10 mL prior to administration of vesicants and monitor frequently thereafter (Goolsby and Lombardo [88], Weinstein and Hagle [265]). Checking blood return after every 2–5 mL is recommended but cannot be relied upon as the key sign when giving a bolus injection; monitor the site every 5–10 minutes for any swelling (Weinstein and Hagle [265]). If a vesicant is administered as an infusion over less than 30 minutes the site should be constantly observed (Wilkes [268]).
It is important that the nurse does not rely on infusion pumps to alarm downstream occlusion and alert her/him to an infiltration or extravasation (Huber and Augustine [106], INS [112], Marders [144]) (see Table 23.2 and Box 23.11).
Table 23.2 Nursing assessment of extravasation
| Assessment parameter | Flare reaction | Venous irritation | Immediate manifestations, i.e. during drug administration | Delayed manifestations, i.e. from 24 hours after extravasation |
|---|---|---|---|---|
| Pain | None | Aching, throbbing sensation along vein and in the limb | Severe stinging or burning pain (not always present). This can last from minutes to hours and will eventually subside. Occurs during drug administration at the device site and surrounding areas | Can continue following extravasation or start within 48 hours. Pain may intensify over time |
| Redness | Immediate blotches or tracking along the vein. This will subside within 30–45 minutes with or without treatment (usually steroid cream) | Vein may become red or darkened | Not always present immediately: more likely to see blanching of the skin. As area becomes inflamed, redness will appear around the device site | Later occurrence |
| Swelling | Unlikely | Unlikely | May occur immediately but may not always be easy to identify immediately | Usually within 48 hours |
| Blood return | Usually present | Usually present but may require application of heat to improve blood return | Inability to obtain blood return (peripheral or central) but blood return may be present throughout | |
| Ulceration | Unlikely | Unlikely | Unlikely | Can occur within 48–96 hours but may take 3–4 weeks to develop |
| Others | Urticaria | None | Change in quality of the infusion or pressure on the syringe | Local tingling and sensory deficits |
Box 23.11
Signs of extravasation
- The patient complains of burning, stinging pain or any other acute change at the injection site, although this is not always present (Wilkes [268]). This should be distinguished from a feeling of cold, which may occur with some drugs, or venous spasm which can be caused by irritation and is usually accompanied by pain described as an achiness or tightness (Wilkes [268]). Any change of sensation warrants further investigation (Goolsby and Lombardo [88]).
- Swelling is a common symptom (Polovich et al. [194]). Induration or leakage may also occur at the injection site. Swelling may not always be immediately obvious if the patient has the cannula sited in an area of deep subcutaneous fat, in a deep vein or if the leak is via the posterior vein wall (Dougherty [59]).
- Blanching of the skin occurs (Comerford et al. [35]). Erythema can occur around the injection site but this is not usually present immediately (Wilkes [268]). It is important that this is distinguished from a flare reaction (Polovich et al. [194]).
- Blood return is one of the most misleading of all signs, particularly in relation to peripheral devices. In peripheral devices, if blood return is sluggish or absent, this may indicate lack of patency or incorrect position of the device. However, if no other signs are apparent, this should not be regarded as an indication of a non‐patent vein, as a vein may not bleed back for a number of reasons. Extravasation may occur even in the event of good blood return as the device may still be in the vein but the leak may be in the posterior vein wall (Wilkes [268]). Any change in blood flow should be investigated (Weinstein and Hagle [265], Wilkes [268]). In CVADs there should always be blood return. If this is absent, steps should be followed to verify correct tip and needle position or resolve a fibrin sheath (see Figure 23.5).
- A resistance is felt on the plunger of the syringe if drugs are given by bolus (Stanley [239]).
- There is absence of free flow when administration is by infusion, once other reasons have been excluded, for example position (Polovich et al. [194], Stanley [239]).
- Leaking around the IV cannula or implanted port needle (Polovich et al. [194]).
Figure 23.5 Persistent withdrawal occlusion flowchart. Source: Dougherty and Lister ([62]).
Legal and professional issues
Competencies
Nurses are now being named in malpractice allegations, and infiltration and extravasation injuries are an area for concern (Dougherty [55], Masoorli [146], Roth [212], Weinstein and Hagle [265]). Therefore, it is vital that nurses have the correct level of knowledge and skills to perform the following (Dougherty [60], Goolsby and Lombardo [88], Sauerland et al. [218], Schrijvers [222]):
- correct choice of device and location
- the ability to use the most appropriate vasodilation techniques
- early recognition of infiltration/extravasation and ability to take prompt action.
Successful cannulation at the first attempt is ideal, as vesicants have been known to seep into tissues at a vein entry site of a previous cannulation (Gault and Challands [83]). This also includes accessing a port as it is vital that the correct selection of needle is made and that the device is secured adequately (Camp‐Sorrell [26]).
Consent
Patients should be informed of the potential problems of administering vesicants and the possible consequences of extravasation (Polovich et al. [194], Sauerland et al. [218], Stanley [239], Weinstein and Hagle [265]). Adequate information given to patients will ensure early recognition and co‐operation as patients are the first to notice pain. The patient should be urged to report immediately any change in sensation such as burning or stinging (Goolsby and Lombardo [88]).
Pre‐procedural considerations
Equipment
Extravasation kits
The use of extravasation kits has been recommended to provide immediate management (Khan and Holmes [126]). Kits should be assembled according to the needs of individual institutions. They should be kept in all areas where staff are regularly administering vesicant drugs, so that staff have immediate access to equipment (Gabriel [80]). The kit should be simple, to avoid confusion, but comprehensive enough to meet all reasonable needs (Wilkes [268]) (see Procedure guideline 23.3). Instructions should be clear and easy to follow, and the use of a flowchart enables staff to follow the management procedure in easy steps (Figure 23.6).
Figure 23.6 Flowchart of management of extravasation. Source: Dougherty and Lister ([62]). DMSO, dimethyl sulfoxide.
Decision‐making tools have been developed both nationally (Figure 23.3) and locally (Figure 23.7) to address issues related to selecting the correct vascular access device (Vessel Health Preservation; Hallam et al. [93]) as well as grading extravasation (see Table 23.3) (INS [112]).
Figure 23.7 Decision‐making tool for vascular access device. Source: Dougherty and Lister ([63]). CVAD, central venous access device; IV intravenous(ly); LMWH, low molecular weight heparin; SVC, superior vena cava; TPN, total parenteral nutrition.
Table 23.3 Grading scale for monitoring extravasation
| Grade | 1 | 2 | 3 | 4 | 5 |
|---|---|---|---|---|---|
| Skin colour | Normal | Pink | Red | Blanched area surrounded by red | Blackened |
| Skin integrity | Unbroken | Blistered | Superficial skin loss | Tissue loss and exposed subcutaneous tissue | Tissue loss and exposed bone/muscle with necrosis/crater |
| Skin temperature | Normal | Warm | Hot | ||
| Oedema | Absent | Non‐pitting | Pitting | ||
| Mobility | Full | Slightly limited | Very limited | Immobile | |
| Pain | Grade using a scale of 0–10 where 0 = no pain and 10 = worst pain | ||||
| Temperature | Normal | Elevated (indicate actual temperature) |
Pharmacological support
Many ‘antidotes’ are available but there is a lack of scientific evidence to demonstrate their value and so the role of antidotes is still not clear (Polovich et al. [194]). There appear to be two main methods: (i) localize and neutralize (using hyaluronidase) (CP Pharmaceuticals [36]); and (ii) spread and dilute (using an antidote) (Stanley [239]). Administration of injectable antidotes if not via the cannula is by the pincushion technique, that is, instilling small volumes around and over the areas affected using a small‐gauge (25) needle towards the centre of a clock face. The procedure causes considerable discomfort to patients and, if large areas are to be tackled, analgesia should be considered (Stanley [239]).
Hyaluronidase
This is an enzyme which breaks down hyaluronic acid, a normal component of tissue ‘cement’, and helps to reduce or prevent tissue damage by allowing rapid (within 10 minutes) diffusion of the extravasated fluid and restoration of tissue permeability within 24–48 hours (Doellman et al. [52], Few [75], INS [112]). The usual dose is 1500 IU (Bertelli [12]). It should be injected within 1 hour of extravasation, ideally through the intravenous device in situ, to deliver the enzyme to the same tissue (Perez Fidalgo et al. 2012, Weinstein and Hagle [265]).
Note: Hyaluronidase increases the absorption of local anaesthetic. Therefore, if local anaesthetic has been applied to the area, for example Ametop gel prior to cannulation, within 6 hours of extravasation, then the patient should be monitored for signs and symptoms of systemic anaesthesia such as increased pulse rate and decreased respirations and the doctor informed immediately (Joint Formulary Committee 2018).
Corticosteroids
These have long been advocated as a treatment for anthracycline extravasation in reducing inflammatory components, although inflammation is not a prominent feature of tissue necrosis (Camp‐Sorrell [25]) and they appear to have little benefit. Data now discourage the use of locally injected corticosteroids as there is little evidence to support their use (Bertelli [12], Gault and Challands [83], Perez Fidalgo et al. 2012, Wickham et al. [267]). However, given as a cream, they can help to reduce local trauma and irritation (Stanley [239]).
Dimethyl sulfoxide (DMSO)
This is a topically applied solvent that may improve absorption of vesicants. It acts as a potent free radical scavenger that rapidly penetrates tissues and prevents DNA damage (Bertelli [12], Doellman et al. [52]). Reports on the clinical use of topical DMSO show that it is effective and well tolerated in extravasation (Bertelli [12]). However, this is based on a high dose (99%) solution which is not always available (Pérez Fidalgo et al. [190]). Side‐effects from DMSO include itching, erythema, mild burning and a characteristic breath odour (Bertelli [12]).
Dexrazoxane (Savene)
A topoisomerase II catalytic inhibitor, used clinically to minimize the cardiotoxicity of doxorubicin, dexrazoxane was first tested in animals (Langer et al. [130]) and then a small number of patients for its use in extravasation (Doroshow [53]). It is given IV as soon as possible after the extravasation and it appears to reduce the wound size and duration of tissue damage with anthracyclines. The triple dosage appears to be more effective than a single dose (El‐Saghir et al. [70], Langer et al. [129]). In two multicentre studies, it was shown that the administration of dexrazoxane reduced the need for surgical interventions, and late sequelae such as pain, fibrosis, atrophy and sensory disturbance were judged as mild (Doroshow [53], Mouridsen et al. [160]).
A consensus group (Jackson [114]) developed recommendations for the use of dexrazoxane and these have been further adapted by the European Oncology Nursing Society ([72]) which recommended that in anthracycline extravasations resulting from peripheral administration, the site expert or team should be consulted to determine whether the use of dexrazoxane is indicated. Absolute indications are if the peripherally extravasated volume exceeds 3–5 mL and in the event of a central venous access device extravasation (Langer [128]). Dexrazoxane is now recommended in many treatment algorithms for anthracycline extravasations (Gonzalez [86], INS [112], Pérez Fidalgo et al. [190], Roe [206], Vidall et al. [260]). See Figure 23.8.
Figure 23.8 Dexrazoxane fowchart, an extravasation has occurred.
Non‐pharmacological support
Stopping infusion/injection and aspirating the drug
It appears that most authors agree that aspirating as much of the drug as possible, as soon as extravasation is suspected, is beneficial (Polovich et al. [194], Rudolph and Larson [214], Weinstein and Hagle [265]) and can help lower the concentration of the drug in the area (Goolsby and Lombardo [88]). However, withdrawal is only possible immediately during bolus injections, because if the drug was being delivered via an infusion this would need to be stopped and a syringe attached in an attempt to aspirate. Aspiration may be successful if extravasation presents as a raised blister, but may be unsuccessful if tissue is soft and soggy (CP Pharmaceuticals [36], Stanley [239]). It may help to reduce the size of the lesion. In practice, it may achieve little and often distresses the patient (Gault and Challands [83]). The likelihood of withdrawing blood (as suggested by Ignoffo and Friedman [[110]]) is small and the practitioner may waste valuable time attempting this which could lead to delay in the rest of the management procedure.
Removing the device
Some clinicians advocate that the peripheral vascular access device be left in situ to instil the antidote via the device and into the affected tissues (Kassner [118], Stanley [239], Weinstein and Hagle [265]). However, others recommend that the peripheral device should be removed to prevent any injected solution increasing the size of the affected area (CP Pharmaceuticals [36], Rudolph and Larson [214]). There appears to be no research evidence to support either practice.
Application of hot or cold packs
Cooling appears to be a better choice, except for the vinca alkaloids and some non‐cytotoxic drugs, than warming (Bertelli [12], CP Pharmaceuticals [36]). Cold causes vasoconstriction, localizing the medication in the tissues, and reduces inflammation, perhaps allowing time for local vascular and lymphatic systems to contain the drug (INS [112]). It should be applied for 15–20 minutes, 3–4 times a day for up to 3 days (Polovich et al. [194], Wilkes [268]). Heat promotes blood flow and disperses medication through the tissues (Polovich et al. [194], Weinstein and Hagle [265]). Increasing the blood flow also decreases local drug concentration, which results in enhanced resolution of pain and reabsorption of a localized swelling.
Elevation of limb
This is recommended as it minimizes swelling (Rudolph and Larson [214]). This can be achieved by use of a Bradford sling but is usually recommended when the extravasation has occurred in the hand. Gentle movement should be encouraged to prevent adhesion of damaged areas to underlying tissue (Gabriel [80], INS [112]).
Surgical techniques
It is now recognized that a plastic surgery consultation should be performed as part of the management procedure to remove the tissue containing the drug. Surgical intervention is recommended, especially if the lesion is greater than 2 cm, there is significant residual pain 1–2 weeks after extravasation, or there is minimal healing 2–3 weeks after injury despite local therapeutic measures (Goolsby and Lombardo [88], Pérez Fidalgo et al. [190]). A liposuction cannula can be used to aspirate extravasated material and subcutaneous fat or a flush‐out technique can remove extravasated drug without resorting to excision and skin grafting.
Flush‐out technique
If there is little subcutaneous fat, then the saline flush‐out technique is recommended, particularly if it can be done within the first 24 hours (Dionyssiou et al. [51], Gault [82]). It has been suggested as a less traumatic and cheaper procedure than surgery. Only appropriately trained doctors or nurses may perform the flush‐out technique for superficial peripheral extravasations where there is no visible skin damage or extensive swelling (Dougherty and Oakley [64]). A few small stab incisions are made and large volumes of 0.9% sodium chloride are administered which flush out the extravasated drug (Dougherty and Oakley [64], Gault and Challands [83]); this is more successful if performed within 24 hours of extravasation (Dionyssiou et al. [51]) (see Procedure guideline 23.4).
Procedure guideline 23.3
Extravasation management: peripheral cannula
Procedure guideline 23.4
Extravasation: performing flush‐out following an extravasation
Post‐procedural considerations
Ongoing care
Patient follow‐up will depend upon the patient's needs and the degree of damage. Assessment should be carried out using a standardized tool (INS [112]) and include inspection and management of the area of extravasation, skin integrity, presence of pain and other symptoms such as mobility and sensation of the limb (see Table 23.3). If damage has occurred, it will be determined by the site, amount of drug, concentration of the agent and if it binds to DNA or not (Polovich et al. [194]). Blistering may occur within 24 hours (for example, with vinorelbine) or ulceration may occur over a period of days to weeks (for example, with epirubicin), and extravasation wounds may be complicated by tissue ischaemia related to endothelial damage (Naylor [171]). The type of injury will dictate the type of dressing. Assessment of the wound should include position and size of the wound, amount and type of tissue present, amount and type of exudate, and extent and spread of erythema (Naylor [171]). If the flush‐out technique has been undertaken then the incisions should be dressed using a dressing that allows the fluid to continue to leak from the site, for example Mepitel. It is also important to recognize the impact on the patient's psychological and situational dynamics that may diminish their quality of life (Gonzalez [86]).
Documentation
An extravasation must be reported and fully documented because it is an accident and the patient may require follow‐up care (NMC [177], RCN [201]). The Oncology Nursing Society has listed the key elements of vesicant extravasation documentation (Polovich et al. [194]) (see Box 23.12). Statistics on the incidence, degree, causes and corrective action should be monitored and analysed (Gonzalez [86], INS [112], Pérez Fidalgo et al. [190]). Finally, documentation may be required in the case of litigation, which is now on the increase (Doellman et al. [52], Dougherty [55], Masoorli [146]).
Box 23.12
Key elements of vesicant extravasation documentation
- Date and time the extravasation occurred.
- Type and size of vascular access device.
- Length and gauge of needle (ports only).
- Location of device.
- Details of how patency was established before and during administration (description and quality of blood return).
- Number and location of all cannulation attempts.
- Vesicant administration method, for example bolus/infusion.
- Estimated amount of extravasated drug.
- Symptoms reported by the patient.
- Description of device site, for example swelling, redness and so on.
- Assessment of limb (where applicable) for range of movement.
- Immediate nursing interventions.
- Follow‐up interventions.
- Patient information.
Education of patient and relevant others
Patients should always be informed when an extravasation has occurred and be given an explanation of what has happened and what management has been carried out (INS [112], McCaffrey Boyle and Engelking [151]). An information sheet should be given to patients with instructions of what symptoms to look out for and when to contact the hospital during the follow‐up period (Gabriel [80]).
