Guideline for the Management of Extravasation

Version History

Version Date Brief Summary of Change

Issued
1.0 19.03.07
Endorsed by the Governance Committee
1.1 21.08.08
Prepared for review
1.2 09.02.09
Changes made following review by Andrew Stanley
1.3 04.10.10
Discussion at Chemotherapy Network Site Specific Group
1.4 14.11.10
With comments from Andrew Stanley
1.5 31.01.11
Discussion at Chemotherapy Network Site Specific Group and
updated by Andrew Stanley
1.6 – 01 – 04 Various versions for consideration – sent to NSSG April 2011
1.8 .11
1.9 05.05.11 Final version by Andrew Stanley for review by the
Chemotherapy NSSG and Jeanette Hawkins
2.0 14.06.11 Endorsed by the Governance Committee

Date Approved by Network Governance June 2011

Date for Review June 2014

Changes since version 1

Part 1 has been added to describe the use of dexrazoxane. The updated version of
the Royal Marsden Hospital Manual has been added.

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1 Scope of the Guideline

This guidance has been produced to support the following:

The prevention of the extravasation of intravenous anti-cancer drugs.

The early detection of the extravasation of intravenous anti-cancer drugs.
The treatment of the extravasation of intravenous anti-cancer drugs.

2 Guideline Statement

Statement 2

The Network Site Specific Group has agreed to adopt the Royal Marsden Hospital
Manual of Clinical Nursing Procedures 7th Edition; Blackwell Publishing (2008),
chapter on extravasation, with the addition of a section on dexrazoxane.

Part 1 is: Detailed guidance on the use of dexrazoxane.

Part 2 is: The Royal Marsden Hospital Manual of Clinical Nursing Procedures 7th
Edition; Blackwell Publishing (2008), chapter on extravasation.

These have been adopted as guidelines for the management of extravasation of anti-
cancer drugs used in the cancer care setting.

Statement 2

There are a number of drugs included which normally have a three year review. This
guideline will be reviewed in between times if new drugs become available.

Part 1 - Detailed Guidance on the Use of dexrazoxane

3 Dexrazoxane

3.1 DEXRAZOXANE IS NOT RECOMMENDED FOR USE IN CHILDREN. FOR

MANAGEMENT OF ANTHRACYCLINE EXTRAVASATION IN CHILDREN
USE COOLING AND DMSO.

3.2 Dexrazoxane (Savene) is the first systemic antidote for the treatment of
anthracycline extravasation; it is a cytotoxic drug. Dexrazoxane has two major
mechanisms of action:

a. It inhibits DNA topoisomerase II.

b. It acts as an iron chelator and thereby reduces iron-dependant free
radical oxidative stress associated with anthracycline induced toxicity.

3.3 As a cytotoxic drug disposal and safe handling requirements should be as any
cytotoxic drug. Reconstitution needs to be carried out by an oncology
pharmacist. It is administered as an intravenous infusion over 1-2 hours, once

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 a day for 3 days following extravasation. The first infusion needs to be
administered within the first 6 hrs of extravasation. Dosing schedule is as
follows:

Day one: dexrazoxane 1000mg/m2

Day two: dexrazoxane 1000mg/m2
Day three: dexrazoxane 500mg/m2
Maximum single dose is 2000mg

3.4 Site for Administration: Administration should be through a large vein away
from the site of extravasation, so as not to cause any further tissue damage
due to leakage of another drug. If the other arm cannot be used a site proximal
to the area of extravasation should be used. If the extravasation is from a
central venous access device (CVAD) the antidote should be given
peripherally. If the extravasation is from a PICC line then the opposite arm
should be used.

3.5 Prior to Administration: Discontinue any cooling procedures 15 minutes before

administration. Do not use DMSO in conjunction with dexrazoxane.

3.6 When to Administer Dexrazoxane:

a. Peripheral extravasations; dexrazoxane should only be administered

when a positive diagnosis of an anthracycline extravasation has
occurred. This is most likely when sufficient volume has extravasated
to allow the attending practitioner to palpate the area and feel the
‘spongey’ nature of the tissues around the site of the cannular tip. The
current view is that this represents an extravasated volume of
approximately 3mls. Volumes below 3mls or where the attending
practitioner is unsure whether an extravasation has occurred should be
treated with the application of DMSO and cold compression.
Extravasation diagnosed substantially beyond the 6 hour ‘window’ for
treatment recommended by the manufacturer, i.e. up to 9 hours, should
be treated with DMSO.
b. Dexrazoxane is also recommended for any suspected extravasations of
anthracyclines from central catheters.

3.7 Subsequent Chemotherapy Treatments: As dexrazoxane is an antidote to

anthracyclines and blocks their action the MDT will need to decide whether
the course of chemotherapy that the extravasation occurred on needs to be
repeated. This will depend on when the extravasation occurred during the
administration of the cytotoxic drug, i.e. if not much had been administered
the treatment may be repeated, if most of the anthracycline had been
administered the patient may progress onto the next course, although
dexrazoxane may have blocked the action of that particular dose. Details
of what drugs had been successfully delivered must be available for
discussion with the oncologist.

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 3.8 Side Effects: Results from clinical trials and case studies indicate that
dexrazoxane is a safe and well-tolerated drug. Side effects include those
common to most cytotoxic drugs. Those to note are: neutropenia,
infection, phlebitis, stomatitis, nausea and vomiting. Dexrazoxane is
excreted via the kidneys therefore decreased renal function may increase
serum concentrations. Following administration haematological and
biochemical monitoring should take place; the regularity will depend on the
patient and will need to be clarified with the medical team. The solution
contains potassium, therefore potassium levels should be monitored in
patients who are at risk of hyperkalaemia.

Reporting see page 14 number 16 of RMH guideline. These incidents

should be reported in accordance with the Trust clinical incident reporting
procedure for each organisation.

3.9 Where is it Stored? Dexrazoxane is stored in pharmacy. It is the

responsibility of individual units to ensure access to dexrazoxane is
possible within 6 hours of an extravasation.

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4 Royal Marsden Hospital Guidance
THE NUMBERING FOR THIS SECTION RESTARTS AS IT IS TAKEN
DIRECTLY FROM THE RMH MANUAL

Part 2 - The Royal Marsden Hospital Manual of Clinical Nursing Procedures 7 th

Edition; Blackwell Publishing (2008), chapter on extravasation

Extravasation of Vesicant Drugs - Definition

Extravasation is a well-recognised complication of intravenous (IV) chemotherapy

administration, but in general is a condition that is often under-diagnosed,
undertreated and under-reported (Stanley 2002). The incidence of extravasation is
estimated to be between 0.5 and 6.0% of cytotoxic drug administration (Kassner
2000; Khan & Holmes 2002; Lawson 2003; Masoorli 2003; Goolsby & Lombardo
2006) with some estimates for peripheral extravasation between 23 and 25% (Roth
2003). CVADs have decreased the incidence of extravasation but it can still occur,
usually as a result of a leaking or damaged catheter, fibrin sheath formation (Mayo
1998) or a port needle dislodgement (Schulmeister 1998). The incidence estimated is
up to 6% with ports (Masoorli 2003). However, whilst the incidence is lower, the
severity of the injuries is far greater as detection tends to occur later (Kassner 2000;
Stanley 2002; Polovich et al. 2005). 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 2007). Early detection and
treatment are crucial if the consequences of an untreated or poorly managed
extravasation are to be avoided (Figure 12.3). These may include:

Pain from necrotic areas

Physical defect
The cost of hospitalization and plastic surgery
Delay in the treatment of disease
Psychological distress

Litigation: nurses are now being named in malpractice allegations, and extravasation
injuries are an area for concern (Dougherty 2003; Masoorli 2003; Roth 2003;
Weinstein 2007).

1 Prevention of Extravasation

The nurse's focus should be on safe intravenous technique and implementing

strategies to minimize the risk (Weinstein 2007). This includes the following
strategies.

2. Monitoring the Site

Confirming venous patency by flushing with 0.9% sodium chloride solution with at
least 5–10 ml prior to administration of vesicants and frequent monitoring thereafter
(Goolsby & Lombardo 2006; Weinstein 2007). Checking blood return after every 2–5
ml is recommended but cannot be relied upon as the key sign when giving a bolus

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injection, and monitoring the site every 5–10 minutes for any swelling (Weinstein
2007).

3. Location of the Device

The most appropriate site for the location of a peripheral cannula is considered to be
the forearm (Schrijvers 2003; Weinstein 2007). However, a large straight vein over
the dorsum of the hand is preferable to a smaller vein in the forearm (Weinstein
2007). 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 (Hayden & Goodman 2005;
Weinstein 2007; Gabriel 2008). Avoid venepuncture sites in limbs with impaired
circulation, sclerosis, thrombosis or scar formation. Also avoid cannulation below a
recent venepuncture site (Goolsby & Lombardo 2006).

4. Patients at Risk

Patients who are at increased risk of extravasation (Box 12.2) should be observed
more closely and cared for with extra caution.

Box 12.2 Patients at Risk of Extravasation

Infants and young children.

Elderly patients.
Those who are unable to communicate, e.g. sedated, unconscious, confused,
language issues.
Those with chronic diseases, e.g. 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.

* Polovich et al. 2005; Hayden & Goodman 2005; Sauerland et al. 2006.

Sequence of Drugs (Table 12.3)

Vesicants should be given first (Kassner 2000; Hayden & Goodman 2005; Goolsby &
Lombardo 2006). Reasons for this include:

1. Vascular integrity decreases over time.

2. Vein is most stable and least irritated at start of treatment.
3. Initial assessment of vein patency is most accurate.
4. Patient's awareness of changes more acute (Weinstein 2007).

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Table 12.3 Drug sequencing – rationale for administering vesicant drugs first or last
(Stanley 2002; Weinstein 2007).

Vesicants First Vesicants Last

1 Vascular integrity decreases over 1 Vesicants are irritating and increase
time vein fragility
2 Vein is most stable and least irritated 2 Venous spasm may occur and mask
at start of treatment signs of extravasation
3 Initial assessment of vein patency is
most accurate
4 Patient's awareness of changes more
acute

5. Types of Devices

The use of steel needles is associated with a greater risk of extravasation and should
be discouraged and a plastic cannula should be used instead (Schrijvers 2003;
Polovich et al. 2005; Sauerland et al. 2006). Vesicants should be given via a newly
established cannula wherever possible (Dougherty 2005; Goolsby & Lombardo 2006)
and consideration should be given to changing the cannula site after 24 hours
(Hayden & Goodman 2005). 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 2007). Consideration
should be given to a CVAD if peripheral access is difficult.

6. Method 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, e.g. 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 2002; Weinstein 2007).

7. Skill of the Practitioner

Correct choice of device and location, the ability to use the most appropriate
vasodilatation techniques, early recognition of extravasation and prompt action come
from ensuring only skilled and knowledgeable practitioners administer vesicant drugs
and/or insert the vascular access device (Schrijvers 2003; Dougherty 2005; Goolsby
& Lombardo 2006; Sauerland et al. 2006). 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 & Challands 1997; Perdue 2001). 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 2005).

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8. Patient Information

Patients should be informed of the potential problems of administering vesicants and

the possible consequences of extravasation (Stanley 2002; Sauerland et al. 2006;
Weinstein 2007). 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
& Lombardo 2006).

9. Drugs Capable of Causing Tissue Necrosis

Before administration of vesicant cytotoxic drugs the nurse should know which
agents are capable of producing tissue necrosis. The following is a list of examples of
those in common use:

Group A Drugs Group B Drugs

Vinca alkaloids Amsacrine
Vinblastine Carmustine (concentrated solution)
Vindesine Dacarbazine (concentrated solution)
Vinorelbine Dactinomycin
Vincristine Daunorubicin
Vinflunine Doxorubicin
Paclitaxel Epirubicin
Idarubicin
Mithramycin
Mitomycin C
Mechlorethamine
Streptozocin

If in any doubt, the drug data sheet should be consulted or reference made to a
research trial protocol. Drugs should not be reconstituted to give solutions which are
higher than the manufacturer's recommended concentration, and the method of
administration should be checked, e.g. infusion, injection.

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A variety of vesicant non-cytotoxic agents in frequent use are also capable of causing
severe tissue damage if extravasated. Examples include:

Group A Drugs Group B Drugs

Calcium chloride Aciclovir
Calcium gluconate Amphotericin
Phenytoin Cefotaxime
Hypertonic solutions, e.g. sodium
Diazepam
chloride >0.9%
Ganciclovir
Sodium bicarbonate (>5%) Potassium chloride (>40 mmol/l)
Glucose 50% Mannitol

This potential hazard should always be remembered. The actions listed in this
procedure may not be appropriate in all these instances. Drug data sheets should
always be checked and the pharmacy departments should be consulted if the
information is insufficient, regarding action to take if a vesicant drug extravasates.

10. Signs and Symptoms of Extravasation (see Table 12.4)

Extravasation should be suspected if:

1. The patient complains of burning, stinging pain or any other acute change at
the injection site, although this is not always present (Hayden & Goodman
2005). This should be distinguished from a feeling of cold, which may occur
with some drugs, or venous spasm which can be caused by irritation usually
accompanied by pain described as an achiness or tightness (Hayden &
Goodman 2005). Any change of sensation warrants further investigation
(Goolsby & Lombardo 2006).
2. Swelling is the most common symptom (Polovich et al. 2005). 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 2005).
3. Blanching of the skin occurs (Comerford et al. 2002). Erythema can occur
around the injection site but this is not usually present immediately (Hayden &
Goodman 2005). It is important that this is distinguished from a ‘flare’ reaction
(Polovich et al. 2005).
4. Blood return is one of the most misleading of all signs particularly related 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 and
extravasation may occur even in the event of good blood return (Hayden &
Goodman 2005). Any change in blood flow should be investigated (Hayden &
Goodman 2005; Weinstein 2007). In CVADs there should always be blood
return and if this is absent steps should be followed in order to be able to verify
correct tip and needle position or resolve a fibrin sheath (see Figure 45.1).
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 5. A resistance is felt on the plunger of the syringe if drugs are given by bolus
(Vandergrift 2001; Stanley 2002).
6. There is absence of free flow when administration is by infusion, once other
reasons have been excluded, e.g. position (Vandergrift 2001; Stanley 2002).

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 (Polovich et al. 2005; Infusion Nurses Society 2006; Weinstein 2007).

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Table 12.4 Nursing assessment of extravasation versus other reactions (Polovich et al. 2005; Weinstein 2007)
Extravasation
Assessment Flare reaction Venous irritation Immediate manifestations, i.e. Delayed
parameter during drug administration manifestations, i.e.
from 24 hours after
extravasation
Pain None Aching, throbbing Severe stinging or burning pain (not Can continue following
sensation along always present). This can last from extravasation or start
vein and in the minutes to hours and will eventually within 48 hours
limb subside. Occurs during drug
administration at the device site and
surrounding areas
Redness Immediate blotches or Vein may become Not always present immediately: more Later occurrence
tracking along the vein. red or darkened likely to see blanching of the skin. As
This will subside within area becomes inflamed redness will
30–45 minutes with or appear around the device site
without treatment (usually
steroid cream)
Swelling Unlikely Unlikely May occur immediately but may not Usually within 48 hours
always be easy to identify immediately
Blood return Usually present Usually present Inability to obtain blood return
but may require (peripheral or central) but blood return
application of heat may be present throughout
to improve blood
return
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 Local tingling and
pressure on the syringe sensory deficits

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11. Management of Extravasation

The management of extravasation of chemotherapy agents is controversial and there

is little documented evidence of efficacy. Until recently, no antidote has received
clear validation in controlled clinical trials and no randomized trials managing
cytotoxic extravasation in humans have been completed (Bertolli 1995). Some
studies performed on animals have demonstrated both effective and ineffective
treatments but extrapolation from animals to humans is limited (Polovich et al. 2005;
Wickham et al. 2006). Other studies have been small with low numbers of patients.
Another problem is that it is often difficult to ascertain whether any extravasation has
actually occurred (Weinstein 2007). Therefore recommendations are based on more
consistent experimental evidence, cumulative clinical experience from available case
reports and uncontrolled studies and empirical guidelines (Bertolli 1995). Drugs
where there is evidence of effective management include: anthracyclines (Rudolph &
Larson 1987), vinca alkaloids (Bertolli 1995), computed tomography (CT) contrast
media (Federle et al. 1998) and paclitaxel (Bertolli et al. 1997).

The management of extravasation involves several stages including the following.

Stage 1: stopping infusion/injection and aspirating the drug

It appears that most authors are agreed that aspirating as much of the drug as
possible, as soon as extravasation is suspected, is beneficial (Rudolph & Larson
1987; Vandergrift 2001; Polovich et al. 2005; Weinstein 2007) and can help lower the
concentration of the drug in the area (Goolsby & Lombardo 2006). However,
withdrawal is only immediately possible during bolus injections, as an infusion would
need to be stopped and a syringe attached in an attempt to aspirate. Aspiration may
be successful if extravasation presents itself as a raised blister, but may be
unsuccessful if tissue is soft and soggy (CP Pharmaceuticals 1999; Stanley 2002). It
may help to reduce the size of the lesion (Vandergrift 2001). In practice it may
achieve little and often distresses the patient (Gault & Challands 1997). The
likelihood of withdrawing blood (as suggested by Ignoffo & Friedman 1980) is small
and the practitioner may waste valuable time attempting this which could lead to
delay in the rest of the management procedure.

Stage 2: removing device

Some clinicians advocate that the peripheral vascular access device be left in situ in
order to instil the antidote via the device and into the affected tissues (Kassner 2000;
Stanley 2002; Weinstein 2007). However, others recommend that the peripheral
device should be removed to prevent any injected solution increasing the size of the
affected area (Rudolph & Larson 1987; CP Pharmaceuticals 1999; Vandergrift 2001).
There appears to be no research evidence to support either practice.

Stage 3: applying hot or cold packs

Cooling appears to be a better choice, with the exception of the vinca alkaloids and
some non-cytotoxic drugs, than warming (Bertolli 1995; CP Pharmaceuticals 1999).
Cold causes vasoconstriction, localizing the extravasation and perhaps allowing time
for local vascular and lymphatic systems to contain the drug. It should be applied for
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15–20 minutes, 3–4 times a day for up to 3 days (Gault & Challands 1997; CP
Pharmaceuticals 1999; Polovich et al. 2005). Heat promotes healing after the first 24
hours by increasing the blood supply (Polovich et al. 2005; Weinstein 2007). It also
decreases local drug concentration, increasing the blood flow which results in
enhanced resolution of pain and reabsorption of local swelling.

Stage 4: use of antidotes

A number of antidotes are available, but again there is a lack of scientific evidence to
demonstrate their value and so the role of antidotes is still not clear (Polovich et al.
2005). There appear to be two main methods: (i) localize and neutralize (using
hyaluronidase) (CP Pharmaceuticals 1999); and (ii) spread and dilute (using an
antidote) (Stanley 2002). Administration of 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 2002).

Hyaluronidase 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 diffusion of the extravasated fluid and promoting drug absorption (Few
1987). The usual dose is 1500 IU (Bertolli 1995; Vandergrift 2001). It should be
injected within 1 hour of extravasation, ideally through the intravenous device
delivering the enzyme to the same tissue (Gault & Challands 1997; Vandergrift 2001;
Stanley 2002; Weinstein 2007). NB. Hyaluronidase increases the absorption of local
anaesthetic. Therefore if local anaesthetic has been applied to the area, e.g. 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 (BMA/RPSGB
2008).

Corticosteroids 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 1998) and they appear to have
little benefit. Data now discourages the use of locally injected steroids, as there is
little evidence to support their use (Bertolli 1995; Gault & Challands 1997; Wickham
et al. 2006). However, given as a cream they can help to reduce local trauma and
irritation (Stanley 2002).

Dimethyl sulfoxide (DMSO) is a potent free radical scavanger that rapidly penetrates
tissues when applied topically (Bertolli 1995). Reports on the clinical use of topical
DMSO show it is effective and well tolerated in extravasation (Bertolli 1995).
However, this is based on a high dose (95%) and only 50% is easily available in the
UK (Stanley 2002). Side-effects from DMSO include itching, erythema, mild burning
and a characteristic breath odour (Bertolli 1995).

Recently dexrazoxane, a topoisomerase II catalytic inhibitor, used clinically to

minimize the cardiotoxicity of doxorubicin, has been tested in animal models and a
small number of patients for its use in extravasation. It is given IV 3–6 hours after the
extravasation and it appears to reduce the wound size and duration with
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anthracyclines. The triple dosage appears to be more effective than a single dose
(Langer et al. 2000; El Saghir et al. 2004). A consensus group (Jackson et al. 2006)
have developed recommendations for the use of dexrazoxane:

1. For anthracycline extravasations resulting from peripheral administration, the

site expert or team should be consulted in order to determine whether the use
of dexrazoxane is indicated.
2. Absolute indications are if the peripherally extravasated volume exceeds 15 ml
and in the event of a central venous extravasation.

Finally, granulocyte macrophage-colony stimulating factor (GM-CSF) is a growth

factor and has been found effective in accelerating wound healing and inducing
formation of granulation of tissue (Ulutin et al. 2000; El Saghir et al. 2004).

Stage 5: elevation of limb

This is recommended as it minimizes swelling (Rudolph & Larson 1987) and

movement should be encouraged to prevent adhesion of damaged areas to
underlying tissue (Gabriel 2008).

Stage 6: surgical techniques

Some centres suggest that a plastic surgery consultation be performed as part of the
management procedure in order 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 & Lombardo 2006).
Liposuction or a flush-out technique can remove extravasated drug without resorting
to excision and skin grafting. A liposuction cannula can be used to aspirate
extravasated material and subcutaneous fat. If there is little subcutaneous fat, e.g.
preterm infants, then the saline flush-out technique is recommended, particularly if
done within the first 24 hours. It has been suggested as a less traumatic and cheaper
procedure than surgery. Four small stab incisions are made and large volumes of
0.9% sodium chloride are administered which flush out the extravasated drug (Gault
& Challands 1997). Management of large extravasations from CVADs is usually by
surgical intervention and washout of affected tissues.

12. Extravasation Kits

The use of extravasation kits has been recommended in order to provide immediate
management (Khan & Holmes 2002; Hayden & Goodman 2005). Kits should be
assembled according to the particular needs of individual institutions. They should be
kept in all areas where staff are regularly administering vesicant drugs, so staff have
immediate access to equipment (Gabriel 2008). The kit should be simple to avoid
confusion, but comprehensive enough to meet all reasonable needs (Stanley 2002)
(see Procedure guidelines: Extravasation management: peripheral cannula, below).
Instructions should be clear and easy to follow, and the use of a flow chart enables
staff to follow the management procedure in easy steps (Figure 12.4).

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13. Mixed Vesicant Extravasation

Consideration should be given to the management of mixed vesicant drug

extravasation in terms of which drug to treat with which antidote. It has been
recommended to act in accordance with the drug which possesses the most
deleterious properties (How & Brown 1998).

14. Informing the Patient

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 (McCaffrey Boyle & Engelking 1995). 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 2008).

15. Wound Management

Damage will be affected by the site, amount of drug, concentration of the agent and if
it binds to DNA or not (Polovich et al. 2005). Ulceration may occur over a period of
days to weeks and extravasation wounds may be complicated by tissue ischaemia
related to endothelial damage (Naylor 2005). 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 2005).

16. Documentation and Follow Up

An extravasation must be reported and fully documented as it is an accident and the

patient may require follow-up care. (NMC 2005; RCN 2005). Information may also be
used for statistical purposes, for example collation and analysis using the green card
scheme devised by St. Chad's Hospital, Birmingham (Stanley 2002). Statistics on the
incidence, degree, causes and corrective action should be monitored and analysed
(Infusion Nurses Society 2006). Finally, it may be required in case of litigation, which
is now on the increase (Dougherty 2003; Masoorli 2003).

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Figure
Equipment

To assist the nurse, an extravasation kit should be assembled and should be readily
available in each ward/unit.
It contains:

1. Gel packs × 2 : one to be kept in the fridge and one available for heating (an
electric heating blanket can be used whilst pack is heating).
2. Hyaluronidase 1500 IU/2 ml sterile water.
3. Hydrocortisone cream 1% 15 g tube × 1.
4. 2 ml syringes × 1.
5. 25 G needles × 2.
6. Alcohol swabs.
7. Documentation forms.
8. Copy of extravasation management procedure.
9. Patient information leaflet.

Procedure

Action Rationale
1 Explain and discuss the procedure To ensure that the patient understands
with the patient. the procedure and gives his/her valid
consent (DH 2002a: C; NMC 2008b: C).
2 Stop injection or infusion immediately, To minimize local injury. To allow
leaving the cannula in place. aspiration of the drug to be attempted
(Polovich et al. 2005: C; RCN 2005: C).
3 Aspirate any residual drug from the To minimise local injury by removing as
device and suspected extravasation much drug as possible and only attempt if
site. appropriate. Subsequent damage is
related to the volume of the
extravasation, in addition to other factors
(Polovich et al. 2005: C; RCN 2005: C).
4 Remove the cannula. To prevent the device from being used
for antidote administration (Rudolph &
Larson 1987: E).
5 Collect the extravasation pack and It contains all the equipment necessary
take it to the patient. for managing extravasation (Stanley
2002: E; Dougherty 2005: E).

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 Group A Drugs:
Draw up hyaluronidase 1500 IU in 1 ml This is the recommended agent for group
water for injection and inject volumes of A drugs. The warm pack speeds up
0.1–0.2 ml subcutaneously at points of absorption of the drug by the tissues
the compass around the circumference of (Bertolli 1995: C).
the area of extravasation.
Apply warm pack

Group B Drugs:
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. 2005: C).
However, if extravasation is with any of This is the recommended agent for these
the following category B drugs: mitomycin anthracyclines and helps to reduce local
C; doxorubicin; idarubicin; epirubicin; tissue damage (Bertolli 1995: C).
actinomycin D then:
Draw around area of extravasation
with indelible pen
Put on gloves.
Apply thin layer of 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.
Where possible elevate the extremity To minimize swelling and to prevent
and/or encourage movement. adhesion of damaged area to underlying
tissue, which could result in restriction of
movement (Rudolph & Larson 1987: E).
Inform a member of the medical staff at To enable actions differing from agreed
the earliest opportunity and administer policy to be taken if considered in the
any other prescribed antidotes, e.g. best interests of the patient. To notify the
dexrazoxane. doctor of the need to prescribe any other
drugs (E).
Apply hydrocortisone cream 1% twice To reduce local inflammation and
daily, and instruct the patient how to do promote patient comfort (Stanley 2002:
this. Continue as long as erythema E).
persists.
Where appropriate, apply DMSO every 2 To help reduce local tissue damage
hours on day 1 and then every 6 hours (Bertolli 1995: C).
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).

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Heat packs (group A drugs) should be To localize the steroid effect in the area
reapplied after initial management for 2–4 of extravasation. To reduce local pain
hours. Cold packs (group B drugs) should and promote patient comfort (Bertolli
be applied for 15–20 minutes, 3–4 times 1995: C).
a day for up to 3 days.
Provide analgesia as required. To promote patient comfort. To
encourage movement of the limb as
advised (E).
Document the following details, in
duplicate, on the form provided:
a) Patient's name/number.
b) Ward/unit.
c) Date, time.
d) Signs and symptoms.
e) Venepuncture 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 To provide an immediate full record of all
and time of each step performed and details of the incident, which may be
medical officer notification. referred to if necessary.
To provide a baseline for future
observation and monitoring of patient's
condition. To comply with NMC
guidelines (Kassner 2000: E; NMC 2005:
C; RCN 2005: C; Weinstein 2007: E).
l) Patient's complaints, comments,
statements.
m) Indication that patient's information
sheet given to patient.
n) Follow-up section.
o) Whether photograph was taken.
p) If required, when patient referred to
plastic surgeon.
q) Signature of the nurse.
Explain to the patient that the site may To reduce anxiety and ensure continued
remain sore for several days. co-operation (P: E).
Observe the area regularly for erythema, To detect any changes at the earliest
induration, blistering or necrosis. possible moment (RCN 2005: C).
Inpatients: monitor daily. Where
appropriate, take photograph.

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All patients should receive written To detect any changes as early as
information explaining what has occurred, possible, and allow for a review of future
what management has been carried out, management. This may include referral to
what they need to look for at the site and a plastic surgeon (Gault & Challands
when to report any changes. For 1997: E; Polovich et al. 2005: C; RCN
example, increased discomfort, peeling 2005: C).
or blistering of the skin should be
reported immediately.
If blistering or tissue breakdown occurs, To minimize the risk of a superimposed
begin dressing techniques and seek infection and sterile increase healing
advice regarding wound management. (Naylor 2005: E).
Depending on size of lesion, degree of To prevent further pain or other
pain, type of drug, refer to plastic complications as chemically induced
surgeon. ulcers rarely heal spontaneously
(Polovich et al. 2005: C; Dougherty 2005:
E).

Monitoring of the Guideline

Implementation of the guidance will be considered as a topic for audit by the NSSG in
and reviewed in.

Authors

Andrew Stanley Network Pharmacist

References

The Royal Marsden Hospital Manual of Clinical Nursing Procedures 7th Edition;
Blackwell Publishing (2008).

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Approval Signatures

Pan Birmingham Cancer Network Governance Committee Chair

Name: Doug Wullf

Signature Date July 2011

Pan Birmingham Cancer Network Manager

Name: Karen Metcalf

Signature Date July 2011

Network Site Specific Group Clinical Chair

Name: Frances Shaw

Signature Date July 2011

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