What to do in case of chemotherapy extravasation?

Management of Chemotherapy Extravasation

Immediate management of chemotherapy extravasation requires stopping the infusion, attempting to aspirate residual drug, applying appropriate thermal compresses, administering specific antidotes based on the extravasated agent, and documenting the incident thoroughly. 1, 2

Immediate Steps for Peripheral Extravasation

1. Stop the infusion immediately when extravasation is suspected
2. Leave the IV catheter in place initially
3. Attempt to aspirate any residual drug from the IV line and surrounding tissue
4. Remove the IV catheter after aspiration attempt
5. Apply thermal compresses based on drug type:
   • Cold compresses: For anthracyclines, mitomycin C, and most vesicants (20-30 minutes, 4 times daily for 24-48 hours)
   • Warm compresses: For vinca alkaloids, epipodophyllotoxins, and taxanes

Drug-Specific Antidotes

• Anthracyclines (doxorubicin, daunorubicin, epirubicin):

  • Dexrazoxane IV: 1000 mg/m² within 6 hours of extravasation, then 1000 mg/m² at 24 hours, and 500 mg/m² at 48 hours
  • Reduce dose to 50% if creatinine clearance <40 ml/min 2
  • DMSO topical application may also be used 3

• Vinca Alkaloids (vincristine, vinblastine):

  • Hyaluronidase: 1-6 ml of 150 U/ml solution (typically 1 ml per 1 ml of extravasated drug) 1, 2

• Nitrogen Mustard:

  • Sodium thiosulfate 3

Central Venous Access Device (CVAD) Extravasation

1. Stop infusion immediately
2. Leave the central line in place
3. Attempt to aspirate as much solution as possible
4. Obtain thoracic imaging (preferably CT scan) to confirm diagnosis 1, 2
5. Consider specific treatments:
   • If anthracycline extravasation: administer dexrazoxane
   • Consider antibiotics, IV corticosteroids, and analgesia for symptoms of mediastinitis/pleuritis
   • Surgical drainage may be considered in selected cases 1

Documentation Requirements

Each extravasation incident must be documented with:

1. Patient identification
2. Date and time of extravasation
3. Name of drug and diluent used
4. Signs and symptoms reported by patient
5. Description of the IV access
6. Extravasation area and approximate amount of infiltrated solution
7. Management steps with time and date 1, 2

Photographic documentation is strongly recommended for follow-up and legal purposes.

Follow-up Care

• Regular assessment: Daily or every 2 days during the first week, then weekly until complete resolution 1
• Monitor for: Progressive inflammation, redness, edema, pain, blistering, and potential necrosis
• Surgical consultation: Consider for unresolved tissue necrosis or pain lasting more than 10 days 1, 2
• Surgical intervention: Wide excision of all involved tissue may be necessary for severe cases, with temporary biologic dressing and delayed skin grafting 1

Prevention Strategies

• Use central venous access for high-concentration vesicant medications when possible
• Ensure proper IV site selection (avoid joints, previous venipuncture sites, limbs with compromised circulation)
• Verify blood return before and during vesicant administration
• Engage patients in prevention by instructing them to report any pain or burning during infusion 4

Common Pitfalls to Avoid

• Delayed recognition: Early signs of extravasation may be subtle - maintain high vigilance
• Applying pressure to the extravasation site, which can worsen tissue damage
• Delaying antidote administration: Specific antidotes should be administered promptly, especially dexrazoxane for anthracyclines (within 6 hours)
• Inadequate follow-up: Tissue damage may develop or worsen days to weeks after the initial extravasation 1, 2

Remember that proper management of chemotherapy extravasation is critical for preventing long-term tissue damage, preserving function, and maintaining quality of life for patients receiving chemotherapy.