What medication is indicated for treating an IV infiltration of a vesicant or irritant drug?

Treatment of IV Infiltration/Extravasation

The medication given for IV infiltration depends entirely on which drug extravasated: use dexrazoxane for anthracyclines, hyaluronidase for vinca alkaloids and hyperosmotic agents, and sodium thiosulfate for mechlorethamine. 1

Drug-Specific Antidotes

Anthracycline Extravasation (Doxorubicin, Daunorubicin, Epirubicin, Idarubicin)

Dexrazoxane is the recommended antidote for anthracycline extravasation. 1

• Administer intravenously at 1000 mg/m² on days 1 and 2, then 500 mg/m² on day 3 1
• Must be started within 6 hours of extravasation for maximum efficacy 1
• Infuse in a large vein away from the extravasation site (opposite arm) 1
• In clinical trials of 54 patients, only 1.8% required surgical debridement when treated with dexrazoxane 1
• Remove ice packs 15 minutes before and during dexrazoxane administration (cold interferes with drug efficacy) 1
• Reduce dose by 50% if creatinine clearance <40 mL/min 1
• Do not use DMSO concurrently with dexrazoxane 1

Vinca Alkaloid Extravasation (Vincristine, Vinblastine, Vinorelbine)

Hyaluronidase is the recommended antidote for vinca alkaloid extravasation. 1

• Inject 1-6 mL of 150 U/mL solution through the existing IV line or subcutaneously around the extravasation site 1
• Standard dosing: 1 mL of hyaluronidase solution per 1 mL of extravasated drug 1
• In a study of 7 patients with vinca alkaloid extravasation, none developed skin necrosis after hyaluronidase treatment 1
• Hyaluronidase works by degrading hyaluronic acid, improving absorption and diffusion of the extravasated drug away from the injury site 1, 2

Mechlorethamine (Nitrogen Mustard) Extravasation

Sodium thiosulfate is the specific antidote for mechlorethamine extravasation. 1

• Inject 2 mL of 1/6 molar sodium thiosulfate solution subcutaneously for each milligram of mechlorethamine extravasated 1
• Prepare by mixing 4 mL of 10% sodium thiosulfate with 6 mL of sterile water for injection 1
• Must be administered immediately after extravasation by intradermal/subcutaneous injection (not IV) 1

Hyperosmotic Agent Extravasation (Calcium, Contrast Media, TPN)

Hyaluronidase is effective for hyperosmotic extravasations. 2, 3

• Use same dosing as for vinca alkaloids: 1-6 mL of 150 U/mL solution 1, 2
• Particularly useful for calcium extravasation, which can cause delayed tissue injury 3
• Reduces ulcer rate by 50-60% and ulcer size by up to 50% in animal models 2

General Management Measures (All Extravasations)

Immediate actions must be taken regardless of the specific drug involved: 1

1. Stop the infusion immediately but leave the cannula in place 1
2. Attempt to aspirate as much extravasated solution as possible through the existing IV line 1
3. Avoid applying manual pressure over the extravasated area (this spreads the drug further) 1
4. Elevate the affected limb 1
5. Apply dry cold compresses for 20 minutes, 4 times daily for 1-2 days (for most drugs except vinca alkaloids, which require warmth) 1
6. Administer analgesia as needed 1

Alternative Topical Treatment: DMSO

Topical DMSO 99% is an alternative treatment option for anthracyclines, mitomycin C, and platinum-based agents. 1

• Apply 4 drops per 10 cm² of affected skin surface 1
• Cover twice the area of extravasation 1
• Repeat every 8 hours for 7 days 1
• Allow to air dry without dressing 1
• In a series of 144 patients, only 1 developed ulceration when DMSO was applied within 10 minutes 1
• Do not use DMSO if dexrazoxane will be administered (contraindicated combination) 1

Treatments to AVOID

Subcutaneous corticosteroids are NOT recommended and may worsen outcomes. 1

• A retrospective series showed 46% of patients receiving intralesional corticoids required surgical debridement versus only 13% without corticoids 1
• Despite one small study showing benefit, larger data suggest deleterious effects 1

Surgical Intervention

Surgical debridement is reserved for unresolved tissue necrosis or pain lasting more than 10 days. 1

• Only one-third of extravasations progress to ulceration 1
• Procedure involves wide three-dimensional excision, temporary biologic dressing, and delayed split-thickness skin grafting at 2-3 days 1

Critical Pitfalls to Avoid

• Never apply ice packs before dexrazoxane administration (removes protective effect) 1
• Never use DMSO and dexrazoxane together (contraindicated) 1
• Never inject sodium thiosulfate intravenously for mechlorethamine (must be intradermal/subcutaneous) 1
• Never apply pressure to the extravasation site (spreads the vesicant) 1
• Never delay treatment (efficacy decreases rapidly with time) 1