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Extravasation

Extravasation. Extravasation Is…. Infiltration, tissuing , displacement……………….. - at the end of the day they are all the same injury

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Extravasation

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  1. Extravasation

  2. Extravasation Is…. • Infiltration, tissuing, displacement……………….. - at the end of the day they are all the same injury • The inadvertent administration of a cytotoxic drug, targeted therapy or iodinated contrast agent into the surrounding tissues, rather than into the vascular pathway as intended. • Vesicant extravasation is an oncological / parenteral therapy emergency.

  3. If we don’t take them seriously

  4. Late PresentationVinorelbine Extravasation..

  5. Anthracycline Extravasation (? Incomplete washout ? )9 weeks after the event

  6. Day 1 Day 7 Day 30

  7. Often Difficult to Diagnose • Extravasation? • Flare reaction?

  8. Flare reaction • Flare reaction – red streak, flushing along the vein • Caused by an inflammatory response • Does not cause pain, although does cause ‘itching’ • Usually the area is red and ‘blotchy’ (like nettle rash) • Occurs in 3 – 6% of patients • Often associated with Doxorubicin • Responds to topical steroids • Usually resolves in over 85% of patients within 45 minutes

  9. Recognising an extravasation 1. Visual assessment Initial Redness/erythema Swelling/oedema Later Inflammation Induration Exfoliation Blistering 2. Patient reporting Pain, discomfort Burning, stinging 3. The infusion – warning signs! The device alarms! Increased resistance when administering drugs – BACK FLOW Infusion becomes slow or sluggish Schulmeister 2011, Doherty 2010

  10. The Nature of Extravasation Injuries Has Changed • The most important development in the prevention and management of extravasation is ‘the Chemotherapy Trained nurse’. • This has led to earlier detection of smaller volume extravasations, and a greater appreciation of the hazard and nature of the risk. • This has diminished the potential consequences of the injury and altered the intervention / observation dynamic. • The average volume of drug extravasated in 1985 was 11.6mls, in 1995 - 7.2mls and in 2005 - 3.1mls (www.extravasation.org.uk)

  11. Extravasation Rate • Statistics show that extravasations occur in 0.5% - 6.5% of cytotoxic administrations (Albanell and Baselga 2000) • Between 0.5% - 6% of cytotoxic drug administrations will result in an extravasation. (Dougherty and Oakley 2011)

  12. How quickly should a vesicant extravasation be washed out? • Ideally within 6 hours (Giunta 2004)

  13. Surgical Intervention – The ‘Saline Wash Out Technique’ Gault 1993

  14. Documentation!!! • Need a complete history of the extravasation event with diagrams and photographs in the patient’s notes, including the planned follow-up for the patient. • Follow up – what was the outcome?! • PHOTOGRAPHIC EVIDENCE

  15. Alternative to SWOT? Antidotes…… Anthracyclines Topical DMSO, corticosteroids Mechlorethamine and Bendamustine Sodium Thiosulphate (injected locally) Vinca-Alkaloids Hyaluronidase (inj localy) Taxanes Hyaluronidase Schulmeister 2011, Doherty 2010, EONS 2007

  16. Dexrasoxane (Savene) • Only antidote licensed for anthracycline extravasation • Given as a peripheral infusion within 6 hours of extravasation, then again at day 2 and 3. • The anthracycline (full dose) then has to be re given at day 4. • Cost– around £6,000 per treatment ‘package’.

  17. How can we help to minimize the risk of extravasation? • Do not site cannula in ACF or over bony prominences • Avoid multiple venepuncture! • Avoid small fragile veins! • Always cannulate distal to previous cannulation • Take time when cannulating (view the whole arm!) • Use a cannula placed specifically for purpose • Vesicant first (if possible) • Use a heat pad during administration • Refer for a CVC before problems arise!!

  18. Litigation? • £22.5k compensation - woman left scarred after chemotherapy drugs leaked from a port catheter site during treatment for breast cancer

  19. Remember • Extravasation is just one hazard of IV chemotherapy – not directly life threatening, but certainly has one of the most serious long term consequences.

  20. References.. National Extravasation Service www.extravasation.org.uk (2007) Dougherty Extravasation: Prevention, recognition and Management Nursing Standard (2010) Vol 24, no 52, p 48-55 European Oncology Nursing Society (EONS) Extravasation Guidelines Implementation Toolkit (2007) http://www.cancernurse.eu/documents/EONSClinicalGuidelinesSection6-en.pdf Gault D T Extravasation Injuries British Journal of Plastic Surgery (1993) Vol: 46, no 2, p 91 – 96 Schulmeister L Extravasation Management: Clinical Update Seminars in Oncology Nursing (2011) Vol 27, no1, p 82 – 90 Giunta R Early sub cutaneous washout in acute extravasations Ann Onc (2004) 15, p1146

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