E xtravasation of Chemotherapeutic Agents

1. Extravasation of Chemotherapeutic Agents PREPARED BY: UMMU HABIBAH MUKHTAR PRECEPTOR: MS GIAM WEI LI

3. Is it an Infiltration or an Extravasation ?? Is it a Vesicant or an Irritant ??

4. DEFINITIONS • INFILTRATION - inadvertent administration of “nonvesicant” medication or solution into the surrounding tissue. • EXTRAVASATION inadvertent administration of “vesicant” medication or solution into the surrounding tissue.

7. Examples of vesicant drugs • Actinomycin D • Amsacrine • Bisantrene • Daunorubicin • Doxorubicin • Epirubicine • Idarubicin • Mechlorethamine • Mitomycin C • Vinblastine • Vincristine • Vindesine • Vinorelbine

9. Irritant drugs • Bleomycine • Carboplatin • Cyclophosphamide • Carmustine • Gemcitabine • Ifosfamide • Irinotecan • Melphalan • Pentostatin • Plicamycin • Streptozocin • Topotecan

11. Recognizing an Extravasation • Pain at the site • Pain usually burning or stinging • Inability to flush IV catheter • Fluid leakage • Feeling of tightness • Swelling • Tenderness • Absent blood return

12. Figure 1. Untreated Doxorubicin Extravasation (A) Three days after extravasation. (B) Same patient, 10 months postextravasation, after surgical debridement of the affected tissue

13. Treatment

14. 2 Approaches….. • EITHER “Spread and Dilute” using: • Hyaluronidase • Warm, continuous compression • OR “Localize and Neutralize using: • • Antidote if available • • Intermittent cold compression

15. Antidote

16. Surgical (skin grafting) • Indicated • if lesion >2cm • Minimal healing 2-3 weeks after injury despite local therapeutic measure • Large extravasation from CVAD

17. Monitoring the Site Location of the Device PREVENTION Patients at Risk Method of Administration Types of Devices Sequence of the drug Patient Information

18. 1- monitoring the site • Confirming venous patency • Forearm (preferrable) • Avoid limbs with impaired circulation • Avoid antecubitalfossa – risk of damage to local structure 2- Location of the devices

19. 3- Patient at risk • unable to communicate • chronic diseases • on medications: steroids.

20. 4- types of devices • Vesicants give via a newly established cannula • changing the cannula site after 24 hours • if peripheral access is difficult, CVAD is prefferable 5- sequence of the drug • Vesicants should be given first

21. 6- Method of Administration • given as a slow bolus injection • e.g. vincristine must be given intravenously • repeated infusions – CVAD or PICC (preferrable)

22. 7- patient information • Inform potential problem and consequence of extravasation

23. Conclusion The proper maintenance of intravenous lines, application of local cooling or warming for certain extravasations, and the use of antidotes to prevent the local toxic action of the extravasated drugs are the basis of medical management.

24. Reference 1.Lacy, C. A. (2009). Drug Information Handbook 18th edition.Lexi- Comp Inc. 2.Polovich, M. Whitford, J.M. & Olsen, M. (Eds.). (2009). Chemotherapy and biotherapy guidelines and recommendations for practice. Pittsburgh, PA: Oncology Nursing Society. 3.R. A. Ener, S. B. (2004). Extravasation of systemic hemato oncological therapies. Annals of Oncology 15 , 858–862. 4.Schulmeister, L. (2010). Preventing and Managing Vesicant Extravasations. Journal of Supportive Oncology , 212-215. 5.Administering (Non-vesicant) Chemotherapeutic Agents By Intravenous (Iv) Push by Sarasota Memorial Hospital Nursing Procedure

25. adebamowo.com/Documents/Cancer%20Chemotherapy.pdf • http://www.scottbrownent.com/sample-chapters/Chapter%204%20Mechanisms%20of%20anticancer%20drugs.pdf • Drug Delivery in Oncology: From Basic Research to Cancer Therapy, First Edition. http://www.wiley-vch.de/books/sample/3527328238_c01.pdf • Per St. Louis Children’s Hospital Guideline • Guideline for the Management of Extravasation