- Irritants cause a short-lived and self-limited phlebitis and tender, warm, erythematous reaction along the vein or at the site of intravenous administration.
- A variant of this local irritation is an erythematous and urticarial hypersensitivity “flare reaction” that has been associated with the anthracyclines (Daunorubicin, doxorubicin, and epirubicin).
- Chemical cellulitis which initially presents in a similar way to irritation but may worsen, depending on the amount of drug that has extravasated. The erythema associated with small-volume extravastions will usually resolve over a few weeks. Chemical cellulitis is rare with fluorouracil and less severe with vinblastine and vincristine.
- Necrosis--Large-volume extravasations may induce necrosis within a matter of days. Eschars generally follow with subsequent development of painful ulcerations with red, raised edges. It has been estimated that about one-third of all vesicant extravasations will develop into ulcerations. (photo credit)
- Extravasation recall reaction--This is a reaction at a previous extravasation site that happens when there is an extravasation at a new site. This reaction can range from erythema to ulcerations. It has been seen with Paclitaxel.
Vigilance in the proper and timely recognition and management of extravasation plays a major role in limiting tissue injury. When extravasation is suspected:
- Prompt discontinuation of the infusion is recommended
- Aspirate any residual drug and removal of the catheter.
- Apply local cold application--Intermittent local cooling (for 20 minutes QID x 3 days) alone has an 89.1% success rate in preventing ulceration. For the vinca alkaloids, heat application (apply heat packs for 20 minutes QID x 3 days) is recommended instead, as cold application may actually induce ulceration.
- Elevate the affected extremity
- On September 6, 2007, the U.S. Food and Drug Administration approved dexrazoxane hydrochloride for injection (Totect™ made by TopoTarget USA, Inc.), equivalent to 500 mg dexrazoxane, for the treatment of extravasation resulting from IV anthracycline chemotherapy. The first dexrazoxane hydrochloride dose should be given as soon as possible and within six hours following extravasation. After the first dose, treatment is repeated 24 and 48 hours later for a total of three doses. Dexrazoxane hydrochloride is administered as a 1-2 hour IV infusion through a different venous access location.
- Sodium thiosulfate has been recommended for mechlorethamine. Use 4ml 10% sodium thiosulfate + 6ml water and instill via multiple injections in and around the area of extravasation (ie. SQ/ID) using a small gauge needle (eg. 25g).
- Hyaluronidase had been recommended for vinca alkaloids (Vincristine, Vinblastine, and Vinorelbine). Use 150U (1ml) and instill via multiple injections in and around the area of extravasation (ie. SQ/ID) using a small gauge needle (eg. 25g).
- Locally injected corticosteroids --the results have been variable. As few inflammatory cells are involved in extravasation reactions, these reactions may not be inflammatory and would not, hypothetically, benefit from locally injected corticosteroids.
- Locally injected granulocyte macrophage colony-stimulating factor (GM-CSF) has been used to promote healing of doxorubicin ulcerations. It needs more study.
- Pyridoxine has been used to treat mitomycin extravasation, This also needs further study.
- Locally injected saline alone has proven successful in resolving extravasation reactions and preventing ulceration.
- The use of a central venous catheter (CVC) or port is recommended for continuous infusion therapies. However, the use of CVC administration does not prevent extravasation injury, since devices may be dislodged, or venous vessels may be perforated with potentially disastrous consequences, including mediastinitis. Thus, central extravasation should be considered in the differential in the presentation of fever, severe pleuritic pain, upper extremity and neck swelling, and a widened mediastinum.
- In the case of peripheral intravenous administration, the selection of sites should be in the order of forearm, dorsal hand, wrist, and antecubital fossae (inner elbow), on the basis of the presence of vital underlying structures. Optimally, vesicants should not be given in areas of recent administration, irradiation, or lymphedema. It is also wise to avoid sites, which are distal to a recent site of venipuncture, as leakage could occur at these sites.
Cancer Medicine e.5; by BC Decker Inc. First published 1981. Fifth Edition 2000
Preventing and Managing Peripheral Extravasation; Nursing, May 2004 by Hadaway, Lynn C
What is the appropriate management of tissue extravasation of antitumor agents?; Plastic and Reconstr Surg 75:397-402, 1985 ; Larson DL
Discussion - What is the appropriate management of tissue extravasation of antitumor agents?; Plastic and Reconstr Surg 75:403-405, 1985: Dorr RT