Extravasation of Nonchemotherapy Vesicants...administer short-or long-term continuous or intermittent infusion solutions such as antineoplastic medications, vesicants or known irritants,

LEAD Leadership, Education, Accountability, Development

Extravasation of Nonchemotherapy Vesicants

Session Code: 402 Contact Hours: 0.8 CRNI Units: 1

Dora Hallock, RN, MSN, CRNI, OCN, CHPN Clinical Nurse Specialist

Cancer Center of Excellence UMass Memorial Medical Center


Disclosures

•  Nothing to disclose


Objectives

•  Identify measures to prevent extravasation through peripheral and central venous delivery.

•  Discuss early recognition and treatment of common nonchemotherapy vesicants.


Definitions •  Extravasation – The inadvertent

infiltration of vesicant solution or medication into surrounding tissue.

•  Vesicant – An agent capable of causing blistering, tissue sloughing, or necrosis when it escapes from the intended vascular pathway into surrounding tissue.

»  Infusion Nursing Standards of Practice, 2011, S103, S110


•  Irritant – An agent capable of producing discomfort or pain along the internal lumen of the vein.

•  Infiltration – The inadvertent administration of a nonvesicant solution or medication into surrounding tissue.

»  Infusion Nursing Standards of Practice, 2011 S104


INS Standard •  The nurse should use CVADs to

administer short-or long-term continuous or intermittent infusion solutions such as antineoplastic medications, vesicants or known irritants, parenteral nutrition, a variety of antibiotics, and any medications with a pH of less than 5 or greater than 9 and osmolarity of greater than 600mOsm.L (V)

»  Infusion Nursing Standards of Practice, 2011 S38


Barriers to Evidence-based Practice

•  Rare occurrences •  No centralized reporting mechanism

– Reported rates vary from 0.01 – 6.5% •  Unethical to inject humans with vesicants

– Use of animal models •  Management of extravasations not

standardized – Highly variable and individualized


Factors Causing Tissue Damage

•  The ability to find directly to DNA – cytotoxic drugs

•  The ability to kill replicating cells – anti-viral and cytotoxic agents

•  An ability to cause tissue or vascular dilatation

•  The pH, osmolarity and excipience in the formulation of the drug


Osmolality

•  Plasma osmolarity – 290 mosmol/L •  Hypertonic solutions – cell implosion or

cell dehydration •  Hypotonic solutions – cell explosion or

cell fluid overload


Examples of Hyperosmolor Agents

•  Hypertonic glucose - >12.5% •  Hypertonic saline - >3% •  Potassium chloride •  Calcium chloride •  Sodium bicarbonate •  Parenteral nutrition •  X-ray contrast media •  Antibiotics •  Mannitol •  Lorazepam


pH •  pH of blood – 7.35-7.45 •  Acid and alkaline agents

– Thiopentone – 10.5 – Methohexitone – Phenytoin – 12 – Amphotericin – Methylene blue – Doxycycline – 1.8-3.3 – Gentamycin – Vancomycin – Phenergan – 4-5.5 (phenol)


Vascular Regulators •  Vasoconstrictors – ischemic necrosis •  Vasodilators – increasing local blood flow

and enlarging the area of injury •  Examples

– Adrenaline Dobutamine – Norepinephrine Vasopressin – Dopamine Epoprostenol – Prostaglandins

.


INS Position Paper

•  The nurse should advocate for central vascular access administration of vasoconstrictor agents whenever possible as these agents can cause severe tissue necrosis with extravasation.


Cell Toxicity

•  Continually released from dying to healthy cells

•  Doxorubicin shown to remain in tissue for 5 months after extravasation

•  Examples – Acyclovir – pH 10.4 – Azathioprine – Many antineoplastic agents


INS Standard •  The nurse shall select the appropriate type

of catheter (peripheral or central) to accommodate the patient’s vascular access needs based on the prescribed therapy or treatment regimen, length of treatment, duration of dwell, vascular integrity, patient preference, and ability and resources available to care for the device.

»  Infusion Nursing Standards of Practice, 2011 S 37


Central Lines and Vesicants

•  Use of central lines does not prevent extravasation! •  Benefits

–  Reliable venous access –  High flow rate –  Rapid drug dilution

•  Risks –  Tip improperly positioned –  Tip migration –  Needle improperly inserted –  Catheter punctured or rupture


Avoiding Extravasation •  Appropriate infusion device

–  Peripheral - appropriate nursing interventions during insertion

•  New site, No rigid IV devices •  Avoid pumps •  Smallest size to meet infusion needs

–  Central •  Required for continuous infusion

•  Appropriate location – site selection •  Adequate securement, stabilization

–  Dressing allow site visualization •  Effective assessment •  Patient/family education and involvement

–  Signs and symptoms of infiltration/extravasation


Patient Factors •  Altered mental status, sensory deficits •  Infants and children

–  Recommend “Reducing Risk of Harm From Extravasation” January/February 2013 Journal of Infusion Nursing, pp. 37-45

•  Elderly •  Body habitus

–  Veins •  Size •  Limited selection – lymphedema, limb removal •  Venipuncture site distal to earlier venipuncture •  Skin condition – eczema, psoriasis •  Previous therapy

–  Previous radiation therapy at site –  Significant metastatic disease –  Obesity or malnutrition

•  Movement


Assessment •  Per institutional policies •  INS Position Paper /ONS – Recommendations for

Frequency of Assessment of the Short Peripheral Catheter Site, 2012 –  Peripheral

•  Remain with patient •  Visually monitor site for signs of extravasation •  Verify blood return before, during, and after administration and

at least every 5-10 minutes (infusion) or 2-5 mL (push) •  Avoid infusing vesicant agents for more than 30-60 minutes

–  Central •  Verify placement •  Inspect exit site and ipsilateral chest •  Verify blood return before, during, and after administration •  At least every 2-5 mL (push)


Timing Makes a Difference

•  Early identification and intervention at the first sign of infiltration is a critical step.


Signs and Symptoms

•  Pain – burning or tingling •  Redness •  Swelling •  Pruritus •  Loss of blood return •  Resistance to injection


Initial Management •  Immediately STOP vesicant and IV fluids •  Elevate the affected extremity •  Disconnect IV tubing •  DO NOT remove IV device or noncoring port needle •  Attempt to aspirate residual vesicant using a 1-3 mL

syringe •  Notify provider •  Remove peripheral IV device or port needle if antidote

will not be injected. Avoid pressure to site •  Initiate appropriate management measures in

accordance with institutional policies –  Heat, cold - controversial


Central Line Extravasation

•  Utility of local antidotes is unclear and not recommended

•  CT scan of chest is often obtained – Catheter tip migration through the superior

vena cava or atrium is a surgical emergency and requires immediate operation


Antidotes

•  Controversial – Based on case reports and animal studies – Sodium bicarbonate – actually destroys

tissues – Steroids – no inflammatory response in

subcutaneous tissue •  Dexamethasone 8 mg twice daily for 14 days

recommended treatment for oxaliplatin, an irritant with vesicant properties


Recommended agents •  Phentolamaine (Regitine)

–  Indicated for extravasation of vasopressors •  Hyaluronidase

–  Protein enzyme that breaks down the cellular cement in the subcutaneous tissue

–  Indicated for osmotic, plant alkaloid, and irritant drug extravasation

•  Sodium thiosulfate – subcutaneous injection into site with 25 gauge or smaller needle –  chemotherapy

•  Totect (dexrazoxane) – FDA approved –  Indicated for anthracycline extravasation


Acute Compartment Syndrome

•  Gross extravasation even of normal saline, may result in serious harm including compartment syndrome, causing ischemia and loss of tissue or permanent loss of limb function.

•  Swelling and increased pressure within a compartment –  Damage to blood vessels, nerves, muscles, and

tendons •  Compromised capillary blood flow, increased venous

pressure, decreased arterial pressure, increased peripheral vascular resistance

–  Compartments within compartments in the hand •  Fasciotomy within 6 hours


Patient/Caregiver Teaching

•  Possible progression of signs and symptoms •  What to report to LIP

– Changes in limb mobility – Changes in sensation – Elevated temperature – Signs of infection

•  Protect site from sunlight •  Frequency of followup visits •  Information about needed consultation visits •  Evaluate patient/caregiver comprehension

ability to perform required actions


Documentation •  Date and time •  Type, size, type, gauge, length of vascular device •  Location and patency of venous access device •  Number and location(s) of venipuncture attempts if peripheral •  Description and quality of blood return before and during vesicant

administration •  Administration technique, concentration, estimated amount vesicant •  Symptoms reported by patient •  Detailed description of administration site appearance •  Photograph of administration site with include date and time •  Assessment of range of motion and discomfort with movement if

extremity •  Immediate nursing interventions – provider notification, heat, cool •  Follow-up recommendations – return appointments •  Patient teaching


In Summary-----

•  In order for the extravasated compound to do damage . . .it must move out from the initial site of extravasation.

•  Nurse who administer IV medication or fluid know its adverse effects and appropriate interventions to take before starting the infusion.


You Make a Difference

•  The role of nursing is to use appropriate nursing interventions during IV catheter insertion and early recognition and intervention upon the first signs and symptoms of infiltration and extravasation.


Thank You &

Questions

Documents

Extravasation of Nonchemotherapy Vesicants...administer short-or long-term continuous or intermittent infusion solutions such as antineoplastic medications, vesicants or known irritants,