Clinical procedure - extravasation management of intravenous anti-cancer therapies and contrast media

The following is a list of recommended equipment required to undertake this procedure:

• extravasation kit
• trolley cleaned with approved cleaning agent
• personal protective equipment (PPE)
• cold/warm pack with waterproof cover
• medication orders
• equipment to disconnect CVAD if required
• cytotoxic waste bag, bin and sharps container
• cytotoxic spill kit
• imaging device e.g. camera, or electronic device linked to electronic medical record.

Primary actions (SLAP):

1. Perform hand hygiene
2. STOP the injection or intravenous infusion immediately and SEND for help:
   • notify team member and ask for assistance to inform senior nursing staff, treating medical team and pharmacist
   • collect equipment
3. Put on personal protective equipment (PPE)
4. Disconnect intravenous infusion line/s and discard appropriately. Note the amount of solution administered.
5. LEAVE the venous access device (VAD) in place
6. ASPIRATE any residual drug from the VAD using a sterile syringe. Do not flush.
7. PLAN actions.

Secondary actions:

8. Explain event and actions required to the patient and obtain consent
9. Assess and grade the affected area using a standardised tool including skin colour, skin temperature, integrity, oedema, mobility, pain and systemic temperature. 

Vascular Access Device (VAD) management

10. Appropriate management according to type of VAD

Peripheral intravenous cannula (PIVC)

• remove PIVC
• avoid applying pressure to the area
• if the site is bleeding, apply gentle pressure only until haemostasis obtained.

Central venous access device (CVAD)

• leave non-coring needle (totally implantable venous access device or TIVAD) or catheter in situ
• discuss plan to assess CVAD with the treating medical team e.g. radiological flow studies in interventional radiology.

11. Outline the affected area with a marker pen
12. Measure and photograph for the medical history
13. Assess the patient for pain and administer pain relief as prescribed (if required).

Conservative management:

Antidotes and topical thermal applications for:

14. DNA-binding vesicant

• e.g. amsacrine, dactinomycin (actinomycin D), daunorubicin, doxorubicin, epirubicin, idarubicin and mitomycin

DMSO 99% solution (DMSO) application:

1. apply as soon as possible - ideally within 10 to 25 minutes

• ensure the skin is dry before applying DMSO
• apply a thin layer of DMSO topically to cover the total area of extravasation (use sparingly):
  • using a cotton bud or swab stick that has been soaked in DMSO; or
  • a glass dropper (4 drops of DMSO per 10 cm² of affected area)
• allow to air dry; do not cover with a dressing.

Cold compress application:

NOTE: If there is a delay in obtaining the DMSO 99% solution, the cold pack may be applied prior.

2. cover cold pack with a waterproof covering to prevent moisture contacting patient's skin
3. place over affected area for 15 to 20 minutes.

Alternatively, dexrazoxane (e.g. Totect^®, Savene^®) may be used to manage anthracycline extravasation:

1. considerations:

• dexrazoxane is a cytotoxic drug - may cause additional myelosuppression
• consider 50% dose reduction for patients with kidney dysfunction (eGFR less than 40 mL/min)
• not for use with paediatric patients
• not for use with DMSO as it may decrease efficacy of dexrazoxane
• is not registered for use in Australia, but is available via Special Access Scheme (SAS)
• refer to institutional guidelines for obtaining and administration procedures
• for further information regarding safety issues with DMSO 99% solution see the Material Safety Data Sheet.

2. administration:

• administer within 6 hours of extravasation
• administer via a newly inserted PIVC, not near the affected area
• dose based on patient's body surface area
• infuse each dose over 1 to 2 hours
• Day 1: 1000 mg/m² intravenously (IV) (max dose of 2000 mg)
• Day 2: 1000 mg/m² IV (max dose of 2000 mg), 24 hours +/-3 hours after Day 1
• Day 3: 500 mg/m² IV (max dose of 1000 mg), 48 hours +/- 3 hours after Day 1

15. Non-DNA binding vesicant

• vinca alkaloids e.g. vincristine, vinblastine, vindesine, vinflunine or vinorelbine

Hyaluronidase:

• assess and provide analgesia prior to and during hyaluronidase administration as required.

Hyaluronidase administration:

1. commence as soon as possible (ideally within 1 hour of extravasation)
2. reconstitute hyaluronidase 1500 International Units in 2 to 5 mL (depending on size of extravasation) sterile water for injection or sodium chloride 0.9%
3. administer hyaluronidase 1500 International Units subcutaneously in 0.2 to 0.4 mL volumes around the area of injury using the "pin cushion" technique:​

• mark the circumference of the area using an imaginary "clock face"
• start at "12 o'clock" and inject the prepared hyaluronidase at "2 hourly intervals" as per institutional policy
• gently massage area to facilitate the dispersal of the drug
• STOP the procedure and administer further pain relief as required.

Warm compress application:

4. cover warm pack with a waterproof covering
5. place over affected area for 15 to 20 minutes 

16. Irritant with vesicant properties 

Cold compress:

• e.g. bendamustine, docetaxel, liposomal doxorubicin, melphalan, mitozantrone,  paclitaxel or nab-paclitaxel, cisplatin > 0.5 mg /mL

1. cover cold pack with a waterproof covering
2. place over affected area for 15 to 20 minutes
3. reapply every 6 hours for 48 hours.

Warm compress:

• e.g. oxaliplatin

1. cover warm pack with a waterproof covering
2. place over affected area for 15 to 20 minutes
3. reapply every 6 hours for 48 hours.

Hyaluronidase:

• consider use with taxane extravasations e.g. paclitaxel, docetaxel
• if used for taxane extravasation, no compress is recommended
• see step 15 above for hyaluronidase administration.

17. Irritant

Cold compress:

• e.g. gemcitabine, cabazitaxel, carboplatin, fluorouracil, irinotecan

1. cover cold pack with a waterproof covering
2. place over affected area for 15 to 20 minutes.

Warm compress:

• e.g. etoposide, etoposide phosphate

1. cover warm pack with a waterproof covering
2. place over affected area for 15 to 20 minutes.

18. Consider elevating the affected arm if it provides comfort to the patient, otherwise encourage patient to use limb normally.
19. Remove PPE.
20. Perform hand hygiene
21. Dispose of all hazardous waste as per institutional guidelines.
22. Document extravasation in the medical record including:

• drug/solution, dose and volume, date and time
• assessment findings including position and size of the injury
• interventions including analgesia required
• patient response
• patient education
• post-acute management planning.

23. Complete incident report as per local policy.

Surgical management:

24. Refer to specialist services (e.g. surgical, plastics, wound specialist) if required for assessment and management as per individual patient and injury. Factors to be considered include:

• vesicant extravasation
• extravasation that involves a damaged CVAD
• patient develops pain or delayed healing
• large volume extravasation.

This may be at the time of the initial injury or during the clinical course of the injury.

Replace extravasation kits items including drugs from pharmacy if required.

Continue treatments as prescribed:

DNA-binding vesicant:

• apply DMSO 99% solution every 6 hours for a minimum of 7 days
• apply a cold compress (with a waterproof covering) for 15 to 20 minutes, every 6 hours, for 48 hours.

Non-DNA binding vesicant

• apply warm pack (with a waterproof covering) over the affected area for 15 - 20 minutes, every 6 hours, for 48 hours.

Contrast media

• apply cold or warm compress (with a waterproof covering) over the affected area for 15 - 20 minutes, every 6 hours, for 48 hours.

Irritant with vesicant properties:

• apply a cold or warm pack (according to the drug; refer to step 16) for 15 to 20 minutes, every 6 hours, for 48 hours.

Irritant:

• apply a cold or warm pack (according to the drug; refer to step 17) for 15 to 20 minutes every 6 hours for 48 hours.

Inpatient:

• assess injury at least once per shift
• notify medical team of any changes
• notify medical team immediately of any signs/ symptoms of infection.

Patient at home:

• patient to assess affected area at least daily for any skin changes or breakdown until extravasation management is complete
• regular assessment by healthcare team (dependent on severity of injury, response to treatment). This may include the patient sending images to healthcare team.
• notify medical team with any changes
• notify medical team immediately or attend emergency department with any signs/ symptoms of increased severity or extension of injury, or complications e.g. infection
• provide verbal and written information.

Subsequent review/ appointments:

• obtain photographs for the patients’ medical history to track progress of injury
• regular review of pain management (as required)
• consider referral to community nurse or GP referral (if appropriate).

Note: early vesicant extravasation signs or symptoms may be subtle, and not always evident until days or weeks late. Regular patient review is recommended; consider daily or second daily review for the first week, and then weekly until complete resolution of injury.

Provide verbal and written education for the patient, family/carer including:

• What is an extravasation injury?
• Treatment given and ongoing treatment required including safe storage of DMSO 99% solution (if used).
• Regular assessment: at least daily assessment of affected area or more frequently if indicated (at home).
• How and when to report:
  • if any of the following occur: an increase in injury size or severity, any new symptoms, pain, signs or symptoms of infection (including temperature > 38 ^oC). Contact treating medical team immediately or attend nearest emergency department (ED) if after hours.
  • any other changes: contact treating medical team as soon as practical in working hours. If out of hours, this may require assessment at the nearest hospital ED
• Provide contact numbers for during and after hours.
• Strategies to reduce risk of further damage:
  • avoid rubbing or scratching affected area
  • avoid wearing tight clothing over affected area
  • protect from sunlight
  • avoid use of creams or lotions on affected area without speaking with doctor or nurse.
• Raise affected arm on a pillow if it provides comfort.
• Encourage the patient to continue use of and exercise for affected arm.
• Equipment required to care for the injury.
• Dates and times of follow up appointments.

Refer to patient information sheets Care at home after an extravasation injury: cold or warm pack and Care at home after an extravasation injury: DMSO and cold pack for written information.

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Version 2

History related to ID 1108 - Clinical procedure - management of extravasation during intravenous (IV) contrast administration for radiation therapy simulation scans:

Version 1