Clinical procedure - extravasation management - vesicants using dimethyl sulfoxide solution

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

• from the extravasation kit: 
  • 10 mL syringes
  • 5 mL syringes
  • 20 mL dimethyl sulfoxide (DMSO) 99% topical solution
  • cotton buds/glass dropper/swab stick
  • disposable paper tape measure
  • permanent marker pen
• trolley cleaned with approved cleaning agent
• personal protective equipment (PPE)
• cold pack with waterproof cover
• medication chart
• equipment to disconnect CVAD if required
• cytotoxic waste bag, bin and sharps container
• spill kit
• camera

1. STOP the injection or intravenous infusion immediately.
2. Explain to the patient the intended procedure and obtain consent.
3. Perform hand hygiene
4. Put on personal protective equipment (PPE).
5. Set up equipment.
6. Disconnect intravenous infusion line(s).
7. LEAVE  the venous access device (VAD) in place.
8. ASPIRATE any residual drug from the VAD using a sterile syringe.
9. Notify medical staff, pharmacist and/or senior nurse of extravasation.
10. Assess the affected area
    1. mark the area of erythema and induration with a marker pen
    2. measure and photograph the area.
11. Remove cannula or needle
    1. avoid applying pressure to the area
    2. if the site is bleeding apply gentle pressure only.
12. For an extravasation from a CVAD refer to a medical officer for further instructions.
13. Assess the patient for presence of pain
    1. administer pain relief as prescribed if required.
14. DMSO 99% solution application: DMSO 99% solution should be applied as soon as possible after extravasation has occurred (ideally within 10 to 25 minutes)
    1. ensure the skin is dry before applying DMSO 99% solution (if skin is wet or DMSO 99% solution is applied with wet gloves, it will cause the skin to blister)
    2. apply a thin layer of DMSO 99% solution topically to the area of extravasation (use sparingly):
       1. using a cotton bud or swab stick that has been soaked in DMSO 99% solution; or
       2. a glass dropper (4 drops of DMSO 99% solution per 10 cm² of affected area)
    3. Allow to air dry; do not cover with a dressing.
15. Cold compress application:
    1. cover a cold pack with a waterproof covering and place over the affected area
    2. leave for 15 to 20 minutes (no moisture should come in contact with the patient's skin)
    3. NOTE: If there is a delay in obtaining the DMSO 99% solution, the cold pack may be applied prior to the DMSO 99% solution.
16. Consider elevating the affected limb if it provides comfort to the patient, otherwise encourage patient to use limb normally.
17. Dispose of all hazardous waste as per institutional guidelines.
18. Remove PPE.
19. Perform hand hygiene
20. Document details of the extravasation in the patient notes including:
    1. drug extravasated, approximate dose and volume
    2. the position and size of the injury
    3. amount and type of exudate
    4. presence of swelling or oedema
    5. extent and spread of erythema
    6. presence of pain and analgesia administered
    7. management steps taken
    8. education given to patient.

Link to antineoplastic drug extravasation assessment tool

21. Complete incident form as per institutional guidelines.
22. Educate and provide written information to patient on extravasation – see patient education section below.

Post procedure care

• Apply DMSO 99% solution every 6 hours for a minimum of 7 days or as per medical officer's orders.
• Apply a cold compress for 15 to 20 minutes every 6 hours for 48 hours (no moisture should come into contact with the patient’s skin).

Referral

There are no uniform guidelines in the literature on the surgical management of extravasation injuries, including guidelines on the optimal timeframe for referral to a plastic surgeon.

With most patients conservative management (including “watch and wait”, the use of pharmacological measures and the application of topical cooling) is sufficient. However in cases where conservative measures fail or functional damage is suspected, surgical intervention may be required.

Clinical assessment of the individual case is paramount in determining if surgical review is necessary. Referral to a plastic surgeon or other specialist surgeon (according to individual case and site of extravasation) is recommended for:

• vesicant extravasation at the discretion of the medical officer
• extravasation that involves a fractured or displaced CVAD
• in the event that the patient develops pain or the area is not healing
• large volume extravasation (the volume which constitutes a large extravasation is undefined in the literature and clinical judgement must be used).

Follow up care

• The patient is to monitor the affected area daily for any skin changes or breakdown, and to notify medical team immediately if any changes.
• Careful monitoring by a healthcare professional is recommended; the length of monitoring should be at the advice of the medical officer, and will depend on the cytotoxic drug extravasated and the clinical course of the injury.
• It is important to note that early vesicant extravasation signs or symptoms can be subtle, and not always evident until several days or weeks later. Regular patient review is recommended, consider daily or second daily review for the first week, and then weekly until complete resolution of symptoms.
• Patients should be informed about the follow-up policy before leaving the treatment area
• Obtain photographs at follow up appointments.
• Community nurse or GP referral may be required for follow up care.

Link to antineoplastic drug extrvasation assessment tool

In the event of an extravasation injury, educate the patient and provide written information on:

• what an extravasation is
• what treatment has already been given
• the safe application of cold packs and DMSO 99% solution
• safe storage of DMSO 99% solution
• measures for general management and reducing further damage:
  • do not rub or scratch the area
  • do not wear tight clothing on area
  • protect the area from sunlight
  • raise the affected arm on a pillow if it provides comfort
  • move/exercise the affected arm gently
  • do not use creams or lotions on affected area without speaking with your doctor or nurse
• the equipment required to care for the injury
• how to check the affected area daily and report any skin changes or increase in pain
• how to monitor temperature and seek urgent medical attention if temperature 38°C or higher
• contact numbers for during and after hours
• when to contact clinic or present to emergency
• dates and times of follow up appointments
• the importance of follow-up.

Access the patient information sheets - care at home after an extravasation injury - cold or warm compress, or care at home after an extravasation injury - DMSO and cold compress.

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