Clinical procedure - extravasation management - vesicants using hyaluronidase

The administration of subcutaneous hyaluronidase is a painful procedure. Ensure that the patient receives adequate pain relief as per medical officer's orders prior to commencing this procedure.

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

• from the extravasation kit: 
  • 10 mL syringes
  • 5 mL syringes
  • blunt drawing up needles
  • 25 or 27 gauge needles
  • hyaluronidase 1500 International Units
  • 5 mL to 10 mL sterile water for injection or sodium chloride 0.9% x 4
  • gauze squares
  • warm compress
  • disposable paper tape measure
  • permanent marker pen
• trolley cleaned with approved cleaning agent
• personal protective equipment (PPE)
• protective cloth or gauze covering
• 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 through 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. Hyaluronidase administration:
    1. reconstitute hyaluronidase 1500 IU in 2 to 5 mL (depending on size of extravasation) of sterile water for injection or sodium chloride 0.9%
    2. administer hyaluronidase 1500 IU subcutaneously in 0.2 to 0.4 mL volumes around the area of injury using the "pin cushion" technique:
       1. mark the circumference of the area using an imaginary "clock face"
       2. start at "12 o'clock" and inject the antidote at "2 hourly intervals" as per institutional policy
    3. gently massage area to facilitate the dispersal of the drug
    4. if patient complains of pain, STOP the procedure and administer further pain relief as per medical officer's orders.
15. Warm compress application (not recommended for paclitaxel extravasations):
    1. cover a warm 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).
16. Consider elevating the affected limb if it provides comfort to the patient; otherwise encourage patient to use the 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 patients notes including:
    1. drug extravasated, approximate dose and volume
    2. the position and size of 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. Education and provide written information to patient an extravasation – see patient education section below.

Post procedure care

• Apply a warm pack (with a waterproof covering) over the affected area for 15 to 20 minutes every 6 hours for 48 hours (no moisture should come in contact with the patients skin).
• Refer to your local institutional guidelines on using warm packs.

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 heating or 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 extravasations at discretion of medical officer
• extravasations that involve a fractured or displaced CVAD
• in the event that the patient develops pain or the area is not healing
• large volume extravasations (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 extravasation 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 warm packs 
• 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.

Version 4