Primary actions (SLAP):
- Perform hand hygiene
- 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
- Put on personal protective equipment (PPE)
- Disconnect intravenous infusion line/s and discard appropriately. Note the amount of solution administered.
- LEAVE the venous access device (VAD) in place
- ASPIRATE any residual drug from the VAD using a sterile syringe. Do not flush.
- PLAN actions.
Secondary actions:
- Explain event and actions required to the patient and obtain consent
- 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
- 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.
- Outline the affected area with a marker pen
- Measure and photograph for the medical history
- Assess the patient for pain and administer pain relief as prescribed (if required).
Conservative management:
Antidotes and topical thermal applications for:
VESICANT |
DNA-binding - refer to step 14 |
Non-DNA binding - refer to step 15 |
Contrast media - refer to cold or warm compress applications in step 16 |
IRRITANT WITH VESICANT PROPERTIES |
Refer to step 16 |
IRRITANT |
Refer to step 17 |
-
DNA-binding vesicant
- e.g. amsacrine, dactinomycin (actinomycin D), daunorubicin, doxorubicin, epirubicin, idarubicin and mitomycin
DMSO 99% solution (DMSO) application:
- 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.
- cover cold pack with a waterproof covering to prevent moisture contacting patient's skin
- place over affected area for 15 to 20 minutes.
Alternatively, dexrazoxane (e.g. Totect®, Savene®) may be used to manage anthracycline extravasation:
- 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.
- 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
-
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:
- commence as soon as possible (ideally within 1 hour of extravasation)
- reconstitute hyaluronidase 1500 International Units in 2 to 5 mL (depending on size of extravasation) sterile water for injection or sodium chloride 0.9%
- 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:
- cover warm pack with a waterproof covering
- place over affected area for 15 to 20 minutes
-
Irritant with vesicant properties
Cold compress:
- e.g. bendamustine, docetaxel, liposomal doxorubicin, melphalan, mitozantrone, paclitaxel or nab-paclitaxel, cisplatin > 0.5 mg /mL
- cover cold pack with a waterproof covering
- place over affected area for 15 to 20 minutes
- reapply every 6 hours for 48 hours.
Warm compress:
- cover warm pack with a waterproof covering
- place over affected area for 15 to 20 minutes
- 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.
-
Irritant
Cold compress:
- e.g. gemcitabine, cabazitaxel, carboplatin, fluorouracil, irinotecan
- cover cold pack with a waterproof covering
- place over affected area for 15 to 20 minutes.
Warm compress:
- e.g. etoposide, etoposide phosphate
- cover warm pack with a waterproof covering
- place over affected area for 15 to 20 minutes.
- Consider elevating the affected arm if it provides comfort to the patient, otherwise encourage patient to use limb normally.
- Remove PPE.
- Perform hand hygiene
- Dispose of all hazardous waste as per institutional guidelines.
- 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.
- Complete incident report as per local policy.
Surgical management:
- 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.