REPORTED BY:

CZARINA CID
STAFF NURSE, IVIU June 11, 2012

 PHLEBITIS
The inflammation of a vein (not permanent)

RECALL
A delayed local response at a prior administration site. May have no evidence of extravasation on administration of medication but it may develop later on.

 FLARE
An injection-site reaction (typically seen following the first IV infusion of an anthracycline such as doxorubicin) which is localized to the area of injection or nearby. It may involve redness, itching and possibly hives. It is self-limiting and should not be treated as an extravasation reaction. It may be avoided with pretreatment of antihistamines (with an order from a physician).

 EXTRAVASATION
considered an adverse event. The leakage of a vesicant out of the vein upon intravenous drug administration. Extravasation is characterized by severe pain and swelling at the site of administration.

 The two main categories of medications to describe the local consequences of their extravasation are:
Vesicant
Is an agent which has the potential to cause serious tissue destruction (i.e.necrosis). Injection of these medications may cause disruption of the endothelial lining with thrombosis.

Irritant
Is a drug which has the potential to cause temporary irritation (i.e. itching, redness, swelling) to surrounding tissues with or without an inflammatory reaction. These medications cause pain and discomfort along the venous pathway.

 Local hypersensitivity reactions

Presentation
Immediate burning, itching, erythema, flare/reaction along the length of the vein. Usually self-limited and subside within a few hours. Treatment: administration of diphenhydramine before the next course may reduce the severity or duration of reaction.

Irritation of the vein (or phlebitis) reactions

Presentation
Burning with administration of agent, tracking Treatment: stopping therapy, removing the peripheral line, and placing new IV line in other hand.

 Extravastation
Localized, self-limiting inflammation (irritants) to full thickness destruction and sloughing of the skin (vesicants). Presentation: patients who experience an extravastation can show a range of different signs or symptoms. Mild pain and swelling at the site of infiltration with marked edema and erythema, hyperpigmentation, induration, can also occur. Infiltration of a vesicant into tissue often produces a severe burning sensation that may persist for hours. Extravastation may ultimately lead to soft tissue ulcers and necrosis. Initially, it may be impossible to distinguish a local irritant reaction from a vesicant extravastation. Treatment: once extravastation is suspected, therapy should be stopped and extravastation procedures for agent should be utilized

 All suspected or actual extravasation will be treated promptly to minimize any ill effects. Despite every precaution, extravasation may occasionally occur. Vesicants include antineoplastic as well as non-antineoplastic agents (including radiographic contrast agents).

Vascular disease Advanced age Vascular obstruction Vascular ischemia History of irradiation to area Small vessel diameter Venous spasms Traumatic catheter Needle insertion

 Pain or burning associated with drug administration at and around the IV catheter injection site Swelling, usually occurs immediately Change in quality of infusion May loose ability to obtain a blood return May have blotchy redness around the IV catheter injection site, may be delayed May have local tingling and sensory deficits, often delayed Ulceration develops insidiously usually 48 - 96 hours later

INFILTRATION / EXTRAVASATION GRADING SCALE

Assess Vascular Access Device (VAD) as per management of peripheral intravenous catheter policy and follow the corresponding intervention guidelines CLINICAL SYMPTOMS ACTIONS Stage 1 Skin blanched For All Stages: Vesicant refer to Stage 4 Edema <1 inch in any direction 1. Stop Nonvesicant remove IV Cool to touch infusion/Establish With or without pain alternative IV site. Stage 2 Skin blanched 2. Determine infusate Vesicant refer to Stage 4 Edema >1 inch 3. Refer to Drug Non-vesicant-remove IV Cool to touch Information / Notify primary service With or without pain Pharmacy to If tissue damage progresses, refer to Stage 3 determine if infusate or 4 Stage 3 Skin blanched, translucent is a vesicant Vesicant refer to Stage 4 Gross edema >6 inches in any direction 4. Elevate extremity Non-vesicant-remove IV Cool to touch 5. Continue assessment Call primary service for assessment and need Mild to moderate pain of site surrounding for plastic surgery consultant Possible numbness tissue PRN If tissue damage progresses, refer to Stage 4 Skin blanched, translucent Skin tight, leaking Skin discolored, bruised, swollen Gross edema >6 inches in any direction Circulatory impairment Moderate to severe pain Possible numbness Infiltration of any blood product, irritant, vesicant Deep pitting tissue edema Vesicant refer to Stage 4 Non-vesicant-remove IV Notify primary service Notify plastic surgery and/or orthopedics for assistance in determining further treatment

Stage 4

1. Stop the procedure or process of the chemotherapeutic agent immediately. 2. Leave the needle in place. Do Not Remove Needle/Catheter (it may be used for administration of antidote/diluent and to prevent further needle sticks). 3. Put on gloves (if not already on). 4. Attach syringe and attempt to aspirate any residual drug in the needle, and suspected extravasation site. Administer a volume of sodium chloride for injection into existing needle/catheter equal to amount of fluid removed. Avoid unnecessary trauma. If unable to aspirate, IV should be removed to prevent further vesicant extravasation. 5. Refer to chart on the next page for specific antidote.

6. If an antidote is to be administered, use the same needle/catheter through which the vesicant drug extravasated. 7. All drugs except mechlorethamine (nitrogen mustard), remove needle/syringe. 8. Dispose of syringe and contents into biohazard container. 9. Notify physician on call. 10.Elevate area if possible. 11.Apply cold pack if the extravasated drug is amsacrine, doxorubicin, daunorubicin, or mechlorethamine. The ice pack should be applied for 15 minutes four times a day for 3 days. Refer to individual drug in the following table. The rationale for cold was vasoconstriction, thereby "containing" the drug at the site of extravasation and minimizing the size of the subsequent ulceration.

12.Apply hot pack if the extravasated drug is etoposide, teniposide, navelbine, vinblastine, vincristine, or vindesine. The warm, dry pack should be applied for 60 minutes, one time. Refer to individual drug in the list following. The rationale for heat was vasodilation, thereby "diluting" the drug and minimizing the size of the subsequent ulcer. 13.Complete Medication Error Report form. 14.Documentation in patient's chart: date and time, needle size and type, drug sequence, drug administration technique, approximate amount of drug extravasated, management, patient complaints, appearance of site, physician notification, and follow-up interventions, signature, return patient appointments.

15. The extravasation site should be evaluated by the physician as soon as possible after the extravasation and periodically thereafter as indicated by symptoms. 16. For inpatients, assess the site every day for pain, erythema, induration, or skin breakdown, and document assessment at least every shift (8-12 hours) for 48 hours. For outpatient, telephone contact should be made daily for 3 days to assess the site for pain, redness, and swelling weekly thereafter until the problem is resolved. 17. The physician should consult the Plastic Surgery service when pain and/or tissue breakdown occur.

1. Stop the administration of the drug. 2. Remove the intravenous needle or catheter. 3. Observe the site every eight hours for any signs of tissue change (redness, swelling, or pain). 4. If area of infiltration is swollen, elevate the affected extremity for 24-48 hours or until the swelling subsides. 5. Document as for vesicant/irritant drug.

Should contain the following: Instructions for use. List of contents. List of cytotoxic drugs and their antidotes. Antidotes and instructions for use:
DMSO (Dimethyl sulphoxide) topical solution. Hyaluronidase.

Swabs or swab sticks for applying DMSO. 10ml syringes. Water for injection. Drawing up needles. 25gage needles. Spare gloves. Alcohol wipes. Access to icepacks and heat packs.

 Only qualified, chemotherapy-certified nurses should be allowed to administer vesicants Choose a large, intact vein with good blood flow The digits, hands, and wrists should be avoided Place the smallest gauge and shortest length catheter to accommodate the infusion. Monitor the venipuncture site closely The IV infusion should be freely flowing. The infusion should consist of a suitable carrier solution with an appropriately diluted medicinal/chemotherapy drug inside. After the IV infusion has finished, flush the cannula with the appropriate fluid. Finally, depending on clinical circumstances, central line access may be most appropriate for patients who require repeated administrations of vesicants and irritants.