TITLE:



TITLE: EXTRAVASATION POLICY

PURPOSE: Extravasation of drugs from intravenous lines into surrounding subcutaneous tissue has the potential to cause severe tissue damage at the site of the extravasation. Immediate intervention is required when extravasation is suspected to prevent or to reduce potential tissue damage.

POLICY: Appropriate interventions as described in the following procedure will be implemented upon recognition of a suspected extravasation.

PROCEDURE:

DEFINITIONS

Extravasation: The unintentional instillation or leakage of intravenous drug solution out of the vein and into the perivascular or subcutaneous tissue during administration.

Vesicant: An agent that causes blistering and/or ulceration with tissue necrosis.

Exfoliant: An agent capable of causing inflammation and shedding of skin but less likely to cause tissue death.

Irritant: An agent capable of causing inflammation and irritation, rarely proceeding to breakdown of tissue. It may produce stinging and induce spasms of the vessel wall due to epithelial irritation.

Inflammatory Agents:

An agent capable of causing inflammation and flare in local tissues.

PREVENTION OF EXTRAVASATION

All intravenous infusions can extravasate. Extravasation may occur from central or peripheral venous catheters. Some drugs have the potential to cause severe tissue damage if extravasated. These drugs are classified as vesicants and exfoliants. But, any agent that extravasates in sufficient amounts may cause tissue damage. Prevention of extravasation by appropriate administration techniques is the most important step in preventing injury. Vesicant medications should be administered through a central line or through the largest appropriate vein.

(See central line protocol).

RECOGNITION OF EXTRAVASATION: Suspect extravasation in the following instances:

1. The patient complains of burning, stinging, pain or any acute change at the injection site. Examine IV sites frequently for patients who are unable to report these symptoms.

2. Induration, erythema, swelling, or blanching at the injection site is observed or the site is cool to the touch.

3. No blood return is obtained. (A lack of blood return from the cannula is commonly sited as a sign that extravasation has occurred. However, an extravasation may have occurred even when a blood return is obtained.)

4. The flow rate is reduced.

5. Increased resistance to administration. Once possible changes in body position or cannula support have been excluded as possible causes of increased resistance, then a displaced cannula is the next most likely cause of an extravasation.

MANAGEMENT OF EXTRAVASATION: General treatment for all extravasations:

1. Stop the infusion immediately. Do not remove the needle.

2. Slowly aspirate as much of the infiltrated drug as possible through the needle. (Withdraw 3-5ml of blood to remove some of the drug). Lower the IV tubing to create backflow. Do not apply pressure to the area.

3. Consult the attached drug list to determine if the extravasated drug might cause tissue damage. Determine if an antidote should be infused through the needle.

4. Remove IV access while aspirating unless antidote will be infused into this needle. Do not use this site for IV access any longer.

5. Immediately notify the nursing supervisor and the supervising physician.

6. Outline the extravasated area with an indelible marker.

7. Clean the area with alcohol and apply a sterile transparent dressing.

8. Institute drug specific measures as indicated. A nurse may institute the treatment protocol for vasopressors using the Vasopressor Extravasation Treatment Orders form. The Antineoplastic Agent Extravasation Treatment Orders form may be instituted for antineoplastic agents.

9. Apply a compress. Consult the attached drug list and treatment protocols to determine if warm or cold compresses should be used. Apply the compress to the area for 15 to 20 minutes every 6 hours for the first 72 hours.

10.Elevate the extremity above the area of the heart using pillows. Avoid any pressure or friction to the skin that may aggravate the injury.

11.Document the occurrence of the extravasation in the nursing notes noting the location and describing the condition of the patient and of the extravasated area. If possible, take a color photograph of the affected area within 4 hours. If unable to obtain a photograph, provide a diagram of the area.

plete a Quality Review Report Form.

TREATMENT RECOMMENDATIONS FOR SPECIFIC AGENTS:

A. Non-Antineoplastic Agents:

1. Vasopressor Extravasation: Dopamine, Dobutamine, Epinephrine, Norepinephrine, Phenylephrine

Antidote: Phentolamine: Reconstitute the 5mg vial of Phentolamine with 1ml of Sterile Water for Injection. Further dilute the reconstituted vial of Phentolamine with 9ml of sterile 0.9% Sodium Chloride for Injection. Prepare eleven syringes as follows: Draw up one syringe with 5ml of the reconstituted Phentolamine solution and ten 1ml tuberculin syringes with a 27g 1/2 inch needle attached with 0.5ml of the solution. Clean the extravasated area with alcohol. Inject 5ml of the phentolamine into the catheter then infiltrate the area of the extravasation with multiple small injections subcutaneously using a different syringe and needle for each skin entry. (Blanching should reverse immediately.) Additional injections may be required if blanching returns. Do not exceed 5 mg total dose for an adult or 0.1mg-0.2mg/kg for a child. Treatment must be done within 12 hours of the extravasation. (It may not be necessary to use all ten syringes). 1.5 inches of Nitroglycerin paste may also be applied to the area of extravasation. Cardiac monitoring is required for at least 2 hours after a vasopressor extravasation. Continue with general measures.

2. Radiocontrast Media

Antidote: No specific antidote. The application of cold compresses may be of benefit for extravasation of radiocontrast media. Apply ice compresses to the site for 15 minutes every 6 hours for 48 hours.

Outpatients who experience a radiocontrast medium extravasation of greater than 30ml during a procedure in the Diagnostic Imaging Department will be observed in the department for at least one hour. Instruct the patient to elevate and rest the extremity for 72 hours then resume normal activities.

3. Other Vesicant and Irritant Non-neoplastic agents

Antidote: No specific antidote. Consult the attached drug list to determine if hot or cold compresses should be used. Follow general measures.

B. Antineoplastic Agents

1. Etoposide, Vinblastine, Vincristine, Vinorelbine

Antidote: Hyaluronidase: Use Vitrase 200 units/ml vial obtained from the pharmacy. Dilute 0.75ml of Vitrase with 0.25 ml of Sterile 0.9% Sodium Chloride for Injection. Prepare five 1ml tuberculin syringes with a 27g1/2 inch needle attached with 0.2ml of the diluted Vitrase.

Clean the extravasated area. Give five 0.2ml injections subcutaneously or intradermally around the extravasated area using a different syringe for each skin entry. Apply warm compresses for 15 minutes every 6 hours for 48 hours. Continue with general measures.

2. Mechlorethamine (Nitrogen Mustard) and Cisplatin in volumes greater than 20ml at concentrations greater than 0.5mg/ml

Antidote: 1/6Molar Sodium Thiosulfate: To prepare 50ml of the 1/6Molar Sodium Thiosulfate solution, dilute 8ml of the 25% Sodium Thiosulfate with 42ml of Sterile Water for Injection. (The pharmacy will prepare this.)

Mechlorethamine (Nitrogen Mustard) extravasation: The dose of 1/6 Molar Sodium Thiosulfate is based on the amount for Mechlorethamine (Nitrogen Mustard) that has extravasated. Administer a dose of 0.5ml of the 1/6 Molar solution for every estimated milligram of Mechlorethamine (Nitrogen Mustard) extravasated. Administer Sodium Thiosulfate through the extravasated IV site if possible; it may be injected subcutaneously around the site of extravasation. Use a separate syringe and needle for each skin entry.

Cisplatin in volumes greater than 20ml at concentrations of greater than 0.5mg/ml extravasation: The dose of Sodium Thiosulfate is based on the estimated amount of Cisplatin that has extravasated. Inject 2ml of 1/6 Molar Sodium Thiosulfate for each estimated milligram of Cisplatin extravasated. If possible, administer Sodium Thiosulfate through the extravasated IV site and inject subcutaneously around the site of extravasation. Use a separate syringe and needle for each skin entry.

3. Anthracyclines: Doxorubicin, Epirubicin, Mitoxantrone

(Liposomal Doxorubicin is not a vesicant. It is an irritant. Follow general extravasation guidelines for Liposomal Doxorubicin.)

Contact oncologist immediately.

Antidote: Dexrazoxane may be used for anthracycline extravasation at a dose of 1000 mg/m2 given on days 1 and 2 and a dose of 500mg/ m2 given on day 3. Patients with a BSA greater than 2m2 should receive a maximum of 2000 mg on days 1 and 2 and 1000 mg on day 3. The dose of Dexrazoxane should be decreased by 50% in patients with creatinine clearance values less than 40ml/min. After reconstitution of each 500mg Dexrazoxane vial with the 50ml of 0.167 Molar Sodium Lactate Injection USP provided with the drug, the total amount of Dexrazoxane to be infused is further diluted in 1000ml of Dextrose 5% or 0.9% Sodium Chloride. The Dexrazoxane dose should be infused over 1 to 2 hours in a large caliber vein in an extremity/area other than the one affected by the extravasation. The first infusion should be initiated as soon as possible and within the first six hours after the extravasation. The infusions on Day 2 and Day 3 should start at the same hour as on the first day. If ice packs have been applied to the extravasation site, they should be removed from the area at least 15 minutes before the Dexrazoxane infusion begins in order to allow for sufficient blood flow to the extravasated area.

FOLLOW UP MEASURES FOR ALL EXTRAVASATIONS:

Institute any further orders from the supervising physician. Since the extravasated drug may be absorbed before treatment of the extravasation can be completed, the patient should be monitored for at least one hour or until vital signs normalize. Observe the wound carefully for the next several days for signs of increased erythema, pain or skin necrosis. Contact the supervising physician if there are signs of increased erythema, pain or skin necrosis.

If the patient is sent home after the extravasation, the patient/caregiver should receive specific discharge instructions for monitoring the site and necessary care required upon discharge. Discharge instruction should also include when to return for care and signs and symptoms to watch for with appropriate action. The nursing supervisor or designated agent will contact the patient daily to follow up on the patient’s condition and make arrangements for the patient to return to the Infusion Department or the Emergency Department for assessment in 48 hours. When the patient returns, they should be seen by the Nursing Supervisor or the Infusion Center Charge Nurse, who will assess the wound and determine follow up care.

References:

Cancer Chemotherapy Manual published by Facts and Comparisons, 2001

Management of Drug Extravasations in Lexi-Drug, Lexi-Comp (database online), Lexi-Comp, Inc, 2008.

Protection Against the Extravasation of Anticancer Drugs by Standardization of the Management System, Hospital Pharmacy, Volume 43, Number 7,pp 571-576, 2008

New: 04/10

Approval Signatures:

_____________________________________ ____________________

Director, Pharmacy Services Date

_____________________________________ ____________________

Chief Clinical Officer Date

_____________________________________ ____________________

Chair, Pharmacy and Therapeutics Committee Date

_____________________________________ ____________________

Chief Executive Officer Date

_____________________________________ ____________________

President, Board of Directors Date

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download