Chemotherapy Extravasation (CE)is an oncology emergency. It is the infiltration of chemotherapeutic agent into the subcutaneous tissues instead of the vein. It is associated with morbidity and may lead to mortality if not well handled. The effect of Extravasated chemotherapy depends on the type of chemotherapy, the quantity of chemotherapeutic agent. These factors also include whether they are irritants, inflammitants neutrals or vesicants. Patient and also hospital factor affect chemotherapy Extravasation, Early recognition, adequate evaluation and management is key to reducing the burden of CE on oncology patients.CE is preventable and management needs multidisciplinary approach.
2. Introduction/ Definition
• Inadvertent administration of chemotherapeutic
drugs into surrounding perivascular tissues or
subcutaneous space rather than the vein
• There is usually a resulting injury
• Degree can be from very mild to sever and depends
on drugs
• It is a surgical oncology emergency
• Sever injury may need a skin graft or flap cover
• Management is multidisciplinary
3. Epidemiology
• According to Emiko et al ... Among 43,557 that
received chemotherapy 35 ( 0.08%) had
extravasation and duration was >2hrs
• There was an incidence of 4.7% to 6.5% according
to study done leon Alexander et . Al
• Zayneb Alami et al, morocco ; total of 18 patients;
7 females, 11 males out of 2000 0.9% incidence
5. • Neutrals : Inert or neutral compounds that do not
cause inflammation or damage
• Inflammitants : mild to moderate inflammation and
flare in local tissues
• Irritants: materials that cause reversible
inflammation or irritation to a body surface
• Vesicants: They are fluid or medication that causes
the formation of blisters with subsequent sloughing
of tissues occuring from the tissue necrosis
• E.g DNA binding; doxorubicin,
non-DNA binding vincristine
6. Flare reaction
• Symptoms reside within 30 mins with or without
treatment, may last 24 or 48hrs
Symptoms
• Immediate red blotches or streaks along the vein
puncture
• Local wheals
• Irritants near the site of injection
• Localised warmth and tenderness
• Localised erythma and edema
• Blood returns will occur with flare reaction
13. Organisational factors
• Poor staff training
• Organisational issues
• Interruption or distraction during drug
administration
14. Drug related factor
• Vesicant potential
• Multiple vesicant
• Concentration of drugs
• Volume of drugs administered
• Chemical properties
15. Device factor
• High flow pressure
• Long infusion period
• Repeated use of same vein
• Multiple attempts at cannulation
• Unfavourable canulation site
• Poor choice of equipment
• Deeply implanted port
• Displacement or migration
16. Clinical presentation
• Burning stinging, pain or any acute change at the
injection site
• Induration erythema, venous discoloration or
swelling observd at the site
• Alteration to the rate of flow or increased
resistance to the administration of the cytotoxic
drugs that can not be explained by change in
postion of the body
• No blood return obtained
• Leakage from around the injection site
• Bleb formation or blisters
17. Evaluation
• Drug extravasated, dose ,volume
• Position and size of injury
• Amount and type of exudate
• Presence of swelling
• Pain
18. Grading
• Grade 1 painless edema
• Grade 11 erythma with associated symptoms
• Grade 111 ulceration or necrosis
• Grade 1v life threatening concequences
• Grade v death
19. Treatment of extravasation
• Monitor closely
• Instruct patient on alarm symptoms
• Stop infusion
• Call for help
• Do not remove canular
• Disconnect infussion
• Attempt aspiration of residual drug
• Elevate limb and immobilise
• Apply ice for some drugs
20. • Consider antidote
• Remove cannular
• Assesss for site, erthyma, induration
• Administer pain control
• Refer to plastic surgery , or specilist on affected part
• Debridement very important and should be early
• Document incidence
• Follow up for 2 weeks
21. Content of extravasation kit
• Inj hyaluronidase 1 ampoul / 1500iu
• Hydrocortisone1% cream
• S/ W for injection
• DMSO98% Solution
• Hot pack
• Cold pack
22. For port or CVAD
• Imaging may be needed
• Portogram may be done to ensure no fracture
23.
24. Hyaluronidase
• Hyaluronidase for nonvesicant 200units in 2mls
dilute to 3:1 to NS subcute, intradermal
• Acts by dispersion of the drugs
• For vinblastine, vincrstine, vinflunine
• May partially work for paclitaxel
• Topical visafilator and intradermal terbutaline
• Dry cold compress for 20 to 30 min, 4x a day for 24
to 48hrs
• Apply dry warm compress 20 to 30min
25. Dimethyl sulfoxide (DMSO) 99%
Solution
• Works for doxorubicin, epirubicin, mitomycin
• Apply as soon as possible withim 10- 20mins
• Do not use with lysosomal doxorubicin
• Do not apply to wet skin
• Side effect inlude itching, erythma, characteritics
garlic breath odor
26. Warm compress
• Topical application for use in vinca alkaloid
• May decrease local drug concentration
• Increase blood flow which reduces pain
• Synergestic with hyaluronidase
27. Cold compress
• Management of vesicants or irritants with
exception of vinca alkaloid
• Use in oxaliplatin will execerbate sensory
neuropathy
30. Prevention
• Avoids sites near joints and bone
• Do not give versicant into cubital fossa via
peripheral vein
• Frequent re-access the patency of the canaular
• Do not infuse in areas of poor venous return or
lymphatic drainage
• If vein punture is unsuccesful make a second
attempt in the opposite arm. Chose a proximal site
if same arm must be used
31. • Administer vesicant first
• Line should be free flowing
• Do not use infusion pump
• Observe for signs of infiltration
• Do not pinch the tubbing
• Flush line after drug admintration 20mls before
decanulation
32. • Select a small gauge cannular
• Ensure it can be visualised
• Site and secure adequately
• Do not use butter fly needle with vesicant
• Begine a new infusion for drug adminitration
33.
34. Conclusion
• Chemotherapy extravasation is one of the
commonest complications in oncology
• Seems subtle but may have very adverse effect
• Increases mobility and mortality of oncology
patients
• Early diagnosis, early intervention is needed to
preserve the affected limb
• Good patient education, adequate staff training in
oncology management will reduce if not eliminate
it occurance in oncology centers
35. Reference
• Indian J plast surg 2023 oct;56(5):439-442 pubmed
journal article 38026779
• Emiko Sakaida etal Jpn J clin Oncol.2014 feb
• Zayneb Alami et al pan African medical journal(
ISSN:19378688
• Yuuka Shibata et al extravasation of non cytotoxic
agents, skin injury and risk classification . Jounal
home 2023volume 46 issue 6
36. • Leon Alexander et. Al Extravasation injuries: A
trivial injury often overlooked with disatrous
consequnces . World jounal of plastic Surg 2020
sep;9(3):326-330
