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1. Guidelines of extravasation, infection &pain
management in Oncology
Dr. O.P. Singh M.D.FICRO.
Prof & H.O.D
(Radiotherapy)
Gandhi Medical College Bhopal
, India
Dr. Gopa Ghosh M.D,
Associate prof (Radiotherapy)S.S. Medical
College Rewa ,India
2. Extravasation can be defined as
leakage of drug in to subcutaneous
tissue which leads to either irritation
or vescication.
3. Classification of Cytotoxic drugs
according to local site reaction
1.Irritan
ts
Inflamm
ation,irr
itation,
Pain
2.Inflam
mitants
Inflamma
tion/flare
3.Exfolia
nts
Shedding
/Exfoliati
on of
skin ,no
necrosis
4.Vescica
nts
Tissue
Ulceratio
n&necros
is
5.Neutrals do not cause any damage
4. Extravasation of a vescicant is a
medical emergency hence calls
for early detection &prompt
action to prevent functional loss
of limb involved.
6. Probable risk factors for
Peripheral
Extravasation:
Thin fragile veins
Site of cannulation
Peripheral neuropathy(Diabetes)
Excessive movements due to altered mental
status,vomitting,coughing
SVC Syndrome
Elderly/ Paediatric
Obese
Prior chemotherapy
7. Cause of Central venous catheter
leakage
Backflow secondary to thrombosis in the catheter.
Needle dislodgement from the port
Damage of the catheter
Thrombocytopenia
8. Prevention of extravasation
Careful assesment of cannulation site
Cannulation over joints to be avoided
Patients at increased risk of extravasation should be
identified.
Vescicant drugs to be given before other drugs
Bolus doses are given via fast running infusion of
compatible fluid
9. Continuous observation of cannulation site for signs of
swelling ,pain inflammation, slowing of drip rate.
Opinion for placement of CVAD should be sought if
Peripheral access difficult.
Extravastion can also occur in central access often of
delayed onset .
10. Signs/Symptom's
Burning ,stinging ,pain at injection site
Swelling ,redness , blister.
Absence of free flow of infusion
Resistance on the plunger of the syringe in
case of bolus drug infusion
No blood return in the cannula.
11. Steps in management of
extravasation
Stop infusion ,disconnect tubing
Withdraw as much as drug possible via existing
cannula or CVAD
Mark skin area with indelible pen
Take photograph of the area
Open extravasation kit
Apply hot/cold pack as applicable for the concerned
drug.
12. Elevate the limb
Inform treating oncologist
Urgent assesment by oncologist regarding referral to
plastic surgeon for saline flush out of extravasated
area.
Follow up at regular intervals.
13. Contents of extravasation kit
Inj Hyaluronidase (1ampoule/1500iu)
Hydrocortisone 1%cream
S/w for injection
DMSO98%solution
Hot pack
Cold pack
17. Cancer pain a matter of
concern
60-80% of terminal cancer patients have severe pain
Moderate pain exists in earlier course of the disease
also.
QOL of such patients are significantly impaired due to
pain.
Chronic pain expressed in vague terms (stiffness
,anxiety ,insomnia), actual prevalance underestimated
85% cases can be pain free with modern drugs &
techniques.
18. Etiology
1. Direct infiltration to mucosa, soft tissues ,nerve
&bone.
2.Treatment related (Sx/RT/CT) accounts for 20%
pain cases.
Pain produced- stimulation of peripheral pain
receptors.(nociceptive)
Neurogenic/Neuropathic-( involvement of
afferent nerves or nerve pathways.)
19. Broad Principles of drug treatment
Simplest dosage and least invasive route to be used
first
Analgesics to be given preferably around the clock basis
than as need basis for more effective pain control.
Opioid dose till ultimate pain relief or unacceptable
side effects.
NAIDS &adjuvant analgesics with ceiling effect, dose
till upper limit of recommended dose
Switching of analgesics when required
20. Primary cause of pain i.e. tumour to be treated with
palliative appropriate modality (RT/CT/Sx )
Adjuvants( Antidepressants, Anticonvulsants
biphosphonates, steroids, etc)used when required to
enhance efficacy of analgesia, treat concurrent
symptoms ,independent analgesic effect for specific type
of pain .
21. Reasons for Comprehensive pain
assesment
1.Pain expression influenced by factors:
Cognitive status
Extreme of age
Psychological reasons(fear of morphine related side
effects, progressive disease)
Religious beliefs
Communication barrier
23. Some Pain assesment scale
1.Numeric scale(0-10) based on patients own pain report
2. Rupee scale.
Children : Face scale Happy to sad
2.Comprehensive pain evaluation:
By PQRST factor(Provocative, quality
, referred/regional
severity, temporal factors like onset ,duration ,frequency
etc.
24. WHO designed simple, effective ,well validated
adjustment of pain therapy which results in pain relief in
90% cases, known as WHO pain ladder
Some common analgesics proposed for use:
NSAIDs-Aspirin, Ibuprofen , Naproxen , Piroxicam
, Celecoxib
Weak Opioid-Codeine, dextropropoxyphine, Tramadol,
Strong opioid-Morphine, buprenorphine, transdermal
Fentanyl
30. Infection in oncology
Reason for significant morbidity & mortality
Oncologist should have thorough understanding of risk
factors &common etiologic microbes
Prompt work up & therapy are key to successful
management
31. Causes
immunity-disease itself
-treatment induced neutropenia
.Protein malnutrition
Altered cellular/Humoral immunity
.Nosocomial
Post operative
.Secondary to obstruction & necrosis
.Exposure to community acquired pathogens(HSV,CMV)
.Reactivation of latent infections
32. Common Symptoms
Fever
Tachypnea
Tachycardia
Hypotension
Hypothermia
Organ specific
Organ failure
Routinely diagnosed by laboratory, microbial
,radiological tests
33. Guidelines for treatment
Prompt initiation of broad spectrum antimicrobial empiric
monotherapy in suspected infections without waiting for
lab reports
Directed therapy against specific pathogens as per
microbial culture report.
In case β-lactam allergy fluoroquinolone based therapy
given.
Diagnosis of febrile neutropenia should be done in
fever cases with ANC< 500/μl ,WBC <1000/μl.
Documented bacteremia treated at least for 14 days.
