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Chemotherapy Extravasation in Oncology 1.pptx
- 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
- 4. Classification of Chemotherapeutic agent according to reactions to tissue
- 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
- 7. Classification Vesicants • Doxorubicin • Epirubicin • Paclitaxel • Vincristine • Vincristine Irritants • Carboplastin • Etoposide • Teniposide
- 8. Classification ctd Inflammitants • Fluorouracil • Methotrexate Neutrals • Bleomycin • Cyclophosphomide • Cetuximab • Asparginase • Gencitabin • Ifosfamide
- 10. Mechanism of injury • Vasoconstriction= ischemic necrosis • Osmotic pressure in cell membrane • Ph related • Cellular toxicity • Mechanical compression
- 11. Risk factors ( patients factor) • Small fragile veins • Multiple treatment • Generalised vascular disease • Age • Restlessness or confusion • Impaired lymph flow and venous circulation • SVC syndrome • Impaired sensory perception • Limited available veins
- 12. • Impaired sensory perception • Obesity
- 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
- 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
- 28. Dexrazoxane • Apply within 6 hours • Prevents athracycline wound formation • May show myelosuppresion
- 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
- 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