The document provides guidelines for nurses on recognizing and managing extravasation, which is the accidental leakage of intravenous medications from the vein into surrounding tissues, by discussing signs and symptoms to watch for, prevention strategies, and treatment protocols depending on the type and severity of extravasation. It emphasizes the nurse's key role in preventing extravasation by maintaining high standards of care during IV administration and in properly diagnosing and treating extravasation if it occurs.
Extravasation is the accidental leakage of intravenous drugs into surrounding tissues from a vein. This can cause immediate pain and inflammation and potentially tissue damage or necrosis depending on the drug. The risk of extravasation is between 0.1-6% for peripheral lines and 0.26-4.7% for central lines. Drugs are classified based on their damage potential from vesicants, which can cause blistering, to exfoliants, irritants, inflammitants and neutrals. Management involves stopping the infusion, aspirating drug if possible, and then treatments ranging from dispersing and diluting for non-DNA binding vesicants to localizing and neutralizing for DNA binding vesicants. Prevention
This document discusses extravasation, which is the unintentional leakage of drugs or substances out of blood vessels into surrounding tissue. It describes different types of extravasations based on the properties of the leaked substance. It identifies numerous risk factors for extravasation related to patients, medications, devices, clinicians and procedures. Symptoms and a grading system for extravasations are provided. The document outlines extensive guidelines for the prevention, assessment, management and treatment of extravasations with various antidotes and approaches depending on the substance extravasated. It emphasizes the importance of education for patients and clinicians to prevent and properly handle extravasations.
1) An extravasation occurs when a vesicant medication or solution is inadvertently administered into the surrounding tissues, potentially causing tissue injury. This is a common complication among neonates receiving intravenous therapies.
2) The NICU nurse plays an important role in monitoring intravenous sites for early signs of infiltration or extravasation and preventing injury. If extravasation occurs, immediate treatment is needed to minimize damage, such as stopping the infusion and applying saline compresses.
3) Proper peripheral intravenous insertion and maintenance can help prevent complications. When extravasation injury does occur, hyaluronidase may be used to help distribute the vesicant over a larger area and reduce edema, in addition to wound
This document discusses infiltration and extravasation which are complications of intravenous (IV) therapy. Infiltration occurs when IV fluid leaks into surrounding tissue due to improper catheter placement or dislodgement. Extravasation is when vesicant (toxic) drugs leak into tissue. Both can cause swelling, pain, and tissue damage. To prevent these complications, health care providers should select appropriate IV sites, use proper insertion technique, securely fix catheters, and monitor sites frequently. If complications occur, the IV should be removed and the site elevated, documented, and further treated based on symptoms and severity.
An extravasation occurs when a vesicant solution is inadvertently administered into surrounding tissue instead of the vein. Signs and symptoms include pain, swelling, skin tightness, and discoloration at the IV site. Initial signs may be subtle but can progress to skin necrosis, blistering, and permanent damage if not properly managed. To manage an extravasation, the infusion must be stopped immediately, the drug withdrawn from the cannula, and the limb elevated. Further treatment depends on the drug involved and extent of damage. Proper training, assessment of competence, and documentation are important for preventing extravasation complications.
Management of Extravasations of Chemotherapy
1) Extravasation occurs when chemotherapy drugs leak into the surrounding tissues rather than entering the vein, and can cause damage ranging from mild skin reactions to severe tissue necrosis, depending on the drug.
2) Drugs are classified as vesicants, irritants, inflammitants, or neutrals based on their propensity to cause tissue damage. Vesicants like doxorubicin are most likely to cause damage.
3) Risk of extravasation is higher for fragile veins, elderly or ill patients, and irritating/vesicant drugs. Signs include pain, swelling, discoloration at the injection site.
4)
Remove
the catheter and
notify the
physician.
Prevention:
- Secure tubing
and catheter to
prevent snagging
- Use blunt
scissors only near
IV site
- Avoid
reinserting
needles
Extravasation is the accidental leakage of intravenous drugs into surrounding tissues from a vein. This can cause immediate pain and inflammation and potentially tissue damage or necrosis depending on the drug. The risk of extravasation is between 0.1-6% for peripheral lines and 0.26-4.7% for central lines. Drugs are classified based on their damage potential from vesicants, which can cause blistering, to exfoliants, irritants, inflammitants and neutrals. Management involves stopping the infusion, aspirating drug if possible, and then treatments ranging from dispersing and diluting for non-DNA binding vesicants to localizing and neutralizing for DNA binding vesicants. Prevention
This document discusses extravasation, which is the unintentional leakage of drugs or substances out of blood vessels into surrounding tissue. It describes different types of extravasations based on the properties of the leaked substance. It identifies numerous risk factors for extravasation related to patients, medications, devices, clinicians and procedures. Symptoms and a grading system for extravasations are provided. The document outlines extensive guidelines for the prevention, assessment, management and treatment of extravasations with various antidotes and approaches depending on the substance extravasated. It emphasizes the importance of education for patients and clinicians to prevent and properly handle extravasations.
1) An extravasation occurs when a vesicant medication or solution is inadvertently administered into the surrounding tissues, potentially causing tissue injury. This is a common complication among neonates receiving intravenous therapies.
2) The NICU nurse plays an important role in monitoring intravenous sites for early signs of infiltration or extravasation and preventing injury. If extravasation occurs, immediate treatment is needed to minimize damage, such as stopping the infusion and applying saline compresses.
3) Proper peripheral intravenous insertion and maintenance can help prevent complications. When extravasation injury does occur, hyaluronidase may be used to help distribute the vesicant over a larger area and reduce edema, in addition to wound
This document discusses infiltration and extravasation which are complications of intravenous (IV) therapy. Infiltration occurs when IV fluid leaks into surrounding tissue due to improper catheter placement or dislodgement. Extravasation is when vesicant (toxic) drugs leak into tissue. Both can cause swelling, pain, and tissue damage. To prevent these complications, health care providers should select appropriate IV sites, use proper insertion technique, securely fix catheters, and monitor sites frequently. If complications occur, the IV should be removed and the site elevated, documented, and further treated based on symptoms and severity.
An extravasation occurs when a vesicant solution is inadvertently administered into surrounding tissue instead of the vein. Signs and symptoms include pain, swelling, skin tightness, and discoloration at the IV site. Initial signs may be subtle but can progress to skin necrosis, blistering, and permanent damage if not properly managed. To manage an extravasation, the infusion must be stopped immediately, the drug withdrawn from the cannula, and the limb elevated. Further treatment depends on the drug involved and extent of damage. Proper training, assessment of competence, and documentation are important for preventing extravasation complications.
Management of Extravasations of Chemotherapy
1) Extravasation occurs when chemotherapy drugs leak into the surrounding tissues rather than entering the vein, and can cause damage ranging from mild skin reactions to severe tissue necrosis, depending on the drug.
2) Drugs are classified as vesicants, irritants, inflammitants, or neutrals based on their propensity to cause tissue damage. Vesicants like doxorubicin are most likely to cause damage.
3) Risk of extravasation is higher for fragile veins, elderly or ill patients, and irritating/vesicant drugs. Signs include pain, swelling, discoloration at the injection site.
4)
Remove
the catheter and
notify the
physician.
Prevention:
- Secure tubing
and catheter to
prevent snagging
- Use blunt
scissors only near
IV site
- Avoid
reinserting
needles
Peripheral venous catheters (PVCs) are commonly used to deliver intravenous therapy, but are associated with complications like infection and phlebitis. It is estimated that one in three hospital patients have a PVC inserted at any given time. Careful observation and monitoring of PVC sites, along with strict hygiene practices during insertion and maintenance, are essential to minimize risks and quickly identify any complications. PVCs should be removed as soon as they are no longer clinically necessary to reduce health risks.
1) All patients with an intravenous access device must have their IV site checked at least daily for signs of infusion phlebitis and the results documented.
2) Various "good practice points" can help reduce the risk of infusion phlebitis, such as observing the cannula site daily, using the proper dressing, and replacing the cannula at the first sign of phlebitis.
3) The document provides a visual infusion phlebitis scale to classify the severity of phlebitis from no signs to advanced thrombophlebitis and outlines the corresponding recommended actions.
Intravenous (IV) therapy delivers liquid substances directly into a vein. IV injections are the fastest way to deliver medications and fluids throughout the body. IV injection involves introducing a small amount of drug directly into the bloodstream via a vein. It allows for fast drug action in emergencies and delivers medications that may be irritating or ineffective through other routes. Potential complications include infiltration, hematoma, air embolism, phlebitis, and allergic reactions. Nurses are responsible for verifying medications, maintaining sterile technique, and monitoring for adverse reactions.
Notes to support the presentation 'Introduction to the Visual Infusion Phlebi...ivteam
1) Premature peripheral IV catheter failure and infusion phlebitis negatively impact patient treatment and safety. Regular monitoring of IV sites using a standardized tool like the VIP score is essential.
2) The VIP score was developed to reduce infusion phlebitis and has benefits for early recognition of other issues. It encourages observation of IV sites and identifies problems early.
3) The VIP score is recommended internationally and incorporated into national guidelines for appropriate discontinuation of peripheral IV catheters based on the level of phlebitis.
Intravenous (IV) injection delivers medication directly into the bloodstream through a vein. An IV infusion involves a slow drip of medication over time to provide a constant volume of therapy. IV injection allows for quick delivery of large amounts of medication into the bloodstream and rapid action. The procedure involves selecting a suitable vein, preparing the site, inserting a needle, attaching tubing, and monitoring the infusion for complications. While effective, IV injection can cause pain, requires supervision, and risks infection.
An intravenous bolus involves rapidly administering a concentrated dose of medication directly into the bloodstream over a short period of time, usually 1 to 30 minutes. It is used when quick absorption of the medication is needed but not for patients with low cardiac output or edema. Proper preparation of the nurse, environment, equipment and patient is required to safely administer an IV bolus. Potential complications include local issues like infiltration or thrombosis at the injection site as well as systemic issues such as air embolism, hematoma, infection, circulatory overload, or allergic reaction.
This document outlines negative pressure wound therapy (NPWT), also known as vacuum assisted closure (VAC). It discusses the mechanism of action, components, indications, contraindications, application process, advantages, monitoring considerations, potential complications, and conclusion regarding NPWT. NPWT applies sub-atmospheric pressure to a wound through a sealed dressing to promote healing in acute or chronic wounds by removing excess fluid, increasing blood flow, and stimulating the growth of new tissue. It is indicated for various open wounds where closure is not possible, such as pressure ulcers, surgical wounds, diabetic ulcers, and more. Contraindications include wounds with necrotic tissue or exposed anatomy. Monitoring includes pressure levels, drainage
This document provides guidance on inserting a peripheral intravenous cannula. It describes the equipment needed, vein selection, insertion procedure, documentation, and potential complications. The aim is to safely deliver treatment without discomfort or tissue damage while maintaining venous access. Proper preparation, aseptic technique, and site care are emphasized to prevent infections and other complications.
Intravenous therapy involves administering liquid substances like medications directly into a vein. There are different methods of intravenous access, including peripheral IV lines inserted into arm or leg veins and central lines that terminate in larger veins near the heart. IV therapy carries risks like infection, phlebitis from vein irritation, fluid overload, and electrolyte imbalances if improper fluids are administered. Precise equipment and trained staff are needed to safely deliver intravenous medications and fluids.
True. Backflow of blood into the tubing proves that the catheter tip is properly placed within the vein and not outside the vein where it could cause infiltration.
This document provides guidance on intravenous cannulation. It discusses the indications for IV cannulation including fluid replacement, medication administration, blood transfusions, and monitoring. The key steps for cannulation are outlined, including preparing the patient, identifying a suitable vein, inserting the cannula at a 10-30 degree angle, securing the cannula with a dressing, and documenting the procedure. Potential complications from cannulation like infection, infiltration of fluids, thrombosis, and extravasation are also summarized.
Dr. Vishal Kr. Kandhway presented on IV cannulation. IV cannulation is the second most invasive hospital procedure, with 85-95% of patients receiving IVs. It is used to administer fluids, medications, blood products, and for imaging with contrast. Proper vein selection is important, avoiding areas near joints, scars, or previous cannulation. The forearm and back of the hand are common sites. Proper equipment, cleaning, and insertion technique are emphasized to safely place the IV and avoid complications like hematoma, infection, or puncturing an artery. New methods like AccuVein use infrared light to illuminate veins, aiding cannulation for difficult patients.
The document discusses intravenous (IV) admixtures and preparations. Some key points:
- IV admixtures involve preparing mixtures of two or more drugs into an IV fluid bag or bottle, done under doctor's orders by a trained pharmacist to avoid errors.
- Characteristics like solubility, osmolality, and pH must be considered and adjusted to match blood levels.
- IV sets include spikes, drip chambers, clamps, tubing, and needles to administer fluids and drugs via IV. Proper sterile technique is crucial when preparing IVs.
Postoperative care & management after sui operationsWafaa Benjamin
Surgeries for SUI are not without hazards.
Proper preoperative assessment, patient counseling, meticulous postoperative care& early discovery of complications are the mainstays of management.
Voiding difficulty after anti-incontinence surgeries can become persistent and have a significant impact on quality of life.
Supra-pubic catheter & CISC should be added to our practice.
Careful surgical technique with avoidance of over-elevation might play a role in prevention of VD.
This presentation is about Iv injection which is used by all health professionals to the patients. This presentation includes definition, purpose, types, equipment with procedure and role of nurse all are included.. this is very helpful demonstration for health care settings.
There are three main types of intravenous cannulation: peripheral IV cannula, central line IV cannula, and mid-line IV cannula. IV cannulation is indicated for blood sampling, fluid/medication administration, hemodynamic monitoring, and transfusion of blood or blood products. Contraindications include sites near infection, edematous areas, and areas with bleeding/clotting disorders. The procedure involves preparing equipment and the patient, finding a suitable vein, inserting the cannula, securing it with a dressing, and documenting. Potential complications are infiltration, infection, phlebitis, and thrombophlebitis, which can be prevented through proper technique, regular site inspection, and early troubleshooting.
This document discusses different types of injections and injection techniques. It describes intradermal injections which are administered just under the skin, subcutaneous injections which are used for slow, sustained absorption of medications like insulin into fatty tissues, intramuscular injections which deliver medications into muscles for rapid systemic action, and intravenous injections which deliver fluids directly into blood vessels. It provides details on sites, needle sizes, and proper techniques for each type of injection to ensure safety and effectiveness.
The guidelines address whether blood loss should be routinely quantified during management of the third stage of labour to diagnose PPH. No study directly answered this question. Evidence from observational studies showed that visual estimation of blood loss consistently underestimates actual blood loss compared to quantitative measurement. However, the guidelines note that some women may require intervention for PPH even with less blood loss if they are anemic. Therefore, the guidelines do not recommend routine quantification but emphasize the need for timely diagnosis and treatment of PPH.
This Quick Reference Guide summarizes evidence-based guidelines for the prevention and treatment of pressure ulcers developed by the European Pressure Ulcer Advisory Panel and American National Pressure Ulcer Advisory Panel over 4 years. It provides definitions for pressure ulcers and classifications, as well as recommendations for assessment, wound care, dressings, infection treatment, and other areas. The full Clinical Practice Guideline contains more detailed analysis, research discussion, methodology, and acknowledgments.
Peripheral venous catheters (PVCs) are commonly used to deliver intravenous therapy, but are associated with complications like infection and phlebitis. It is estimated that one in three hospital patients have a PVC inserted at any given time. Careful observation and monitoring of PVC sites, along with strict hygiene practices during insertion and maintenance, are essential to minimize risks and quickly identify any complications. PVCs should be removed as soon as they are no longer clinically necessary to reduce health risks.
1) All patients with an intravenous access device must have their IV site checked at least daily for signs of infusion phlebitis and the results documented.
2) Various "good practice points" can help reduce the risk of infusion phlebitis, such as observing the cannula site daily, using the proper dressing, and replacing the cannula at the first sign of phlebitis.
3) The document provides a visual infusion phlebitis scale to classify the severity of phlebitis from no signs to advanced thrombophlebitis and outlines the corresponding recommended actions.
Intravenous (IV) therapy delivers liquid substances directly into a vein. IV injections are the fastest way to deliver medications and fluids throughout the body. IV injection involves introducing a small amount of drug directly into the bloodstream via a vein. It allows for fast drug action in emergencies and delivers medications that may be irritating or ineffective through other routes. Potential complications include infiltration, hematoma, air embolism, phlebitis, and allergic reactions. Nurses are responsible for verifying medications, maintaining sterile technique, and monitoring for adverse reactions.
Notes to support the presentation 'Introduction to the Visual Infusion Phlebi...ivteam
1) Premature peripheral IV catheter failure and infusion phlebitis negatively impact patient treatment and safety. Regular monitoring of IV sites using a standardized tool like the VIP score is essential.
2) The VIP score was developed to reduce infusion phlebitis and has benefits for early recognition of other issues. It encourages observation of IV sites and identifies problems early.
3) The VIP score is recommended internationally and incorporated into national guidelines for appropriate discontinuation of peripheral IV catheters based on the level of phlebitis.
Intravenous (IV) injection delivers medication directly into the bloodstream through a vein. An IV infusion involves a slow drip of medication over time to provide a constant volume of therapy. IV injection allows for quick delivery of large amounts of medication into the bloodstream and rapid action. The procedure involves selecting a suitable vein, preparing the site, inserting a needle, attaching tubing, and monitoring the infusion for complications. While effective, IV injection can cause pain, requires supervision, and risks infection.
An intravenous bolus involves rapidly administering a concentrated dose of medication directly into the bloodstream over a short period of time, usually 1 to 30 minutes. It is used when quick absorption of the medication is needed but not for patients with low cardiac output or edema. Proper preparation of the nurse, environment, equipment and patient is required to safely administer an IV bolus. Potential complications include local issues like infiltration or thrombosis at the injection site as well as systemic issues such as air embolism, hematoma, infection, circulatory overload, or allergic reaction.
This document outlines negative pressure wound therapy (NPWT), also known as vacuum assisted closure (VAC). It discusses the mechanism of action, components, indications, contraindications, application process, advantages, monitoring considerations, potential complications, and conclusion regarding NPWT. NPWT applies sub-atmospheric pressure to a wound through a sealed dressing to promote healing in acute or chronic wounds by removing excess fluid, increasing blood flow, and stimulating the growth of new tissue. It is indicated for various open wounds where closure is not possible, such as pressure ulcers, surgical wounds, diabetic ulcers, and more. Contraindications include wounds with necrotic tissue or exposed anatomy. Monitoring includes pressure levels, drainage
This document provides guidance on inserting a peripheral intravenous cannula. It describes the equipment needed, vein selection, insertion procedure, documentation, and potential complications. The aim is to safely deliver treatment without discomfort or tissue damage while maintaining venous access. Proper preparation, aseptic technique, and site care are emphasized to prevent infections and other complications.
Intravenous therapy involves administering liquid substances like medications directly into a vein. There are different methods of intravenous access, including peripheral IV lines inserted into arm or leg veins and central lines that terminate in larger veins near the heart. IV therapy carries risks like infection, phlebitis from vein irritation, fluid overload, and electrolyte imbalances if improper fluids are administered. Precise equipment and trained staff are needed to safely deliver intravenous medications and fluids.
True. Backflow of blood into the tubing proves that the catheter tip is properly placed within the vein and not outside the vein where it could cause infiltration.
This document provides guidance on intravenous cannulation. It discusses the indications for IV cannulation including fluid replacement, medication administration, blood transfusions, and monitoring. The key steps for cannulation are outlined, including preparing the patient, identifying a suitable vein, inserting the cannula at a 10-30 degree angle, securing the cannula with a dressing, and documenting the procedure. Potential complications from cannulation like infection, infiltration of fluids, thrombosis, and extravasation are also summarized.
Dr. Vishal Kr. Kandhway presented on IV cannulation. IV cannulation is the second most invasive hospital procedure, with 85-95% of patients receiving IVs. It is used to administer fluids, medications, blood products, and for imaging with contrast. Proper vein selection is important, avoiding areas near joints, scars, or previous cannulation. The forearm and back of the hand are common sites. Proper equipment, cleaning, and insertion technique are emphasized to safely place the IV and avoid complications like hematoma, infection, or puncturing an artery. New methods like AccuVein use infrared light to illuminate veins, aiding cannulation for difficult patients.
The document discusses intravenous (IV) admixtures and preparations. Some key points:
- IV admixtures involve preparing mixtures of two or more drugs into an IV fluid bag or bottle, done under doctor's orders by a trained pharmacist to avoid errors.
- Characteristics like solubility, osmolality, and pH must be considered and adjusted to match blood levels.
- IV sets include spikes, drip chambers, clamps, tubing, and needles to administer fluids and drugs via IV. Proper sterile technique is crucial when preparing IVs.
Postoperative care & management after sui operationsWafaa Benjamin
Surgeries for SUI are not without hazards.
Proper preoperative assessment, patient counseling, meticulous postoperative care& early discovery of complications are the mainstays of management.
Voiding difficulty after anti-incontinence surgeries can become persistent and have a significant impact on quality of life.
Supra-pubic catheter & CISC should be added to our practice.
Careful surgical technique with avoidance of over-elevation might play a role in prevention of VD.
This presentation is about Iv injection which is used by all health professionals to the patients. This presentation includes definition, purpose, types, equipment with procedure and role of nurse all are included.. this is very helpful demonstration for health care settings.
There are three main types of intravenous cannulation: peripheral IV cannula, central line IV cannula, and mid-line IV cannula. IV cannulation is indicated for blood sampling, fluid/medication administration, hemodynamic monitoring, and transfusion of blood or blood products. Contraindications include sites near infection, edematous areas, and areas with bleeding/clotting disorders. The procedure involves preparing equipment and the patient, finding a suitable vein, inserting the cannula, securing it with a dressing, and documenting. Potential complications are infiltration, infection, phlebitis, and thrombophlebitis, which can be prevented through proper technique, regular site inspection, and early troubleshooting.
This document discusses different types of injections and injection techniques. It describes intradermal injections which are administered just under the skin, subcutaneous injections which are used for slow, sustained absorption of medications like insulin into fatty tissues, intramuscular injections which deliver medications into muscles for rapid systemic action, and intravenous injections which deliver fluids directly into blood vessels. It provides details on sites, needle sizes, and proper techniques for each type of injection to ensure safety and effectiveness.
The guidelines address whether blood loss should be routinely quantified during management of the third stage of labour to diagnose PPH. No study directly answered this question. Evidence from observational studies showed that visual estimation of blood loss consistently underestimates actual blood loss compared to quantitative measurement. However, the guidelines note that some women may require intervention for PPH even with less blood loss if they are anemic. Therefore, the guidelines do not recommend routine quantification but emphasize the need for timely diagnosis and treatment of PPH.
This Quick Reference Guide summarizes evidence-based guidelines for the prevention and treatment of pressure ulcers developed by the European Pressure Ulcer Advisory Panel and American National Pressure Ulcer Advisory Panel over 4 years. It provides definitions for pressure ulcers and classifications, as well as recommendations for assessment, wound care, dressings, infection treatment, and other areas. The full Clinical Practice Guideline contains more detailed analysis, research discussion, methodology, and acknowledgments.
This document provides guidelines for the identification, management, and referral of adults with chronic kidney disease (CKD) in the UK. It was developed by a committee representing nephrology, general practice, clinical biochemistry, and other relevant specialties. The guidelines include recommendations on organizing care for CKD patients, identifying CKD through measurements of kidney function and tests for proteinuria, managing CKD patients based on disease severity, and referring patients to nephrologists. The committee reviewed available evidence to develop evidence-based guidelines appropriate for the UK healthcare system. Implementation of the guidelines aims to improve care for adults with CKD.
Putting triage theory into practice at the scene of multiple casualty vehicul...Jamie Ranse
This research project investigated the experiences of ambulance paramedics in undertaking pre-hospital multiple casualty triage at the scene of a motor vehicle accident. Key objectives included the investigation of the application of principles and procedures of multi casualty triage systems, the use of situational cues and other contextual factors influencing triage practice. This led to the development of recommendations for the future education of practitioners in the process of multiple casualty triage.
PHÒNG NGỪA VÀ ĐIỀU TRỊ BĂNG HUYẾT SAU SINH THEO WHOSoM
The document provides recommendations from the WHO for the prevention and treatment of postpartum haemorrhage (PPH). It details the guideline development process, which included reviewing evidence from 22 systematic reviews using the GRADE methodology. The WHO Technical Consultation adopted 32 recommendations, which are presented in Boxes A, B and C. The recommendations cover the prevention of PPH during vaginal and caesarean births, the treatment of PPH, and the organization of PPH care. Key recommendations include the use of uterotonics (preferably oxytocin) for PPH prevention and treatment, and misoprostol administration by community health workers when skilled attendants are unavailable.
The document provides recommendations from the WHO for the prevention and treatment of postpartum haemorrhage (PPH). It details the guideline development process, which included reviewing evidence from 22 systematic reviews using the GRADE methodology. The WHO Technical Consultation adopted 32 recommendations, which are presented in Boxes A, B and C. The recommendations cover the prevention of PPH, treatment of PPH, and organization of PPH care. Key recommendations include the use of uterotonics (preferably oxytocin) during the third stage of labour to prevent PPH, and the use of uterotonics (preferably oxytocin), uterine massage, fluid resuscitation and other conservative interventions for PPH treatment. The
European clinical practice guideline on diagnosis hiponatremiaJaime dehais
1. Hyponatraemia, defined as a serum sodium concentration less than 135 mmol/l, is common in clinical practice and associated with increased mortality, morbidity, and length of hospital stay.
2. Despite this, management of patients with hyponatraemia remains problematic due to diverse approaches across institutions and specialties.
3. The European Society of Intensive Care Medicine, European Society of Endocrinology, and European Renal Association developed this joint clinical practice guideline to provide a standardized approach to diagnosis and treatment of hyponatraemia.
This document provides guidelines for physiotherapists on the use of injection therapy. It was developed by a panel with expertise in medicine, pharmacology, and injection therapy. The panel conducted a literature review to identify the clinical efficacy, drugs used, indications, contraindications, techniques, frequency of use, aftercare, and record keeping for injection therapy. The guidelines are intended to encourage high standards of practice and reduce variation by making evidence-based recommendations.
The presentation provides an overview of a hospital training program at several hospitals in Jashore, Bangladesh. It discusses the objectives of the training program which are to learn standard treatment patterns, communicate with patients, understand how hospital pharmacies operate, and share information with doctors. The training areas covered include the Chowgacha Upazilla Health Complex, 250 Bedded General Hospital Jashore, Queens Hospital PVT Ltd, and Ad-Din Sakina Medical College Hospital. The presentation outlines the roles and responsibilities of pharmacists in different hospital units including the pharmacy, outdoor patient dispensary, emergency ward, medicine unit, pediatric unit, gynecology unit, CCU, surgery department, and orthopedics unit. It
This document provides an overview of negative pressure wound therapy (NPWT), including its principles, evidence base, treatment applications, and perspectives. NPWT uses subatmospheric pressure to promote wound healing by removing excess fluid, stimulating blood flow, and encouraging granulation tissue formation. The evidence for NPWT comes primarily from case studies and randomized controlled trials showing improved healing outcomes for various acute and chronic wounds compared to standard care. Future developments may include more portable single-use devices and systems that integrate sensors for remote monitoring. Overall, NPWT is a valuable tool for managing hard-to-heal wounds, but its use and cost-effectiveness require careful consideration.
1. This study evaluated the effectiveness of early physiotherapy in reducing the risk of secondary lymphedema after breast cancer surgery involving axillary lymph node dissection.
2. 120 women were randomly assigned to either an early physiotherapy group or a control group that received only education. The physiotherapy group underwent manual lymph drainage, scar massage, and shoulder exercises for three weeks after surgery.
3. At the one year follow-up, 18 women developed secondary lymphedema, with 14 in the control group and 4 in the physiotherapy group. This difference was statistically significant, indicating early physiotherapy may help prevent secondary lymphedema.
This protocol outlines guidelines for inserting, maintaining, and removing peripheral vascular devices (PVDs). It aims to standardize practices to improve patient care. The document defines relevant terms and lists indications for PVD insertion, such as blood sampling or IV medication administration. Contraindications are also noted, such as inserting a device in an injured extremity. Equipment, patient preparation, insertion procedure, maintenance including dressing changes, and removal are described. The goal is to provide standards for proper PVD care while allowing for clinical judgement in individual cases.
This document provides a summary of recommendations for preventing and treating pressure ulcers from an international guideline developed by the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance. The guideline aims to assist healthcare professionals in providing evidence-based care for individuals at risk of or experiencing pressure ulcers. It was developed using an explicit scientific methodology and consensus process to evaluate available research studies and expert opinions. Printed copies of the full clinical practice guideline are available in English through the websites of the collaborating organizations.
The document is a quick reference guide for the prevention and treatment of pressure ulcers published by the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance. It provides concise summaries and recommendations based on an evidence review. The guide defines key terms, outlines risk assessment and prevention strategies like nutrition, repositioning and support surfaces. It also covers treatment methods such as wound dressings, debridement and biophysical agents. Special populations like bariatric and critically ill individuals are addressed as well.
Modern perioperative fluid management
1. What's wrong with traditional practice? Traditional practices rely on surrogate endpoints for fluid resuscitation that have limitations.
2. Fluid restriction. Evidence shows hypervolemia from excessive fluids can cause harm through salt and water loads.
3. Fluid optimisation and goal directed fluid therapy. Using preload-sensitive parameters to guide optimal fluid therapy for high-risk patients, while still correcting hypovolemia which is important for resuscitation.
4. Time to change practice? The evidence calls for a change in practice away from arbitrary decision making toward optimized, goal-directed fluid management.
This randomized controlled trial examined the effect of manual lymph drainage (MLD) combined with guidelines and exercise therapy, compared to guidelines and exercise therapy alone, on arm lymphedema related to breast cancer. 160 patients receiving axillary lymph node dissection for breast cancer were randomly assigned to receive either 6 months of MLD combined with guidelines and exercise therapy (intervention group), or guidelines and exercise therapy alone (control group). The cumulative incidence of arm lymphedema at 12 months was comparable between the groups, with rates of 24% in the intervention group and 19% in the control group. The time to develop lymphedema was also comparable between groups during the first year after surgery. The study found that MLD
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
All manuscripts are subject to rapid peer review. Those of high quality (not previously published and not under consideration for publication in another journal) will be published without delay
Radiotherapy plays an important role in the treatment of lung cancer. It can be used as a primary treatment for early-stage lung cancers, as an adjuvant treatment after surgery, and concurrently with chemotherapy. New techniques like IMRT and SBRT allow for more precise radiation delivery to tumors while minimizing dose to surrounding healthy tissues. Ongoing challenges include improving prevention, early detection, access to innovative treatments, and multidisciplinary coordination of lung cancer care.
The nursing management of patients with venous leg ulcersGNEAUPP.
This document provides recommendations for the nursing management of patients with venous leg ulcers. It covers recommendations for assessment, compression therapy, cleansing, debridement, dressings, skin grafts, contact sensitivity, drug treatments, education and training. The recommendations are based on evidence from systematic reviews and clinical evidence, with recommendation statements graded based on the strength of evidence. The aim is to improve outcomes for patients with venous leg ulcers by reducing variations in practice.
Similar to Guias clinicas de extravasacion EONS (20)
The document discusses guidelines for preventing and treating dermatologic toxicities caused by EGFR inhibitor therapies, noting that a rash occurs in the majority of patients and can impact quality of life. It recommends systemic minocycline or doxycycline during the first 1-6 weeks of EGFR inhibitor therapy to prevent acneiform rash based on level II evidence with a grade A recommendation. Topical hydrocortisone cream with sunscreen and moisturizer is also recommended to prevent and treat rash.
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El documento proporciona instrucciones sobre los cuidados necesarios para pacientes que reciben radioterapia interna con fuentes selladas, incluyendo preparación del paciente, restricciones para el personal y visitas, y medidas de protección contra la radiación. Se requiere que el paciente permanezca aislado en una habitación privada y que el tiempo de exposición al paciente se limite estrictamente. El personal solo puede pasar 15 minutos por turno junto al paciente y debe trabajar detrás de blindajes para protegerse de la radiación.
El documento proporciona instrucciones sobre los cuidados necesarios para pacientes que reciben radioterapia con fuentes radiactivas no selladas, incluyendo informar al paciente sobre el procedimiento, asignar una habitación privada con puerta cerrada, limitar las visitas y actividades de la paciente, tomar precauciones con secreciones corporales usando guantes y utensilios desechables, cambiar la ropa de cama solo si está manchada, y dar de alta a la paciente cuando los isótopos radiactivos en su cuerpo sean seguros.
El documento resume los conceptos básicos de la nutrición como el proceso de asimilación de alimentos y líquidos para el funcionamiento y mantenimiento del organismo. Explica que la nutrición estudia el equilibrio homeostático a nivel molecular y de los macrosistemas, y cómo determinar dietas para personas sanas o enfermas. Además, clasifica los macronutrientes, micronutrientes y los principales grupos de alimentos, y menciona las consecuencias del exceso o déficit nutricional.
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El documento habla sobre emergencias oncológicas. Menciona algunas situaciones urgentes como el síndrome de vena cava superior, taponamiento cardíaco, obstrucción intestinal, obstrucción urinaria, obstrucción biliar, compresión de la médula espinal, hipertensión endocraneana, meningitis neoplásica, convulsiones, leucocitostasis intracerebral, hemoptisis, obstrucción aérea, hipercalcemia, síndrome de secreción inapropiada de hormona antidiurética, acidosis láctica
El documento resume la epidemiología, factores de riesgo, manifestaciones clínicas, diagnóstico, estadificación y tratamiento del cáncer de cuello uterino y cáncer de endometrio. El cáncer de cuello uterino afecta a aproximadamente 500,000 mujeres por año y es causado principalmente por el virus del papiloma humano. El cáncer de endometrio es el segundo cáncer ginecológico más común y factores como la obesidad y la falta de hijos aumentan el riesgo. Ambos cán
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La quimioterapia es un tratamiento importante para el cáncer que usa medicamentos para destruir células cancerosas. Existen diferentes tipos de medicamentos quimioterapéuticos que actúan en diferentes puntos del ciclo celular. La quimioterapia se administra en ciclos para permitir que las células sanas se recuperen entre tratamientos y suele tener efectos secundarios como náuseas. El proceso de administración de quimioterapia requiere seguridad y monitoreo del paciente.
El documento habla sobre la prevención del cáncer. Explica que el cáncer se produce por la interacción entre factores genéticos y ambientales como carcinógenos físicos, químicos y biológicos. Detalla la importancia de la prevención primaria a través de estilos de vida saludables y la eliminación de factores de riesgo como el tabaco. También habla sobre la prevención secundaria mediante exámenes periódicos para detección temprana, lo que mejora los resultados del tratamiento.
El documento trata sobre genética y cáncer. Explica que el cáncer se produce por la acumulación de varias mutaciones genéticas que alteran el control del crecimiento celular. Algunos genes como los supresores tumorales y los protooncogenes juegan un papel clave. Existen algunos tipos de cáncer hereditarios asociados a mutaciones en genes específicos como el retinoblastoma.
Este documento describe los tipos y usos de catéteres para acceso venoso, así como los procedimientos para su colocación, habilitación y cuidados. Explica que los catéteres implantables se usan comúnmente para quimioterapia y nutrición parenteral en pacientes con cáncer. Detalla dos tipos principales de catéteres, los semi-implantables y los totalmente implantables, y sus ventajas e inconvenientes. Además, explica los pasos para habilitar un catéter de forma aséptica y los cuidados necesarios para
Las extravasaciones ocurren cuando un medicamento se escapa del vaso sanguíneo durante su administración. Pueden causar dolor, necrosis o formación de escaras en el tejido. El tratamiento consiste en detener la administración del fármaco, intentar eliminarlo de la zona, administrar corticoides localmente y enfriar o calentar la zona según el tipo de quimioterápico. Es importante prevenir las extravasaciones eligiendo buenas venas y formando al personal médico en el procedimiento correcto.
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The biomechanics of running involves the study of the mechanical principles underlying running movements. It includes the analysis of the running gait cycle, which consists of the stance phase (foot contact to push-off) and the swing phase (foot lift-off to next contact). Key aspects include kinematics (joint angles and movements, stride length and frequency) and kinetics (forces involved in running, including ground reaction and muscle forces). Understanding these factors helps in improving running performance, optimizing technique, and preventing injuries.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdfRahul Sen
Time-lapse embryo monitoring is an advanced imaging technique used in IVF to continuously observe embryo development. It captures high-resolution images at regular intervals, allowing embryologists to select the most viable embryos for transfer based on detailed growth patterns. This technology enhances embryo selection, potentially increasing pregnancy success rates.
PGx Analysis in VarSeq: A User’s PerspectiveGolden Helix
Since our release of the PGx capabilities in VarSeq, we’ve had a few months to gather some insights from various use cases. Some users approach PGx workflows by means of array genotyping or what seems to be a growing trend of adding the star allele calling to the existing NGS pipeline for whole genome data. Luckily, both approaches are supported with the VarSeq software platform. The genotyping method being used will also dictate what the scope of the tertiary analysis will be. For example, are your PGx reports a standalone pipeline or would your lab’s goal be to handle a dual-purpose workflow and report on PGx + Diagnostic findings.
The purpose of this webcast is to:
Discuss and demonstrate the approaches with array and NGS genotyping methods for star allele calling to prep for downstream analysis.
Following genotyping, explore alternative tertiary workflow concepts in VarSeq to handle PGx reporting.
Moreover, we will include insights users will need to consider when validating their PGx workflow for all possible star alleles and options you have for automating your PGx analysis for large number of samples. Please join us for a session dedicated to the application of star allele genotyping and subsequent PGx workflows in our VarSeq software.
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“Psychiatry and the Humanities”: An Innovative Course at the University of Montreal Expanding the medical model to embrace the humanities. Link: https://www.psychiatrictimes.com/view/-psychiatry-and-the-humanities-an-innovative-course-at-the-university-of-montreal
Giloy in Ayurveda - Classical Categorization and SynonymsPlanet Ayurveda
Giloy, also known as Guduchi or Amrita in classical Ayurvedic texts, is a revered herb renowned for its myriad health benefits. It is categorized as a Rasayana, meaning it has rejuvenating properties that enhance vitality and longevity. Giloy is celebrated for its ability to boost the immune system, detoxify the body, and promote overall wellness. Its anti-inflammatory, antipyretic, and antioxidant properties make it a staple in managing conditions like fever, diabetes, and stress. The versatility and efficacy of Giloy in supporting health naturally highlight its importance in Ayurveda. At Planet Ayurveda, we provide a comprehensive range of health services and 100% herbal supplements that harness the power of natural ingredients like Giloy. Our products are globally available and affordable, ensuring that everyone can benefit from the ancient wisdom of Ayurveda. If you or your loved ones are dealing with health issues, contact Planet Ayurveda at 01725214040 to book an online video consultation with our professional doctors. Let us help you achieve optimal health and wellness naturally.
Discover the benefits of homeopathic medicine for irregular periods with our guide on 5 common remedies. Learn how these natural treatments can help regulate menstrual cycles and improve overall menstrual health.
Visit Us: https://drdeepikashomeopathy.com/service/irregular-periods-treatment/
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Statistics- Statistics is the science of collecting, organizing, presenting, analyzing and interpreting numerical data to assist in making more effective decisions.
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Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga
GASTROINTESTINAL INFECTIONS AND GASTRITIS
Osvaldo Bernardo Muchanga
Gastrointestinal Infections
GASTROINTESTINAL INFECTIONS result from the ingestion of pathogens that cause infections at the level of this tract, generally being transmitted by food, water and hands contaminated by microorganisms such as E. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Staphylococcus, Rotavirus among others that are generally contained in feces, thus configuring a FECAL-ORAL type of transmission.
Among the factors that lead to the occurrence of gastrointestinal infections are the hygienic and sanitary deficiencies that characterize our markets and other places where raw or cooked food is sold, poor environmental sanitation in communities, deficiencies in water treatment (or in the process of its plumbing), risky hygienic-sanitary habits (not washing hands after major and/or minor needs), among others.
These are generally consequences (signs and symptoms) resulting from gastrointestinal infections: diarrhea, vomiting, fever and malaise, among others.
The treatment consists of replacing lost liquids and electrolytes (drinking drinking water and other recommended liquids, including consumption of juicy fruits such as papayas, apples, pears, among others that contain water in their composition).
To prevent this, it is necessary to promote health education, improve the hygienic-sanitary conditions of markets and communities in general as a way of promoting, preserving and prolonging PUBLIC HEALTH.
Gastritis and Gastric Health
Gastric Health is one of the most relevant concerns in human health, with gastrointestinal infections being among the main illnesses that affect humans.
Among gastric problems, we have GASTRITIS AND GASTRIC ULCERS as the main public health problems. Gastritis and gastric ulcers normally result from inflammation and corrosion of the walls of the stomach (gastric mucosa) and are generally associated (caused) by the bacterium Helicobacter pylor, which, according to the literature, this bacterium settles on these walls (of the stomach) and starts to release urease that ends up altering the normal pH of the stomach (acid), which leads to inflammation and corrosion of the mucous membranes and consequent gastritis or ulcers, respectively.
In addition to bacterial infections, gastritis and gastric ulcers are associated with several factors, with emphasis on prolonged fasting, chemical substances including drugs, alcohol, foods with strong seasonings including chilli, which ends up causing inflammation of the stomach walls and/or corrosion. of the same, resulting in the appearance of wounds and consequent gastritis or ulcers, respectively.
Among patients with gastritis and/or ulcers, one of the dilemmas is associated with the foods to consume in order to minimize the sensation of pain and discomfort.
2. Contents
Extravasation guidelines 2007
Introduction to the Extravasation guidelines
Introduction 4
Overall Goal 4
Specific Targets and Aims 4
The Nurse’s Role 5
Key points to understand from the extravasation guidelines
What is extravasation? 6
Types of extravasation 6
When does extravasation occur? 8
Prevalence 8
Risk factors 8
What are the implications of extravasation? 10
Initial symptoms 10
Tissue damage 10
Surgery 11
Impact on cancer therapy 11
Other consequences 11
How is extravasation recognised? 12
Patient reporting 12
Visual assessment 13
Checking the infusion line 13
Distinguishing extravasation vs. other conditions 14
How is extravasation prevented? 15
Standard procedures 15
Training 15
Patient education 16
Equipment selection 16
Vein selection in peripheral administration 17
Administering intravenous treatment 17
2
3. How is extravasation managed? 19
Procedures and protocols 19
Management – initial steps 20
Management – next steps 21
Antidotes 24
Anthracycline extravasation 26
Extravasation kit 26
Surgery and debridement 26
Documentation and reporting 27
Summary 29
Appendices 30
List of drugs: vesicants, irritants and non-vesicants 30
Distinguishing extravasation from other conditions 31
Vein selection procedure 32
Administering Savene™ (dexrazoxane) 33
Administering dimethylsulfoxide 34
Administering hyaluronidase 35
Extravasation kit 36
Documentation template 37
References 41
We would like to thank the following people for their guidance in helping to develop these
documents:
Yvonne Wengström OCN, PhD, Past President of the European Oncology Nursing Society
(EONS)
Jan Foubert RPN, PhD, Senior Lecturer in Nursing and Midwifery, Erasmushogeschool,
Department of Healthcare, Brussels, Belgium
Anita Margulies BSN, RN, Clinical Nurse and Lecturer, Board Member of EONS, Klinik und
Poliklinik für Onkologie, Universitätsspital, Zürich, Switzerland
Helen Roe RN, BSc(Hons), Consultant Cancer Nurse / Lead Chemotherapy Nurse,
North Cumbria Acute Hospitals NHS Trust; Chair of the United Kingdom
Oncology Nursing Society (UKONS) North Zone Chemotherapy Group,
United Kingdom
Sebastien Bugeia Oncology Nurse at the “Institut Gustave Roussy” (Villejuif, FRANCE), Board
Member of the French Oncology Nursing Society (AFIC).
3
4. Introduction
With over 100,000 doses of chemotherapy and in excess of 1,000,000 intravenous (IV) infusions
given every day around the world, keeping adverse events and complications of these
procedures to a minimum is important both for the patients receiving them and the healthcare
systems in which they take place.
Extravasation is a serious condition that warrants special attention from the healthcare
professionals involved in administering intravenous medications. This educational module
summarises and explains the most recent literature and recommendations on extravasation in
the clinical setting – from prevention and recognition to possible treatment with antidotes. It
also provides an outline of the pivotal role that nurses play in the patient management process.
The scope of this document is to describe and explain the prevention, recognition and
management of extravasation in general terms. More detailed descriptions of techniques for
proper cannulation or phlebotomy (an important skill for the prevention of extravasation) will
not be dealt with in this guideline.
Overall Goal
Specific Targets and Aims
The Nurse’s Role
Overall Goal
The overall goal of these guidelines is to help nurses understand and recognise extravasation,
and improve the prevention and overall management of extravasations in cancer patients.
Specific Targets and Aims
The targets and aims of this module are to:
■ Increase nurses’ knowledge of specific elements of extravasation:
Causes and risk factors for extravasation
Features and symptoms of extravasation
Differences vs. flare and other reactions
Consequences of extravasation
Prevention measures
The use of antidotes in treating extravasation
■ Encourage successful management of extravasation
■ Update and inform nurses of the current standards from different guidelines and protocols
■ Encourage adoption of procedures for extravasation that fit with the current guidelines
4
Table of contents
5. The Nurse’s Role
Nurses are among the best placed professionals to recognise and deal with extravasation in the
clinical setting. The nurses who routinely provide cancer therapies intravenously (either
peripherally or through central venous access devices (CVADs) are particularly important in the
ongoing management of this possibly serious complication of therapy.
Nurses have a key role to play in identification and management of extravasation, and, of course,
in preventing it. From maintaining a high standard of care in the delivery of IV drugs to
managing the treatment strategy for extravasation, they have many important duties in this area.
Nurses represent an important link for ensuring that extravasation is prevented, diagnosed and
managed where possible. Their role in providing information and providing ongoing support for
patients relating to cancer therapy (and the need to be vigilant for any symptoms) is critical in
cutting the incidence of extravasation.
This module will discuss the role of the nurse in extravasation management and highlight
information and issues that will assist nurses to perform these roles more efficiently.
5
Table of contents
6. What is extravasation?
In a general sense, extravasation refers to the process by which one substance (e.g., fluid, drug)
leaks into the surrounding tissue.1 In terms of cancer therapy, extravasation is defined as the
accidental leakage from its intended compartment (the vein) into the surrounding tissue. 2
Usually, this occurs when intravenous (IV) medication passes from the blood vessel into the
tissue around the blood vessels and beyond.1–4
A broader definition of extravasation includes the resulting injury. Depending on the substance
that extravasates into the tissue, the degree of injury can range from a very mild skin reaction to
severe necrosis.4
Types of extravasation
Types of extravasation
Extravasation can be classified according to the reaction that is caused by the substance passing
into the surrounding tissue. Many different drugs have been classified according to the type of
reaction they cause; however, for the purpose of this discussion, we will refer only to cancer
therapies. It should be noted, however, that cancer therapies are not the only drugs that cause
damage when extravasated, and non-cancer therapies (e.g., aminophylline, calcium solutions,
hypertonic glucose, phenytoin, total parenteral nutrition, X-ray contrast media) can be equally as
destructive.5
Cancer drugs can be grouped into 3 broad categories, based on their potential to cause tissue
damage upon extravasation:3
■ Non-vesicants
■ Irritants
■ Vesicants
Non-vesicants do not cause ulceration. In fact, if they are extravasated, they rarely produce an
acute reaction or progress to necrosis.3 Irritants, on the other hand, do tend to cause pain at, and
around the injection site, and along the vein. They may or may not also cause inflammation.
Some irritants do also have the potential to cause ulceration, but only in the case that a very
large amount of the drug is extravasated into the tissue.3
6
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7. Vesicants are drugs that have the potential to cause blistering and ulceration and which when
left untreated, can lead to the more serious side effects of extravasation such as tissue
destruction and necrosis.3 These drugs can be sub-classified according to the mechanism by
which they cause damage, which is also important since it affects the management strategy.3
■ DNA-binding: These drugs are absorbed locally and enter the cells, bind to nucleic acids (i.e.,
DNA) and precipitate the death of the cell. Following cell death these agents can be re-
released to destroy non-cancer cells. They can be divided into 3 categories:3
Anthracyclines
Alkylating agents
Others
■ Non-DNA-binding: These drugs initiate cancer cell death by mechanisms other than binding
DNA. They can be divided into 2 groups:3
Vinca alkaloids
Taxanes
For a comprehensive list of vesicants (including all subcategories), irritants and non-vesicants
please refer to Appendix 1.
7
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8. When does extravasation occur?
In an ideal situation, extravasation of vesicant cancer therapies would never occur. Despite the
many precautionary measures in place, accidental extravasation does still occur, both from
peripheral lines and from CVADs.
Prevalence
Risk factors
Prevalence
Extravasation is not as rare as some people may think. In cancer therapy experts estimate that it
accounts for 0.5% to 6.0% of all adverse events associated with treatment. 4 But, when you
consider that adverse events with cancer therapy are quite common, the absolute number of
extravasations which take place is significant.6
Data regarding extravasation from CVADs is more limited. One small study estimated that
extravasation occurs about 6% of the time.4
Risk factors
Some extravasations can be accounted for by error in the IV procedure, etc.4,7 However, patients
receiving these cancer therapies may have multiple risk factors that make IV infusion very
difficult. For example, cancer patients – with a tendency for thin, fragile and mobile veins – are at
higher risk of extravasation than the general population.4
In addition to factors relating to the procedure and to the patient, factors associated with the
equipment/material used, concomitant medications and the treatments themselves can also
increase the likelihood of extravasation. Some the most common factors known to increase the
risk of extravasation are listed below:4,8-10
■ Patient factors
Small blood vessels (e.g., infants and young children)
Fragile veins (e.g., elderly, cancer patients)
Hard, sclerosed veins
Mobile veins
Impaired circulation (e.g., cannula sited on side of mastectomy, lymphoedema)
Obstructed vena cava (elevated venous pressure can cause leakage)
Pre-existing conditions (diabetes, peripheral circulatory conditions like Raynaud’s syndrome,
radiation damage)
Obesity
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9. ■ Trouble reporting symptoms early
Inability to report stinging/discomfort (e.g., sedated, confused)
Decreased sensation (e.g., as a result of neuropathy, diabetes, peripheral vascular disease)
■ Cannulation and infusion procedure
Untrained or inexperienced staff
Multiple attempts at cannulation
Unfavourable cannulation site (e.g., back of hand vs. forearm, close to bone)
Bolus injection
High flow pressure
■ Equipment
Steel butterfly needle
Catheter size and type
■ Treatment
Ability to bind directly to DNA
Ability to kill replicating cells
Ability to cause tissue or vascular dilatation
pH
Osmolality
Characteristics of diluent
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10. What are the implications of extravasation?
In general, extravasation is to be avoided. Even in patients who do not progress to ulcerative and
necrotic tissue damage may still experience pain and discomfort, as well as indirect
consequences, such as disruption of treatment and committing hospital resources to the
management of extravasation.3,4 The specific symptoms of extravasation, as well as their wider
consequences, are discussed in this section.
Initial symptoms
Tissue damage
Surgery
Impact on cancer therapy
Other consequences
Initial symptoms
The initial symptoms of extravasation occur immediately after the blood vessel has been
breached. Depending on the agent and the patient extravasation may be accompanied by
discomfort or pain, which can range from mild to intense. Patients often describe the pain as a
burning sensation.4
The pain may be followed, in the next few hours, by erythema and oedema near the injection
site.3 In addition, there may be discolouration or redness of the skin near the site.4
The initial symptoms of extravasation are subtle, however, and can be similar for the
extravasation of different agents (i.e., irritants vs. vesicants). The progression from these initial
symptoms, however, differs greatly for irritants and vesicants – particularly relating to
permanent damage to the tissue.3
Tissue damage
Vesicants, by definition, have the potential to cause tissue damage upon extravasation from the
vein. Like the initial symptoms, the extent of tissue damage can vary greatly between different
treatment regimens and patients.4
Tissue destruction caused by leakage of vesicants into surrounding tissue may be progressive in
nature, and may happen quite slowly with little pain. Induration or ulcer formation is by no
means an immediate phenomenon – as it takes time to develop. 5 In general, tissue damage
begins with the appearance of inflammation and blisters at or near the site of injection.
Depending on the drug and other factors, this can then progress to ulceration, and then in some
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11. cases may progress to necrosis of the local tissue.5 Necrosis can occasionally be so severe that
function in the affected area cannot be recovered and surgery is required.5
If extravasation occurs in the forearm, the damage to tissue includes skin and subcutaneous
tissue damage. If the extravasation occurs next to a nerve, ligament or tendon, then the damage
can extend to that tissue and have an impact on sensation and function.11
Surgery
If vesicant extravasation is not recognised and dealt with promptly, the tissue damage can
become so severe that surgical debridement and plastic surgery (possibly including skin
grafting) may become necessary.5 In the event that extravasation does affect nerves, ligaments
or tendons, the damage may necessitate more extensive surgery.4
It is estimated that one third of vesicant extravasations give rise to ulceration. This ulceration, in
combination with pain and necrosis, can be an indication for surgical intervention.5,12
Impact on cancer therapy
Most extravasation protocols call for the immediate cessation of the drug delivery, followed by
measures to prevent further spread of the cancer drug into the tissue. 8,13–16 As a result, the
delivery of cancer therapy may be delayed until the extravasation is resolved.
Some guidelines specifically address the issue of re-establishment of IV cancer therapy –
recommending the establishment of an IV site in another limb.13 However, most guidelines do
not specifically address this process.8,14–16
Other consequences
Apart from the physical consequences, extravasation can lead to longer hospital stay, more
consultations and increased length of follow-up care; the need for physical therapy; high
treatment costs; psychological consequences (e.g., distress, anxiety); and even lost wages.4 In
addition, it is not uncommon for hospitals and their staff to be faced with a lawsuit following an
extravasation.5
All of these factors contribute to the seriousness of an extravasation, and can add to the toll on
the patient, their family and the healthcare system. One of the primary goals of extravasation
protocols and guidelines is to educate healthcare professionals about the avoidance of serious
complications and preventions of extravasations before patients require surgical processes.
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12. How is extravasation recognised?
It is critical that an extravasation is recognised and diagnosed early. The most effective way to
recognise and detect extravasation in its early stages is to be aware of and act on all relevant
signs and symptoms. Telltale signs and symptoms can be gathered from patient reports, simple
visual assessment of the injection site, and careful monitoring of the IV device. Then, once an
extravasation is suspected, it will also be important to rule out other possible conditions, such as
flare reaction.4,7
The quality of the nursing assessment during administration can play a key role in minimising
frequency and severity, since delays in the recognition and treatment of vesicant extravasation
increase the likelihood of developing tissue damage and necrosis.4,17
Since extravasation could have serious consequences, a second opinion is always warranted. If
there is any doubt as to whether or not it has occurred, stop and ask for help.
Patient reporting
Visual assessment
Checking the infusion line
Distinguishing extravasation vs. other conditions
Patient reporting
Patients need to know the possible side effects of the treatments they are receiving. In the case
of extravasation, it is recommended that the patient be told about the possible complications
and to be aware of any pain/sensation at the site of infusion. Patients should feel that they can
report any strange sensations as soon as they arise, so the healthcare team can take these
symptoms into account.
The most important patient-reported symptoms for assessing extravasation relate to the
sensation around the site of injection – or, in the case of a central line, around the CVAD and
surrounding area. Typically these complaints include:8,18
■ Pain
■ Swelling
■ Redness
■ Discomfort
■ Burning
■ Stinging
■ Other acute changes at the site of extravasation
None of these are confirmation of an extravasation on their own, but should be treated with
concern and warrant further examination, such as testing the patency of the infusion with blood
return. In addition, the nature of the complaints should be verified against the signs and
symptoms of other possible diagnoses.
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13. Visual assessment
Visual signs, while by no means exclusive to extravasation, do provide useful confirmation for
patient reports in suspected extravasation. The common signs, occurring at or around the site of
the cannula – or, in the case of central line around the CVAD and the surrounding area –
include:8,18,19
■ Early symptoms
Swelling/oedema
Redness/erythema
■ Later symptoms
Inflammation
Induration
Blistering
Importantly, many of these symptoms do not occur immediately upon infusion. Induration and
blistering, in particular, tend to appear later in the extravasation process. Therefore, careful
monitoring of the site should continue during the infusion time and for some time following an
infusion.7
Checking the infusion line
Apart from patient reporting and visible symptoms of extravasation, it is possible to determine
whether extravasation has occurred by checking the infusion line itself. Verification of the line
should be used to help confirm any suspected extravasation (peripheral or central line), if
possible.
Signs of extravasation, in relation to the cannula, include:8,18
■ Increased resistance when administering IV drugs
■ Slow or sluggish infusion
■ Change in infusion flow
■ Lack or loss of blood return from the cannula
Look for blood return (flashback) upon insertion of the needle. If the needle is in the lumen of
the vein, you should notice some blood return. If you confirm blood return, the cannula can be
glided carefully into position, ready to stop if met with any resistance.
Brief blood return may be seen if the needle passes through the lumen of the vein and then out
the other wall. However, the return will halt once the needle has passed the posterior venous
wall.20 If this occurs, the needle has passed through the lumen and anything infused will be
administered straight into the surrounding tissue. The cannula should be removed and the
procedure recommenced using another vein, if necessary in another vein above the original site
on the same vein (closer to the heart).7
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14. Distinguishing extravasation vs. other conditions
Distinguishing between extravasation and other local reactions is an important step in
diagnosis. Initially, making the distinction can be very difficult and requires sound clinical
judgment. Familiarity with the different symptoms increases the likelihood of appropriate
treatment. In the case of extravasation, that means that interventions and management will be
initiated at an early stage and help to prevent some of the more serious consequences
associated with it.4,8
Other conditions that resemble extravasation include:4,7,8,18
■ Flare reaction
■ Vessel irritation
■ Venous shock
■ Phlebitis
■ Hypersensitivity
The principal differences between extravasation and these conditions relate to the nature and
timing of the patient’s complaints, the type and extent of erythema noted and the location and
presence of swelling. 4,8 A guide describing symptoms and differences between conditions
commonly associated with IV infusion can be found in Appendix 2.
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15. How is extravasation prevented?
The most important approach to minimising the consequences of extravasation is prevention.12
Healthcare professionals involved in the handling and administration of IV cancer therapies
should become familiar with their local procedures and protocols and develop an
understanding of the important precautionary steps that should be taken to avoid extravasation
and the resulting injuries.
Given this cautious and systematic approach, most episodes of extravasation can be avoided
altogether. 21 The following sections provide advice for good practice and may help prevent
extravasation and minimise injury.
Standard procedures
Training
Patient education
Equipment selection
Vein selection in peripheral administration
Administering intravenous treatment
Standard procedures
Local policies and protocols for preventing, identifying risk factors, diagnosis, and managing
extravasation represent one of the best ways with which to combat extravasation in the clinical
setting. The protocols should be drug specific and be developed with input from the whole
healthcare team involved.
If they are already in place, efforts should be taken to make them readily available to all who
require them (i.e., those healthcare professionals involved in the administration of IV cancer
therapy). 22 If protocols do not exist, efforts should be made to formally document the local
procedures for dealing with extravasations.
There are several examples of existing policies and protocols; some of them can even be found
online (see references section).2,13–16
Training
As mentioned above, local policies and protocols are very important for the delivery of quality
cancer care. As well as making these documents available, active education of the relevant staff
members including doctors, would help to keep the standard of care at a consistently high level
across the board.18 All staff should be encouraged to regularly review the relevant literature on
cytotoxics handling and relating to new agents, as part of their ongoing training.22
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16. Those involved in the administration of IV cancer therapies should be educated on the
techniques of IV infusion as well as the local organisational policies for:18
■ Venous access
■ Venous assessment
■ Administration of chemotherapy
■ Management of extravasation
■ Management of hypersensitivity, etc.
Patient education
With regard to extravasation, communication with the patient is very important, since they are
being relied upon to report symptoms critical in its recognition.
Using positive language, patients should be told about the nature of the cancer therapy they are
receiving and the real possibility of side effects. They should be asked to report any change in
sensation, stinging or burning, no matter how insignificant it appears to them. An informed
patient can then help to recognise extravasation early and should always be listened to.11
In addition, training relating to meeting the information needs of patients within cancer care, for
example presenting a positive approach to delivering information vs. a negative one: “XXX is a
possible side effect, but we can’t predict your reaction; most patients take these drugs and
tolerate them well.”11
Equipment selection
The choice of equipment/material for administering cancer therapy is important when trying to
minimise the risk of extravasation. Important considerations include the size and type of cannula
or catheter, and whether to use a subcutaneous device or a central line.
In general, the goal is to choose a needle that is least likely to become dislodged, and one that
allows the blood to flow around it. As a rule, it is advisable to use the smallest gauge cannula in
the largest vein possible. Specific recommendations include:4,7,12,20
■ Use of a small bore plastic cannula (1.2–1.5 cm long)
■ For peripheral access, short, flexible polyethylene or Teflon
■ Use a clear dressing to secure the cannula – to allow for constant inspection
■ Secure the infusion line, but never cover the line with a bandage (the insertion point must
always be visible)
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17. Vein selection in peripheral administration
The choice of vein for the infusion is an equally important consideration for the prevention of
extravasation. Finding the largest, softest and most pliable vein is the best choice to avoid
complications.9 Some general guidelines include:8,12,18
■ Try to use the forearm, not the back of the hand
■ Avoid small and fragile veins
■ Avoid insertion on limbs with lymphoedema or with neurological weakness
■ Avoid veins next to joints, tendons, nerves or arteries
■ Avoid the antecubital fossa (area near the elbow)
For a more detailed overview of vein selection please refer to Appendix 3.
If a first attempt to insert a cannula failed, the second insertion should be made above (closer to
the heart) the original site if possible. In general, it is thought that it is best to avoid
administering cytotoxic drugs below a previous venepuncture site.7
Administering intravenous treatment
In addition to careful selection of equipment and veins for administration of IV cancer therapy,
there are many precautions that can be considered during the infusion to help reduce the risk of
extravasation.8,12,18,22
Starting IV treatment: 8,12,18,22
■ Become familiar with the manufacturers' recommendations for administration of each
treatment
■ Dilute drugs to the recommended concentrations and give at the appropriate rate
■ Check blood return from the cannula, or CVAD, prior to administration
■ Before administering therapy, flush the line with saline (sodium chloride 0.9%) or glucose 5%
(as well as between infusions)
■ Ensure that the cannula is secure during the administration of drugs – the appropriate
dressing (e.g., IV OPSITE 3000, VecaFix or Tegaderm IV) should be used
■ Never cover the insertion point (i.e., cover cannula site with a bandage)
■ If in doubt, re-cannulate
Monitoring IV treatment:8,12,18
■ Check for swelling, inflammation, redness and pain around cannula site during administration
of IV drugs
■ Check blood return from the cannula when vesicants are administered
■ Question the patient about any possible symptoms (i.e., heat, pain and swelling during
administration)
■ Do not allow patients receiving intravenous infusions of vesicant drugs to leave clinical area
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18. Considerations for vesicants:8,12
■ Whenever possible, always give vesicant drugs into a recently inserted cannula
■ Patients receiving repeated doses of potentially harmful drugs peripherally should have the
cannula resited at regular intervals – every few days (depending on hospital recommendations)
■ Consider the order of the infusions being given – attempt to administer treatments so
vesicants present the least risk to the patient
■ A CVAD could be considered if veins are very difficult to access. This might minimise the risk
of extravasation
■ In no case should a butterfly needle be used for any chemotherapeutic infusion
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19. How is extravasation managed?
If extravasation does occur, prevention of serious injury and tissue damage becomes the main
focus of those involved in the patient management. Swift action is important to limit the
damage caused by the extravasated drug. 22 In general the management of extravasation
includes detection (covered in the “How is extravasation recognised?” section), analysis and
action.23
Procedures and protocols
Management – initial steps
Management – next steps
Antidotes
Anthracycline extravasation
Extravasation kit
Surgery and debridement
Documentation and reporting
Procedures and protocols
Just as they play a key role in the prevention of extravasation, local procedures and protocols are
paramount in the timely recognition and management of extravasation and the prevention of
serious tissue damage.
If they are already existing, efforts should be made to make them readily available to all who
need them (i.e., those healthcare professionals involved in the administration of IV cancer
therapy). 22 If protocols do not exist, efforts must be made to formally document the local
procedures for dealing with extravasations.
It is highly recommended that all healthcare professionals involved in the administration of IV
cancer therapy should be aware of:22
■ The extravasation policy
■ The contents and whereabouts of the extravasation kit and a replacement kit
There are several examples of existing policies and protocols which can be found online.2,13–16
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20. Management – initial steps
Specific courses of action depend on the nature of the drug, how much of it has extravasated
and where.3 Delays in recognition and treatment can increase the risk of tissue necrosis.
If extravasation is suspected, treatment should begin as soon as possible as commencing
treatment within 24 hours can reduce damage to tissues, however, extravasation may only
become apparent 1–4 weeks after the administration.3
No matter what the nature of the drug, if extravasation is suspected the initial response remains
the same. The most important thing initially is to limit the amount of drug extravasating into the
surrounding tissue.13–16,22 Depending on your hospital or centre, there may be prescribed steps
and procedures to undertake before any action is taken (i.e., getting a physician’s signature on
the extravasation protocol).
In general, the first course of action is to stop the infusion, aspirate as much of the infusate as
possible, mark the site and then remove the cannula (while continuing to aspirate from the
extravasation site). Elevate the affected limb and administer analgesia if required.8,15 If possible
take a digital image of the extravasated area. Then, depending on the drug being infused, the
correct protocol should be followed to determine the next steps. An example protocol is
illustrated in Figure 1.
Figure 1. Management of extravasation.8
Step 1 Stop the infusion immediately. DO NOT remove the cannula at this point.
Step 2 Disconnect the infusion (not the cannula/needle).
Step 3 Leave the cannula/needle in place and try to aspirate as much of the drug as possible
from the cannula with a 10 mL syringe. Avoid applying direct manual pressure to
suspected extravasation site.
Step 4 Mark the affected area and take digital images of the site.
Step 5 Remove the cannula/ needle.
Step 6 Collect the extravasation kit (if available), notify the physician on service and seek
advice from the chemotherapy team or Senior Medical Staff.
Step 7 Administer pain relief if required. Complete required documentation.
NOTE: STEP 8 onwards appear in Figures 3, 4 and 5, depending on whether the extravasation
requires Localisation and neutralisation or Dispersion and dilution. How to determine which
pathway to follow is described in the following sections.
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21. Management – next steps
From this point forward, the nature of the treatment prescribed by the presiding physician or
hospital policy will depend on the drug, which has extravasated. Figure 2 shows the decision
pathway as it relates to individual treatments.
Figure 2. Decide on appropriate treatment.8
Decide on appropriate treatment
Amsacrine Vinblastine
Actinomycin D Vincristine
Carmustine Vindesine
Dacarbazine Vinorelbine
Daunorubicin
Doxorubicin Aminophilline
Epirubicin Calcium solutions
Idarubicin Hypertonic glucose
Mitomycin C Phenytoin
Mustine TPN
Streptozotocin X-ray contrast media
Localise and neutralise Disperse and dilute
If the drug is a non-vesicant, application of a simple cold compress and elevation of the limb
may be sufficient to limit the swelling etc.8 In contrast, the extravasation of a vesicant requires
several steps and differs for the various classes of drug. There are two broad approaches to
limiting the damage caused by extravasation: localisation and neutralisation; or dispersion and
dilution.8
Localise and neutralise strategy (Figure 3):8
■ Use cold compresses to limit the spread of infusate. It used to be thought that cold limited
spread through vasoconstriction. In animal models, it appears that cold prevents spread by a
mechanism other than vasoconstriction – suggested to be decreased cellular uptake of drug
at lower temperatures
■ Consider using antidotes to counteract vesicant actions.
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22. Figure 3. Localise and neutralise.8
NOTE: The initial steps leading to STEP 7 are described in Figure 1.
Step 8 – LOCALISE
Apply a cold pack to the affected area for 20 minutes 4 times daily for 1—2 days.
Step 9 – NEUTRALISE
Neutralise the drug by using the specific antidote (if available). The antidote should
be given as per the specific directions provided by the manufacturer.
(N.B. Only anthracyclines*, mitomycin C and mustine have specific antidotes – for
drugs without antidotes omit step 9)
LOCALISE AND NEUTRALISE
STEP 10
Remove the cannula (delivering the antidote) after confirming no more antidote will
be prescribed or given.
STEP 11
Elevate the limb.
STEP 12
Document the incident using extravasation documentation sheet.
STEP 13
Arrange follow up for the patient as appropriate.
*For a detailed list of anthracyclines, please refer to Appendix 1)
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23. Disperse and dilute strategy (Figure 4):8
■ Appropriate for the extravasation of vinca alkaloids
■ Use warm compresses to prompt vasodilation and encourage blood flow in the tissues,
thereby spreading the infusate around
■ Consider using hyaluronidase to dilute infusate
Figure 4. Disperse and dilute.8
NOTE: The initial steps leading to STEP 7 are described in Figure 1.
STEP 8 – DISPERSE
Apply a warm compress to the affected area for 20 minutes 4 times daily for 1—2 days.
STEP 9 – DILUTE
DILUTE AND DISPERSE
Give several subcutaneous injections of 150–1500 IU of hyaluronidase diluted in 1 mL
sterile water around the extravasated area to dilute the infusate.
STEP 10
Document the incident using extravasation documentation sheet.
STEP 11
Arrange follow up for the patient as appropriate.
In addition, measures can be taken to limit inflammation, discomfort and pain.22
■ A saline flush out technique could also be used – but this approach requires specialist advice
■ Corticosteroids can be given to treat inflammation – although there is little evidence to
support their use in extravasation
■ Antihistamines and analgesics may be required for relief of pain and other symptoms
If the infusate is a non-vesicant, the procedure is similar to localise and neutralise, but does not
involve any antidotes.8 A step-by-step approach for non-vesicants is shown in Figure 5.
It is worth noting that beyond the measures described here, unfortunately, the management
of extravasation is not well standardised due to a lack of documented evidence. As such,
extravasation and often calls for specialist advice.
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24. Figure 5. Treatment for non-vesicants.8
STEP 8
Elevate the limb.
NON-VESICANTS STEP 9
Consider applying a cold pack if local symptoms occur.
STEP 10
Document the incident using extravasation documentation sheet.
STEP 11
Arrange follow up for the patient as appropriate.
Antidotes
Antidotes are agents applied or injected to the extravasated area to counteract the effects of the
infiltrated agent – usually vesicants. They form an important part of the “localise and neutralise”
and the “disperse and dilute” strategies. For example, Savene™ (dexrazoxane) can help to
neutralise anthracyclines; whereas hyaluronidase helps to facilitate the dilution of vinca
alkaloids into the surrounding tissues. Provided they are used in the appropriate way and for the
appropriate infusate they might help to prevent progression to ulceration, blistering and
necrosis. The evidence supporting the use of different antidotes is often inconclusive and their
use (including pros and cons) should be carefully considered.
Antidotes currently available used for treating extravasation (and their proposed mechanism)
include:12,24–28
■ Savene™ (dexrazoxane): The only registered antidote for anthracyclines, inhibits DNA
topoisomerase II, which is the target of anthracycline chemotherapy, blocking the enzyme so
it is no longer affected by anthracyclines and damage to the cells is averted
■ Dimethylsulfoxide (DMSO): Prevents ulceration. May work by virtue of its free radical
scavenging property
■ Sodium thiosulfate: Prevents alkylation and subsequent destruction in subcutaneous tissue
by providing a substrate for alkylation
■ Hyaluronidase: Breaks down hyaluronic acid ("cement") in connective/soft tissue, allowing for
dispersion of the extravasated drug, thereby reducing the local concentration of the damaging
agent and increasing its rate of absorption
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25. Table 1. Antidote use after extravasation.12*
Extravasated drug Suggested antidote Level of evidence Advice
Anthracyclines Savene™ Efficacy in biopsy-verified 3 day course of Savene™
(dexrazoxane) anthracycline extravasation treatment: 1000 mg/m2 IV
has been confirmed in as soon as possible (no
clinical trials later than 6 hours) after
extravasation on day 1;
1000 mg/m2 on day 2; and
500 mg/m2 on day 3
See Appendix 4 for full
details
Anthracyclines Topical DMSO (99%) Suggested as a possible Apply locally as soon as
antidote in many literature possible. Repeat every 8
sources. Due to lack of hours for 7 days
evidence it is recommended See Appendix 5 for full
that this is further studied details
Mitomycin C Topical DMSO (99%) Suggested as a possible Apply locally as soon as
antidote in many literature possible. Repeat every 8
sources. Due to lack of hours for 7 days
evidence it is recommended See Appendix 5 for full
that this is further studied details
Mechlorethamine Sodium thiosulfate Due to lack of evidence, 2 mL of a solution made
(Nitrogen mustard) this antidote is not from 4 mL sodium
recommended thiosulfate + 6 mL sterile
water for subcutaneous
injection
Vinca alkaloids Hyaluronidase Suggested as a possible 150–1500 IU
antidote in many literature subcutaneously around
sources. Due to lack of the area of extravasation
evidence it is recommended See Appendix 6 for full
that this is further studied details
Taxanes Hyaluronidase Suggested as a possible 150–1500 IU
antidote in many literature subcutaneously around
sources. Due to lack of the area of extravasation
evidence it is recommended See Appendix 6 for full
that this is further studied details
*For a detailed list of vesicants, please refer to Appendix 1)
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26. Anthracycline extravasation
For anthracycline extravasation, a new treatment, Savene™, and the data supporting it is
changing the way antidotes are recommended in the “localise and neutralise” strategy.
In the past, several protocols and policies suggested the use of topical DMSO (99%) to stop the
development of ulcers in anthracycline extravasation.12 In the past few years, new data from
preclinical and clinical studies has changed the way antidotes are used in anthracycline
extravasation, particularly that for Savene™. 29–32 And, it has since become the only licensed
specific antidote to anthracycline extravasation.
As a result, more recent guidance in this area recommends the use of Savene™ in the treatment
of anthracycline extravasation from both a central- and a peripheral line. 2
Extravasation kit
The idea behind the extravasation kit is to store all the drugs and equipment that would be used
in an emergency situation. The kit should be put together to deal with any eventuality, including
extravasation of a variety of vesicant drugs.19 The kit should be checked regularly and restocked
from pharmacy following use.22
An example of a recommended extravasation kit can be found in Appendix 7.
Surgery and debridement
Even if extravasation is identified early, progressive extravasation can give rise to ulcerated and
necrotic tissue over time. However, the early steps to prevent and manage extravasation help to
limit the need for surgery.5
Ulcerative cases caused by anthracycline extravasations are common (about 1⁄3 of all cases),
therefore surgery should not be considered as the initial primary treatment of choice.4 When
there is ulceration or continued pain, surgical intervention is indicated to excise the damaged
tissue.
In general, the goal of surgery is to remove the damaged tissue and the vesicant infusate to
prevent progression of the extravasation, as well as to restore function and reduce pain to the
affected area.5 Once this tissue is removed, the remaining wound often needs to be closed. The
options for wound closure include skin flap and skin grafts (from other areas of the body).5 In
most cases, the surgeon would opt for a wait and see conservative approach – to establish
whether ulceration will occur naturally and to attempt to avoid surgery and skin grafting. 12
However, in cases where there is pain, surgical debridement of the extravasated area must be
considered 24 hours to 1 week after an extravasation.12
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27. Documentation and reporting
Each incident of extravasation must be thoroughly documented and reported.23 Documentation
serves several purposes:
■ To provide an accurate account of what happened (in the event that there is litigation)
■ To protect the healthcare professionals involved (showing they followed procedure)
■ To gather information on extravasations, how and when they occurs – for audit purposes
■ Highlight any possible deficits in practice which require review
In different centres, the documentation procedure may differ slightly between organisations,
however the information collected will be very similar. Following an extravasation, the following
details should be documented:15,18,23
■ Patient name and number
■ Clinical area
■ Date and time of extravasation
■ Name of drug which has extravasated
■ Signs and symptoms
Colour of surrounding skin
Size of extravasation
■ Description of the IV access
Venepuncture site
Size and position of cannula
Number of attempts at obtaining venous access and positions
Drugs administered and the sequence
Drug administration technique (bolus or infusion)
Blood return
■ Extravasation area
Approximate amount of the drug extravasated
Photograph of extravasated area
Size (diameter, length and width) of extravasation area
Appearance of extravasation area
■ Step-by step management with date and time of each step performed and medical
notification
Aspiration possible (including amount) or not, location (venous and/or subcutaneous),
and amount
Cold/heat
Antidote
Referral details (if any)
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28. ■ Patient’s complaints, comments, statements
■ Indication that patient’s information sheet given to patient
■ Follow-up instructions given (to patient, nurse, physician, etc.)
■ Names of all professionals involved in the patient management
■ Signature of nurse
In addition to the initial documentation, the extravasated area should be checked and any
changes documented every 8 hours. Any oedema, erythema, stinging, burning, pain, or fluid
leakage at insertion site should be included in this report.15
A couple of examples of extravasation documentation forms have been included for your
reference in Appendix 8.
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29. Summary
Managing extravasation in accordance with the latest scientific understanding and medical
consensus allows for optimal treatment to be delivered across different regions. By following the
example set out in this module, which includes the latest information on extravasation and a
selection of current protocols and policies from prominent centres, 8,13–16 nurses and other
healthcare can help to raise the standard of care in cancer therapy.
Nurses have a key role to play in implementing these improvements to practice. As outlined in
this module, they have a unique interaction with the patient and play a large part in the
administration of IV cancer therapy. By learning how to effectively recognise extravasation and
by becoming familiar with all the local protocols for dealing with it, including the use of
antidotes nurses can help to minimise the incidence of this complication of cancer treatment.
Nurses also have the opportunity to play a lead role in expanding the use of best practice in this
area. They can help to initiate and develop local protocols and policies where there aren’t any
due to their role in administration of the drugs and thanks to their knowledge of the patient and
unique perspective regarding extravasation management.
By helping to broaden the understanding of extravasation and its management across the
nursing and other healthcare professions, it is hoped that this educational module will achieve
its objective of improving prevention and overall management of extravasations in cancer
patients by utilising the latest available evidence.
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30. Appendix 1. List of drugs: vesicants, irritants and non-vesicants8,12,15
Vesicants Irritants Non-vesicants1
DNA-binding Carmustine Asparaginase
Cyclophosphamide Bleomycin
Alkylating agents
Dacarbazine Bortezumib
Mechlorethamine
(Nitrogen mustard) Etoposide Cladribine
Fluorouracil Cytarabine
Anthracyclines
Ifosfamide Etoposide phosphate
Daunorubicin
Mephalan Gemcitabine
Doxorubicin
Mitoxantron Interferons
Epirubicin
Streptozocin Interleukin-2
Idarubicin
Possible irritants2 Methotrexate
Others
Monoclonal antibodies
Dactinomycin Carboplatin
Pemetrexed
Mitomycin C Cisplatin
Raltitrexed
Docetaxel
Non-DNA-binding Thiothepa
Irinotecan
Vinca alkaloids Oxaliplatin
Vinblastine Paclitaxel
Vincristine Topotecan
Vindesine
Vinorelbine
1
Any agent extravasated in high enough concentration may be an irritant.
2
There have been few reports of these agents acting as irritants, but there is no clear evidence
for this.
NOTE: For those medications that are not considered a vesicant but cause prolonged patient
discomfort at the infusion site, it is strongly recommended that a central line be placed.
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31. Appendix 2. Distinguishing extravasation from other conditions4,7,8
Characteristic Flare reaction Vessel irritation Venous shock Extravasation
Presenting Itchy blotches Aching and Muscular wall of Pain and
symptoms or hives; pain tightness the blood vessel burning are
and burning in spasm common at
uncommon injection site;
stinging may
occur during
infusion
Colouration Raised red Erythema Erythema
streak, blotches or dark around area of
or “hive-like” discolouration needle or
erythema along along vessel around the
the vessel; venepuncture
diffuse or site
irregular pattern
Timing Usually appears Usually appears Usually appears Symptoms start
suddenly and within minutes right after to appear right
dissipates after injection. injection after injection,
within 30–90 Colouration may symptoms
minutes only appear endure
later in the
process
Swelling Unlikely Unlikely Occurs often;
does not
dissipate for
several days
Blood return Usually, but not Usually, but not Often absent Usually absent
always intact always intact or sluggish
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32. Appendix 3. Vein selection procedure11
Assess veins in both arms and hands
Do not use veins in compromised limbs/lower extremities
Criteria for Appropriate choice
vein selection of venepuncture site
Most IDEAL VEIN / BEST LOCATION Forearm
desirable large, soft, resilient veins in forearm
IDEAL VEIN / LESS DESIRABLE LOCATION Hand
large, soft, resilient veins in hand/antecubital fossa
SATISFACTORY VEIN / BEST LOCATION Forearm
small, thin veins in forearm
SATISFACTORY VEIN / UNDESIRABLE LOCATION Hand
small, thin veins in hand; veins in forearm not
palpable or visible
UNSATISFACTORY VEIN / UNDESIRABLE LOCATION Consider central
small, fragile veins, which easily rupture in venous line
forearm/hand
Least UNSATISFACTORY VEIN / UNDESIRABLE LOCATION Consider central
desirable veins in forearm/hand not palpable or visible venous line
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33. Appendix 4. Administering Savene™ (dexrazoxane)2,26
Savene™ is the only licensed treatment for anthracycline extravasation (doxorubicin, epirubicin,
daunorubicin, idarubicin).
Steps for administration:
1) Follow steps for localisation and neutralisation of extravasation (Figure 1 and Figure 3)
2) Administration of Savene™ should begin as soon as possible and no later than 6 hours after
the accident
3) Remove ice packs (or other cooling procedures) from the area at least 15 minutes before the
administration of Savene™
4) Reconstitute Savene™ with 25 mL sterile water before further dilution in diluent
5) Give Savene™ as an intravenous infusion once daily for 3 consecutive days according to body
surface area:
a. Day 1: 1000 mg/m2
b. Day 2: 1000 mg/m2
c. Day 3: 500 mg/m2
6) For patients with a body surface area of more than 2.0 m2 the single dose should not exceed
2000 mg on day 1 and day 2 and 1000 mg on day 3
Please refer to Savene™ prescribing information for a full list of contraindications, precautions
and warnings.
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34. Appendix 5. Administering dimethylsulfoxide25
Dimethylsulfoxide (DMSO 99%) is an option for the treatment of extravasation with anthracyclines,
mitomycin C, doxorubicin, idarubicin, epirubicin and actinomycin D. DMSO/corticosteorids should
not be used.
Steps for administration:
1) Follow steps for localisation and neutralisation of extravasation (Figure 1 and Figure 3)
2) Draw around area with indelible pen
3) Put gloves on
4) Apply thin layer of DMSO topically to the marked area
5) Allow it to dry
6) Apply a non-occlusive dressing
7) This should be applied within 10–25 minutes
8) Check for erythema caused by DMSO
Please refer to DMSO 99% prescribing information for a full list of contraindications, precautions
and warnings.
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35. Appendix 6. Administering hyaluronidase*27
Hyaluronidase may be indicated for suspected or known extravasation of: dextrose in
concentration of >10%; parenteral alimentation solution (glucose or protein); solutions
containing calcium or potassium; aminophylline; antibiotics. In addition, there are
recommendations for hyaluronidase in response to vinca alkaloid extravasation.12
Steps for administration:
1) Follow steps for dispersion and dilution of extravasation (Figure 1 and Figure 4)
2) Administration of hyaluronidase should begin within 1 hour of extravasation for best results
3) Dilute 150–1500 IU of hyaluronidase in 1 mL sterile water
4) If there is no blood return in the affected IV catheter, consider infusing 0.4 CC of dose directly
through the affected IV catheter before removing the catheter and administering the
remainder of the dose subcutaneously around the periphery extravasation
5) Use 25 or 27 gauge needle and change after each injection
6) Subcutaneously (or intradermally) inject 1 ml (150 IU) of hyaluronidase as 5 separate 0.2 mL
injections around the periphery of extravasation site
* Hyaluronidase is not available in all countries
Please refer to hyaluronidase prescribing information for a full list of contraindications,
precautions and warnings.
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36. Appendix 7. Extravasation kit19
Below is an example of a typical extravasation kit, which included:
■ Instant cold pack
■ Instant hot pack
(Or a reusable pack, which can be use for both)
■ Antidotes according to local procedures
■ 2 mL syringes
■ 25 G needles
■ Skin disinfectant as per local guidelines (e.g., alcohol swabs)
■ Indelible pen for marking the affected area
■ Documentation forms
■ Copy of extravasation management procedure
■ Patient information leaflet
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40. Specific extravasation template*
Extravasation of anthracycline Observation and prescription form
Name: Height/weight _____/_____
Date of birth: Surface (m2) __________
Telephone number:
Time /Da y 0 -6 hrs Da y: __ Day: _ _ Day: __ Day: _ _ Day: __ Da y: _ _ Day: __ Da y: _ _
O bse rva tion Date :
O bse rva tion Time :
Time of ext ravasa tion
L oca tion of Extravasa tio n
Describe IV access from wh ich
E xtra vasatio n occurre d
A spiratio n o n cath ete r (yes/ no)
S ize of t he aff ecte d a rea (cm x cm) x x x x x x x x x
Name o f an th racyclin e d ilue nt
A mo unt of fluid e xtra vasate d ML
A mo unt of an thra cycline extravasa ted Mg
L oca l ice tre atmen t (yes/ no)
R emo ve at least 15 min b efore Sa vene ™
O the r lo cal tre atmen t (ye s/n o)
If yes d escrib e
Describe symptoms listed below using yes/no or use CTC grades none, mild, moderate, severe
Date
L oca l swellin g
L oca l re dne ss
L oca l blistering
L oca l ne cro sis
P ain
S ensory disturban ces
S kin atro ph y
Impa ired limb fun ctio n
Disfig ure me nt
O the r:
O the r:
Day 1 Day 2 Day 3 S ave ne™ d osa ge to be ad min iste red :
Date Day 1 an d 2 : 1 00 0 mg/ m2 , Da y 3 : 5 00 mg /m2
S ave ne ™ infu sion (mg/t ota l) Max surf ace 2. 0 m2
S tart time o f S ave ne ™ infu sion
S top time o f S ave ne ™ infu sion
S ign atu re d octor
S ign atu re n urse
* T reatm ent of anthra cycli ne ext ravasa tion in mice with dexraz oxane with or wit hout D MSO and h ydroco rtison e, LAN GER Sep po W, Canc er che mothe rapy a nd ph armac ology 2006 , vol. 5 7, no1 , pp. 1 25-12 8.
A ddition al comme nts:
* By courtesy of TopoTarget A/S
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41. References
1. Jones L, Coe P. Extravasation. Eur J Oncol Nurs 2004;8:355–358.
2. Jackson G, Buter J, Cavenagh J, et al. Consensus opinion on the use of dexrazoxane (Savene™) in
the treatment of anthracyclines extravasation. Consensus Meeting Report 2006.
3. Ener RA, Meglathery SB, Styler M. Extravasation of systemic hemato-oncological therapies. Ann
Oncol 2004;15:858–862.
4. McCaffrey Boyle D, Engelking C. Vesicant extravasation: myths and realities. Oncol Nurs Forum
1995;22(1):57–67.
5. Rudolph R, Larson DL. Etiology and treatment of chemotheraupeutic agent extravasation
injuries: a review. J Clin Oncol 1987;5(7):1116–1126.
6. Weiner MG, Ross SJ, Mathew JI, et al. Estimating the costs of chemotherapy-associated adverse
event clusters. Health Serv Outcomes Res Method 2007: In print.
7. Wood LS, Gullo SM. IV vesicants: how to avoid extravasation. Am J Nurs 1993;93(4):42–46.
8. Whiteland M. Policy for the management of extravasation of intravenous drugs. 2001. Available
at: www.cancerresource.co.uk/nursing%20developments/extravasation%20policy.pdf.
9. Pan-Birmingham NHS. Guidelines for the Management of Extravasation. Available at:
www.birminghamcancer.nhs.uk/viewdoc.ashx?id=oHV9ZQbj92im6AaanFEnvw%3D%3D.
10. National Extravasation Information Service website. Available at:
http://www.extravasation.org.uk/home.html.
11. Hughes CB. Giving cancer drugs IV: some guidelines. Am J Nurs 1986;86(1):34–38.
12. Schrijvers DL.Extravasation:a dreaded complication of chemotherapy.Ann Oncol 2003;14(Suppl
3):iii26-iii30.
13. Pharmaceutical Sciences, Vancouver General Hospital. Appendix II: Extravasation of
antineoplastic agents. 2007 Revision. Available at: www.vhpharmsci.com/PDTM/APDX7i.htm.
14. Children's Hospital Medical Center. II-113 Vesicant Chemotherapy Extravasation. 2003 Revision.
Available at: www.cincinnatichildrens.org/NR/rdonlyres/390692D4-CD68-4CD8-A4FA-
82F1CF3DD259/0/II113.pdf.
15. Medical University of South Carolina (MUSC). Work practice policy for personnel dealing with
cytotoxic (antineoplastic) drugs. 2005 Revision. Available at: www.musc.edu/fanda/risk/oshp/
safetymanual03/cytodrug.pdf.
16. Co-operative Cancer Departments, Denmark.Paravenous cytostatica administration.December,
2006.
17. Loth TS, Eversmann WW Jr.Treatment methods for extravasations of chemotherapeutic agents:
a comparative study. J Hand Surg 1986;11(3):388–396.
18. Polovich M,White J,Kelleher L.Chemotherapy and biotherapy guidelines and recommendations
for practice, 2nd ed. Oncology Nursing Society, 2006.
19. Allwood M, Stanley A, Wright P, eds. The cytotoxics handbook. 3rd ed. Oxford: Radcliffe Medical
Press Ltd., 1997.
20. Hadaway LC, Millam DA. On the road to successful IV starts. Nursing 2005;35:1–14.
21. Bertelli G. Prevention and management of extravasation of cytotoxic drugs. Drug Safety
1995;12(4):245–255.
41
Table of contents
42. 22. Management and Awareness of the Risks of Cytotoxics Group. Managing cytotoxic
extravasation. 2007.
23. Dougherty L and Lister S. Chapter 10: Drug administration: cytotoxic drugs. The Royal Marsden
Hospital Manual of Clinical Nursing Procedures, 6th ed. Blackwell Science, 2004, 233–245.
24. de Lemos ML. Role of dimethylsulfoxide for management of chemotherapy extravasation. J
Oncol Pharm Pract 2004;10(4):197–200.
25. Bertelli G, Gozza A, Forno GB, et al. Topical dimethylsulfoxide for the prevention of soft tissue
injury after extravasation of vesicant cytotoxic drugs: a prospective study. J Clin Oncol
1995;13(11):2851–2855.
26. Savene™ Summary of Product Characteristics.TopoTarget A/S, Copenhagen, Denmark, 2006.
27. Treatment of extravasation of IV fluids: hyaluronidase. 2006. Available at:
http://info.med.yale.edu/pediat/pedres/Policies/NICU%20Guidelines%202006/YNHH%20NBSC
U%20PDF%20Guidelines%20wo%20stats%20Aug06/Treatment%20of%20Extravasation%20of
%20IV%20fluids-Hyaluronidase%20Jul06.pdf.
28. Shamseddine AI, Khalil AM, Kibbi AG, et al. Granulocyte macrophage-colony stimulating factor
for treatment of chemotherapy extravasation. Eur J Gynaecol Oncol 1998;19:479–481.
29. Sauerland C, Engelking C, Wickham R, Corbi D. Vesicant extravasation part I: Mechanisms,
pathogenesis, and nursing care to reduce risk. Oncol Nurs Forum 2006;33(6):1134–1141.
30. Wickham R, Engelking C, Sauerland C, Corbi D. Vesicant extravasation part II: Evidence-based
management and continuing controversies. Oncol Nurs Forum 2006;33(6):1143–1150.
31. Mouridsen HT, Langer SW, Buter J, et al. Treatment of anthracycline extravasation with Savene
(dexrazoxane). Results from two prospective clinical multicenter studies. Ann Oncol
2007;18(3):546–550.
32. Schulmeister L. Totect™: A new agent for treating anthracycline extravasation. Clin J Oncol Nurs
2007:11(3):387-395.
33. Mader I, Furst-Weger PR, Mader RM, et al. Extravasation of Cytotoxic Agents. Vienna: Springer-
Verlag, 2003.
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