Overview, prevention and management of chemotherapy extravasation

Table 1 The different types of the above mentioned drugs according to their vesicant potential

Neutrals	Inflammitants	Irritants	Exfoliants (may have low vesicant potential)	Vesicants
Asparaginase Bevacizumab bleomycin Bortezomib cetuximab, Cyclophosphamide	Bortezomib	Bendamustine	Aclacinomycin cisplatin Docetaxel liposomal Doxorubicin mitoxantrone Oxaliplatin paclitaxel	Actinomycin D
Cytarabine eribulin Fludarabine gemcitabine Ifosfamide	5-Fluorouracil methotrexate raltitrexed	Bleomycin		Dactinomycin daunorubicin Doxorubicin epirubicin Idarubicin mitomycin C Vinblastine vindesine
Melphalan rituximab		Carboplatin dexrasoxane		Vincristine vinorelbine
Trastuzumab		Etoposide
		Teniposide
		Topotecan

Table 2 Grades of Infusion site extravasation according to common terminology criteria for adverse events (V4.0, May 2009)

Adverse event	Grade
	1	2	3	4	5
Infusion site extravasation	-	Erythema with associated symptoms (e.g., edema, pain, induration, phlebitis)	Ulceration or necrosis; severe tissue damage; operative intervention indicated	Life-threatening consequences; urgent intervention indicated	Death

Table 3 Overall summary of guidelines for prevention of chemotherapy extravasation

Continuous education of the medical team about all policies and protocols regarding chemotherapy administration

Classification of chemotherapeutic drugs: Knowledge of characteristics of the drug and compliance to the manufacturer’s recommendations

Appropriate vascular access

In case a central vascular access is not possible, an adequate peripheral vein is used[16]

Veins that are small and/or fragile should be avoided[2,20]

It is not recommended to use veins located at the dorsum of the hand, the antecubital fossa, and the radial and ulnar aspects of forearm[2,20]

Appropriate peripheral arm assessment[1,2,16]

Palpation of the vein

History of previous venipunctures

Available extremities where veins can be punctured

Level of consciousness of the patient

Appropriate equipment selection[42,43]

Use of the smallest size of cannula in the largest available vein

Use of 1.2-1.5 cm long small bore plastic cannula

Use of a clear dressing

Avoiding the use of a butterfly needle

Educating the patient about all risks associated with chemotherapy administration

Devising and updating standards and policies regarding chemotherapy administration at each healthcare center

Documentation and reporting of any extravasation incident

Table 4 Non-pharmacological management of chemotherapy extravasation

Institutions should always ensure availability of “extravasation kits” at floors in which chemotherapy can be given

Initial non-pharmacologic management

Continuous monitoring at the beginning and during the infusion is essential every 5 to 10 min

Aspiration of the vesicant by a 10 mL syringe, percutaneous needle aspiration, liposuction, simple squeeze maneuver, or by surgical fenestration and irrigation

Elevation of the affected limb and thermal application (cold or hot)

Table 5 Pharmacological management of chemotherapy extravasation

Dexrazoxane as an antidote to anthracyclines extravasation has level III-B evidence[16]

Hyaluronidaseas an antidote to vinca-alkaloids and to taxanes extravasation has level V-C evidence[16]

Topical DMSO (99%) as an antidote to anthracycline extravasation and to Mytomicin C has level IV-B evidence[16]

Sodium thiosulfate as an antidote to mechlorethamine extravasation has level V-C evidence[16]

DMSO: Dimethyl sulfoxide.