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GUIDE TO EXTRAVASATION MANAGEMENT IN ADULT & PEDIATRIC PATIENTS
Large, well-designed, controlled clinical trials
in humans are not available to support the
Nursing Standard of Practice & Procedures:
1) Extravasations, Patient Management of 2) Care of the Patient by a Non-Chemotherapy Certified RN
guidelines. Available data generally consists of
case reports, trials utilizing animal models, and
Stop injection/infusion immediately. 1,3, 5-7
Leave the needle/catheter in place. 1,5-7
1. Mullin S, Beckwith CM, Tyler LS. Prevention and management of
inconsistent quality. This lack of evidence
antineoplastic extravasation injury. Hospital Pharmacy. 2000; 35:57-
Slowly aspirate as much of the drug as possible. 3,5-7
creates challenges in validating specific
2. eFacts [database online]. St. Louis, MO: Wolters Kluwer Health,
Do not apply pressure to the area. 3,6-7
3. Gahart BL, Nazareno AR. Intravenous Medications. 21st ed. St
Use of this site for further IV access is not
Interventions listed within this guide were
McEvoy G, ed. American Hospital Formulary Service: Drug
Information. Bethesda: American Society of Health-System
derived from a consensus of the cited tertiary
references. Greater consideration was given to
Inform physician and obtain orders per substance-
5. Lexi-Comp [database online]. Hudson, OH: Lexi-Comp, Inc; 2007.
more detailed, substance-specific references
6. Polovich M, White JM, Kelleher LO, eds. Chemotherapy and
biotherapy guidelines and recommendations for practice. 2nd ed.
Pittsburgh, PA: Oncology Nursing Society; 2005.
7. Camp-Sorrell D. Developing extravastation protocols and monitoring
Elevate the area for 48 hours to minimize swelling. 1,3,6-7
The information provided is intended as a
outcomes. J Intravenous Nursing 1998; 21(4):232-239.
8. Thomas, Juliana. Letter. New York, NY: Sanofi-Aventis; 2005 Sept
Initiate substance-specific measures per physician
9. Mouridsen HT, Langer SW, et al. Treatment of anthracycline
extravasation with Savene (dexrazoxane): results from two
propective clinical multicentre studies. Annals of Oncology, 2007;
(> 20 mL and
Other agents that have been reported to cause irritation, phlebitis, or
necrosis with extravasation include but may not be limited to:
Cytarabine, liposomal Gemcitabine
Physician’s order should be obtained to initiate warm or cold therapy when suspect extravasation is greater than 24 hours old
Apply cold compress for 15-20 minutes at least four times a day
Note on Oxaliplatin:
Some references suggest cold compresses as a therapeutic alternative
for oxaliplatin extravasation. Oxaliplatin administration is associated with sensory
neuropathies that may be exacerbated or precipitated by cold temperatures or objects.
Utilization of warm therapy may be more comfortable for patients with oxaliplatin-associated
Physician’s order required prior to antidote administration
Note on Promethazine:
The package insert states that there “is no proven successful
management of (extravasation) after it occurs, although sympathetic block and heparinization are commonly employed during acute management”. This is based on results in animals with
other known arteriolar irritants. A case study report entitled “Extravasation of i.v.
promethazine” can be found in Am J Health-Syst Pharm. 1999; 56:1742-3.
*Note on Anthracyclines:
Dexrazoxane may be used to treat anthracycline extravasations
in adult patients. Treatment should begin as soon as possible and no later than 6 hours after extravasation. 9
Document all procedures in the medical record. 1,6,7
Complete Patient Safety Net (PSN) Report. Provide patient education. 1,6,7
Documentation recommendations reproduced/adapted from: Mullin S, Beckwith MC, Tyler LS. Prevention and management of antineoplastic extravasation injury. Hospital Pharmacy. 2000; 35:57-76.
SUGGESTED INFORMATION FOR DOCUME
SUGGESTED PATIENT EDUCATION
(MAY VARY BASED ON PATIENT CARE SETTING)
Drug name, dose, volume, and concentration
Describe the physical measures used to prevent
Ensure that the patient is able to obtain follow-up
Describe the care of the site: elevate arm; use
Other agents administered and the sequence of administration
Note the name, dose, and route of antidotes.
warm or cold compresses; protect from sun or
Method of IV administration (e.g., push, drip)
Describe use of warm or cold compresses.
Instruct patient to call provider for any of the
Type of venous access device (e.g., central, peripheral)
following: increased pain, skin color change,
Note surgical or other medical consultations
increased edema or swelling, stiffness in the
Extravasation site, size, and color description (may delineate
extremity, skin breakdown, fever, any additional
infiltrated area on patient’s skin with felt-tip marker)
Ensure that the patient has follow-up appointment.
Patient complaints or statements at the time of vesicant or
Pain management follow up & reassessment.
Observe the region for pain, induration or necrosis. 1,3,6 Continue warm/cold therapy for 48-72 hours. 1,3
Advise patient to resume activity with affected limb as tolerated. 1 Consider surgical evaluation for persistent or worsening symptoms. 3,7
ANTIDOTE PREPARATION AND ADMINISTRATION INSTRUCTIONS
Hyaluronidase (Amphadase [bovine])
Preparation: Use solution as provided (150 unit/1 mL vial); do not dilute further. Inject subcutaneously or intradermally into the extravasation site using a 25-gauge needle or smaller. Dosage: The dose is
150 units (1 mL) given as five 0.2 mL injections into the extravasation site at the leading edge; change the needle after each injection.
Adapted from: Saint Francis Hospital Department of Pharmacy Services Protocol
Prepare by diluting 5 mg phentolamine in 10 mL of 0.9% sodium chloride. Inject subcutaneously into the extravasation area within 12 hours of extravasation. Blanching should reverse immediately; additional
injections may be required if blanching returns. Do not exceed 0.1-0.2 mg/kg or 5 mg total.
Mix 4 mL of sodium thiosulfate 10% with 6 mL sterile water for injection to prepare a 0.17 mol/L (4%) solution. Inject 3-10 mL subcutaneously into extravasation site; use clinical judgment and size of
extravasation site to determine volume. This dosing is based on limited and varied information.
Mix each 500mg vial with 50mL of diluent (provided by manufacturer); mixed solution should be further diluted in 1000mL NS and begin administration within 4 hours. Infuse over 1 to 2 hours in a large
caliber vein in an extremity/area other than the one affected by the extravasation. Cooling procedures such as ice packs should be removed from the area at least 15 minutes before administration in order
to allow sufficient blood flow to the area of extravasation. ADULT Dose: 1000mg/m2 (maximum 2000mg) on Days 1 and 2, 500mg/m2 (maximum 1000mg) on day 3. Adjust dose for renal impairment.
December 2009 Adapted from: Saint Francis Hospital Department of Pharmacy Services Protocol
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