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Emcrit.org

GUIDE TO EXTRAVASATION MANAGEMENT IN ADULT & PEDIATRIC PATIENTS
Large, well-designed, controlled clinical trials RELATED POLICIES
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; Aminophylline
Nafcillin
Dacarbazine
Cisplatin
Dobutamine
Dactinomycin
Idarubicin*
Paclitaxel
Carmustine
(> 20 mL and
Dopamine
Daunorubicin*
Irinotecan
Parenteral nutrition
Etoposide
Potassium
concentrations
Epinephrine
Dextrose 10%
Magnesium sulfate
Phenytoin
Teniposide
0.5 mg/mL)
Norepinephrine
Doxorubicin*
Metoprolol
Radiocontrast Media
Vinblastine
Mechlorethamine
Phenylephrine
Epirubicin*
Mitomycin
Vincristine
bicarbonate
Vindesine
Other agents that have been reported to cause irritation, phlebitis, or Vinorelbine
necrosis with extravasation include but may not be limited to: Arsenic trioxide
Cytarabine
Fluorouracil
Pamidronate
Bleomycin
Cytarabine, liposomal Gemcitabine
Plicamycin
Busulfan
Dexrazoxane
Gemtuzumab
Promethazine
Carboplatin
Docetaxel
Ifosfamide
Streptozocin
Cladribine
Dolasetron
Mitoxantrone
Thiotepa
Cyclophosphamide
Floxuridine
Oxaliplatin
Topotecan
Valrubicin
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])
2
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 Phentolamine (Regitine)2,5
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.

Sodium Thiosulfate5
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.

Dexrazoxane9
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

Source: http://emcrit.org/wp-content/uploads/2013/09/Extravasations-diagram.pdf

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