South East London Cancer Network (SELCN)
Cytotoxic Extravasation Guidelines
Applicable to:
Staff who administer cytotoxic
chemotherapy within GSTFT and SELCN
Date Issued:
19.04.12
Principal Author(s):
Updating Authors
Jacky Turner
Catherine Oakley
Michael Flynn
Dr Janine Mansi
Expiry date/ Review date:
19.04.14
Version:
3.1
Updated on:
19th April 2012
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SELCN Cytotoxic Extravasation Guidelines version 3.1
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April 2012
Document
Version
Status
South East London Cancer Network (SELCN)
Cytotoxic Extravasation Guidelines
3.0
DRAFT
Distribution
Organisation
Group / Person & Role
Joint Network Pharmacists & Chemotherapy Nurses Group
Catina Bernadis, Plastic Surgery Governance lead Guy’s &
St Thomas’ NHS Foundation Trust (GSTFT)
SELCN Drugs and Therapeutics Advisory Committee
Document History
Version
Date
Author /
Editor
Details of Change
Draft
17/01/08
M Evans & R Verity
Draft version
Draft
28/01/08
Jacky Turner
Comments incorporated from plastic surgery
governance lead GSTFT
Final Draft
Version
22/04/08
Jacky Turner
Comments incorporated pre- DTAC meeting
Final
Version
27/06/08
Jacky Turner
Comments incorporated from Kevin Saltmarsh and
Network Chemotherapy nurses
Version
1.0
01/10/08
Jacky Turner
Comments incorporated form DTAC 3rd July 2008
Version
1.0
15/01/09
Jacky Turner
Approved by SELCN Drugs & Chemotherapy
Advisory Committee
12/02/09
Jacky Turner
Approved by SELCN Forum
13/02/09
Jacky Turner
Comments from GSTFT Haem & Onc Clinical
Governance incorporated
24/03/09
Jacky Turner
Network Board approved when lead for Plastic
Surgery identified in the document
05/05/09
Jacky Turner
Named lead for plastic surgery specified within the
document.
26.2.10
Catherine Oakley
Revised following consultation with Named lead for
plastic surgery: Ms Jenny Geh and Governance Lead
for plastics, Catina Bernadis.
13.5.10
Catherine Oakley
Comments incorporated from DTAC 21.4.10
28.5.10
Catherine Oakley
Comments incorporated from JM/JG/JT
Version 3
08.09.11
Michael Flynn
Comments incorporated from DTAC 4.8.11
Version 3.1
19.04.12
Michael Flynn
Revision to immediate actions and plastics referral
2
Version 2
Draft
SELCN Cytotoxic Extravasation Guidelines version 3.1
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CYTOTOXIC EXTRAVASATION GUIDELINES
Contents
Acknowledgements
Page 4
Introduction
Page 4
Definition of terms
Page 4
Prevention of extravasation
Page 5
Signs and symptoms of extravasation
Page 6
Classification of drugs
Page 7
Extravasation treatment algorithm – Immediate treatment
Page 7
Vesicant drugs
Page 8
Flush out technique
Page 8
Plastic surgery intervention
Page 9
Irritant & non-vesicant drugs
Page 9
Use of antidotes
Page 10
Documentation
Page 10
Extravasation kit
Page 11
Appendix 1 – Flush out procedure
Page 12
Appendix 2 - Patient information sheet
Page 15
Appendix 3 - Plastic Surgery referral details
Page 16
Appendix 4 - Plastic Surgery Cytotoxic extravasation referral form
Page 17
Appendix 5 - Green card
Page 18
Appendix 6 – Follow up report
Page 21
References
Page 23
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Acknowledgments
We would like to thank and acknowledge the Royal Marsden NHS Foundation Trust upon whose
work these guidelines were largely based. 12
1.
Introduction
1.1. Extravasation is a severe complication of the administration of cytotoxic chemotherapy.
It causes pain, erythema, inflammation and discomfort and if left undiagnosed or
inappropriately treated, can lead to necrosis and functional loss of the tissue and limb
concerned. Extravasation injuries can range from apparently insignificant erythematous
reactions, through skin sloughing to severe necrosis.1
1.2. The scope of this policy is to provide clear and concise guidance on how to minimise
the risk of an extravasation injury when administering cytotoxic drugs and also to
provide guidance on the management of extravasation injuries.2
1.3. All extravasation incidents will be reported formally to the South East London Cancer
Network Drugs and Therapeutics Advisory Committee at the scheduled quarterly
meetings. The register of extravasation and it’s treatment (appendix 5) and follow up
report (appendix 6) should be utilised for this purpose. Learning from local
investigations and Root Cause Analysis should be shared at these meetings.
2.
Definition of Terms
2.1. Extravasation is the inappropriate or accidental administration of drugs or intravenous
fluids into the subcutaneous or subdermal tissues rather than into the intravenous
compartment. 1
2.2. A vesicant drug is one which is capable of causing pain, inflammation and blistering of
the local skin, underlying flesh and structures, leading to tissue death and necrosis.1
2.3. An irritant drug is one which is capable of causing inflammation and irritation, rarely
proceeding to breakdown of the tissue.1
2.4. A non-vesicant drug is one which may cause some mild inflammation and flare in local
tissues but will not cause lasting tissue damage.
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3.
Prevention of Extravasation
3.1. The following groups of patients are at increased risk of extravasation and extra care
should be taken :
3.1.1
Elderly, confused or agitated patients1,5
3.1.2
Patients with fragile veins, peripheral vascular disease, Raynaud’s
phenomenon or lymphoedematous limbs1,5
3.1.3
Patients with thrombocytopenia1,5
3.1.4
Paediatric patients1,5
3.2. Patients must be informed about the risk of extravasation and asked to report any
change in sensation at the intravenous site, especially pain or a burning sensation.
3.3. All systemic cytotoxic drugs should be administered in a quiet, calm environment. 6 The
administration of cytotoxic drugs should never be hurried. The drugs should be
administered slowly to allow the drug to be diluted by the carrier solution and to enable
careful assessment of the injection site.
3.4. The importance of skilled cannulation and administration techniques is paramount in
preventing extravasation. Only appropriately trained nursing staff are permitted to
administer systemic cytotoxics (refer to the Trust Cytotoxic drug policy).
3.5. Venous access should be assessed by a chemotherapy nurse for all patients requiring
the systemic administration of cytotoxic drugs.
3.6. The patency of the venous access device should be established prior to the
administration of each cytotoxic drug by flushing with 0.9% Sodium Chloride.
3.7. Siting over joints should be avoided as tissue damage in this area has very serious
consequences. Therefore, the recommendation is that the antecubital fossa should
NEVER be used for the administration of vesicants. The forearm is the preferred site of
administration of vesicants.1,3,4
3.8. If cannulation is not achieved at first attempt or the cannula requires resiting, the
subsequent puncturing of the vein must be at a point proximal to the previous puncture
site to avoid leakage from distal sites. In preference, a different vein should be
selected.9
3.9. The ability to obtain blood return should be checked before, during and after the
administration of cytotoxic drugs.
3.10. All antiemetics must be given before any chemotherapy. Subject to the sequencing
specified on the prescription form, vesicant cytotoxic drugs should be administered
before non-vesicant cytotoxic drugs to ensure agents most likely to cause tissue
damage are delivered when venous integrity is greatest.1,7
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3.11. All systemic bolus cytotoxic injections must be administered via a fast running drip.
3.12. The venous access site and limb must be observed throughout administration.1,7
3.13. If continuous infusions of vesicant drugs are required (e.g.VAD regimen), then this
must be via a central venous catheter (PICC, Port-a-Cath or Hickman line)
3.14. The use of an infusion device (pump) for the peripheral administration of vesicant drugs
should be avoided if possible, unless a full risk assessment has been undertaken to
ensure risk of extravasation is negligible. If an infusion device is required (e.g.
anthracycline infusions), the administration site must be closely monitored throughout
the infusion.8
4.
Signs and Symptoms of Extravasation
4.1. The patient complains of a change in sensation at the injection site, particularly a
burning or stinging pain. Be aware of non-verbal manifestations, which may include
crying and distress in some patients e.g. young children.1,4,8
4.2. Observation of induration, swelling, redness, blistering or leakage at the injection
site1,4,8.
4.3. No blood return is obtained. This is not a sign of an extravasation if found in isolation.1,8
Be aware that blood return may still be obtained if the vascular access device
has partially dislodged.
4.4. Resistance is felt on the plunger of a drug administered by bolus injection.1,4,8
4.5. There is an absence of free flow of a drug administered by infusion.1,4,8
4.6. If extravasation is suspected advice must be sought immediately from an experienced
chemotherapy nurse. It is recognised that many intravenous solutions and additives
can cause phlebitis (both acute and delayed). All suspected extravasations that are
subsequently excluded as extravasations should be documented in the patient’s
medical record as to why they have been excluded. A register of extravasation
excluded incidents should be kept locally by the Lead Chemotherapy Nurse and shared
at the quarterly DTAC meetings.
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5.
Classification of drugs.
Cytotoxic drugs are classified as vesicants, irritants or non-vesicants. Please note:
•
Any agent extravasated in high enough concentration may be irritant
•
This table is not an exhaustive list. In the event that an extravasation is suspected for a
drug / solution not on the list then the extravasation treatment algorithm in section 6 should
be followed. An oncology Pharmacist or the Trust’s Pharmacy medical information
department should then be contacted to provide the extravasation classification of the drug
/ solution involved.
Vesicants
Irritants
Amsacrine1
Epirubicin1
Busulphan2
Carmustine1
Chlormethine
(Mustine) 2
Dacarbazine1
Dactinomycin1
Daunorubicin1
Docetaxel6
Doxorubicin1
Idarubicin1
Liposomal
Daunorubicin
Mitomycin C1
Paclitaxel1
Streptozocin1
Treosulfan1
Vinblastine1
Vincristine1
Vindesine1
Vinorelbine1
1www.extravasation.org.uk
Arsenic
trioxide4
Cisplatin2
Carboplatin1
Etoposide1
Fluorouracil1
Irinotecan1
accessed 14th
Non-vesicants
Liposomal
Doxorubicin
(Caelyx) 3
Methotrexate1
Mitoxantrone2
Oxaliplatin2
Topotecan2
Asparaginase1
Alemtuzumab2
Bleomycin1
Bortezomib5
Cetuximab2
Cladribine1
Cyclophosphamide1
Cytarabine
(Cytosine) 1
4Communications
May 2009
2009
2www.cancercare.on.ca
Drug monographs
accessed 14th May 2009
5Communications
3Communications
6Communications
with Schering Plough 15th
May 2009
Fludarabine1
Gemcitabine1
Gemtuzumab1
Ifosfamide1
Melphalan1
Pentostatin1
Raltitrexed2
Rituximab1
Thiotepa1
Trastuzumab1
with Cephalon 15th May
with Janssen-Cilag 15th
May 2009
with Sanofi-Aventis 27th
May 2009
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6.
Extravasation treatment algorithm
IMMEDIATE ACTION FOR ALL DRUG CATEGORIES
STOP the infusion / injection, disconnect drip. DO NOT REMOVE THE CANNULA
Inform the patient what is happening
Inform / delegate a colleague to inform a member of medical staff and/or experienced
senior chemotherapy nurse
If not already, put on protective clothing – gloves, gown, goggles
ASPIRATE the extravasated drug, try to draw some blood back
REMOVE THE CANNULA
(consider leaving in situ if the patient is in need of an immediate plastic surgery review)
Cleanse the area with sterile Sodium Chloride 0.9%
Mark the extravasated area with a pen and apply a non-adhesive dressing
Digitally photograph the extravasated area with a scaled measure against a well lit neutral
background- Ensure the photograph is filed in the patient’s medical record
Discuss the subsequent treatment plan with the patient’s oncologist / haematologist or the
senior oncologist / haematologist on duty.
The Flush Out Technique should be carried out for All Vesicant Extravasations
or Irritant Extravasations over 10mls
This may be carried out by an appropriately trained nurse or doctor (Please see
section 8)
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7.
Vesicant Drugs
7.1
Extravasation of a vesicant drug is very serious as it can result in tissue necrosis and loss
of limb function.
7.2
Management of the extravasation of vesicant drugs is centred on minimising the damage
caused by the drug as well as reducing any inflammation, pain and discomfort.
7.3
There is a lack of robust clinical evidence for the use of preventative plastic surgery
intervention and topical / systemic administration of antidotes in treating extravasation
injuries caused by vesicant drugs. The recommended treatment of such injuries as
described in this policy is based on small clinical studies and the consensus of professional
opinion and practice in this area.
8.
Flush Out Technique
8.1
Is the treatment of choice of the GSTT plastic surgical team who provide a service for
extravasations which occur within the South East London Cancer Network.
8.2
Only appropriately trained doctors or nurses may perform the flush-out technique for
superficial peripheral extravasations where there is no visible skin damage or extensive
swelling. Those nurses trained must have completed the network role development profile
for flush-out technique and follow the agreed procedure detailed in appendix 1.
8.3
If no trained doctors or nurses are available to perform the procedure immediate plastic
surgery opinion and transfer must be sought
8.4
This technique will be used for extravastions of bolus injections (which include all
anthracyclines) as well as infusion such as vinca alkaloids and potassium (greater than
40mmols in 1 litre). Speed is of the essence and early use of the flush-out technique is
recommended 16 to reduce the damage done by vesicant extravasation.
8.5
All patients who have undergone the flush out procedure should be reviewed by Plastic
Surgery within 24 hours of carrying out the procedure.
For details of this procedure, see appendix 1.
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9.
Plastic Surgery Intervention
See appendix 3 and 4
9.1
It is recommended that the patient is referred for IMMEDIATE plastic surgery opinion if:
•
A member of staff trained in the flush out technique is not immediately available.
•
Greater than 5ml of vesicant drug or 10ml of irritant drug is suspected to have been
extravasated.
•
The extravasation is suspected to have occurred around the site of a central venous
catheter. For example in some haematology treatments such as the VAD regimen,
anthracyclines and vinca alkaloids are administered together using an infusion cassette /
elastomeric pump. If an extravasation occurs in this scenario, the treatment should be
carried out as if it was an anthracycline extravasation. This is because of the relatively large
volume of anthracyline used in the drug mixture compared to vinca alkaloid.
•
There are any concerns at any time.
10
Irritant (<10mls) and Non-Vesicant drugs.
10.1
These drugs may cause mild to moderate inflammation, irritation, discomfort and pain but
are unlikely to result in tissue breakdown.
10.2
Management of the extravasation of irritant and non-vesicant drugs is centred on reducing
any inflammation, pain and discomfort. The following treatment plan should be adhered to:
10.3
Elevate the limb and encourage movement.
10.3.1
Provide the patient with an extravasation patient information leaflet
(appendix 2).
10.3.2
Supply a tube of hydrocortisone cream 1% from the extravasation kit and
ask the patient to apply it twice daily to affected area to reduce further
inflammation. This should continue to be applied until inflammation has
subsided.
10.3.3 Supply or administration of medicines used to treat patients with extravasation
must comply with the governance processes within the relevant Trust, i.e. by
prescription or by Patient Group Directives.
10.3.4 Provide advice regarding pain relief and supply analgesia to the patient if
necessary.
10.3.5 Complete all necessary extravasation documentation as outlined in section 9 of
this policy.
10.3.6 NB The application of heat, cold packs or DMSO can lead to further
unnecessary burns to the skin so these treatments should be used with caution
and following consultation with a plastic surgeon.
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11.
Use of antidotes
11.1
The use of antidotes to treat vesicant extravasations should be considered only following
consultation with a plastic surgeon.
12.
Documentation
12.1
In the event of an extravasation the following documentation must be completed:
12.1.1
A local Trust incident form.
12.1.2
Medical photograph is recommended as part of the documentation
12.1.3
National Extravasation Information Service (NEXIS) ‘Green card’, (available
from http://www.extravasation.org.uk/home.html and see Appendix 5). Once
completed, two photocopies should be made with one copy being filed in the
patient’s notes and the other being sent to the Trust Chemotherapy Lead
Nurse. The Original form should be posted to NEXIS at the following
address: Extravasation Report Co-ordinator, c/o St Chad’s Unit, City
Hospital, Dudley Road, Birmingham, B18 7QH.
12.1.4
Any documentation used at individual trusts for the follow up and monitoring
of extravasation injuries in addition to the ‘green card’ documentation. An
example of follow up documentation is seen in Appendix 6
12.1.5
Trusts may like to consider developing Patient Group Directives for the
treatment of extravasation in order to minimise delays in prescribing of
medicines used in its treatment.
12.1.6
All incidents will be discussed/reported to the local chemotherapy board and
at the Network DTAC meeting
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13.
Extravasation and Flush Out Kit
13.1
Extravasation and Flush Out kits must be available at all times on each ward or clinic
where chemotherapy is being administered.
13.2
It is the responsibility of the nurse in charge of each ward or clinic to ensure that
Extravasation and Flush Out kits are in place and are within allocated expiry date.
13.3
Extravasation and Flush Out kits are available from the Pharmacy. When an extravasation
and/or Flush Out kit is used, a replacement kit should be obtained and the used kit/s
returned to pharmacy.
13.4
A Flush Out kit should accompany any patient transferred to St Thomas’ Hospital Accident
and Emergency department for Plastics intervention.
EXTRAVASATION KIT CONTENTS
Item
Copy of extravasation policy
NEXIS green card
Hydrocortisone cream 1%
Quantity
1
1
1
1 xx 15g
15g
Indelible ink marking pen
1
1
Equipment for Flush Out Kit
Separate Kit
Lidocaine 1% injection
4 x 10ml amps
Hyaluronidase injection 1500iu
1 amp
Sodium chloride 0.9%
1 x 10ml steri-amps
5ml luer lock syringes
5
20ml luer lock syringes
5
25G needles
10
Large bore needle or cannulae
1 x (14G-16G)
Sodium Chloride 0.9% 500ml bag
1
3 way tap
1
Sterile gloves
1 x medium
Sterile Paraffin gauze dressing
1 x (7.5cm x 7.5cm)
Dry gauze dressing
1 x (7.5cm x 7.5cm)
Bandage
1
Disposable Scapel
1 x size 11
Adsorbent pad
1
Administration / Giving Set
1
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Appendix 1
Flush-out procedure for the treatment of superficial peripheral extravasation
Developed by Dr Lisa Dougherty, Nurse Consultant at the Royal Marsden Hospital
Policy statement
Only appropriately trained doctors or nurses may perform the flush-out technique for superficial peripheral
extravasations where there is no visible skin damage or extensive swelling. Those nurses trained must have
completed the role development profile for flush-out technique and follow the procedure outlined below.
The flush-out technique will be used for the treatment of any peripheral vesicant extravasation that has been
assessed and deemed necessary by healthcare professional who has been trained in the use of the flushout technique. This technique will be used for extravastions of bolus injections (which include all
anthracyclines) as well as infusion such as vinca alkaloids and potassium (greater than 40mmols in 1 litre).
Speed is of the essence and early use of the flush-out technique is recommended (Gault 1993) to reduce the
damage done by vesicant extravasation.
Procedure
Rationale
1.
Explain the procedure and reason
for performing it to the patient and
gain written consent. Warn the
patient of scarring
To ensure that the patient understands the
procedure and gives his/her valid consent
2.
Ascertain
what
emergency
treatment has been carried out e.g
was hyaluronidase administered
To ensure that only required treatment is carried
out e.g. if hyaluronidase has been given, no
further dose would be administered as could
result in a sensitivity reaction.
3.
Assemble
all
the
equipment
necessary for the procedure
To ensure that time is not wasted and the
procedure
goes
smoothly
without
any
unnecessary interruptions.
4.
Check all packaging before opening
and preparing the equipment to be
used
To maintain asepsis throughout and check that
no equipment is damaged or out of date
5.
Carefully
wash
hands
using
bactericidal soap and water or
bactericidal alcohol handrub before
commencement and dry.
To minimise the risk of infection
6.
Place the patients arm on the
plastic backed towel
To prevent leakage of the flushed out solution
and possible contamination of the area with
cytotoxic drugs.
7.
Apply disposable gown and eye
protection
To prevent possible contamination of practitioner
with cytotoxic drugs
8.
Open a pack, empty all equipment
onto the pack and place a sterile
dressing towel under the patients
arm
To create a sterile working area
9.
Wash hands using bactericidal soap
and water
To minimise the risk of infection
10.
Apply sterile gloves
To minimise the risk of infection and prevent
contamination of the nurse
11.
Clean skin with 2% chlorhexidine
and allow the area to dry
To maintain asepsis and remove skin flora
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Procedure
Rationale
12.
Draw up 1% lidocaine in 10ml
syringe and label
To prepare for infiltration of area
13.
Reconstitute hyaluronidase injection
1500 units with 1ml sodium chloride
0.9% in a separate 5ml syringe and
label
To enable both drugs to be administered at
same time
14.
Mark the area of extravasation with
a sterile marker where incisions will
be made
To ensure the correct area is treated
15.
Using a 25g needle make a small
bleb by inserting the needle
intradermally and administering 0.1
– 2ml of Lidocaine slowly towards
the 4 points of compass. Allow it to
take effect.
To reduce any discomfort to the patient
16.
Then using a 23g needle infiltrate
the marked area with lidocaine
subdermally towards the 4 points of
compass. Check with patient what
kind of sensation they can feel e.g.
sharp or dull before proceeding
To ensure administration of anaesthetic to area
and to ensure anaesthetic has taken effect
17.
Attach a 23g needle to the syringe
of Hyaluronidase and infiltrate the
anaesthetised area at 4 points of
compass.
This will facilitate the flush out by loosening the
tissues
18.
Attach the administration set, 3 way
tap and extension set to the bag of
0.9% sodium chloride and withdraw
20 ml via the tap.
To prepare the syringe and to enable continued
access without having to open the system
19.
Make at least 4 incisions at 4 points
of compass using a size 11 scalpel
by inserting the blade straight down
to subcutaneous fat and one small
one to use for insertion of cannula
To prepare the area for flushing. The number of
incisions will be dependant on the size of the
area to be treated. To reduce risk of damage of
tendons, nerves and other anatomical structures
20.
Gently press on the area
This alone may allow the fluid to escape
21.
Insert the cannula through one of
the incisions and push along tissues
within marked area
To free up tissues from skin and to aid
advancement of cannula and flush
22.
Remove the stylet and attach the
extension set to the cannula
To facilitate the flushing
23.
Flush the saline through – it will exit
out of the other incision holes. Pat
with a sterile gauze swab,
massaging and milking the area at
same time. The area will become
puffy and swollen – this is normal
To commence the flushing procedure. To assist
with removal of saline
24.
Draw up 0.9% sodium chloride and
repeat procedure using a minimum
of 0.9% sodium chloride
To facilitate the flushing of the drug from the
area
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Procedure
Rationale
25.
If saline does not flow out of one
incision it may be necessary to
remove the cannula from the
original incision and insert it into
another one – a new cannula must
then be used.
To ensure all areas are flushed.
26.
Clean and dry the area although it
will continue to leak
To aid patient comfort
27.
Apply a mepitel dressing and a
loose bandage (do not wrap tightly)
To reduce the risk of infection and to prevent
compression of the skin
28.
Elevate the limb so hand is on level
with head
To aid reduction of oedema
29.
Discard waste
containers
To ensure safe disposal in the correct containers
and avoid laceration or injury of other staff
30.
Document in patients medical and
nursing notes and on flushout
technique form.
Post procedure
Discuss with medical colleagues re
prescribing oral antibiotics
(flucloxicillin is recommended for
reducing skin pathogens) and if
necessary analgesia.
To ensure adequate records
continued care of the patient
Refer to plastic surgeon if any
problems during procedure or any
skin problems (see appendix 3 & 4)
To ensure rapid access for further Management
32.
Dressing will need to be changed
every 48 hours and should remain
in situ for up to a week. The skin
incisions will heal within 1 – 2
weeks
To prevent risk of infection
33.
Ensure patient has details of who
and when to contact if any problems
once at home and organise for
dressing changes with hospital or
district nurses. Inform patient to
contact hospital if swelling does not
reduce, they have pain or there is
any tingling or numbness in the
fingers or arm.
To ensure patient receives immediate treatment
should there be any problems post procedure.
31.
in
appropriate
and
enable
If the patient is neutropenic they may be more at
risk of infection. To minimise pain and
discomfort.
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Appendix 2
Patient information sheet
What is extravasation?
Extravasation is when a drug has leaked outside of the vein. You may have noticed pain, stinging,
swelling or other changes to the skin at the site of the cannula or the nurse may have noticed that
the drug wasn’t flowing in easily.
Why did this happen?
We don’t know why the drug has leaked into the tissues although it can happen sometimes even
though we take all essential precautions to avoid it. The important thing is that it has been detected
and treated.
Why is extravasation a problem?
If extravasation goes untreated it can lead to pain, stiffness and tissue damage.
What treatment have I received to prevent this tissue damage?
The Doctor / Nurse has given you the recommended treatment for the drug that has leaked. This
means that you shouldn’t have any problems. You need to keep looking at the area every day to
make sure the treatment has worked.
What do I need to do?
1) Gently exercise the affected arm or hand. Take mild pain killers if you need to.
2) Look at the area once a day:




Has the area changed colour or increased in redness?
Is the area blistering, peeling or flaking?
Is the area more uncomfortable?
Is the pain making it difficult for you to exercise the arm or hand?
When should I contact you?
If you answered yes to any of the questions in section 2) above or you have any other concerns
then you should contact us.
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Appendix 3 - Plastic Surgery Referral details
Who do I contact?
Please call the Registar on call via the St Thomas’.Hospital switchboard (020 7188 7188)
bleep number:
• 0550 Plastics registrar on call
Please allow time for bleeps to be responded to.
* If you experience any difficulties the query should go through to the on call
consultant contactable through GSTT Switchboard
Any faxed transfer material should go to the dept fax machine in office hours on
Fax 0207188 5131 (confirm fax receipt by contacting secretary ext 85130)
Documentation required: If no ‘flush-out’ facilities are available on site, and after discussion with
the Registrar for plastics, it is decided this process is required the patient should be transferred as
an emergency to St Thomas’ Hospital Accident & Emergency Department.
A Flush Out Kit should accompany the patient when they are transferred to St Thomas’
Hospital Accident & Emergency Department
Complete the referral form to ensure the following details are recorded and send it with the patient:
to St Thomas’ Hospital

History of the extravasation event, including drug, estimated quantity, site of cannulation,
(include number of cannulation attempts at the treatment episode), time of the event and action
that has been taken

Patient details to include name, date of birth, address & telephone contact details, patient’s
general practitioner

Name and contact details of referring clinician and lead chemotherapy nurse at the unit where
the extravasation injury took place.
If the extravasation injury is detected at a time when it is too late to implement a ‘flush-out’
technique (for example days after the infusion causing the injury took place), and the patient is
still symptomatic of an extravasation injury, then the referral to plastic surgery is not an
emergency. If in any doubt always discuss the incident with the on call SHO or registrar (contact
details above).
If appropriate, it may be useful to send a digital photograph of the extravasation injury via trust email to the plastics registrar on-call.
In this instance fax a referral letter (containing the same information as above) to the plastic
surgery secretary at St Thomas’ on 020 7188 5131.
The secretary will deal with the request on the next working day, send a clinic appointment to the
patient. The referring clinician and lead chemotherapy nurse will be informed in the usual way, with
a copy of the clinic letter.
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Appendix 4
PLASTIC SURGERY CYTOTOXIC EXTRAVASATION REFERRAL FORM
Switch board number: 020
7188 7188
Date &
Sign
Referral discussed with
Outcome of referral discussion
(please tick)
(Please tick)
Urgent (send completed
form with patient & transfer as
an emergency to St Thomas’
Hospital)
On Call Registrar (via switch) bleep 0550
Non-urgent (Fax form to
plastic surgery secretary at St
Thomas’ Hospital- 020 7188
5131)(confirm receipt ext
85130)
Patient Name
Date of Birth
Address
Telephone No:
Home:
Mobile;
General Practitioner
Name & address
Referring Hospital
Name of Lead
Chemotherapy Nurse
from referring unit
Contact details
Telephone No:
Bleep/pager:
Details of
extravasation
Drug
Estimated Quantity
Date & time of event
Action that has been taken (continue on a separate page if necessary):
Referring Clinician
Name:
Signature
Contact details
Telephone No:
Bleep/pager:
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Appendix 5
GREEN CARD- available from http://www.extravasation.org.uk/home.html
IN CONFIDENCE
REGISTER OF EXTRAVASATION AND ITS TREATMENT
Patient’s name:
Hospital No:
Date of Birth:
Sex: Male / Female
Date:
Time:
Height:
Weight:
BSA:
Clinical area:
Cannula type & size:
Hickman type:
Chemotherapy Regimen:
Course no:
Drug/s name:
Dose/s:
(1) Was the intravenous chemotherapy administered via a fast running drip?
Fluid type?
Normal saline

Dextrose

Dextrose saline
(2) Was the chemotherapy administered via a pump?
If YES please indicate model used:
(3) Was the chemotherapy added to a specific type of fluid?
Dextrose

Normal Saline
Drug

Yes / No

Yes / No
Yes / No
Other:___________
Total Dose
Infusion or
bolus
Time
Already
Given
Not Yet
Given
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
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SITE OF EXTRAVASATION
Page 1 of 2
Please indicate site of extravasation with measurements on the diagrams below
HANDS
Left
Right
BODY
*Please mark with an X on the part of the body, where the device was placed and the extravasation site occurred.
NB Please indicate of other site of the body……………………………………………………………………
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CONTINUED page 2 of 2
Other method of administration:
Central or /Hickman line*/Portacath* /PICC line*
(Please
specify)________________________________________________________________________
Location (please specify – USE DIAGRAM ABOVE) _____________________________________
Details of extravasation action taken (Drug, Dose, Procedure)
Acute extravasation treatment started on_______________ Stopped on:_____________________
Signature:
Photograph
taken
Print name:
Consent
obtained for
photographs
Date:
Position:
Yes / NO
Yes / No
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Appendix 6
FOLLOW UP REPORT
All extravasation events must be reviewed every 24 hours following the adverse incident
Patient’s name:
Date of Birth:
Hospital no:
Date:
Time:
Date of incident:
(1) Give details below of any further pharmacological treatment given:
(2) Outcome (please indicate):
Resolved following acute treatment
Yes / No
Resolved using pharmacological treatment only
Yes / No
Skin grafts required
Yes / No
Patient unable to follow up: i.e. Transferred to another NHS Trust
Yes / No
If the extravasation injury ulcerated, was there any functional loss in the
affected limb? If yes, please give details below:
Yes / No
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(3) If any surgical intervention was initiated, please give brief details:
Signature:
Treatment Stopped:
Date:
Yes  / to continue 
Print name:
Next review date (if applicable):
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References
1)
The Cytotoxic Handbook, 4th edition. Allwood, Stanley, Wright
2)
Manual of cancer service standards. DoH. 2004
3)
Dougherty L and Lamb J. Intravenous therapy in nursing practice. Churchill Livingstone.
1999.
4)
Shulman et al. UCL Hospitals Injectable drug administration guide. Blackwell Science Ltd.
1998.
5)
Extravasation, how quickly could you act? CP pharmaceuticals, 1999
6)
A policy framework for commissioning cancer services. DoH. 1995 (Calman-Hine)
7)
West Midlands regional chemotherapy services extravasation treatment protocol
8)
National Extravasation Information service Web site. (www.extravasation.org.uk)
9)
Cancer Chemotherapy – a guide for practice. Holmes, 1997
10)
Schrijvers D.L. Extravasation: a dreaded complication of chemotherapy. Annals of
Oncology 14 (Supplement 3):iii26-iii30, 2003
11)
Tiffany V et al. Extravasation of Chemotherapeutic agents: Prevention and Treatment.
Seminars in Oncology 33:139-143, 2006
12)
Royal Marsden NHS Foundation Trust. 2007. Policy for the management of Extravasation of
vesicant drugs.
13)
Kings College Hospital Chemotherapy Resource file 2007
14)
Final Appraisal Report All Wales Medicines Strategy Group Dexrasoxane (Savene®)
Advice no 0207 June 2007, accessed 20th June 2008
http://www.wales.nhs.uk/sites3/docmetadata.cfm?orgid=371&id=85240
15)
Scottish Medicines Consortium assessment Dexrazoxane (Savene®) No. (361/07),
accessed 20th June 2008 http://www.scottishmedicines.org.uk/smc/5186.html
16)
Gault D.T. Extravasation injuries British Journal of Plastic Surgery 46:91-96, 1993
17)
Mouridsen H.T. et al. Treatment of anthracycline extravasation with Savene (dexrasoxane):
results from two prospective clinical multicentre studies. Annals of Oncology 18:(3) 546550, March 2007
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