Draft
Title: IV Medication, Extravasation Management
Distribution: Hospital Wide
Desired Outcome:
1. Patients receiving IV medication with the potential for causing irritation/tissue
necrosis will be monitored closely to prevent extravasation.
2. If infiltration of a high risk drug occurs, extravasation management will be
implemented to minimize tissue damage.
3. Patient will be instructed on measures to prevent extravasation, symptoms,
interventions and appropriate follow-up management if extravasation occurs.
Definitions:
Extravasation: Passage or escape into tissue of antineoplastic drugs. Tissue slough and
necrosis may occur if the condition is severe.
Vesicant: An agent that has the potential to cause blistering, severe tissue injury or tissue
necrosis when extravasated.
Irritant: Any agent that causes aching, tightness, and phlebitis along the vein or at the
injection site, with or without a local inflammatory reaction but does not cause tissue
necrosis.
Flare Reaction: A local allergic reaction to an agent, manifested by streaking or red
blotches along the vein, but without pain.
The most damaging, VESICANT EXTRAVASATION, results when chemotherapeutic
agents that are capable of causing tissue necrosis infiltrate from vein to subcutaneous
tissue and cause progressive, severe tissue damage. The degree of damage is related to
the amount of drug that has infiltrated and the vesicant properties of the drug.
A list of recommended antidotes and topical treatments for specific drugs is located on
the SJMC intranet under the pharmacy section.
A list of antineoplastic drugs that are classified as vesicants and irritants include the
following commercially available agents:
VESICANTS
Cisplatin (in concentrations of 0.5mg/ml), Dactinomycin, Daunorubicin, Doxorubicin
Epirubicin, Esorubicin, Idarubicin, Mechlorethamine hydrochloride, Mitomycin,
Mitoxantrone, Paclitaxel ( rare risk), Vinblastine, Vincristine, Vindesine, Vinorelbine
IRRITANTS
Bleomycin, Carboplatin, Carmustine, Dacarbazine, Daunorubicin citrate liposomal,
Doxorubicin liposomal, Etoposide, Ifosfamide, Oxaliplatin, Teniposide
Non-antineoplastic agents that can cause irritation or extravasation include:
Aminiophylline, Calcium, Dextrose 10%, Diazapem, Dobutamine, Dopamine,
Doxycycline, Epinephrine, Erythromycin, Lorazepam, Nafcillin, Norephinephrine,
Penicillin, Phenylephrine, Phenytoin, Piperacillin/Tazobactam, Potassium Solution,
Promethazine, Contrast Media, Sodium Bicarbonate, TPN Solution, Vancomycin
Signs and Symptoms of an Extravasation Versus vein irritation vs. Flare reaction
Assessment Parameter
Pain
Redness
Ulceration
Swelling
Blood Return
Other
Extravasation
Vein Irritation
Flare
Reaction
No pain.
Immediate: severe pain or burning that last for
minutes or hours and eventually subsides;
usually occurs while the drug is being given
and around the needle site
Delayed: pain within 24 hours.
Immediate blotchy redness around the needle
site
Delayed: may not occur at time of immediately
Aching and
tightness around
vein
The full length of
the vein may be
reddened or
darkened.
Immediate
blotches or
streaks along
the vein,
which
usually
subside
within 30
minutes with
or without
treatment
Develops insidiously; usually occurs 48-96
hours later.
Severe swelling; usually occurs
immediately or within 48 hours.
Not usually.
Not usually.
Unlikely.
Inability to obtain blood return; good blood
return during drug administration.
Change in the quality of the infusion and
local tingling and sensory deficits.
Usually.
Unlikely,
wheals may
appear
along the
vein line.
Usually.
NA
Urticaria
PROCEDURE
A. Extravasation
1. Stop infusion if infiltration/extravasation occurs
2. Notify physician, obtain antidote if indicated and ordered by physician. Note: a list of
recommended antidotes/topical treatments can be found on the intranet under the
pharmacy section.
3. Do not remove I.V. needle, immobilize extremity.
4. Disconnect tubing and gently aspirate any residual drug from needle/catheter with a
small (1-3 cc) syringe.
5. House officer or primary physician will administer appropriate IV antidote into the
extravasated area. If unable to administer antidote through the IV, the antidote should be
given subcutaneously by the house officer or primary physician.
6. If appropriate, administer subcutaneous antidote in the extravasated area.
a. Inject the antidote subcutaneously in multiple injections clockwise around/into
the infiltrated area.
b. Use 25-27 gauge needles and change the needle prior to each new injection.
c. Repeat this process until the entire dose is injected in a full circle around the
estimated borders of the extravasated area.
7. After injecting antidote or if no antidote applicable or ordered, remove IV needle,
avoid applying direct pressure to site.
8. Apply topical ointment if ordered.
9. Apply ice pack for 15 minutes 4 times per day for the first 24-48 hours except for
Vinca alkaloids (Vincristine, Vinblastine, Vinorelbine, Vindesine, Etoposide,
Teniposide). For these 6 Vinca Alkaloids apply heat 4 times a day for the first 24-48
hours.
10. Assess the limb for pulses, capillary refill, and sensory and motor function.
11. Attempt to affected extremity elevated for 48 hours.
12. Measures borders of extravasated material and document width.
13. Document extravasation episode.
Complete an incident report for infiltrations of chemotherapeutic drugs. Also
chart the following:
*
*
*
*
*
*
*
date and time of event
Needle/catheter size, type and location
Drug sequence
Nursing management
Patient complaints, statements
Appearance of site
Physician notification and follow-up measures
14. Instruct the patient to report pain, redness, swelling, which continues more than 48
hours after event and/or at the first signs of the development of ulceration or necrosis at
the site. Instruct patient to protect site from direct sunlight.
B. Flare reaction (lack of pain swelling, and good blood return)
1. Flush the vein slowly with saline and watch for resolution of flare.
2. If no resolution get a physician’s order to administer hydrocortisone. For adults
the dose is 25-50 mg IV followed by saline flush.
3. Once the flare reaction has resolved, slowly resume infusion of the drug.
4. For subsuquent infusions of same drug to same patient, premedication with
antihistamines and or corticosteroids and slowing infusing rates may prevent
further reactions.
5. Document episode including treatment and patient response.
References:
(2003) Paclitaxel package insert. Bristol Myers Squibb Company.
(2005) Cancer Chemotherapy and Biotherapy Guidelines and Recommendations for
Practice, Second Edition, Oncology Nursing Society.
(2005) Martin, S., Cooper, T. and Sterling, J. Guide to Extravasation Management in
Adult Patients. Hospital Pharmacy, Wolters Kluwer Health, Inc.
(2005) Wilkes, G. and Barton-Burke, M. Oncology Nursing Drug Handbook. Jones and
Bartlett.