Vesicant Infusions
A presentation for King Edward VII Memorial Hospital, Bermuda
23 January, 2012
Kristen Bodnaruk, RN, BS
Denise Dreher, RN, CRNI, VA-BC
Mary McCormick-Gendzel, RN, MS, CRNI,
RN-BC
Today’s Discussion:
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Definitions
Patient safety
Peripheral and central VAD assessments
Equipment
Healthcare worker safety
Drug administration
Extravasation
Definitions
• Irritant: medication that may cause itching,
phlebitis, or reaction along the vessel or at the
injection site.
• Vesicant: any IV drug that can cause
blistering, severe tissue injury or tissue
necrosis when extravasated. These may be
chemotherapeutic or non-chemotherapeutic
medications.
Peripheral IV (PIV) Access
• Gauge of catheter:
---bigger is not always better
---use smallest gauge possible to meet
infusion needs
---smaller gauge decreases intimal damage
and promotes hemodilution
• Placement of catheter: avoid areas of flexion such as the hand,
wrist, or antecubital fossa
• Consider new PIV insertion daily if patient receiving daily vesicants
• Start PIV insertions distally on arm and move proximally as therapy
regimen progresses
Risk Factors
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Patient age, condition, or acuity
Large gauge, location, and/or length of catheter
Infusion history
Poor VAD insertion technique
Poor care and maintenance practices
Extended dwell time
Chemical makeup of drug: pH <5 or >9, osmolarity
>600mOsm, or final dextrose concentration > 10%
• Recent proximal peripheral venipunctures, or other
existing PIVs in the same extremity
Risk Factors
• Recent proximal peripheral venipunctures, or other
existing PIVs in the same extremity
• Inadequate device securement
• Confused or active patients could dislodge or damage
access
• Improper length of non-coring needle used with port
access.
• Inadequate device securement
VAD Assessment
• Patient comments/complaints
• What is insertion date? (for PIVs)
• Any swelling/edema noted…is transparent dressing
looking taut?...is ID bracelet tight?
• Is skin blanched or cool to touch?
• Positive blood return?
• Any redness (erythema) or leaking at insertion site?
• Any difficulty flushing?
• Radiological confirmation of central line catheter tip
placement
Some Potential Complications of Central
Venous Access Devices (CVADs)
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Catheter occlusion
Vessel occlusion
Catheter rupture/fracture
Device rotation
Catheter migration
For implanted ports: improper insertion of
non-coring needle or needle dislodgement
Equipment
• IV tubing containing DEHP: (di-2ethylhexylphthalate) is a plasticizer added to
PVC-based plastics to make them soft and
pliable.
There is evidence that certain drugs cause
more leaching of DEHP.
Increased amounts of DEHP in humans is
concerning for its carcinogenic or hepatotoxic
effects.
Personal Protective Equipment (PPE)
• Long-sleeved protective gown or cover-up should
be lint-free and made of a low-permeability
fabric. Gown should have a solid front, back
closure, and tight cuffs.
• Powder-free long-cuffed gloves designed
specifically for chemotherapy should be worn.
Gloves should be changed after each use, after 30
minutes of wear, or if they become torn or
exposed to chemotherapy.
• Face shield, goggles, or safety glasses should be
worn
Healthcare Worker Safety
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Proper handling of infusates and administration sets
Caution with connecting and disconnecting
Proper use of PPE
Exercise caution when handling patient’s emesis,
urine, or feces
• Disposal of equipment into the appropriate
biohazard bag or container
• Follow established protocols and use a
chemotherapy spill kit when cleaning up spills
Vesicant Administration
General Points of Emphasis
• Continuous vesicants are given via central
access.
• Pre-filled administration sets versus
backpriming of tubings
• Vesicants are administered FIRST in a multiple
chemo regimen
• Patient education!!
Pre-infusion
• Informed consent?
• Patient education: including signs/symptoms to notify RN if
they feel any pain, burning, cool sensation, tingling, etc… at
insertion site.
• Gather supplies:
---clean pad or ‘chux’ to place supplies on at bedside
---PPE
---medication
---alcohol wipes
---empty 10ml syringe
---bag of 0.9% saline (NS) with tubing
Pre-infusion
• Check/double-check of correct medication
and dosage per facility policies and
procedures
• Review of patient’s height, weight, body
surface area (BSA), and any pertinent lab
values
• Patient identification using two verifiers
Infusion
• Do you have “the three C’s?”…. correct
patient, correct medication and dose, and
correct VAD?
• Connect NS to VAD. Fluid should be fast and
free-flowing. Chemotherapy should be
connected at the lowest port closest to IV
insertion site. Technique is known as “freeflowing side arm”.
Infusion
• When giving an IVP medication, blood return
must be assessed every 2-3ml of infusate
given. It should be given in a slow, steady
push.
• The NS should be free-flowing the entire time.
• Site assessment should be on-going during
administration.
• End with NS flush of 100-200ml.
Peripheral IV Extravasation
Port Extravasation
Port Extravasation
Extravasation
• Inadvertent administration of vesicant
medication or solution into the surrounding
tissue (INS, 2011)
Extravasation
• Any grade 4 infiltrate of a vesicant is considered an
extravasation
• Incidence is similar for peripheral and central line
administration
• Risk factors, such as fragile vessels, location of peripheral IV,
or catheter integrity are things to consider
• Antidotes may be used, but are considered controversial in
some circles
• Many non-chemotherapy agents have vesicant properties
(e.g., Dopamine, Epinephrine, Gentamycin, Mannitol)
Reference: MGH NPROM 08-02-01
Early warning signs of possible
extravasation
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Swelling
Stinging, burning, or pain at insertion site
IV flow that stops or slows
Resistance when pushing medication
Leaking around the port needle
Lack of blood return
Erythema, inflammation, or blanching
Other symptoms/damage resulting
from extravasation
• Induration
• Vesicle formation
• Necrotic tissue damage can progress for six
months
• Tissue sloughing
• Tendon, nerve, joint damage
• Blistering at insertion site
• Ulceration is usually seen 2-3 days to weeks
following extravasation
Treatment of Extravasation
• IMMEDIATELY STOP INFUSION
• Remove tubing from VAD, attach syringe to VAD, and aspirate
drug
• If via PIV, elevate extremity
• Notify physician ASAP
• Locate your institution’s policies or call Pharmacy for specific
antidote
• Application of heat or cold
• Documentation in patient’s medical record
• Documentation via safety report
DNA-binding agents
• Bind to the DNA in healthy cells when they
extravasate into the tissue and cause cell death.
• Retained in the tissue for long periods of time and
cause progressive tissue necrosis.
• Examples: anthracyclines (daunorubicin,doxorubicin,
epirubicin, and idarubicin)
• Application of cold 15-20 minutes for four to six
times daily for 24 to 48 hours
Non-DNA binding agents
• Do not bind to the DNA in healthy cells, and
are metabolized in the tissue
• Examples: plant alkaloids (vincristine,
vinblastine, and vindesine)
• Application of heat 15 to 20 minutes for four
to six times daily for 24 to 48 hours
Some Available Antidotes
• Totect (dexrazoxane) for anthracycline
extravasation
• Sodium thiosulfate for nitrogen mustard
extravasation
• Hyaluronidase for vinca alkaloid extravasation
Helpful Websites
• www.ins1.org
• www.ons.org
• www.cdc.gov/niosh
References
• Alexander, M., et al., Infusion Nursing. An Evidence-Based
Approach. INS, Saunders, 2010.
• Policies and Procedures for Infusion Nursing. INS, fourth
edition, 2011.
• Infusion Nursing Standards of Practice. INS, Lippincott,
2011.
• Terry, et al. Intravenous Therapy: Clinical Principles and
Practice. INS. WB Saunders, 2001
• Oncology Nurses Society (ONS) website
• MGH Nursing Procedure Manual (NPROM)
• MGH Clinical Policies and Procedures
• MGH Infection Control Manual