Vesicant extravasation Part I: mechanisms, pathogenesis, and nursing care to reduce risk

Oncology Nursing Forum, Nov, 2006 by Carmel Sauerland, Constance Engelking, Rita Wickham, Dominick Corbi

Purpose/Objectives: To review the literature regarding the incidence, current practice, guideline recommendations, nursing management, and knowledge gaps relevant to vesicant extravasation.

Data Sources: Published research articles, books, case reports, and national guidelines.

Data Synthesis: Vesicant extravasation is a relatively rare but significant complication of chemotherapy administration. Extravasation may have a range of consequences that can cause serious physical and quality-of-life effects. Knowledge of risk factors and preventive measures can reduce patient risk. Data-based and empirical management strategies such as immediate local measures (agent withdrawal, comfort measures, and medical interventions) may minimize risk for extravasation, as well as lead to timely recognition and management and decreased morbidity should extravasation occur.

Conclusions: Vesicant extravasation and sequelae constitute a complex patient problem that clinicians should strive to prevent or to minimize injury should it occur. To this end, clinicians must demonstrate awareness of risks and use specialized knowledge while administering vesicant agents.

Implications for Nursing: Only nurses knowledgeable about extravasation and skilled in associated techniques should assume responsibility for vesicant administration.

Key Points ...

* Pharmaceutical agents with vesicant properties can produce pain, swelling, inflammation, and progressive tissue damage, eventuating in necrosis and disability.

* Risks for vesicant extravasation include patient, clinician, therapy, and IV device factors.

* Prevention strategies include diligently monitoring infusions, selecting optimal administration devices, and using appropriate administration techniques.

* Because evidence-based data regarding management of vesicant extravasation are lacking, local comfort measures and antidotes are largely empirical.

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Vesicant extravasation, although uncommon, has enormous potential to affect a patients' quality of life and survival, as well as generate substantial healthcare costs. Clinicians who administer vesicant agents must demonstrate appropriate skills and knowledge regarding the recognition and management of extravasation. The Oncology Nursing Society (ONS) book Chemotherapy and Biotherapy Guidelines and Recommendations for Practice (Polovich, White, & Kelleher, 2005) condensed the minimum standards for practice and is useful in any setting where chemotherapy is administered. However, management of extravasation remains largely based on anecdotes of "efficacious" interventions in small samples or in single clinical cases (Kretzschmar et al., 2003). Consequently, oncology nurses, physicians, and pharmacists face the challenge of determining best practice with a less-than-ideal body of evidence to support clinical decision making. Practitioner awareness and patient management that include use of current guidelines, as well as systematic data collection and case reporting, can contribute to the further development of evidence-based patient care.

Spectrum of Extravasation

Extravasation is the inadvertent leakage or escape of a drug or solution from a vein or unintentional injection into surrounding healthy tissues. Occurrences of vesicant chemotherapy extravasation may be underreported but are estimated to occur in 0.1%-6% of peripheral IV infusions and in 0.3%-4.7% of implanted venous access port infusions (Lemmers et al., 1996; Shetty et al., 1997). The consequences of extravasation range from mild discomfort to severe tissue destruction, depending on whether the drug that leaks is a nonvesicant, irritant, or vesicant (see Figure 1). Extravasation of nonvesicant drugs generally does not cause tissue damage, whereas irritant agents induce inflammatory reactions but usually cause no persistent tissue damage. In either case, nonpharmacologic comfort measures (e.g., applying warm or cold, elevating the extremity) usually reduce swelling and discomfort.

In contrast, extravasation of vesicant agents can cause progressive tissue damage (Ener, Meglathery & Styler, 2004; Luke, 2005; Boyle & Engelking, 1995; Vargel et al., 2002). For example, a DNA-binding vesicant agent trapped in tissues can cause skin blistering and ulcer formation in days to weeks (see Figure 2). Eventually, indolent ulcers and persistent necrosis may extend to underlying tendons, ligaments, nerves, and bone and cause severe pain and functional deficit (e.g., loss in joint motility) (see Figure 3). Central venous catheter (CVC) extravasation may be complicated by local skin and soft tissue necrosis in the chest wall or neck, severe pain, effusions, dysrhythmias, or mediastinitis (Bozkurt, Uzel, Akman, Ozguroglu, & Molinas Mandel, 2003; Curran & Luce, 1990; Davies, Russell, & Thompson, 2003; Schulmeister & Camp-Sorrell, 2000). Furthermore, squamous cell skin carcinoma can occur as a late complication of chronic extravasation ulcers (Lauvin, Miglianico, & Hellegouarc'h, 1995).

One dilemma is that some drugs classified as nonvesicants, irritants, or mild vesicants (e.g., cisplatin, oxaliplatin, paclitaxel, docetaxel, mitoxantrone) have been associated with extravasation injuries (Baur, Kienzer, Rath, & Dittrich, 2000; Berghammer, Pohnl, Baur, & Dittrich, 2001; El Saghir & Otrock, 2004; Ener et al., 2004; Kennedy, Donahue, Hoang, & Boland, 2003; Kretzschmar et al., 2003; Stanford & Hardwicke, 2003). For instance, one patient who had an apparent oxaliplatin extravasation experienced immediate IV site erythema and swelling, local induration four days later, and ultimate skin sclerosis and functional limitation (Foo, Michael, Toner, & Zalcberg, 2003). Similarly, mitoxantrone extravasation into the dorsum of a patient's hand led to small area of discoloration that progressed over three months to a 2 cm by 2.5 cm necrotic lesion requiring surgical debridement and skin grafting (Luke, 2005).