Extravasation Management

Integrating human expertise & automated methods for a dynamic and multi-parametric evaluation of large language models' feasibility in clinical decision-making

BACKGROUND

Recent enhancements in Large Language Models (LLMs) such as ChatGPT have exponentially increased user adoption. These models are accessible on mobile devices and support multimodal interactions, including conversations, code generation, and patient image uploads, broadening their utility in providing healthcare professionals with real-time support for clinical decision-making. Nevertheless, many authors have highlighted serious risks that may arise from the adoption of LLMs, principally related to safety and alignment with ethical guidelines.

OBJECTIVE

To address these challenges, we introduce a novel methodological approach designed to assess the specific feasibility of adopting LLMs within a healthcare area, with a focus on clinical nursing, evaluating their performance and thereby directing their choice. Emphasizing LLMs' adherence to scientific advancements, this approach prioritizes safety and care personalization, according to the "Organization for Economic Co-operation and Development" frameworks for responsible AI. Moreover, its dynamic nature is designed to adapt to future evolutions of LLMs.

METHOD

Through integrating advanced multidisciplinary knowledge, including Nursing Informatics, and aided by a prospective literature review, seven key domains and specific evaluation items were identified as follows:A Peer Review by experts in Nursing and AI was performed, ensuring scientific rigor and breadth of insights for an essential, reproducible, and coherent methodological approach. By means of a 7-point Likert scale, thresholds are defined in order to classify LLMs as "unusable", "usable with high caution", and "recommended" categories. Nine state of the art LLMs were evaluated using this methodology in clinical oncology nursing decision-making, producing preliminary results. Gemini Advanced, Anthropic Claude 3 and ChatGPT 4 achieved the minimum score of the State of the Art Alignment & Safety domain for classification as "recommended", being also endorsed across all domains. LLAMA 3 70B and ChatGPT 3.5 were classified as "usable with high caution." Others were classified as unusable in this domain.

CONCLUSION

The identification of a recommended LLM for a specific healthcare area, combined with its critical, prudent, and integrative use, can support healthcare professionals in decision-making processes.

Seeking American Society of Clinical Oncology-Quality Oncology Practice Initiative (ASCO-QOPI) certification in a northern New England rural health system and cancer care network

In 2006 following several years of preliminary study, the American Society of Clinical Oncology (ASCO) launched the Quality Oncology Practice Initiative (QOPI). This cancer-focused quality initiative evolved considerably over the next decade-and-a-half and is expanding globally. QOPI is undoubtedly the leading standard-bearer for quality cancer care and contemporary medical oncology practice. The program garners attention and respect among federal programs, private insurers, and medical oncology practices across the nation. The MaineHealth Cancer Care Network (MHCCN) has undergone expansive growth since 2017. The network provides cancer care to more than 70% of the cases in Maine in a largely rural health system in Northern New England. In fall 2020, the MHCCN QOPI project leadership, following collaborative discussions with the ASCO-QOPI team, elected to proceed with a health system-cancer network-wide QOPI certification. Key themes emerged over the course of our two-year journey including: (1) Developing a highly interprofessional team committed to the project; (2) Capitalizing on a single electronic medical record for data transmission to CancerLinQ; (3) Prior experience, especially policy development, in other cancer-focused accreditation programs across the network; and (4) Building consensus through quarterly stakeholder meetings and awarding Continuing Medical Education (CME) and American Board of Medical Specialists (ABMS) Maintenance of Certification (MOC) credits to oncologists. All participants demonstrated a genuine spirit to work together to achieve certification. We report our successful journey seeking ASCO-QOPI certification across our network, which to our knowledge is the first-of-its-kind endeavor.

A Primer on the Acute Management of Intravenous Extravasation Injuries for the Plastic Surgeon

Intravenous therapy is a common practice among many specialties. Intravenous therapy extravasation is a potential complication to such therapy. Hospitals without a dedicated wound care team trained in these interventions will often default to plastic surgical consultation, making an understanding of available interventions essential to the initial evaluation and management of these injuries. The goal of this article was to provide plastic surgeons and health care providers with a general overview of the acute management of intravenous infiltration and extravasation injuries. Though the decision for surgical versus nonsurgical management is often a clear one for plastic surgeons, local interventions, and therapies are often indicated and under-utilized in the immediate postinfiltration period. Thorough knowledge of these interventions should be a basic requirement in the armamentarium of plastic surgery consultants.

Risk management of onco-hematological drugs: how and how fast can we improve?

PURPOSE

Medication errors in oncology may cause severe damage to patients, professionals, and the environment. The Italian Ministry of Health issued Raccomandazione 14 to provide guidelines for prevention of errors while using antineoplastic drugs. This work aimed at analyzing Raccomandazione 14 through the different viewpoints of the hospital pharmacist, the nurse, the oncologist, and the hospital director.

METHODS

Twenty-seven Italian healthcare organizations participated in a self-assessment survey evaluating compliance with Raccomandazione 14 within the oncology, hematology, and pharmacy departments.

RESULTS

The self-assessment results showed a general acknowledgement of the need for centralized management of anticancer agents. The specific responsibility of the pharmacist on the centralized management of anticancer drugs from preparation to disposal emerged as a critical point. The nurse, beyond the skills in drug administration and prevention of extravasation, also plays a fundamental role in educating and supporting the patient. The physicians, who are attentive to scientific, clinical, and regulatory criteria in prescribing and monitoring the therapies, are called upon to improve awareness on the importance of sharing standardized procedures with other professionals, to minimize medication error occurrence. The implementation of a complete computerized management from prescribing to drug administration and follow-up was highlighted. Multidisciplinary groups were constituted across the nation by professionals dedicated to the implementation of electronic health records and drug history and medical reconciliation processes.

CONCLUSIONS

Our analysis of the Ministerial Raccomandazione 14 urges implementation of the resources for ensuring quality and safety during prescription, preparation, and administration of anticancer drugs.

Metastatic Serratia endophthalmitis associated with extravasation injury in a preterm neonate

The authors report a case of a preterm neonate who presented with lid edema, corneal edema, and an inflammatory membrane with whitish exudates in the pupillary area, suggestive of endophthalmitis. There was also a cutaneous ulcer with an eschar on the right wrist at the site of extravasation associated with previous intravenous catheter. Cultures from the ulcer and vitreous samples both grew Serratia marcescens with identical antibiotic sensitivity and resistance patterns. The ocular infection was rapidly progressive and did not respond to administered medical and surgical therapy leading to subsequent phthisis bulbi. Serratia can cause endophthalmitis refractory to antibiotics and despite aggressive and timely treatment can have an unfavorable outcome. This report aims at highlighting the possibility of metastatic infection from an extravasation injury with a potentially fatal outcome.

The management of cytotoxic chemotherapy extravasation: a systematic review of the literature to evaluate the evidence underpinning contemporary practice

Management of cytotoxic drug extravasation remains contentious, with differing views on the most effective management strategy. With the increasing drive to provide effective, evidence-based healthcare, while ensuring the patient experience of the treatment provided plays a significant part in the development of clinical practice guidelines, the purpose of this literature review was to both critically analyse the quality of evidence that underpins contemporary practice and to determine if the patient experience is taken into account. A literature search was undertaken sourcing publications from the 1960s to July 2014 identifying all studies detailing strategies aimed at preventing the need for surgical debridement and all studies evaluating extravasation management from the patient's perspective. No conclusive evidence was found to suggest one clinical strategy as more effective than the other. No studies were identified that evaluated outcome from the patient's perspective. It is therefore suggested that outcomes-based research should underpin contemporary extravasation management guidelines to determine what the final outcome or 'end result' is and how this impacts on the patient and that the current lack of research into the patient experience of extravasation management is an area that needs to be addressed.

Eliminating extravasation events: a multidisciplinary approach

Administration of chemotherapy agents can give rise to many safety issues. Extravasation of a vesicant agent causes tissue blistering and necrosis. This complication of chemotherapy administration causes additional pain and suffering in patients who are already suffering with a diagnosis of cancer. Nurses hold key responsibilities for educating patients about administration issues and following practice standards to minimize the risk of extravasation. Defining a path of shared responsibilities among team members is a critical step in assuring the safe administration of drugs classified as vesicants. This article describes a clinical practice change that is used at a large midwestern academic medical cancer center. This practice and policy change has resulted in a 90% reduction in the administration of vesicant agents peripherally, with no occurrence of extravasations in the first 6 months of implementation.

Level of adherence to an extravasation protocol over 10 years in a tertiary care hospital

BACKGROUND

Extravasation of chemotherapy is an undesirable complication related to the administration of antineoplastic therapy. Establishing the real incidence is difficult. Because of the importance of a quick intervention after an extravasation, every hospital should have an extravasation protocol.

OBJECTIVES

The purpose of this study was to determine the degree of observance of an extravasation protocol by nursing staff and to determine extravasation incidence.

METHODS

This descriptive, longitudinal, retrospective study was set in a tertiary-level hospital. The researchers reviewed 117 extravasation notification forms received by the pharmacy department during a 10-year period. Nursing actuation, particularly observance of the extravasation protocol, was analyzed.

FINDINGS

Protocol adherence was 89%. Twelve deviations from the protocol in the application of recommended measures were detected. An antidote was used in 41 patients, and temperature measures were applied in 14 cases. Ninety-nine patients had at least one episode of reported follow-up. No cases of necrosis or skin ulcers were described, except by one patient, who developed a delayed skin ulcer to vinorelbine. Drugs most frequently reported were etoposide, carboplatin, and paclitaxel. Nursing staff should be continuously trained in extravasation protocol because a rapid actuation can prevent skin lesions.

Extravasation injuries: a review

Extravasation injuries are common emergencies in clinical practice. If they are not recognized and treated promptly, they can lead to deleterious functional and cosmetic outcomes. There is a vast range of agents involved in these injuries and marked paucity of evidence to support their specific management. Following an extensive literature review, we outline management principles for clinicians involved in the care of patients with extravasation injuries. Key parameters in deciding appropriate management plans include the volume/toxicity of the agent, the necrosis interval of the injury, patient-related factors, as well as the facilities and expertise available in the setting of individual cases of extravasation.

The management of infantile extravasation injury using maternal platelet-rich plasma

Accidental leakage of infusions into surrounding tissue is an adverse event that commonly occurs in preterm infants in the intensive care unit. Although most of these extravasations do not cause severe damage, a small number progress to tissue necrosis, and extensive tissue loss can sometimes occur. Platelet-rich plasma (PRP) consists of a high concentration of platelets in a small volume of plasma and can be prepared easily from peripheral blood. Its wound healing effect is well known. We report the successful healing of extensive tissue necrosis with maternal PRP and suggest that the application of maternal PRP may be an easy and effective treatment option for infant wound management in selected cases that merits further investigation.

Hyaluronidase for treatment of intravenous extravasations: implementation of an evidence-based guideline in a pediatric population

PURPOSE

To describe the implementation and evaluation of an evidence-based guideline, Hyaluronidase for Treatment of IV Extravasations, in a pediatric population.

CONCLUSIONS

Evidence of hyaluronidase efficacy suggests that timely administration will decrease the severity of tissue damage caused by extravasations, and result in cost savings. Implementation of this guideline increased user knowledge, incident reporting, and initiation of treatment, and decreased the average time to treatment administration.

PRACTICE IMPLICATIONS

Implementation strategies facilitate integration and sustained use of evidence-based treatments in clinical practice. Processes that promote evidence-based treatment are expected to improve outcomes and are therefore an important component of evaluation.

Management of cytotoxic extravasation - ASORS expert opinion for diagnosis, prevention and treatment

BACKGROUND

Cytotoxic extravasation is a rare but potentially serious and painful complication of intravenous drug administration in oncology. Literature is anecdotal, and systematic clinical trials are scarce. The German working group for Supportive Care in Cancer (ASORS) has prepared an expert opinion for the diagnosis, prophylaxis and management of cytotoxic extravasation based on an interdisciplinary expert panel.

MATERIAL AND METHODS

A Pubmed search was conducted for diagnosis, risk factors, symptoms, prophylaxis, and treatment of extravasation by the respective responsible expert. A writing committee compiled the manuscript and proposed the level of recommendation. In a consensus meeting, 13 experts reviewed and discussed the current practice in diagnosis and management of cytotoxic extravasation. In a telephone voting among the experts, the level of recommendation by ASORS was determined.

RESULTS

Every effort should be made to reduce the risk of extravasation. Staff training, patient education, usage of right materials and infusion techniques have been identified to be mandatory to minimalize the risk of extravasation. Extravasation must be diagnosed as soon as possible, and specific therapy including antidotes dependent on the extravasated drug should be initiated immediately. An extravasation emergency set should be available wherever intravenous cytotoxics are applied. Documentation and post-treatment follow-up are recommended.

CONCLUSION

We have developed a literature- and expert-based consensus recommendation to avoid cytotoxic extravasation. It also provides practical management instructions which should help to avoid surgery and serious late effects.

Implementation of a protocol for the prevention and management of extravasation injuries in the neonatal intensive care patient

AIM

This project sought to determine nurses' understanding and management of infants with intravenous (IV) therapy. There were three specific aims: • To improve identification and management of extravasation injuries in neonates • To ensure management of extravasation injuries in neonates is classified according to IV extravasation staging guidelines • To develop a protocol that outlined actions required to manage extravasation injuries.

METHODS

This project utilised a pre- and post-implementation audit strategy using the Joanna Briggs Institute (JBI) Getting Research into Practice (GRIP) program. This method has been used to improve clinical practice by utilising an audit, feedback and re-audit sequence. The project was implemented in four stages over a 7-month period from 21 October 2009 to 30 May 2010.

RESULTS

Initially, there was poor compliance with all four criteria, ranging from zero to 63%. The GRIP phase of the project identified five barriers which were addressed throughout this project. These related to education of staff and the development of a protocol for the prevention and management of extravasation injuries in the neonatal population. Following implementation of best practice, the second audit showed a marked improvement in all four criteria, ranging from 70 to 100% compliance.

CONCLUSIONS

Overall, this project has led to improvements in clinical practice in line with current evidence. This has resulted in enhanced awareness of the risks associated with IV therapy and of measures to prevent an injury occurring within this clinical setting.

Extravasation management: clinical update

OBJECTIVE

To present a clinical update on the prevention, detection, and evidence-based management of vesicant chemotherapy extravasations.

DATA SOURCES

Journal articles, published and unpublished case reports, personal experience.

CONCLUSION

In the 4 years that have elapsed since the publication of the original article, much more is known about vesicant chemotherapy extravasation, and effective evidence-based treatments now are available. The antidotes sodium thiosulfate for mechlorethamine extravasations and hyaluronidase for plant alkaloid extravasations are recommended by the manufacturers of these vesicants and cited in nursing guidelines. The anthracycline extravasation treatment dexrazoxane for injection, the first and only extravasation treatment with proven effectiveness, is now available as Totect (dexrazoxane; TopoTarget USA, Rockaway, NJ, USA) in the US and Savene (SpePharm, Amsterdam, The Netherlands) in Europe.

IMPLICATIONS FOR NURSING PRACTICE

Nurses who administer vesicant chemotherapy agents need to be aware of the most current evidence (or lack of evidence) for various types of extravasation treatment. Well-informed nurses are patient advocates and instrumental in detecting, managing, and documenting extravasations. Most importantly, nurses play a key role in preventing vesicant chemotherapy extravasations.

[Local adverse reactions associated with parenteral administration of drugs]

Parenteral administration of drugs may cause adverse reactions which in severe cases outweigh the intended therapeutic effects. This paper outlines local adverse reactions associated with various routes of parenteral administration. Different measures for prevention and management of such reactions are presented.

Dermatological toxicity in women with breast cancer undergoing chemotherapy treatment

This study aimed to analyze the occurrence of skin toxicity caused by drugs used in the protocol of neoadjuvant and adjuvant chemotherapy among women with breast cancer. Patient records of 72 women who were subject to this therapy between 2003 and 2006 were assessed. Of the 558 cycles of chemotherapy, 152 adverse events were registered. There were 37 registrations of dermatological toxicity, of those, 20 were extravasations that affected 17 women. Nine reports of hardened local injury, local fibrosis, pain, and hyperemia were registered during neoadjuvancy. In adjuvancy, among the 11 extravasations registered there were reports of hardened local injury, fibrosis and local pain. Lack of follow-up records for both periods was observed. Registration of the events and reports by the nursing team are essential to monitor the sites of venous puncture during the chemotherapy treatment, besides measuring and making a photographic record of the site.

Extravasation of chemotherapy

Extravasation of chemotherapy is a feared complication of anticancer therapy. The accidental leakage of cytostatic agents into the perivascular tissues may have devastating short-term and long-term consequences for patients. In recent years, the increased focus on chemotherapy extravasation has led to the development of international guidelines that have proven useful tools in daily clinical practice. Moreover, the tissue destruction in one of the most dreaded types of extravasation (ie, anthracycline extravasation) now can effectively be prevented with a specific antidote, dexrazoxane.

Infiltration and extravasation: update on prevention and management

Infiltration and extravasation are risks of intravenous administration therapy involving unintended leakage of solution into the surrounding tissue. Consequences range from local irritation to amputation. While immediate action using appropriate measures (ie, dilution, extraction, antidotes, and supportive treatments) can decrease the need for surgical intervention, many injuries may be prevented by following established policy and procedures. However, timely surgical intervention, when necessary, can prevent more serious adverse outcomes. Clinicians should be prepared to act promptly when an event occurs. Thorough incident documentation helps determine whether infusion care meets the standard of practice and is a keystone to medicolegal defense.

European Oncology Nursing Society extravasation guidelines

An infrequent, but potential complication of chemotherapy is vesicant chemotherapy extravasation. Vesicants have the potential to cause blistering and ulceration when they extravasate from the vein or are inadvertently administered into the tissue. In 2007, the European Oncology Nursing Society published guidelines for extravasation prevention, detection, and management. Recommended management includes topical heating for plant alkaloid extravasations and topical cooling for anthracycline and other antitumor antibiotic vesicants. For treatment of antracycline extravasations topical dimethylsulfoxide (DMSO), sodium thiosulfate, and hyaluronidase have been described in the literature but due to lack of evidence to support their use as vesicant extravasation antidotes, it is recommended that these agents are studied further. Furthermore, Savene (dexrazoxane) is the only registered drug for the treatment of antracycline extravasation. Nurses need to be aware of current evidence-based guidelines for detecting and managing vesicant extravasations and need to be prepared to administer evidence-based treatment.

IV therapy: recognizing the differences between infiltration and extravasation

Infiltration and extravasation are complications that can occur during intravenous therapy administered via either peripheral or central venous access devices. Both can result in problems with the siting of future venous access devices, nerve damage, infection and tissue necrosis. The nurse is the key to reducing the risk of infiltration and extravasation, through her knowledge and skill in cannulation and the intravenous administration of drugs (by bolus injection or infusion). The nurse must also be able to recognize the early signs and symptoms of infiltration and extravasation and act promptly and effectively to limit tissue damage. The first sign of possible leakage of drugs into the tissues is pain and discomfort, so patients must be informed of what symptoms to look out for and be asked to report any change in sensation as soon as they are aware of it. Finally, accurate documentation of the event is vital to facilitate patient care and in case of litigation.

The use of dexrazoxane for the prevention of anthracycline extravasation injury

BACKGROUND

The use of the anthracycline anticancer drugs doxorubicin, daunorubicin, epirubicin and idarubicin sometimes results in accidental extravasation injury and can be a serious complication of their use.

OBJECTIVE

The object of this review was to evaluate the preclinical and clinical literature on the use of dexrazoxane in preventing anthracycline-induced extravasation injury.

METHODS

A review of the literature was carried out using PubMed.

RESULTS/CONCLUSIONS

Dexrazoxane, which is clinically used to reduce doxorubicin-induced cardiotoxicity, has been shown in two clinical studies and in several case reports to be highly efficacious in preventing anthracycline-induced extravasation injury. Dexrazoxane is a prodrug analog of the metal chelator EDTA that likely acts by removing iron from the iron-anthracycline complex, thus preventing formation of damaging reactive oxygen species.