Extravasation of doxorubicin from vascular access devices

Vesicant extravasation part II: Evidence-based management and continuing controversies

PURPOSE/OBJECTIVES

To review the literature, synthesize current recommendations, and discuss remaining controversies regarding vesicant extravasation management.

DATA SOURCES

Published evidence-based reports, clinical articles, and anecdotal case reports about antineoplastic and nonantineoplastic vesicant agent management.

DATA SYNTHESIS

Prevention of vesicant extravasation sequelae requires knowledge about vesicant extravasation manifestations and differentiation of vesicant extravasation from other local IV site reactions. When evidence is weak or missing, logical application of data-based or empirical management strategies is critical. Actions may include timely administration of subcutaneous or topical antidotes, comfort measures, and surgical interventions to minimize the extent of tissue damage and morbidity should extravasation occur.

CONCLUSIONS

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

IMPLICATIONS FOR NURSING

Nurses who administer vesicant agents should understand the nursing and collaborative actions that should be taken to minimize patient morbidity, pain, and disability.

Vesicant extravasation part I: Mechanisms, pathogenesis, and nursing care to reduce risk

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.

Clinical results after doxorubicin extravasation treated with excision guided by fluorescence microscopy

Doxorubicin (DR) and epirubicin (ER) produce progressive tissue necrosis when extravasation occurs. Early detection and excision of all affected tissue is important. The clinical experience with fluorescence microscopic guided detection and excision in 24 patients is evaluated. 9 patients with fluorescence negative specimens were kept under observation without excision. None developed necrosis. Wide excision was performed on 15 patients with fluorescence positive specimens. Sequelae, defined as impaired function of the affected limb at the last control examination in the out-patient clinic, were observed in 8 patients. 4 of 5 patients with extravasation in the hand and 2 of 3 with extravasation in the cubital fossa were among these. Delay, defined as time from injury to surgery, was a median of 7 h, range from 3 h to 69 days. Patients developing sequelae had a median delay of roughly 4-fold that of patients without these complications. Patients with extravasation in the cubital fossa were hospitalised for the longest period: 30 days, range 24-45 days, vs. 12 days, range 7-80 days, for those with extravasation at other sites (P < 0.03). Our conclusions are: (1) fluorescence microscopic analysis is a reliable method for the detection and delineation of extravasation of DR or ER. (2) Do not use the cubital fossa or hand for the infusion of these cytostatics. (3) Act promptly if extravasation is suspected--delay leads to sequelae.

Basic fibroblast growth factor in retardation of doxorubicin extravasation injury

Extravasation of chemotherapeutic agents such as doxorubicin results in significant morbidity and remains a serious clinical problem. No single agent or combination of agents has proven to be completely effective in preventing the chronic avascular ulcerative wound. Basic fibroblast growth factor (bFGF) is one of many angiogenic agents and is strongly mitogenic for vascular endothelial cells in nanogram quantities. In a Sprague-Dawley rat model, bFGF was moderately effective in retarding the development of doxorubicin-induced skin ulceration.