Extravasation of systemic hemato-oncological therapies

Tisotumab vedotin extravasation injury in a patient with recurrent cervical cancer

•Infusion site extravasation injury is a rare but serious adverse event of tisotumab vedotin.•Central venous access device should be considered in patients with risk factors receiving antibody drug conjugate therapy.•Topical steroids may be used as part of supportive measures.

Exploring Extravasation in Cancer Patients

Extravasation, the unintended leakage of intravenously administered substances, poses significant challenges in cancer treatment, particularly during chemotherapy and radiotherapy. This comprehensive review explores the pathophysiology, incidence, risk factors, clinical presentation, diagnosis, prevention strategies, management approaches, complications, and long-term effects of extravasation in cancer patients. It also outlines future directions and research opportunities, including identifying gaps in the current knowledge and proposing areas for further investigation in extravasation prevention and management. Emerging technologies and therapies with the potential to improve extravasation prevention and management in both chemotherapy and radiotherapy are highlighted. Such innovations include advanced vein visualization technologies, smart catheters, targeted drug delivery systems, novel topical treatments, and artificial intelligence-based image analysis. By addressing these aspects, this review not only provides healthcare professionals with insights to enhance patient safety and optimize clinical practice but also underscores the importance of ongoing research and innovation in improving outcomes for cancer patients experiencing extravasation events.

Extravasation of brentuximab vedotin, an antibody-drug conjugate, in a patient with anaplastic large cell lymphoma

Brentuximab vedotin (BV) is an antibody-drug conjugate, consisting of a CD30-directed antibody, conjugated by a protease-cleavable linker to a microtubule disrupting agent auristatin E (MMAE). Although the safety datasheet of BV does not warn of severe toxic effects of extravasation, we report a third case of a patient with anaplastic large cell lymphoma who developed severe epidermal necrosis after extravasation. The reason for what happened could be attributed to the fact that MMAE belongs to the group of vinca alkaloids so it should be handled like other tissue-necrotising chemotherapeutics. Reporting of all cases of extravasation involving new conjugated chemotherapeutic drugs is of the utmost importance to be able to develop updated guidelines. Hospital pharmacists can provide information on how to manage extravasation, assess the potential risk, and have a crucial role in drafting hospital protocols.

Management of infusion-related reactions in cancer therapy: strategies and challenges

Several anticancer therapies have the potential to cause infusion-related reactions (IRRs) in the form of adverse events that typically occur within minutes to hours after drug infusion. IRRs can range in severity from mild to severe anaphylaxis-like reactions. Careful monitoring at infusion initiation, prompt recognition, and appropriate clinical assessment of the IRR and its severity, followed by immediate management, are required to ensure patient safety and optimal outcomes. Lack of standardization in the prevention, management, and reporting of IRRs across cancer-treating institutions represents not only a quality and safety gap but also a disparity in cancer care. The present article, supported by recently published data, was developed to standardize these procedures across institutions and provide a useful tool for health care providers in clinical practice to recognize early signs and symptoms of an IRR and promptly and appropriately manage the event.

Chemotherapy Extravasation Causing Soft-Tissue Necrosis Mimicking Infection: A Longitudinal Case Study

Extravasation injuries are uncommon, underreported, and often misdiagnosed in patients. The signs and symptoms of extravasation injuries vary from simple pain and tenderness to tissue necrosis and potentially fatal secondary infections. Extravasation may progress to more severe conditions such as necrotizing fasciitis (NF) or cellulitis, so special care is needed by physicians to identify and treat these injuries correctly. Here, we explore a case study on extravasation injuries mimicking NF leading to infectious complications and discuss the proper diagnosis and treatment of extravasation injuries as well as other NF-mimicking diseases. We present a case of a 44-year-old Hispanic male with a history of B-cell acute lymphoblastic leukemia who underwent inpatient chemotherapy treatment via a chest port.

GEDEFO-SEFH management of antineoplastic extravasations survey results

INTRODUCTION

Extravasation is a potentially severe complication of intravenous administration of antineoplastic drugs. The limited data makes it difficult to develop an optimal management scheme. The objective of this study is to describe the clinical practice in the extravasation management of antineoplastic agents in Spanish centers.

METHODS

An online survey was distributed to oncology pharmacists using the email distribution list of the Spanish Society of Hospital Pharmacists. Respondents were surveyed on the standard operational protocol (SOP) of extravasation, tissue damage risk classification, and specific measures of extravasation management.

RESULTS

A total of 68 surveys were completed. A specific extravasation SOP was available in 82.4% centers. The pharmacist participates in the authorship (100%) and actively collaborates in extravasation management (76.5%). A tissue damage risk classification based on the three categories was mostly adopted (48.2%) and 73.2% applied specific criteria based on concentration and/or extravasated volume. Extravasation management was mainly performed with the application of physical measures and/or antidotes (91.2%). High variability in the choices of pharmacological and/or physical measures recommended is outstanding.

CONCLUSION

The results of this study highlight the involvement of Spanish pharmacists in extravasation management, the application of physical measures and/or pharmacological measures as the method of choice in extravasation management, as well as the existing discrepancies in tissue damage risk classification and management recommendations.

Extravasation of Non-Cytotoxic Drugs in Older People

Objective To describe the risk factors of extravasation, its impact on the pharmacokinetics of non-cytotoxic drugs, and management of extravasation in older individuals. Extravasation occurs when vesicants leak from blood vessels into surrounding tissue causing severe injury such as tissue necrosis while infiltration is caused by leakage of an irritant that causes injury but does not lead to tissue necrosis. Extravasation occurs in approximately 0.01% to 6% of patients, particularly with cytotoxic agents. However, there is limited documentation about extravasation of non-cytotoxic agents, particularly in older people. Data Sources A literature search of Pubmed and Medline was performed using the following search items: "extravasation," "infiltration," "elderly," and "non-cytotoxic drugs," as well as a combination of these terms. Conclusion It is important to recognize, identify, and manage extravasation early since it can have deleterious consequences for older people. It is more important to prevent extravasation than manage it using standardized evidence-based protocols, and this can be implemented in the nursing facility and acute care setting.

Complications of Central Venous Access Devices Used in Palliative Care Settings for Terminally Ill Cancer Patients: A Systematic Review and Meta-Analysis

(1) Background: Central venous access devices (CVADs) have been commonly employed during various courses of anticancer treatment. Currently, there are a few types of clinically available CVADs, which are associated with short-term and long-term complications. However, little is known about the complication rates when CVADs are used only in palliative care settings. We therefore performed a systematic review and meta-analysis of all the published literature to evaluate the complication rates of CVADs in this clinical setting. (2) Methods: A systematic review and meta-analysis were conducted to identify publications from PubMed/MEDLINE, Embase (Ovid), Scopus, Cochrane Library, CINAHL, Google Scholar, and trial registries. Publications reporting the complication rates of PICCs, central lines, and PORTs in palliative settings for terminally ill cancer patients were included, while those on the use of systemic anticancer therapy and peripheral venous catheters were excluded. The outcome measures included overall complication rate, rate of catheter-related bloodstream infection (CRBSI), and rate of thromboembolism (TE). This systematic review was registered with PROSPERO (CRD42023404489). (3) Results: Five publications with 327 patients were analyzed, including four studies on PICCs and one study on central lines. No studies on PORTs were eligible for analysis. The overall complication rate for PICCs (pooled estimate 7.02%, 95% CI 0.27-19.10) was higher than that for central lines (1.44%, 95% CI 0.30-4.14, p = 0.002). The risk of CRBSI with PICCs (2.03%, 95% CI 0.00-9.62) was also higher than that with central lines (0.96%, 95% CI 0.12-3.41, p = 0.046). PICCs also had a trend of a higher risk of TE (2.10%, 95% CI 0.00-12.22) compared to central lines (0.48%, 95% CI 0.01-2.64, p = 0.061). (4) Conclusions: PICCs for palliative cancer care were found to have greater complications than central lines. This might aid in the formulation of future recommendation guidelines on the choice of CVAD in this setting.

Radiopharmaceutical extravasations: a twenty year mini-review

Interest and research into radiopharmaceutical extravasation concepts has risen with the increase in use of radiopharmaceutical therapies, growing access to novel molecular imaging agents, and recent regulatory controversies. This mini-review will examine the literature of the last twenty years to summarize the history of radiopharmaceutical extravasations, determine key trends in imaging and therapies, and highlight critical gaps in research that currently exist. The intent of this work is to provide a summary of this complex topic that helps build awareness and promotes new innovations in this interesting aspect of theranostic radiopharmaceuticals.

Engineered NF-κB siRNA-encapsulating exosomes as a modality for therapy of skin lesions

Introduction

Despite the protection and management of skin has been paid more and more attention, effective countermeasures are still lacking for patients suffering from UV or chemotherapy with damaged skin. Recently, gene therapy by small interfering RNA (siRNA) has emerged as a new therapeutic strategy for skin lesions. However, siRNA therapy has not been applied to skin therapy due to lack of effective delivery vector.

Methods

Here, we develop a synthetic biology strategy that integrates the exosomes with artificial genetic circuits to reprogram the adipose mesenchymal stem cell to express and assemble siRNAs into exosomes and facilitate in vivo delivery siRNAs for therapy of mouse models of skin lesions.

Results

Particularly, siRNA enriched exosomes (si-ADMSC-EXOs) could be directly taken up by the skin cells to inhibit the expression of skin injury related genes. When mice with skin lesions were smeared with si-ADMSC-EXOs, the repair of lesioned skin became faster and the expression of inflammatory cytokines were decreased.

Discussion

Overall, this study establishes a feasible therapeutic strategy for skin injury, which may offer an alternative to conventional biological therapies requiring two or more independent compounds.

Determination of Extravasation Effects of Nal-Iri and Trabectedin and Evaluation of Treatment Options for Trabectedin Extravasation in a Preclinical Animal Model

Background: Extravasation during chemotherapy administration can lead to dangerous adverse effects ranging from pain to tissue necrosis. Evidence-based data about prevention and treatment of extravasation injuries of some clinically used compounds still remains elusive. This work aimed to investigate, in a preclinical mouse model, the effects of extravasation of two chemotherapeutic agents, nanoliposomal irinotecan (nal-Iri) and trabectedin. In addition, we aimed to study treatment options for injuries induced by extravasation of these substances. Methods: Mice were subcutaneously injected with nal-Iri or trabectedin applied in clinically used concentration. Doxorubicin was used as a positive control. In subsequently performed experiments, hyaluronidase, DMSO and tacrolimus were tested as potential treatments against extravasation-induced injuries by trabectedin. Systemic effects were analyzed by observation and documentation of the health status of mice and local reactions were measured and graded. In addition, hematoxylin-eosin stained histological sections of the treated skin areas were analyzed. Results: Of the two tested substances, only trabectedin showed vesicant effects. Subcutaneous injection of trabectedin caused erythema formation in mice by day two that was progressing to skin ulcerations by day five. Furthermore, we found that topical treatment of mice with tacrolimus or DMSO reduced the vesicant effects of trabectedin. The results observed in vivo were supported microscopically by the analysis of histological sections. Conclusions: We recommend classifying trabectedin as a vesicant agent and nal-Iri as a non-vesicant agent. Furthermore, our results obtained in a preclinical model suggest that tacrolimus and DMSO might be suitable treatment options of trabectedin extravasations, a finding that might be further utilized in clinical studies.

Enhanced Antitumor Efficacy of PhAc-ALGP-Dox, an Enzyme-Activated Doxorubicin Prodrug, in a Panel of THOP1-Expressing Patient-Derived Xenografts of Soft Tissue Sarcoma

Despite poor response rates and dose-limiting cardiotoxicity, doxorubicin (doxo) remains the standard-of-care for patients with advanced soft tissue sarcoma. We evaluated the efficacy of two tetrapeptidic doxo prodrugs (PhAc-ALGP-Dox or CBR-049 and CBR-050) that are locally activated by enzymes expressed in the tumor environment, in ten sarcoma patient-derived xenografts. Xenograft models were selected based on expression of the main activating enzyme, i.e., thimet oligopeptidase (THOP1). Mice were either randomized to vehicle, doxo, CBR-049 and CBR-050 or control, doxo, aldoxorubicin (aldoxo) and CBR-049. Treatment efficacy was assessed by tumor volume measurement and histological assessment of ex-mouse tumors. CBR-049 showed significant tumor growth delay compared to control in all xenografts investigated and was superior compared to doxo in all but one. At the same time, CBR-049 showed comparable efficacy to aldoxo but the latter was found to have a complex safety profile in mice. CBR-050 demonstrated tumor growth delay compared to control in one xenograft but was not superior to doxo. For both experimental prodrugs, strong immunostaining for THOP1 was found to predict better antitumor efficacy. The prodrugs were well tolerated without any adverse events, even though molar doses were 17-fold higher than those administered and tolerated for doxo.

Recent Strategies to Develop Innovative Photosensitizers for Enhanced Photodynamic Therapy

This review presents a robust strategy to design photosensitizers (PSs) for various species. Photodynamic therapy (PDT) is a photochemical-based treatment approach that involves the use of light combined with a light-activated chemical, referred to as a PS. Attractively, PDT is one of the alternatives to conventional cancer treatment due to its noninvasive nature, high cure rates, and low side effects. PSs play an important factor in photoinduced reactive oxygen species (ROS) generation. Although the concept of photosensitizer-based photodynamic therapy has been widely adopted for clinical trials and bioimaging, until now, to our surprise, there has been no relevant review article on rational designs of organic PSs for PDT. Furthermore, most of published review articles in PDT focused on nanomaterials and nanotechnology based on traditional PSs. Therefore, this review aimed at reporting recent strategies to develop innovative organic photosensitizers for enhanced photodynamic therapy, with each example described in detail instead of providing only a general overview, as is typically done in previous reviews of PDT, to provide intuitive, vivid, and specific insights to the readers.

Combination of ebselen and hydrocortisone substantially reduces nitrogen mustard-induced cutaneous injury

The purpose of the present study was to investigate the vesicant countermeasure effects of hydrocortisone (HC) and ebselen (EB-1), administered as monotherapy or as a combination treatment. The mouse ear vesicant model (MEVM) was utilized and test doses of HC (0.016, 0.023, 0.031, 0.047, 0.063, 0.125 or 0.250 mg/ear), EB-1 (0.125, 0.187, 0.250, 0.375 or 0.500 mg/ear) or the combination of HC + EB-1 were topically applied at 15 min, 4 h and 8 h after nitrogen mustard exposure. Ear punch biopsies were obtained 24 h after mechlorethamine (HN2) exposure. Compared to control ears, ear tissues exposed topically to HN2 (0.500 µmol/ear) presented with an increase in ear thickness, vesication, TUNEL fluorescence and expression of matrix metalloproteinase 9 (MMP-9) and inducible nitric oxide synthase (iNOS). In contrast, HN2 exposed ears treated topically with EB-1 showed a significant decrease in morphometric thickness and vesication vs. HN2 alone. Ear tissues exposed to HN2 and then treated with HC also demonstrated reductions in morphometric thickness and vesication. Combination treatment of HC + EB-1 was found to be the most effective at reducing HN2-induced ear edema and vesication. The combination also dramatically decreased HN2-mediated cutaneous expression of iNOS and MMP-9 and decreased HN2-induced TUNEL staining. Taken together, our study demonstrates that the combination of HC + EB-1 is an efficacious countermeasure to HN2.

Possibility of Taking an Offensive Stance in Extravasation Injury: Effects of Fat Injection in Vesicant (Doxorubicin) Induced Skin Necrosis Model in Rats

INTRODUCTION

Extravasation injuries are one of the most feared complications of intravenous drug administration. The most common drugs associated with extravasation injury include chemotherapy agents and contrast media. Natural course of vesicant extravasation is discomfort, pain, swelling, inflammation, and ultimately skin ulceration. While diligence is the principle approach in prevention, immediate bed-side measures are as important in controlling the extent of tissue damage. Various options, either medical or interventional are next steps in treatment of the condition including antidotes, volume dilution, flushing, suction, hyperbaric oxygen therapy, and surgery.

MATERIALS AND METHODS

12 male Wistar albino rats were divided into two groups; one group received fat injections following subdermal doxorubicin infiltration in their right thighs, while other group received saline injection following subdermal doxorubicin infiltration in their right thighs for dilution. Left thighs of both groups were left untreated following subdermal doxorubicin infiltration. Total area of necrosis, as well as resultant epidermal thicknesses were assessed. Histological analyses were conducted using modified Verhofstad scoring system for comparison.

RESULTS

Mean necrotic area was significantly smaller in the fat injection group compared to other groups. Median Verhofstad score was lesser in the fat injection group as well. Median epidermal thickness, on the other hand, was greater in the fat injection group.

CONCLUSION

Injection of fat grafts following vesicant extravasation might be beneficial in preventing the progression of tissue damage, if employed early.

5-Fluorouracil induced extravasation injury

Antineoplastic drugs based on their ability to cause local damage are classified as irritants, vesicants, and non-vesicants. Previous literature has reported higher rate of vesicants induced extravasation (EV) compared to irritants. We report the first case of irritant, 5-fluorouracil causing grade III EV in 55-year-old woman. The patient was diagnosed with esophageal squamous cell carcinoma. Docetaxel, Cisplatin, and 5-Fluorouracil (DCF) chemotherapy regimen was planned and administered through peripheral venous access. Patient experienced grade 3 extravasation in her 3^rd cycle following 5-fluorouracil (5-FU) administration. The suspected drug was withdrawn immediately and discontinued from the 4^th cycle of the regimen. The patient completely recovered from the symptoms of pain and erythema in the next cycle and care was taken not to infuse drug in the same site again. Since there is no appropriate antidote available to manage this condition, measures need to be taken to identify the predisposing factors for EV and prevent them.

Regimen of 5-Fluorouracil and Cisplatin Increases the Incidence of Extravasation in Patients Undergoing Chemotherapy

BACKGROUND/AIM

Extravasation associated with chemotherapy can induce localised injury, necrosis, and nerve damage, resulting in discontinued chemotherapy and impaired quality of life; however, risk factors for extravasation remain unclear. The present study aimed to identify chemotherapy regimen-associated factors related to extravasation.

PATIENTS AND METHODS

Data on patient and chemotherapy protocol characteristics were extracted from our hospital's electronic database; the frequency of extravasation was compared among patients receiving different chemotherapy regimens.

RESULTS

Twenty-two patients with extravasation undergoing chemotherapy during the study period were enrolled in the present study. Patients undergoing treatment with 5-fluorouracil and cisplatin were most likely to develop extravasation in the present study. All patients presenting with extravasation during treatment with 5-fluorouracil and cisplatin developed swelling and many (40%) developed erythema within the first two cycles of treatment.

CONCLUSION

Treatment with 5-fluorouracil combined with cisplatin increases the incidence of extravasation. Ensuring suitable vascular access and increasing awareness regarding the symptoms and timing of extravasation among patients and medical staff can improve extravasation prevention and diagnosis.

Conventional central venous catheters as tunnelled mid-clavicular midline catheters: Description of novel application and outcome analysis

BACKGROUND

Long peripheral catheters are the ideal devices for intermediate venous access (1-4 weeks). However due to non-availability and cost constraints, these lines are not widely adapted in developing countries. In this clinical report we describe a technique of using conventional Central Venous Catheters as Midclavicular midlines for intermediate venous access and present the outcome analysis of such catheters in the last 2 years from our institute.

METHODS

A single lumen conventional central venous catheter (5 Fr, 20 cm) was introduced through the deep veins of the upper arm, 1 to 1.5 cm distal to the axillary crease. The catheter was tunnelled for a distance of 5 to 7 cm to exit from Dawson's green zone to reduce the incidence of Midline Associated Blood Stream Infection. Patients were followed up by trained staff nurses and outcome parameters were recorded.

RESULTS

Seventy six patients were enrolled and 72 patients underwent successful cannulation and completed the outcome analysis. Administration of intravenous antibiotics and chemotherapy were the commonest indications. The device served the intended duration of therapy in 66 (92%) patients for a median number of 12 (6-20) catheter days. Device related blood stream infection was 1.24/1000 catheter days and catheter related thrombosis rate was 8.3%.

CONCLUSION

Conventional Central Venous Catheters can be effectively used as tunnelled Midclavicular midline catheters in low resource settings. The successful outcome analysis has to be confirmed by larger studies.

Repeatability of in vitro carboplatin elution from carboplatin-impregnated calcium sulfate hemihydrate beads made in a clinic setting

OBJECTIVE

To evaluate the intra-lot and inter-lot consistency and total carboplatin elution over 25 days from carboplatin-impregnated calcium sulfate hemihydrate (C-I CSH) beads manufactured in a clinic setting.

STUDY DESIGN

In vitro elution study.

METHODS

Two volumes of carboplatin were mixed with CSH to yield 4 mg and 8 mg C-I CSH doses. Two lots of beads were made for each concentration and split into five doses (n = 10 per concentration). Beads hardened in molds and were placed in a covered six-well plate, submerged in phosphate-buffered saline, and incubated with samples collected at 12 time points (0, 6, 12, and 24 hours and 2, 3, 5, 7, 10, 14, 18, and 25 days). The amount of carboplatin in each sample was evaluated by high-performance liquid chromatography/mass spectrometry. Correction for carboplatin degradation and dilution was applied, and eluted carboplatin was calculated. Intra-lot and inter-lot coefficient of variation (CV) was calculated for each concentration.

RESULTS

The intra-lot CV ranged between 7.9% and 23.1%, and the inter-lot CV ranged from 3.5% to 10.3%, with improvement noted in each successive lot of beads. Mean peak eluted carboplatin was 2.45 ± 0.43 mg (61%) and 3.68 ± 0.41 mg (45.9%) for the 4-mg and 8-mg C-I CSH beads, respectively, with both occurring at the 12-hour timepoint.

CONCLUSION

Progressive improvement in variability with successive lots of beads indicated a learning curve with bead manufacturing with a low variation both within and between lots of C-I CSH beads.

CLINICAL SIGNIFICANCE

On-site mixing of carboplatin with commercial CSH bead powder leads to a low variation of carboplatin per bead dose.

Development of Newly Synthesized Chromone Derivatives with High Tumor Specificity against Human Oral Squamous Cell Carcinoma

Since many anticancer drugs show severe adverse effects such as mucositis, peripheral neurotoxicity, and extravasation, it was crucial to explore new compounds with much reduced adverse effects. Comprehensive investigation with human malignant and nonmalignant cells demonstrated that derivatives of chromone, back-bone structure of flavonoid, showed much higher tumor specificity as compared with three major polyphenols in the natural kingdom, such as lignin-carbohydrate complex, tannin, and flavonoid. A total 291 newly synthesized compounds of 17 groups (consisting of 12 chromones, 2 esters, and 3 amides) gave a wide range of the intensity of tumor specificity, possibly reflecting the fitness for the optimal 3D structure and electric state. Among them, 7-methoxy-3-[(1E)-2-phenylethenyl]-4H-1-benzopyran-4-one (compound 22), which belongs to 3-styrylchromones, showed the highest tumor specificity. 22 induced subG1 and G2 + M cell population in human oral squamous cell carcinoma cell line, with much less keratinocyte toxicity as compared with doxorubicin and 5-FU. However, 12 active compounds selected did not necessarily induce apoptosis and mitotic arrest. This compound can be used as a lead compound to manufacture more active compound.

Inherent and modifiable risk factors for peripheral venous catheter failure during cancer treatment: a prospective cohort study

PURPOSE

To identify modifiable and non-modifiable risk factors for peripheral intravenous catheter (PIV) failure among patients requiring intravenous treatment for oncology and haematology conditions.

METHODS

A single-centre prospective cohort study was conducted between October 2017 and February 2019. Adult in-patients requiring a PIV for therapy were prospectively recruited from two cancer units at a tertiary hospital in Queensland, Australia. The primary outcome was a composite of complications leading to PIV failure (local and bloodstream infection; occlusion; infiltration/extravasation; leakage; dislodgement; and/or phlebitis). Secondary outcomes were (i) PIV dwell time; (ii) insertion and (iii) failure of a CVAD; (iv) adverse events; (v) length of hospital stay. Outcomes were investigated using Bayesian multivariable linear regression modelling and survival analysis.

RESULTS

Of 200 participants, 396 PIVs were included. PIV failure incidence was 34.9%; the most common failure type was occlusion/infiltration (n = 74, 18.7%), then dislodgement (n = 33, 8.3%), and phlebitis (n = 30, 7.6%). While several patient and treatment risk factors were significant in univariable modelling, in the final multivariable model, only the use of non-sterile tape (external to the primary dressing) was significantly associated with decreased PIV dislodgement (hazard ratio 0.06, 95% confidence interval 0.01, 0.48; p = 0.008).

CONCLUSION

PIV failure rates among patients receiving cancer treatment are high, the sequelae of which may include delayed treatment and infection. Larger studies on risk factors and interventions to prevent PIV failure in this population are needed; however, the use of secondary securements (such as non-sterile tape) to provide further securement to the primary PIV dressing is particularly important.

TRIAL REGISTRATION

Study methods were registered prospectively with the Australian New Zealand Clinical Trials Registry on the 27^th March 2017 (ACTRN12617000438358); https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372191&isReview=true.

Managing chemotherapy extravasation in totally implantable central venous access: Use of subcutaneous wash-out technique

BACKGROUND

Totally implanted venous access is widely used in chemotherapy administration. With over 1 million intravenous chemotherapy infusions given worldwide each day, complications are frequent. Accidental cases of extravasation in the presence of a catheter are rare yet very serious and may require discontinuation of chemotherapy. The aim of this study was to evaluate the feasibility and efficacy of the subcutaneous wash-out technique for chemotherapy extravasation treatment.

METHODS

We retrospectively reviewed the medical charts of patients who had received chemotherapy and sustained extravasation in our hospital between October 2013 and October 2016. Subcutaneous wash-out treatments were carried out exclusively, without the application of antidotes or the use of specific antidotes.

RESULTS

We documented seven cases of chemotherapy extravasation. Two cases were treated with antidotes and suffered necrosis in the following weeks. The five patients treated using subcutaneous wash-out had no necrosis and had a steady decrease in the inflammatory reaction of the cutaneous and subcutaneous soft tissues. For these five patients, chemotherapy was restarted within 1 month following extravasation.

CONCLUSION

This study would argue for the feasibility and effectiveness of subcutaneous wash-out in the treatment of chemotherapy extravasations.

Extravasation accidents with liposomal/liposomal pegylated anthracyclines treated with dexrazoxane: an overview and outcomes

The extravasation of chemotherapeutic agents is a challenge for oncologic care teams. The management of nonliposomal (conventional) anthracyclines is well established in clinical practice guidelines, including general measures and specific antidotes, such as dexrazoxane. However, there is little scientific evidence on the management of liposomal and pegylated liposomal anthracyclines. The aim of this paper was to review the scientific literature on the extravasation of liposomal and pegylated liposomal anthracyclines and determine the clinical impact of this type of extravasation, focusing on dexrazoxane. The literature was searched using two databases: PubMed and Embase. Three searches were conducted, using liposomal anthracycline extravasation, pegylated liposomal anthracycline extravasation, and liposomal doxorubicin extravasation as keywords, respectively. Seven articles fulfilled the study eligibility criteria and included seventeen cases in humans. Extravasation occurred with three drugs: liposomal doxorubicin in nine (53%) patients, liposomal daunorubicin in four (23.5%) patients, and pegylated liposomal doxorubicin in four (23.5%) patients. General measures for extravasations were applied in all patients, but only three patients received dexrazoxane. All cases were completely resolved at 2-3 months, except for one patient, in whom dexrazoxane was not used. In animals, dexrazoxane decreased both the frequency of wounds produced by pegylated liposomal doxorubicin and their extent. The pharmacokinetic profiles of liposomal and pegylated liposomal anthracyclines differ from those of conventional anthracyclines, modifying their effectiveness and safety. General measures may be inadequate to heal areas affected by extravasation, which may require the administration of dexrazoxane. However, each case should be evaluated individually for the administration of dexrazoxane in off-label use until scientific evidence is available on its effectiveness and safety as an antidote for these formulations of anthracyclines.

Minocycline Prevents the Development of Mechanical Allodynia in Mouse Models of Vincristine-Induced Peripheral Neuropathy

Vincristine is an antineoplastic substance that is part of many chemotherapy regimens, used especially for the treatment of a variety of pediatric cancers including leukemias and brain tumors. Unfortunately, many vincristine-treated patients develop peripheral neuropathy, a side effect characterized by sensory, motoric, and autonomic symptoms. The sensory symptoms include pain, in particular hypersensitivity to light touch, as well as loss of sensory discrimination to detect vibration and touch. The symptoms of vincristine-induced neuropathy are only poorly controlled by currently available analgesics and therefore often necessitate dose reductions or even cessation of treatment. The aim of this study was to identify new therapeutic targets for the treatment of vincristine-induced peripheral neuropathy (VIPN) by combining behavioral experiments, histology, and pharmacology after vincristine treatment. Local intraplantar injection of vincristine into the hind paw caused dose- and time-dependent mechanical hypersensitivity that developed into mechanical hyposensitivity at high doses, and lead to a pronounced, dose-dependent infiltration of immune cells at the site of injection. Importantly, administration of minocycline effectively prevented the development of mechanical hypersensitivity and infiltration of immune cells in mouse models of vincristine induce peripheral neuropathy (VIPN) based on intraperitoneal or intraplantar administration of vincristine. Similarly, Toll-like receptor 4 knockout mice showed diminished vincristine-induced mechanical hypersensitivity and immune cell infiltration, while treatment with the anti-inflammatory meloxicam had no effect. These results provide evidence for the involvement of Toll-like receptor 4 in the development of VIPN and suggest that minocycline and/or direct Toll-like receptor 4 antagonists may be an effective preventative treatment for patients receiving vincristine.

Suspected Carboplatin Extravasation Reactions in Seven Dogs

Carboplatin is a platinum chemotherapeutic agent commonly used in veterinary oncology that is currently classified as an irritant to local tissues when extravasated. To the authors' knowledge, there are no reports of vesicant injuries associated with carboplatin administration reported in the veterinary literature. In this case series, seven dogs are described to have experienced injuries following a suspected carboplatin extravasation resembling vesicant injuries a median of 7 days after carboplatin administration (range 4-15 days). Wounds healed with a variety of treatments, including medical management and/or surgical debridement, a median of 25.5 days (range 7-49 days) after observation of the suspected extravasation injury. There were no obvious similarities involving carboplatin administration among patients to explain why these reactions occurred. Extravasation injury should be considered a possible local complication associated with carboplatin chemotherapy.

Surgical treatment of extravasation injuries: experience of the Hospital das Clínicas, Faculty of Medicine, University of São Paulo

OBJECTIVE

to report the experience of the Division of Plastic Surgery of the Hospital das Clínicas of the Medical School of the University of São Paulo in the treatment of cutaneous lesions due to accidental extravasation of drugs.

METHODS

we included patients with lesions due to extravasation of drugs over a period of 18 months. We retrospectively evaluated the following parameters: age, diagnoses during hospitalization and comorbidities, serum levels of albumin and hemoglobin, place of hospitalization, drug involved, anatomic segment affected, therapeutic management and death during hospitalization.

RESULTS

we followed-up 14 patients. The main drug involved was noradrenaline (21%). All patients underwent debridement of tissue necrosis. Three patients were submitted to flaps after preparation of the wound bed with negative pressure therapy, with good results. Seven patients had no definitive treatment of their lesions due to lack of clinical conditions.

CONCLUSION

in patients with favorable clinical conditions, the definitive treatment with flaps was adequate for cases of wounds due to extravasation of drugs in the subcutaneous tissue when there was exposure of noble structures.

Chemotherapy Extravasation Management: 21-Year Experience

Chemotherapy extravasation may result in serious damage to patients, with irreversible local injures and disability. Evidence-based standardization on extravasation management is lacking and many institutions do not practice adequate procedures to prevent the severer damages. Our aim was to explore the prevention and treatment of extravasation injuries, proposing a standard therapeutic protocol together with a review of the literature. From January 1994 to December 2015, 545 cases were reviewed (age range, 5-87 years; 282 men and 263 women). Our therapeutic protocol consisted of local infiltration of saline solution and topical occlusive applications of corticosteroids. The infiltrations were administrated 3 to 6 times a week depending on damage severity. Our protocol allowed us to prevent ulceration in 373 cases. Only 27 patients required surgery (escarectomy, skin graft, regional, and free flap). Numerous treatments have been proposed in literature. The antidotes have been discussed controversially and are not considered standard methods for treatment, especially when polychemotherapy is administrated and the identification of the responsible drug is not possible. We proposed the use of saline solution injection to dilute rapidly the drug, thus reducing its local toxic effects. This method is easy to use and always reproducible even when the drug is not known or when it is administrated in combination with other drugs. It is possible to perform it in ambulatory regimen, and, overall, it represents a standard method.

Management of extravasation of oxaliplatin by mimicking its biotransformation

Although oxaliplatin (Oxali) plays a key role in the treatment of many types of cancer and has been reported to be an irritant, there is no specific and effective method for its extravasation and failure in Oxali extravasation management results in the need for plastic surgery. In the body, Oxali bio-transforms upon dilution in chloride-containing buffer salts to its di-chloro derivative and loses an oxalate molecule. Consequently, the chloride ions exchange with water molecules in the intracellular environment to produce the di-aqua derivative, which is the most active biotransformation product of Oxali in terms of forming the DNA adducts. Thus, inhibiting transformation of di-chloro to di-aqua derivatives by accumulating chloride ions at the site of extravasation and saturating the Oxali molecule with these ions is a strategy that could help manage extravasation. Injecting normal saline at this site is a simple yet effective way to achieve this goal.

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.

Skin Necrosis Due to the Extravasation of Irritant Anticancer Agents

A 70-year-old man with malignant lymphoma was subjected to a fourth course of chemotherapy using gemcitabine and cisplatin. During the intravenous infusion of anticancer agents, pain and redness was observed at the site of insertion. The patient was subsequently treated with the strongest topical steroids and topical cooling agents. However, 2 weeks later, the affected area turned yellow, and the histopathological findings revealed skin necrosis of the entire dermis layer. It took two and a half months to cure the lesion. Close attention should be paid to the development of skin necrosis even when irritant anticancer agents such as gemcitabine and cisplatin are administered.

INFLUENCE OF LONG-TERM CYTOTOXIC CHEMOTHERAPY ON THE CONDITION OF PERIPHERAL VENOUS CHANNEL

The necessity of long-term venous access in cancer patients appears at frequent and long-term courses of cytotoxic therapy. Peripheral veins of forearms are most often used for these aims. The conditions of peripheral venous channel in 32 cancer patients, who underwent the long-term treatment with antitumor preparations were analyzed in the article on own investigatory material. The methods of dopplerography, morphological and immunohystochemical studies were used. The qualitative and quantitative dopplerographic changes in forearm veins in different terms after chemotherapy start were revealed in most patients. The conclusion was made about unsuitability of forearm peripheral veins for the long term administration of cytostatics and the necessity to create the alternative vascular access that would correspond to the criteria of safety, reliability and long-term exploitation.

[Emergency management of extravasation in children]

The subcutaneous diffusion of intravenous drips, or extravasation, is a frequent iatrogenic complication in children, mainly in the neonatal period. This potentially severe pathology can lead to local ischemia that sometimes mimics compartment syndrome. It can also evolve towards vast soft-tissue necrosis. Nursing staff often underestimate the risk of functional, aesthetic, and psychological consequences. The speed and quality of the initial medical and surgical management can greatly decrease morbidity associated with extravasation. Prevention is fundamental, such as raising awareness in and training medical and paramedical staffs and creating efficient protocols. Surgical management involving aspiration and washing the site as early as possible improves the prognosis. Aspiration and washing can be done on a larger area if one criteria of severity is met, particularly in cases of extravasation using a vesicant or hyperosmolar agent. If necrotic lesions appear, it is wise to wait until they become delimited. Debridement and coverage can be performed using classical methods.

The incidence of extravasation of vinca alkaloids supplied in syringes or mini-bags

Study objective. The aim of this retrospective study was to determine the incidence of vinca alkaloid extravasation following administration via syringes or mini-bags.

Methods. An electronic survey was sent to pharmacy departments at hospitals throughout Australia. The survey was designed to collect data on the administration methods of vinca alkaloids (vincristine, vinblastine, vinorelbine) and the corresponding documented incidence of extravasation. The questionnaire requested the following information: how the drugs were prepared for administration (syringe or mini-bag); volume of each product; number of items supplied; and the number of cases of extravasation reported for each product.

Results. Questionnaires were sent to 228 hospital pharmacy departments in Australia. Sixty-eight questionnaires were received (29.8%), including responses from most major cancer centres. Data represented a range of 3 to 120 months (mean: 38 months) of clinical experience. The reported incidence of vincristine extravasation from syringes was 0.03% (11/37 084) and 0.041% (3/7255) with mini-bags. One case of vinblastine extravasation was reported with syringes 0.013% (1/7913), none from mini-bags (0/1421). Vinorelbine data were difficult to interpret as cases may represent phlebitis rather than extravasation. The reported incidence from vinorelbine syringes was 0.029% (2/6914) and 0.146% (8/5475) with mini-bags. Excluding vinorelbine data, the reported vinca alkaloid extravasation episodes from syringes (0.027%) and mini-bags (0.035%) were found to be similar and infrequent.

Conclusion. The data suggest that vinca alkaloids can be given safely as low volume, short infusions via mini-bags. Policies and practices that ensure the same careful monitoring of infusional therapy as is recommended with administration by syringe may further reduce the incidence of untoward effects. Mini-bags should be used for the administration of vinca alkaloids and this practice will prevent the inadvertent intrathecal administration of vinca alkaloids via syringes.

Extravasation reactions associated with the administration of pamidronate: 11 cases (2008-2013)

Pamidronate is a bisphosphonate drug widely utilized in veterinary oncologic practice for the palliation of malignant osteolysis. Pamidronate has not been previously reported to cause tissue injury upon extravasation in dogs. The medical records of 11 client-owned dogs undergoing palliative treatment for primary bone tumors with known or suspected pamidronate extravasation reactions were reviewed. The majority of adverse events were low grade in nature, however in some cases, the reactions were severe and led to euthanasia in one instance. Time to complete resolution of lesions ranged from within several days to greater than one and a half months. Aside from the dog that was euthanized, no long-term sequelae of extravasation were identified. Treatments employed to address the reactions varied widely. Pamidronate extravasation reaction appears to be an uncommon, but potentially serious complication of intravenous administration.

Overview, prevention and management of chemotherapy extravasation

Chemotherapy extravasation remains an accidental complication of chemotherapy administration and may result in serious damage to patients. We review in this article the clinical aspects of chemotherapy extravasation and latest advances in definitions, classification, prevention, management and guidelines. We review the grading of extravasation and tissue damage according to various chemotherapeutic drugs and present an update on treatment and new antidotes including dexrazoxane for anthracyclines extravasation. We highlight the importance of education and training of the oncology team for prevention and prompt pharmacological and non-pharmacological management and stress the availability of new antidotes like dexrazoxane wherever anthracyclines are being infused.

Intrathecal chemotherapy: potential for medication error

BACKGROUND

The central nervous system is a unique sanctuary site for malignant disease. To ensure optimal disease control, intrathecal (IT) chemotherapy is commonly given in conjunction with standard chemotherapy protocols, thus providing the opportunity for medication errors.

OBJECTIVE

A systematic review of the current literature on medication errors associated with the administration of IT chemotherapy was conducted.

METHODS

English-language literature published from January 1960 through June 2013 was accessed. Case reports, clinical studies, and review articles pertaining to IT medication errors were included in the review. References of all relevant articles were searched for additional citations.

RESULTS

Twenty-two cases of accidental IT overdoses have been reported with methotrexate and 1 with cytarabine. There have been numerous cases of antineoplastic agents intended for administration by the parenteral route being inadvertently given intrathecally. Vincristine has been implicated 31 times (25 deaths), as well as vindesine, asparaginase, bortezomib, daunorubicin, and dactinomycin. This has led to profound toxicity and, commonly, death. Unfortunately, many cases go unrecognized or unreported.

CONCLUSIONS

The best method for eliminating the risk of IT medication errors is to develop effective methods of prevention and incorporate them into oncology and hematology practice internationally. Strategies include abolishing the syringe as a method of vinca alkaloid administration and substituting small-volume intravenous bags, and developing novel methods for intraspinal drug administration.

IMPLICATIONS FOR PRACTICE

The nursing profession is in a unique position to influence change and lead the way in establishing preventative strategies into current practice.

Ozone Ameliorates Doxorubicine-Induced Skin Necrosis - results from an animal model

Doxorubicin (DXR) extravasation result with serious morbidity like skin ulceration and necrosis. The purpose of this study is to determine the protective effects of ozone, olive oil, dimethyl sulfoxide (DMSO), and coenzyme Q10 in the treatment of DXR-induced skin ulcers on rats. After an intradermal injection of DXR on a basis of an animal extravasation model, the materials were topically applied. The ulcer sizes were measured, and a punch biopsy was taken from the extravasation site in which the skin ulcers formed at the end of the experiment. The samples were analyzed for tumor necrosis factor alpha (TNF-α), interleukin 1-beta (IL1β), malondialdehyde (MDA), superoxide dismutase (SOD), and glutathione peroxidase (GSH-Px) enzymes, and examined histopathologically. The ulcer sizes clearly decreased in the study groups, including DMSO, olive oil, ozone plus coenzyme Q10, and ozone plus olive oil groups in comparison with the control group with the exception of the coenzyme Q10 group. The malondialdehyde levels were lower in the DMSO, olive oil, ozone plus olive oil, and ozone plus coenzyme Q10 groups than they were in the control group, but they were not significantly different. The TNF-α level was lower in the DMSO, ozone plus olive oil, coenzyme Q10, and ozone plus coenzyme Q10 groups in comparison with the control group. There was no significant change in the SOD, GSH-Px, and IL1β levels in the study groups in comparison with the control and the sham groups. The ozone plus olive oil group could be considered to be an alternate therapy for skin ulcers due to DXR extravasation.

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.

Managing cytotoxic chemotherapy extravasation: use of saline washout

Florence Nightingale Foundation scholar Karen Harrold received funding to support her PhD exploring the patient experience of saline washout as a management strategy for chemotherapy extravasation. She discusses the focus of her thesis, the completion of phase one and looks ahead to phase two.