Management of extravasation is performed by a registered nurse (RN) or healthcare prescriber with specialized training in the detection and treatment of extravasation.
This procedure should be instituted immediately if extravasation of a chemotherapeutic agent with vesicant properties is suspected to minimize or prevent undue harm to the child undergoing chemotherapy.
Extravasation is infiltration of a vesicant chemotherapy drug out of the blood vessel and into the soft tissue surrounding the injection delivery site. A vesicant is a drug that, if infiltrated, is capable of causing pain, ulceration, necrosis, and sloughing of damaged tissue (Chart 28-1).
An extravasation kit should be readily available on a unit where chemotherapeutic agents are administered.
CHART 28-1 Signs and Effects of Extravasation
Local pain, burning sensation, swelling, or erythema at site
Lack of blood return
Immediate intense pain but may, on occasion, be painless
Pain is usually followed by erythema and edema within hours and increased induration within days.
Skin ulceration and skin necrosis may follow within weeks and can lead to necrosis. Ulcer progression becomes more prominent as the superficial edema decreases.
Necrotic tissue of the underlying fascia, tendon, and periosteum can be seen by 7 days after infiltration.
If not recognized early, wide surgical resection and debridement may be required.
Severe permanent disability from contractures or even amputation of involved extremity may be necessary. Damage can be severe enough to result in physical deformity or a functional deficit, such as joint mobility, loss of vascularity, or loss of tendon function.
caREminder
A useful acronym to follow for management of extravasations as described by the Association of Pediatric Hematology/Oncology Nurses is “SLAPP.”
S = Stop the infusion
L = Leave the needle
A = Aspirate
P = Pull the needle
P = Notify the provider
Apply hot or cold pack as indicated
Administer treatment/antidote as ordered
EQUIPMENT
Extravasation kit:
An approved antidotes for extravasation management (Table 28-1)
Gauze pads
1-, 3-, and 10-mL syringes
10 mL sterile water
10 mL sterile saline
Needles of various sizes
Antiseptic wipe
Paper tape
Measuring tape
Warm and cold packs
Nonsterile gloves
CHILD AND FAMILY ASSESSMENT AND PREPARATION
Explain to child/family the hazards of chemotherapy administration before the initiation of therapy.
Instruct child/family to report any changes at the intravenous (IV) site during or after administration of vesicant chemotherapy.
Venous integrity will be assessed before each administration of chemotherapy to validate blood return and proper flow. For chemotherapy administered IV push, blood return will be assessed every 1 to 2 mL. For longer infusions, blood return should be accessed every hour.
Assess the child’s infusion site for the following signs:
Swelling around the catheter insertion site
Excess fluid leaking from insertion site
Unusual warmth or coolness of skin at site
Blanched appearance of skin at or around site
Change in infusion quality as indicated by absence of blood return (although not always present), difficulty flushing the catheter, or continuous alarming of the electronic infusion device (EID) indicating an occlusion
Complaints of pain, pruritus, or unusual sensations such as burning or stinging
Assess the child with a central venous catheter for these additional signs and symptoms:
Complaints of dull, aching pain in the shoulder area
Tingling, burning, or a sensation of warmth in the chest wall
Fever of unknown origin
KidKare Listen to the child during the chemotherapy administration. The child may say the infusion feels “different,” “funny,” “itchy,” or “weird.” If he or she complains about the IV site, do not take any chances. Stop the infusion immediately and report any concerns to the physician.
If extravasation is suspected, explain to the child and the family why you are stopping the chemotherapy administration and the interventions you will initiating.
Alarms from electronic infusion devices (EIDs) should not be relied on to identify infiltration/extravasation. These device alarms are not designed to detect the presence of complications from extravasation.
Note: Refer to agency formulary for further guidelines; DSMO, dimethyl sulfoxide; IV, intravenous; ONS, Oncology Nursing Society; SC, subcutaneous
a a Cisplatin is reported as a vesicant if greater than 20 mL of 0.5 mg/mL concentration extravasates (>0.5 mg/mL) b b Mitoxantrone may act as a vesicant, depending on concentration c c Oxaliplatin has been reported to have vesicant properties
Used with permission. Kline, N. (Ed.). (2014). Essentials of pediatric hematology/oncology nursing: A core curriculum (4th ed.). Glenview, IL: Association of Pediatric Hematology Oncology Nurses (table 8-2, p. 376 ).
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CHART 28-1 Signs and Effects of Extravasation
KidKare Listen to the child during the chemotherapy administration. The child may say the infusion feels “different,” “funny,” “itchy,” or “weird.” If he or she complains about the IV site, do not take any chances. Stop the infusion immediately and report any concerns to the physician.
Alarms from electronic infusion devices (EIDs) should not be relied on to identify infiltration/extravasation. These device alarms are not designed to detect the presence of complications from extravasation.
