n Online Exclusive Article
Level of Adherence to an Extravasation Protocol Over 10 Years in a Tertiary Care Hospital Gloria Molas-Ferrer, PharmD, Elisabet Farré-Ayuso, PharmD, Fernando doPazo-Oubiña, PharmD, Ana deAndrés-Lázaro, PharmD, Jaume Guell-Picazo, RN, Núria Borrás-Maixenchs, RN, Lourdes Corominas-Bosch, RN, Montserrat Valverde-Bosch, RN, MSN, and Natalia Creus-Baró, PharmD, PhD, BCOP
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 © nuiiko/iStock/Thinkstock 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. Gloria Molas-Ferrer, PharmD, and Elisabet Farré-Ayuso, PharmD, are hospital pharmacists; Fernando doPazo-Oubiña, PharmD, is an oncology pharmacist; Ana deAndrés-Lázaro, PharmD, is a hospital pharmacist; Jaume Guell-Picazo, RN, is the head of the oncology-hematology outpatient clinic; Núria Borrás-Maixenchs, RN, is the hematology nursing head; Lourdes Corominas-Bosch, RN, is the oncology nursing head; Montserrat Valverde-Bosch, RN, MSN, is the nursing coordinator of oncology-hematology; and Natalia Creus-Baró, PharmD, PhD, BCOP, is an oncology pharmacist, all at the Hospital Clinic of Barcelona in Spain. The authors take full responsibility for the content of the article. The authors did not receive honoraria for this work. The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias. No financial relationships relevant to the content of this article have been disclosed by the authors, planners, independent peer reviewers, or editorial staff. Mention of specific products and opinions related to those products do not indicate or imply endorsement by the Clinical Journal of Oncology Nursing or the Oncology Nursing Society. Molas-Ferrer can be reached at [email protected], with copy to editor at [email protected]. (Submitted May 2014. Revision submitted July 2014. Accepted for publication August 2, 2014.) Key words: extravasation protocol; chemotherapy; oncology nursing; antineoplastic drugs Digital Object Identifier: 10.1188/15.CJON.E25-E30
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n undesirable complication related to the administration of antineoplastic therapy is extravasation of chemotherapy. Despite being rare, it causes high concern among nursing staff and patients because of the severe consequences it may have. The term extravasation includes the unnoticed leakage or escape of a chemotherapeutic agent from a vessel into the perivascular tissue, as well as the unintentional injection of a drug into surrounding healthy tissues (Sauerland, Engelking, Wickham, & Corbi, 2006; Schrijvers, 2003). Although establishing the real incidence of extravasation is difficult, available data point to a value that ranges from 0.1%–6.5% (Alfaro-Rubio et al., 2006; Ener, Meglathery, & Styler, 2004; Gonzalez, 2013). Typically, the
diagnosis of an extravasation is mainly clinical. Patients have local pain, burning sensation, swelling, or erythema (Ener et al., 2004). Patients and nursing staff must be educated to detect extravasation. Changes in drug infusion rate and absence of blood return are signs that indicate that an extravasation may have happened. Tissue damage after an extravasation develops by different mechanisms, according to the ability of the extravasated agent to bind to DNA (Ener et al., 2004; Schulmeister, 2007). Drugs that bind to DNA enter into cells and cause rapid direct cell death. Drugs that do not bind to DNA are easily metabolized in the tissue into inactive compounds. The degree of tissue injury is lower because they are rapidly neutralized.
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According to their ability to cause tissue damage, drugs are classified as vesicant, irritant, or nonvesicant (Ener et al., 2004; Gonzalez, 2013). Vesicant drugs cause the development of blisters and tissue necrosis, and irritant drugs can cause local irritation. Nonvesicant drugs rarely produce acute reactions or tissue necrosis. The classification of chemotherapeutic agents is presented in Figure 1. In addition to the drugs’ potential to cause tissue damage, the extent of tissue injury also is related to the infusion site, condition of the tissue, concentration and amount of the extravasated agent, treatment applied, and time from extravasation to initiation of the intervention (Ener et al., 2004; Sauerland et al., 2006). The rapid instauration of treatment is mandatory because of the severe consequences that an extravasation can have on tissue integrity and patients’ quality of life. The treatment depends mainly on the ability of the drug to damage tissue (Watanabe et al., 2008). Unfortunately, information about best treatment options, including specific antidotes, is scarce. Available data come from a series of case reports, small uncontrolled trials, and studies in animals. Comparative studies in humans cannot be carried out because of chemotherapy-specific characteristics and ethical considerations. However, the use of the following antidotes is well established: hyaluronidase for the
Vesicant • Amsacrine • Bendamustine • Cisplatin • Dactinomycin • Daunorubicin • Docetaxel • Doxorubicin • Epirubicin • Idarubicin • Mechlorethamine • Mitomycin • Mitoxantrone • Nonpegylated liposomal doxorubicin Irritant • Azacitidine • Bleomycin • Busulfan • Cabazitaxel • Carboplatin • Carmustine • Cyclophosphamide Nonvesicant • Arsenic trioxide bortezomib • Asparaginase • Bortezomib • Cladribine • Clofarabine • Cytarabine • Irinotecan
• Oxaliplatin • Paclitaxel • Pegylated liposomal daunorubicin • Pegylated liposomal doxorubicin • Streptozotocin • Trabectedin • Vinblastine • Vincristine • Vindesine • Vinflunine • Vinorelbine
Established Processes An extravasation kit is available in every area where chemotherapy administration is routinely performed at the researchers’ hospital. The kits are supplied by the pharmacy department and include an extravasation management algorithm (see Figure 2), antidotes, cold and hot packs, general nursing tools, and an extravasation notification form. When an extravasation happens, the doctor in charge is informed, an extravasation kit is opened, and the appropriate actions are made. Afterward, an extravasation notification form is completed. The notification form is filed in the patient’s medical record, and a copy is delivered to the pharmacy department to evaluate and archive. The opened kit also is returned to the pharmacy department to be replaced with a new one.
Methods
• • • • • •
Dacarbazine Floxuridine Fluorouracil Ifosfamide Melphalan Paclitaxel-albumin thiotepa
• • • • • • •
Methotrexate Monoclonal antibodies Pemetrexed Pentostatin Raltitrexed Temsirolimus Topotecan
Note. Drugs are classified according to the most serious reaction they can cause.
FIGURE 1. Classification of Cytostatic Drugs Note. Based on information from Conde-Estévez & Mateu-de Antonio, 2012; Ener et al., 2004; Watanabe et al., 2008. E26
treatment of vinca alkaloid, epipodophyllotoxin, and paclitaxel extravasation; sodium thiosulfate for mechlorethamine and concentrated cisplatin extravasation; and dexrazoxane and dimethyl sulfoxide for anthracycline extravasation (Ener et al., 2004; Polovich, Whitford, & Olsen, 2009). Several other drugs, such as glucocorticoids, antihistamines, sodium bicarbonate, heparin, and lidocaine, are not recommended because they are not effective in treating extravasation injuries (Schulmeister, 2007). Because of the importance of a quick intervention after an extravasation, every hospital should have an extravasation protocol. The aim of the current study was to know the degree of observance of the extravasation protocol at the researchers’ hospital. Secondary objectives were determination of extravasation incidence and descriptive analysis of extravasation.
The researchers performed a descriptive, longitudinal, retrospective study, set in a tertiary-level hospital in Spain, to analyze all the information recorded and to identify strengths and weaknesses during the past 10 years. The extravasation kits were located in three areas: the chemotherapy outpatient clinic, the hospitalization wards, and with the domiciliary chemotherapy administration team. The researchers reviewed all extravasation notification forms received by the pharmacy department from January 2003 to December 2012. Retrospective notifications of past extravasation (occurring days before the notification), recall phenomenon, and phlebitis events were excluded. Notification forms in which the patient and extravasated drug could not be identified were excluded from final analysis but considered in incidence estimation. General information and patient demographics were recorded, including gender, age, type of cancer, chemotherapy treatment, location of the patient in the moment of extravasation (outpatient clinic, hospitalization ward, or patient residence), and nursing shift. Information regarding the extravasation sequence was reviewed as well. This included characteristics related to the administration process, including puncture point, characteristics of the vein used for administration of chemotherapy (e.g., good, thin, difficult approach, tough, weak),
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and medical device access (short peripheral catheter, peripherally inserted central catheter, or long-term implantable central venous catheter). Information about the involved cytostatic drug, including the extravasated drug, its risk category (vesicant, irritant, or nonvesicant), time of infusion, and volume of the extravasated drug, also was recorded. The nurses’ behavior in the face of an extravasation was evaluated by means of the information documented in the notification forms. The appropriate use of specific antidotes, according to the extravasation protocol, was checked. Similarly, follow-up of patients and final outcomes were reviewed.
Results During the study period, 142 notification forms were delivered to the pharmacy department. Of those, 117 were included in the study after removing the ones that did not fulfill inclusion criteria. The main reasons for exclusion were reports of phlebitis or distant lesions and notifications of past extravasation. For final analysis, another seven notification forms were excluded because the extravasated drug was not recorded and could not be identified by other means. One hundred and ten extravasation notifications were selected for final evaluation. Of those, the mean age of patients was 63.6 years, with a range of 21–85 years (see Table 1).
Adherence to the Protocol In the current study, protocol adherence was 89%, without taking into account the use of Burow’s solution application and lack of documentation of general measures. In 81 cases (74%), the nurse applied some kind of initial or general measures, but in 28 cases (25%), it was not documented. In the notification form, the question about initial and general measures was open-ended. Therefore, a high percentage of data was not documented. The most frequent actions described were aspiration of the drug and elevation of the affected limb (percentage not available). In one patient, local pressure was applied despite it not being recommended. Twenty-seven (25%) of the cases included topical application of Burow’s solution, but this measure was not considered in the researchers’ internal protocol. An antidote was used in 41 patients (37%), and temperature measures were applied in 14 cases (13%). The researchers found 12 deviations from the protocol in the application of recommended measures (see Table 2). In two patients, an indicated antidote was not administered. In two cases, heat or cold and an antidote were necessary, but neither was applied. However, in three patients with a reported paclitaxel extravasation, an antidote was administered although it was not included in the researchers’ protocol recommendations. In addition, in three patients, heat or cold was not applied, despite being indicated. One patient also received an antidote and heat or cold although it was unnecessary.
Incidence Global incidence of extravasation during the study period was 117 extravasations of 213,579 doses of chemotherapy administered (0.05%). The majority of the reported extravasations
(n = 102, 93%) took place at the oncology-hematology outpatient clinic; the rest of the extravasations occurred in hospital wards (n = 7, 6%). In addition, one episode of extravasation happened during a home administration of chemotherapy.
Chemotherapy Extravasation Protocol • Notify the pharmacy department about the extravasation. • Contact the doctor. • Immediately use the extravasation kit according to the recommendations. • Fill out the follow-up form. Initial Measures • Stop the drug infusion. • Withdraw the infusion equipment, but not the venous catheter. • Aspire 5–10 ml of blood through the venous catheter to extract the maximum quantity of the extravasated drug. • Withdraw the venous catheter. • Proceed to apply specific treatment, or go on with general measures if the drug does not require specific treatment. Specific Treatment • Amsacrine – Apply topical DMSO 99% onto double the affected area. Allow it to dry without covering it, and apply topical DMSO 99% every six hours for 14 days. • Daunorubicin, doxorubicin, epirubicin, idarubicin, mitomycina, and mitoxantrone – Apply topical DMSO 99% onto double the affected area. Allow it to dry without covering it, and apply topical DMSO 99% every six hours for 14 days. – Apply local cold for 60 minutes. Repeat every eight hours for three days. • Vinblastineb, vincristineb, vindesineb, and vinorelbineb – Administer six injections of 150 IU (0.5 ml) of SC hyaluronidase in the affected and surrounding area. – Apply dry heat for 30 minutes after the injection of hyaluronidase. • Cisplatin, clormetin, and dacarbazine – Administer 2 ml of SC sodium thiosulfate molar concentration of 1/6 for every mg of extravasated drug, in several injections around the affected area. – Cisplatin: Administer thiosulfate only if cisplatin concentration is more than 0.4 mg/ml or if the extravasated volume is more than 20 ml. – Dacarbazine: Administer thiosulfate only if persistent signs of extravasation are present or if the lesion progresses after 12–24 hours. • Etoposideb, ifosfamide, and teniposideb – Administer six injections of 150 IU (0.5 ml) of SC hyaluronidase in the affected and surrounding area. – Ifosfamide: Administer hyaluronidase only if persistent signs of extravasation are present or the lesion progresses after 12–24 hours. General Measures • Raise the affected extremity over the height of the heart. • Do not apply pressure at the affected area. Avoid bandages. • Gently apply common hygienic measures. Do not clean with detergent if tissue necrosis has occurred. • If necessary, prescribe analgesic and antibiotic treatment. a Avoid exposure of the affected area to sunlight. b Pharmacologic treatment with or without hot or cold treatment can be repeated if necessary after 12 and 24 hours. DMSO—dimethyl sulfoxide; SC—subcutaneous
FIGURE 2. Chemotherapy Extravasation Protocol Note. Based on information from Ener et al., 2004; Mateu et al., 1997; Polovich et al., 2009; Schulmeister, 2007.
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information about the quality of the vein. In patients with porta-cath administration, this question did not apply.
TABLE 1. Sample Characteristics (N = 110) Characteristic Age (years) Characteristic Gender Male Female Location of extravasation Outpatient clinic Hospitalization ward Home Nursing shift Afternoon Morning Not identified Type of neoplastic disease Lung Hematologic Gynecologic Gastrointestinal Breast Head and neck Genitourinary Sarcoma Germinal Melanoma Not identified
—
X
Range
63.6
21–85
n
%
060 050
55 46
102 007 001
93 06 01
052 041 017
47 37 16
037 019 012 011 010 006 004 003 002 002 004
34 17 11 10 09 06 04 03 02 02 04
Note. Extravasations (N = 110) of 213,579 doses of chemotherapy administered. Note. Because of rounding, percentages may not total 100.
Extravasated Drugs In terms of risk of tissue damage, 43 (40%) of the drugs involved in the reported extravasations were classified as vesicant and 54 (49%) as irritant. The remaining 12 (11%) were classified as nonvesicant. In one case referring to fotemustine, the risk is not clearly defined in the extravasation protocols or drug bibliography. Twenty-four different drugs were implied in the extravasations. Drugs most frequently reported were etoposide (n = 18, 16%), carboplatin (n = 17, 15%), and paclitaxel (n = 16, 15%). In six patients (5%), the drug extravasated was not considered in the researchers’ protocol (i.e., fotemustine, oxaliplatin, pemetrexed, or temsirolimus). In those cases, the nurse consulted with the pharmacy department or doctor for actions that should be taken. Infusion times of extravasated drugs were divided as follows: 0–30 minutes (n = 51, 46%), 31–180 minutes (n = 48, 44%), and more than 180 minutes (n = 8, 7%). In three cases (3%), this information was not reported. The quantity extravasated also was classified into three groups: volume less than 10 ml (n = 58, 53%), 10–50 ml (n = 25, 23%), and greater than 50 ml (n = 8, 7%). In 19 cases (17%), the volume extravasated was not indicated. The vein affected by the extravasation had already been used for administration of premedication drugs (mostly serum, antiemetics, and corticoids) in 51 patients (46%). The remaining 59 patients (54%) did not receive premedication drugs by the same vein, or it was not documented.
Follow-Up Extravasation Sequence The type of device mainly used for cytostatic administration was a short peripheral catheter, which was employed in 87 patients (78%). In six cases (5%), the patients had a long-term implantable central venous catheter. Three cases of extravasation (3%) were described in which a peripherally inserted central catheter was used. In the remaining 14 patients (13%), the kind of device used for administration was not recorded by the nurse. The point of puncture most frequently related to an extravasation event was in the plexus arm (n = 42, 38%), forearm (n = 23, 21%), hand (n = 16, 15%), and wrist (n = 14, 13%). Nurses did not document a location in nine cases (8%). An additional six cases (5%) were not considered because of a port-a-cath administration. In addition to the point of insertion of the catheter, another important factor that contributes to extravasation is the quality of the vein used for administration of the drug. In the current study, the vein involved in the process was described as good in only 24 extravasations (22%). In the majority of the cases, the patients had one (n = 40, 36%) or more (n = 29, 26%) characteristics that made administration difficult. The most frequent characteristic described was thick (n = 46, 42%), followed by weak (n = 22, 20%), very prickled (n = 18, 16%), difficult approach (n = 10, 9%), and tough (n = 8, 7%). When two venous problems were present in the same patient, weak and thin were the characteristics most frequently described (n = 11, 10%). In 11 cases (10%), the nurse did not record any E28
Ninety-nine patients (90%) who suffered an extravasation event had at least one episode of reported follow-up. The first follow-up took place during the first 24 hours after the extravasation episode in 59 patients (54%), 48–72 hours after in 20 patients (18%), and more than 72 hours after in 14 patients (13%). A second follow-up was documented in 38 patients (35%). These follow-up contacts were made by phone or a face-to-face visit. The most common symptoms described were edema, erythema, and skin toughness. No cases of necrosis or skin ulcers were described, except for in one patient, who developed a delayed skin ulcer to vinorelbine.
Discussion In the current study, protocol adherence was high (89%). Protocol deviations only occurred in 12 extravasations (11%), but some of them could be considered serious (e.g., local pressure application at the injection site, which may cause worsening of the extravasation injury). The reasons why nurses did not follow the protocol are unknown, but several causes are probable. Some extravasations may have been mild, so the nurse may have considered applying all of the measures unnecessary. Lack of knowledge and doctors’ orders differing from the protocol could be other reasons. In the current study, Burow’s solution was applied in 27 patients (25%), although it was not included in the protocol recommendations. Because of its astringent and antibacterial
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properties, Burow’s solution is used to treat TABLE 2. Deviations From the Protocol a number of skin conditions, such as erythema, phlebitis, and swelling (Llopis Clavijo Drug Protocol Recommendations Error Description & Baixauli Comes, 2001), and frequently is Carboplatin Nonspecific actions Local pressure application used in the researchers’ hospital. For this reason, Burow’s solution application was not Cyclophosphamide Nonspecific actions 150 IU hyaluronidase SC administered considered a protocol deviation. However, the Doxorubicin Topical DMSO 99% and cold DMSO 99% not applied researchers cannot confirm the effectiveness application of this measure. The notification form was not complicated, Epirubicin Topical DMSO 99% and cold DMSO 99% and cold not applied but it included some open-ended questions application (e.g., general measures, administrated antiEtoposide 150 IU hyaluronidase SC 150 IU hyaluronidase SC not applied dotes, lesion description, follow-up). In 2011, the format was changed to include more Paclitaxel Nonspecific actions • Hyaluronidase SC application • Dexamethasone SC application closed-ended questions in which nurses had • Hydrocortisone SC, hyaluronidase to mark the most appropriate description. The SC, dexchlorpheniramine SC, and purpose was to facilitate nurse documentation heat application and obtain more uniform information about Vinorelbine 150 IU hyaluronidase SC and • Heat application not documented in extravasation. heat application three cases The incidence of extravasation of antineo• No hyaluronidase or heat applied plastic drugs injected via peripheral vein is reported to be from 0.1%–6.5% (Ener et al., DMSO—dimethyl sulfoxide; SC—subcutaneous 2004; Sauerland et al., 2006; Watanabe et al., 2008) and 0.3%–4.7% in implant venous access port infusions (Sauerland et al., 2006). In the current study, incistandard therapy for patients with breast, lung, ovarian, and dence was low, with a median of 0.05% (range = 0.02%–0.1%). other solid tumors. In early clinical studies, local tissue necroOne reason for the low incidence may be that the researchers’ sis was not reported with paclitaxel, so it was not classified incidence calculation includes central and peripheral adminisas a vesicant. However, case reports suggest that it may have tration. The use of central venous access devices (subcutanevesicant properties, regardless of concentration (Stanford & ously implanted ports or peripherally inserted central catheters) Hardwicke, 2003). Therefore, it currently is classified as a vesireduces but does not eliminate the risk of drug extravasation cant in the protocol of the researchers’ hospital. In 3 of the 16 (Ener et al., 2004). Underreported extravasation also could have patients aforementioned, a subcutaneous drug (e.g., corticoids, contributed to decreased global incidence. However, the data hyaluronidase, dexchlorpheniramine) was administered as an are similar to the data from another study (Langstein, Duman, antidote although it was not considered in the researchers’ proSeelig, Butler, & Evans, 2002) that reported an extravasation tocol. No consequences for the patients were identified. After a incidence of 0.01%. Incidence may be decreasing because of an literature review, the researchers found that hyaluronidase had increase in the use of more secure devices and an increase in been applied in some cases (Dubois, Fehr, Bochtler, & Koechli, knowledge and awareness among healthcare professionals. The 1996) and that some guidelines and reviews recommend its use researchers’ institution is a tertiary hospital with an oncology(Conde-Estévez & Mateu-de Antonio, 2012; European Society hematology outpatient clinic where nurses are well prepared to of Oncology Pharmacy, 2007). However, no recommendations manage this type of medication and specially trained to detect about corticoid use are made. In fact, glucocorticoids have an extravasation and act early. More than 80 chemotherapy been found to be ineffective in treating extravasation injuries agents are administered every day. This explains why patients (Wickham, Engelking, Sauerland, & Corbi, 2006) because the in the current study did not experience as severe consequences mechanism of action of the injury is no longer believed to be as expected. No cases of tissue necrosis were reported, and inflammation (Langstein et al., 2002). However, in at least one most symptoms were mild and reversible. Of note, several studstudy, dexamethasone was used in extravasation of vesicant ies that only included paclitaxel extravasation reported higher drugs and no cases of necrosis were described (Watanabe et al., extravasation incidence (Watanabe et al., 2008) than studies that 2008). The researchers reviewed their extravasation protocol included extravasation of several drugs. This could be related and included hyaluronidase application in taxane extravasation. to the presence in the paclitaxel formulation of an excipient In one patient, heat also was applied. Application of heat or cold (Cremophor®), which also has vesicant properties (Stanford & in taxane extravasation is not a standard recommendation, but Hardwicke, 2003) and could have contributed to worsening the it has been used in several case reports. In one case, the use of quality of the vein. warm compresses appeared to worsen the injury (Stanford & The most frequently extravasated drugs were etoposide, Hardwicke, 2003). carboplatin, and paclitaxel. They also are probably the most Most patients suffering an extravasation had altered veins. In frequently administered cytotoxic drugs. During the study addition, many of them had more than two negative characterperiod, 16 cases of paclitaxel extravasation were described, istics (e.g., thin, tough, weak, difficult approach), complicating which was 15% of the total drugs extravasated. This coincides chemotherapy administration. Consequentially, patients with with the widespread use of this agent because it is part of altered veins must be more closely monitored because they are Clinical Journal of Oncology Nursing • Volume 19, Number 2 • Extravasation Protocol Adherence in a Tertiary Setting
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Implications for Practice u
Update extravasation protocols for oncology nurses regularly.
u
Register every extravasation to determine real incidence and promote methods for reducing it.
u
Document nurse actuation in every extravasation because it is useful in improving quality of patient care and creating new evidence.
at high risk of suffering from an extravasation. Port-a-caths can be considered to reduce this problem. Of note, an extravasation occurred at a patient’s home during administration of chemotherapy. This shows the importance of taking an extravasation kit wherever chemotherapy is administered.
Limitations Owing to the current study’s retrospective design, the data collected depend on the quality of data recorded in notification forms and medical records. In addition, incidence calculation depends on the rate of notification by nursing staff. In 2003, for example, the notification rate was low and incidence may be underestimated.
Nursing Implications Continuing education is important for maintaining nursing staff with updated knowledge on how to proceed in case of extravasation. Nurses should be educated on how to prevent extravasation by selecting appropriate veins and types of devices for drug administration. In addition, the extravasation protocol has to be kept up to date to include new drugs, evidence, and recommendations. Because conducting clinical trials is not ethical, information is lacking about the best procedure in extravasation of new drugs. For this reason, case reports of these drugs are particularly useful. Adherence to the extravasation protocol at the researchers’ hospital is high, but nursing staff must be continuously trained to improve quality of patient care.
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Level of Adherence to an Extravasation Protocol Over 10 Years in a Tertiary Care Hospital Gloria Molas-Ferrer, PharmD, Elisabet Farré-Ayuso, PharmD, Fernando doPazo-Oubiña, PharmD, Ana deAndrés-Lázaro, PharmD, Jaume Guell-Picazo, RN, Núria Borrás-Maixenchs, RN, Lourdes Corominas-Bosch, RN, Montserrat Valverde-Bosch, RN, MSN, and Natalia Creus-Baró, PharmD, PhD, BCOP
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 © nuiiko/iStock/Thinkstock 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. Gloria Molas-Ferrer, PharmD, and Elisabet Farré-Ayuso, PharmD, are hospital pharmacists; Fernando doPazo-Oubiña, PharmD, is an oncology pharmacist; Ana deAndrés-Lázaro, PharmD, is a hospital pharmacist; Jaume Guell-Picazo, RN, is the head of the oncology-hematology outpatient clinic; Núria Borrás-Maixenchs, RN, is the hematology nursing head; Lourdes Corominas-Bosch, RN, is the oncology nursing head; Montserrat Valverde-Bosch, RN, MSN, is the nursing coordinator of oncology-hematology; and Natalia Creus-Baró, PharmD, PhD, BCOP, is an oncology pharmacist, all at the Hospital Clinic of Barcelona in Spain. The authors take full responsibility for the content of the article. The authors did not receive honoraria for this work. The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias. No financial relationships relevant to the content of this article have been disclosed by the authors, planners, independent peer reviewers, or editorial staff. Mention of specific products and opinions related to those products do not indicate or imply endorsement by the Clinical Journal of Oncology Nursing or the Oncology Nursing Society. Molas-Ferrer can be reached at [email protected], with copy to editor at [email protected]. (Submitted May 2014. Revision submitted July 2014. Accepted for publication August 2, 2014.) Key words: extravasation protocol; chemotherapy; oncology nursing; antineoplastic drugs Digital Object Identifier: 10.1188/15.CJON.E25-E30
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n undesirable complication related to the administration of antineoplastic therapy is extravasation of chemotherapy. Despite being rare, it causes high concern among nursing staff and patients because of the severe consequences it may have. The term extravasation includes the unnoticed leakage or escape of a chemotherapeutic agent from a vessel into the perivascular tissue, as well as the unintentional injection of a drug into surrounding healthy tissues (Sauerland, Engelking, Wickham, & Corbi, 2006; Schrijvers, 2003). Although establishing the real incidence of extravasation is difficult, available data point to a value that ranges from 0.1%–6.5% (Alfaro-Rubio et al., 2006; Ener, Meglathery, & Styler, 2004; Gonzalez, 2013). Typically, the
diagnosis of an extravasation is mainly clinical. Patients have local pain, burning sensation, swelling, or erythema (Ener et al., 2004). Patients and nursing staff must be educated to detect extravasation. Changes in drug infusion rate and absence of blood return are signs that indicate that an extravasation may have happened. Tissue damage after an extravasation develops by different mechanisms, according to the ability of the extravasated agent to bind to DNA (Ener et al., 2004; Schulmeister, 2007). Drugs that bind to DNA enter into cells and cause rapid direct cell death. Drugs that do not bind to DNA are easily metabolized in the tissue into inactive compounds. The degree of tissue injury is lower because they are rapidly neutralized.
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According to their ability to cause tissue damage, drugs are classified as vesicant, irritant, or nonvesicant (Ener et al., 2004; Gonzalez, 2013). Vesicant drugs cause the development of blisters and tissue necrosis, and irritant drugs can cause local irritation. Nonvesicant drugs rarely produce acute reactions or tissue necrosis. The classification of chemotherapeutic agents is presented in Figure 1. In addition to the drugs’ potential to cause tissue damage, the extent of tissue injury also is related to the infusion site, condition of the tissue, concentration and amount of the extravasated agent, treatment applied, and time from extravasation to initiation of the intervention (Ener et al., 2004; Sauerland et al., 2006). The rapid instauration of treatment is mandatory because of the severe consequences that an extravasation can have on tissue integrity and patients’ quality of life. The treatment depends mainly on the ability of the drug to damage tissue (Watanabe et al., 2008). Unfortunately, information about best treatment options, including specific antidotes, is scarce. Available data come from a series of case reports, small uncontrolled trials, and studies in animals. Comparative studies in humans cannot be carried out because of chemotherapy-specific characteristics and ethical considerations. However, the use of the following antidotes is well established: hyaluronidase for the
Vesicant • Amsacrine • Bendamustine • Cisplatin • Dactinomycin • Daunorubicin • Docetaxel • Doxorubicin • Epirubicin • Idarubicin • Mechlorethamine • Mitomycin • Mitoxantrone • Nonpegylated liposomal doxorubicin Irritant • Azacitidine • Bleomycin • Busulfan • Cabazitaxel • Carboplatin • Carmustine • Cyclophosphamide Nonvesicant • Arsenic trioxide bortezomib • Asparaginase • Bortezomib • Cladribine • Clofarabine • Cytarabine • Irinotecan
• Oxaliplatin • Paclitaxel • Pegylated liposomal daunorubicin • Pegylated liposomal doxorubicin • Streptozotocin • Trabectedin • Vinblastine • Vincristine • Vindesine • Vinflunine • Vinorelbine
Established Processes An extravasation kit is available in every area where chemotherapy administration is routinely performed at the researchers’ hospital. The kits are supplied by the pharmacy department and include an extravasation management algorithm (see Figure 2), antidotes, cold and hot packs, general nursing tools, and an extravasation notification form. When an extravasation happens, the doctor in charge is informed, an extravasation kit is opened, and the appropriate actions are made. Afterward, an extravasation notification form is completed. The notification form is filed in the patient’s medical record, and a copy is delivered to the pharmacy department to evaluate and archive. The opened kit also is returned to the pharmacy department to be replaced with a new one.
Methods
• • • • • •
Dacarbazine Floxuridine Fluorouracil Ifosfamide Melphalan Paclitaxel-albumin thiotepa
• • • • • • •
Methotrexate Monoclonal antibodies Pemetrexed Pentostatin Raltitrexed Temsirolimus Topotecan
Note. Drugs are classified according to the most serious reaction they can cause.
FIGURE 1. Classification of Cytostatic Drugs Note. Based on information from Conde-Estévez & Mateu-de Antonio, 2012; Ener et al., 2004; Watanabe et al., 2008. E26
treatment of vinca alkaloid, epipodophyllotoxin, and paclitaxel extravasation; sodium thiosulfate for mechlorethamine and concentrated cisplatin extravasation; and dexrazoxane and dimethyl sulfoxide for anthracycline extravasation (Ener et al., 2004; Polovich, Whitford, & Olsen, 2009). Several other drugs, such as glucocorticoids, antihistamines, sodium bicarbonate, heparin, and lidocaine, are not recommended because they are not effective in treating extravasation injuries (Schulmeister, 2007). Because of the importance of a quick intervention after an extravasation, every hospital should have an extravasation protocol. The aim of the current study was to know the degree of observance of the extravasation protocol at the researchers’ hospital. Secondary objectives were determination of extravasation incidence and descriptive analysis of extravasation.
The researchers performed a descriptive, longitudinal, retrospective study, set in a tertiary-level hospital in Spain, to analyze all the information recorded and to identify strengths and weaknesses during the past 10 years. The extravasation kits were located in three areas: the chemotherapy outpatient clinic, the hospitalization wards, and with the domiciliary chemotherapy administration team. The researchers reviewed all extravasation notification forms received by the pharmacy department from January 2003 to December 2012. Retrospective notifications of past extravasation (occurring days before the notification), recall phenomenon, and phlebitis events were excluded. Notification forms in which the patient and extravasated drug could not be identified were excluded from final analysis but considered in incidence estimation. General information and patient demographics were recorded, including gender, age, type of cancer, chemotherapy treatment, location of the patient in the moment of extravasation (outpatient clinic, hospitalization ward, or patient residence), and nursing shift. Information regarding the extravasation sequence was reviewed as well. This included characteristics related to the administration process, including puncture point, characteristics of the vein used for administration of chemotherapy (e.g., good, thin, difficult approach, tough, weak),
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and medical device access (short peripheral catheter, peripherally inserted central catheter, or long-term implantable central venous catheter). Information about the involved cytostatic drug, including the extravasated drug, its risk category (vesicant, irritant, or nonvesicant), time of infusion, and volume of the extravasated drug, also was recorded. The nurses’ behavior in the face of an extravasation was evaluated by means of the information documented in the notification forms. The appropriate use of specific antidotes, according to the extravasation protocol, was checked. Similarly, follow-up of patients and final outcomes were reviewed.
Results During the study period, 142 notification forms were delivered to the pharmacy department. Of those, 117 were included in the study after removing the ones that did not fulfill inclusion criteria. The main reasons for exclusion were reports of phlebitis or distant lesions and notifications of past extravasation. For final analysis, another seven notification forms were excluded because the extravasated drug was not recorded and could not be identified by other means. One hundred and ten extravasation notifications were selected for final evaluation. Of those, the mean age of patients was 63.6 years, with a range of 21–85 years (see Table 1).
Adherence to the Protocol In the current study, protocol adherence was 89%, without taking into account the use of Burow’s solution application and lack of documentation of general measures. In 81 cases (74%), the nurse applied some kind of initial or general measures, but in 28 cases (25%), it was not documented. In the notification form, the question about initial and general measures was open-ended. Therefore, a high percentage of data was not documented. The most frequent actions described were aspiration of the drug and elevation of the affected limb (percentage not available). In one patient, local pressure was applied despite it not being recommended. Twenty-seven (25%) of the cases included topical application of Burow’s solution, but this measure was not considered in the researchers’ internal protocol. An antidote was used in 41 patients (37%), and temperature measures were applied in 14 cases (13%). The researchers found 12 deviations from the protocol in the application of recommended measures (see Table 2). In two patients, an indicated antidote was not administered. In two cases, heat or cold and an antidote were necessary, but neither was applied. However, in three patients with a reported paclitaxel extravasation, an antidote was administered although it was not included in the researchers’ protocol recommendations. In addition, in three patients, heat or cold was not applied, despite being indicated. One patient also received an antidote and heat or cold although it was unnecessary.
Incidence Global incidence of extravasation during the study period was 117 extravasations of 213,579 doses of chemotherapy administered (0.05%). The majority of the reported extravasations
(n = 102, 93%) took place at the oncology-hematology outpatient clinic; the rest of the extravasations occurred in hospital wards (n = 7, 6%). In addition, one episode of extravasation happened during a home administration of chemotherapy.
Chemotherapy Extravasation Protocol • Notify the pharmacy department about the extravasation. • Contact the doctor. • Immediately use the extravasation kit according to the recommendations. • Fill out the follow-up form. Initial Measures • Stop the drug infusion. • Withdraw the infusion equipment, but not the venous catheter. • Aspire 5–10 ml of blood through the venous catheter to extract the maximum quantity of the extravasated drug. • Withdraw the venous catheter. • Proceed to apply specific treatment, or go on with general measures if the drug does not require specific treatment. Specific Treatment • Amsacrine – Apply topical DMSO 99% onto double the affected area. Allow it to dry without covering it, and apply topical DMSO 99% every six hours for 14 days. • Daunorubicin, doxorubicin, epirubicin, idarubicin, mitomycina, and mitoxantrone – Apply topical DMSO 99% onto double the affected area. Allow it to dry without covering it, and apply topical DMSO 99% every six hours for 14 days. – Apply local cold for 60 minutes. Repeat every eight hours for three days. • Vinblastineb, vincristineb, vindesineb, and vinorelbineb – Administer six injections of 150 IU (0.5 ml) of SC hyaluronidase in the affected and surrounding area. – Apply dry heat for 30 minutes after the injection of hyaluronidase. • Cisplatin, clormetin, and dacarbazine – Administer 2 ml of SC sodium thiosulfate molar concentration of 1/6 for every mg of extravasated drug, in several injections around the affected area. – Cisplatin: Administer thiosulfate only if cisplatin concentration is more than 0.4 mg/ml or if the extravasated volume is more than 20 ml. – Dacarbazine: Administer thiosulfate only if persistent signs of extravasation are present or if the lesion progresses after 12–24 hours. • Etoposideb, ifosfamide, and teniposideb – Administer six injections of 150 IU (0.5 ml) of SC hyaluronidase in the affected and surrounding area. – Ifosfamide: Administer hyaluronidase only if persistent signs of extravasation are present or the lesion progresses after 12–24 hours. General Measures • Raise the affected extremity over the height of the heart. • Do not apply pressure at the affected area. Avoid bandages. • Gently apply common hygienic measures. Do not clean with detergent if tissue necrosis has occurred. • If necessary, prescribe analgesic and antibiotic treatment. a Avoid exposure of the affected area to sunlight. b Pharmacologic treatment with or without hot or cold treatment can be repeated if necessary after 12 and 24 hours. DMSO—dimethyl sulfoxide; SC—subcutaneous
FIGURE 2. Chemotherapy Extravasation Protocol Note. Based on information from Ener et al., 2004; Mateu et al., 1997; Polovich et al., 2009; Schulmeister, 2007.
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information about the quality of the vein. In patients with porta-cath administration, this question did not apply.
TABLE 1. Sample Characteristics (N = 110) Characteristic Age (years) Characteristic Gender Male Female Location of extravasation Outpatient clinic Hospitalization ward Home Nursing shift Afternoon Morning Not identified Type of neoplastic disease Lung Hematologic Gynecologic Gastrointestinal Breast Head and neck Genitourinary Sarcoma Germinal Melanoma Not identified
—
X
Range
63.6
21–85
n
%
060 050
55 46
102 007 001
93 06 01
052 041 017
47 37 16
037 019 012 011 010 006 004 003 002 002 004
34 17 11 10 09 06 04 03 02 02 04
Note. Extravasations (N = 110) of 213,579 doses of chemotherapy administered. Note. Because of rounding, percentages may not total 100.
Extravasated Drugs In terms of risk of tissue damage, 43 (40%) of the drugs involved in the reported extravasations were classified as vesicant and 54 (49%) as irritant. The remaining 12 (11%) were classified as nonvesicant. In one case referring to fotemustine, the risk is not clearly defined in the extravasation protocols or drug bibliography. Twenty-four different drugs were implied in the extravasations. Drugs most frequently reported were etoposide (n = 18, 16%), carboplatin (n = 17, 15%), and paclitaxel (n = 16, 15%). In six patients (5%), the drug extravasated was not considered in the researchers’ protocol (i.e., fotemustine, oxaliplatin, pemetrexed, or temsirolimus). In those cases, the nurse consulted with the pharmacy department or doctor for actions that should be taken. Infusion times of extravasated drugs were divided as follows: 0–30 minutes (n = 51, 46%), 31–180 minutes (n = 48, 44%), and more than 180 minutes (n = 8, 7%). In three cases (3%), this information was not reported. The quantity extravasated also was classified into three groups: volume less than 10 ml (n = 58, 53%), 10–50 ml (n = 25, 23%), and greater than 50 ml (n = 8, 7%). In 19 cases (17%), the volume extravasated was not indicated. The vein affected by the extravasation had already been used for administration of premedication drugs (mostly serum, antiemetics, and corticoids) in 51 patients (46%). The remaining 59 patients (54%) did not receive premedication drugs by the same vein, or it was not documented.
Follow-Up Extravasation Sequence The type of device mainly used for cytostatic administration was a short peripheral catheter, which was employed in 87 patients (78%). In six cases (5%), the patients had a long-term implantable central venous catheter. Three cases of extravasation (3%) were described in which a peripherally inserted central catheter was used. In the remaining 14 patients (13%), the kind of device used for administration was not recorded by the nurse. The point of puncture most frequently related to an extravasation event was in the plexus arm (n = 42, 38%), forearm (n = 23, 21%), hand (n = 16, 15%), and wrist (n = 14, 13%). Nurses did not document a location in nine cases (8%). An additional six cases (5%) were not considered because of a port-a-cath administration. In addition to the point of insertion of the catheter, another important factor that contributes to extravasation is the quality of the vein used for administration of the drug. In the current study, the vein involved in the process was described as good in only 24 extravasations (22%). In the majority of the cases, the patients had one (n = 40, 36%) or more (n = 29, 26%) characteristics that made administration difficult. The most frequent characteristic described was thick (n = 46, 42%), followed by weak (n = 22, 20%), very prickled (n = 18, 16%), difficult approach (n = 10, 9%), and tough (n = 8, 7%). When two venous problems were present in the same patient, weak and thin were the characteristics most frequently described (n = 11, 10%). In 11 cases (10%), the nurse did not record any E28
Ninety-nine patients (90%) who suffered an extravasation event had at least one episode of reported follow-up. The first follow-up took place during the first 24 hours after the extravasation episode in 59 patients (54%), 48–72 hours after in 20 patients (18%), and more than 72 hours after in 14 patients (13%). A second follow-up was documented in 38 patients (35%). These follow-up contacts were made by phone or a face-to-face visit. The most common symptoms described were edema, erythema, and skin toughness. No cases of necrosis or skin ulcers were described, except for in one patient, who developed a delayed skin ulcer to vinorelbine.
Discussion In the current study, protocol adherence was high (89%). Protocol deviations only occurred in 12 extravasations (11%), but some of them could be considered serious (e.g., local pressure application at the injection site, which may cause worsening of the extravasation injury). The reasons why nurses did not follow the protocol are unknown, but several causes are probable. Some extravasations may have been mild, so the nurse may have considered applying all of the measures unnecessary. Lack of knowledge and doctors’ orders differing from the protocol could be other reasons. In the current study, Burow’s solution was applied in 27 patients (25%), although it was not included in the protocol recommendations. Because of its astringent and antibacterial
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properties, Burow’s solution is used to treat TABLE 2. Deviations From the Protocol a number of skin conditions, such as erythema, phlebitis, and swelling (Llopis Clavijo Drug Protocol Recommendations Error Description & Baixauli Comes, 2001), and frequently is Carboplatin Nonspecific actions Local pressure application used in the researchers’ hospital. For this reason, Burow’s solution application was not Cyclophosphamide Nonspecific actions 150 IU hyaluronidase SC administered considered a protocol deviation. However, the Doxorubicin Topical DMSO 99% and cold DMSO 99% not applied researchers cannot confirm the effectiveness application of this measure. The notification form was not complicated, Epirubicin Topical DMSO 99% and cold DMSO 99% and cold not applied but it included some open-ended questions application (e.g., general measures, administrated antiEtoposide 150 IU hyaluronidase SC 150 IU hyaluronidase SC not applied dotes, lesion description, follow-up). In 2011, the format was changed to include more Paclitaxel Nonspecific actions • Hyaluronidase SC application • Dexamethasone SC application closed-ended questions in which nurses had • Hydrocortisone SC, hyaluronidase to mark the most appropriate description. The SC, dexchlorpheniramine SC, and purpose was to facilitate nurse documentation heat application and obtain more uniform information about Vinorelbine 150 IU hyaluronidase SC and • Heat application not documented in extravasation. heat application three cases The incidence of extravasation of antineo• No hyaluronidase or heat applied plastic drugs injected via peripheral vein is reported to be from 0.1%–6.5% (Ener et al., DMSO—dimethyl sulfoxide; SC—subcutaneous 2004; Sauerland et al., 2006; Watanabe et al., 2008) and 0.3%–4.7% in implant venous access port infusions (Sauerland et al., 2006). In the current study, incistandard therapy for patients with breast, lung, ovarian, and dence was low, with a median of 0.05% (range = 0.02%–0.1%). other solid tumors. In early clinical studies, local tissue necroOne reason for the low incidence may be that the researchers’ sis was not reported with paclitaxel, so it was not classified incidence calculation includes central and peripheral adminisas a vesicant. However, case reports suggest that it may have tration. The use of central venous access devices (subcutanevesicant properties, regardless of concentration (Stanford & ously implanted ports or peripherally inserted central catheters) Hardwicke, 2003). Therefore, it currently is classified as a vesireduces but does not eliminate the risk of drug extravasation cant in the protocol of the researchers’ hospital. In 3 of the 16 (Ener et al., 2004). Underreported extravasation also could have patients aforementioned, a subcutaneous drug (e.g., corticoids, contributed to decreased global incidence. However, the data hyaluronidase, dexchlorpheniramine) was administered as an are similar to the data from another study (Langstein, Duman, antidote although it was not considered in the researchers’ proSeelig, Butler, & Evans, 2002) that reported an extravasation tocol. No consequences for the patients were identified. After a incidence of 0.01%. Incidence may be decreasing because of an literature review, the researchers found that hyaluronidase had increase in the use of more secure devices and an increase in been applied in some cases (Dubois, Fehr, Bochtler, & Koechli, knowledge and awareness among healthcare professionals. The 1996) and that some guidelines and reviews recommend its use researchers’ institution is a tertiary hospital with an oncology(Conde-Estévez & Mateu-de Antonio, 2012; European Society hematology outpatient clinic where nurses are well prepared to of Oncology Pharmacy, 2007). However, no recommendations manage this type of medication and specially trained to detect about corticoid use are made. In fact, glucocorticoids have an extravasation and act early. More than 80 chemotherapy been found to be ineffective in treating extravasation injuries agents are administered every day. This explains why patients (Wickham, Engelking, Sauerland, & Corbi, 2006) because the in the current study did not experience as severe consequences mechanism of action of the injury is no longer believed to be as expected. No cases of tissue necrosis were reported, and inflammation (Langstein et al., 2002). However, in at least one most symptoms were mild and reversible. Of note, several studstudy, dexamethasone was used in extravasation of vesicant ies that only included paclitaxel extravasation reported higher drugs and no cases of necrosis were described (Watanabe et al., extravasation incidence (Watanabe et al., 2008) than studies that 2008). The researchers reviewed their extravasation protocol included extravasation of several drugs. This could be related and included hyaluronidase application in taxane extravasation. to the presence in the paclitaxel formulation of an excipient In one patient, heat also was applied. Application of heat or cold (Cremophor®), which also has vesicant properties (Stanford & in taxane extravasation is not a standard recommendation, but Hardwicke, 2003) and could have contributed to worsening the it has been used in several case reports. In one case, the use of quality of the vein. warm compresses appeared to worsen the injury (Stanford & The most frequently extravasated drugs were etoposide, Hardwicke, 2003). carboplatin, and paclitaxel. They also are probably the most Most patients suffering an extravasation had altered veins. In frequently administered cytotoxic drugs. During the study addition, many of them had more than two negative characterperiod, 16 cases of paclitaxel extravasation were described, istics (e.g., thin, tough, weak, difficult approach), complicating which was 15% of the total drugs extravasated. This coincides chemotherapy administration. Consequentially, patients with with the widespread use of this agent because it is part of altered veins must be more closely monitored because they are Clinical Journal of Oncology Nursing • Volume 19, Number 2 • Extravasation Protocol Adherence in a Tertiary Setting
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Implications for Practice u
Update extravasation protocols for oncology nurses regularly.
u
Register every extravasation to determine real incidence and promote methods for reducing it.
u
Document nurse actuation in every extravasation because it is useful in improving quality of patient care and creating new evidence.
at high risk of suffering from an extravasation. Port-a-caths can be considered to reduce this problem. Of note, an extravasation occurred at a patient’s home during administration of chemotherapy. This shows the importance of taking an extravasation kit wherever chemotherapy is administered.
Limitations Owing to the current study’s retrospective design, the data collected depend on the quality of data recorded in notification forms and medical records. In addition, incidence calculation depends on the rate of notification by nursing staff. In 2003, for example, the notification rate was low and incidence may be underestimated.
Nursing Implications Continuing education is important for maintaining nursing staff with updated knowledge on how to proceed in case of extravasation. Nurses should be educated on how to prevent extravasation by selecting appropriate veins and types of devices for drug administration. In addition, the extravasation protocol has to be kept up to date to include new drugs, evidence, and recommendations. Because conducting clinical trials is not ethical, information is lacking about the best procedure in extravasation of new drugs. For this reason, case reports of these drugs are particularly useful. Adherence to the extravasation protocol at the researchers’ hospital is high, but nursing staff must be continuously trained to improve quality of patient care.
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April 2015 • Volume 19, Number 2 • Clinical Journal of Oncology Nursing
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