Nurses are ideally positioned to recognize and deal with extravasation in the clinical setting. Nurses who routinely provide IV cancer therapies, either peripherally or through central venous access devices (CVADs), are particularly important in the ongoing management of this potentially serious IV complication. Infusion nurses have a key role to play in the prevention, identification, and management of extravasation.

Extravasation is defined as the accidental administration of intravenously (IV) administered medications into the extravascular space or tissue around an infusion site. ⁶

Extravasation can be caused by:

• Accidental leakage (can be caused by brittle veins in the very elderly)
• Previous Venipuncture (Blood drawn prior to cancer therapy)
• Direct leakage (incorrectly positioned venous access devices)

In regards to cancer therapy, and specifically their highly toxic chemotherapy medications, extravasation is a serious condition that warrants serious attention from health care providers involved in the administration of IV therapy. In regards to cancer therapy, drugs can be classified by their potential to cause harm to surrounding tissue. ⁹ The three general categories of Extravasation are:

• Non-Vesicants
  • These drugs will not produce ulceration. When extravasated they rarely produce an acute reaction or necrosis. Examples include Arsenic Trioxide, Bleomycin, and Pentostatin.
• Irritants
  • These drugs tend to cause pain and irritation at and around the injection site and vein. They may cause inflammation and have the potential to produce ulceration. ⁴ Examples include Carboplatin, and Floxuridine.
• Vesicants
  • These drugs have the potential to cause blistering and ulceration. When left untreated, these drugs can cause severe tissue damage, nerve damage, and necrosis.

Vesicants can be further divided into two sub-categories: DNA Binding and Non-DNA Binding. These categories refer to the mechanism by which the drugs can cause tissue damage when extravasated. Knowing the sub-category of a specific vesicant drug can help health care providers identify the best extravasation management strategy ⁴:

• DNA Binding:
  • These drugs are absorbed locally, enter the cells, bind to the nucleic acids, and precipitate the death of the cell. These are the most serious types of vesicant drugs in that these drugs bind within the tissue and remain there.⁴ The three general DNA Binding categories are:
    • Anthracyclines (Example – Doxorubicin, Epirubicin, and Valrubicin)
    • Note: Anthracyclines are the only DNA-Binding drugs that have a clinically tested antidote – Dexrazoxane.
    • Alkylating Agents (Example – Carboplatin, Busulfan, Chlorambucil)
    • Others (Example – Mitomycin C and Dactinomycin)
• Non-DNA Binding:
  • These drugs precipitate cell death by means other than DNA binding. Although still vesicants, these drugs are less dangerous than DNA Binding vesicants, they are often inactivated or quickly metabolized once extravasated.⁶ Thus allowing the normal healing process to begin. They are grouped into two general categories:
    • Vinca Alkaloids (Example – Vinblastine and Vincristine)
    • Taxanes (Example – Paclitaxel and Docetaxel)

Extravasation can occur in both peripheral lines and CVAD (Central Venous Access Devices) and it is estimated that extravasation occurs in .5% to 6.0% of all chemotherapy infusions.¹ These numbers represent the reported numbers of extravasation, however
many cases go unreported. Therefore, the above listed numbers are likely an underestimation.¹ Many patients receiving cancer therapies may have multiple risk factors that make IV infusion difficult. For example a cancer patient may have thin, fragile, and mobile veins. Other potential risk factors that necessitate further attention are:

• Small Blood Vessels (Infants or Young Children)¹
• Fragile Veins (Elderly or Cancer Patients)
• Hard Sclerosed Veins ⁴
• Pre-existing conditions (Diabetes – decreased sensation)
• Obesity
• Patients is sedated or confused and may have difficulty reporting early symptoms
• The health care team has made multiple attempts at cannulation
• Inappropriate equipment is being used (Steel butterfly needle or wrong catheter size)⁴

The initial signs or symptoms of extravasation are:

• Discomfort or pain, which can range from mild to very intense. This is often described as a burning sensation.
• The pain may be followed, in the next few hours, by erythema and edema near the injection site.
• There may be discoloration or redness of the skin near the access site.
• The initial symptoms are subtle and similar for the extravasation of different drugs (irritants, vesicants, etc.). However, the progression from these initial symptoms differs tremendously between the different types of drugs.

Several of the above listed symptoms do not occur immediately upon infusion. Health Care providers must monitor the site before the infusion, throughout the infusion time, and after the infusion.¹ Documentation at different intervals is advised. Health care providers can also check the infusion line in order to help confirm any suspected extravasation. Potential signs of extravasation may include:

• Increased resistance when administering IV drugs
• Slow or Sluggish Infusion
• Change in Infusion Flow
• Lack or Loss of Blood Return from the Cannula

The best way to manage extravasation is by preventing it. Several best practices of prevention are:

• Ensuring that all staff involved with the preparation and administration of chemotherapy drugs are routinely trained or educated about each drug being administered.
• Placing a priority on staffing levels in order to have the necessary amount of health care providers needed for adequate monitoring. Especially during night shifts or other potentially risky settings.¹
• Regular review and training about the handling of extravasation.
  • This includes regular reviews and trainings on the Personal Protective Equipment (PPE) required for handling cytotoxic drugs. Ensuring that gloves, gowns, and face masks (when at risk of fumes) are being worn in accordance with your organizational policy.³
  • It is important to note that many chemotherapy drugs are potentially dangerous when exposed to women who are trying to conceive a child, are pregnant, or who are breastfeeding. It is advisable to move an employee to an area where the risk of potential exposure is minimized. It is the employee’s responsibility to inform their employer about their reproductive status.³
• Regular training for all staff involved with vein selection.
• Patient education about the risks of extravasation and the early symptoms. It is the duty of the health care provider to create an environment where the patient feels comfortable bringing forward any and all potential issues.⁴

Should extravasation occur, refer to your organizations polices towards documentation, appropriate process to follow, and re-establishment of the IV site. Best practices normally involve:

• Immediate cessation of the drug delivery. The Vesicant and all IV fluids are immediately stopped.
• IV tubing is disconnected from the IV device. The IV device is not removed from the patient.³
• Residual vesicant is aspirated using a small syringe (1-3cc).
• The peripheral IV device or port needle is then removed.
• The site is then assessed for extravasation. All indicators are documented.
• The site is marked and documented. Photos may be taken. (Depends on organizational policy)
• The patient’s symptoms are assessed and documented.
• The necessary health care provider is then notified.
• The appropriate management measure is then implemented.
• Many hospitals across the United States have placed Extravasation kits near an area where infusions may take place.³ These kits typically contain appropriate antidotes, instant cold pack, instant hot pack, 2 mL syringes, 25 G needles, skin disinfectant, indelible pen for marking affected area, documentation forms, copy of extravasation management procedure, and patient handouts or information.

Each incident of extravasation must be thoroughly documented and reported. This will help provide an accurate account of what happened (in the event of litigation). This helps to protect health care providers (showing that they followed procedure). Proper documentation can also help gather information for future potential quality improvements.

1.Al-Benna, S. O’Boyle, C., and Holley. Extravasation in Adult Patients. ISRN
Dermatology. 2013. Doi:10.115/2013/856541 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3664495/#B6

2.Arsenic Trioxide. American Cancer Society. 2013.
http://www.cancer.org/treatment/treatmentsandsideeffects/guidetocancerdrugs/arsenic-
trioxide

3.Clinical – Chemotherapy and Biotherapy Extravasation. Oncology Nursing Society:
Pittsburgh, PA. 2013. http://www.ons.org/about/FAQ/Clinical

4.Extravasation Guidelines-Clinical Guidelines. 2007. European Oncology Nurses Society.
http://www.cancernurse.eu/documents/EONSClinicalGuidelinesSection6-en.pdf#search=%27extravasation%27

5.Improving The Safety of Ambulatory Intravenous Chemotherapy in Canada. 2011.
Canadian Association of Provincial Cancer Agencies. http://www.capca.ca/wp-content/uploads/IV-Ambulatory-Study-Final-Report-ENGLISH-Jan-14-2011_small.pdf

6.Kumar RJ, Pegg SP, Kimble RM. Management of extravasation injuries. ANZ Journal of Surgery. 2001;71(5):285–289

7.Mary Gullatte, PhD, RN. Chemotherapy Safety Standards. American Society of Clinical Oncology/Oncology Nursing Society. Oncology Nursing Society, Pittsburgh, PA. http://www.asco.org/sites/www.asco.org/files/asco-ons_safety_standards-_gullatte.pdf

8. Polovich, M., Whitford, J.M., & Olsen, M. (Eds.). (2009). Chemotherapy and biotherapy guidelines and recommendations for practice. Oncology Nursing Society: Pittsburgh, PA.

9.The MASCC Textbook of Cancer Supportive Care and Survivorship. 2011. Ian N. Olver MD PhD. New York, NY. Multinational Association for Supportive Care in Cancer Society. Pg. 350-353. Doi: 10.1007/978-1-4419-1225-1

10.Woscan Cancer Nursing and Pharmacy Group. 2009. West of Scotland Cancer Advisory Network Clinical Leads Group. Chemotherapy Extravasation Guidelines. http://www.beatson.scot.nhs.uk/content/mediaassets/doc/Extravasation%20guidance.pdf