Antineoplastic extravasation refers to the accidental leakage of chemotherapy drugs from a blood vessel into the surrounding tissues during intravenous administration. These highly potent medications can cause significant local tissue injury, ranging from pain and swelling to severe blistering, tissue death (necrosis), and even permanent functional impairment or disfigurement.
Understanding Antineoplastic Extravasation
Extravasation specifically describes the involuntary leakage of a drug or solution from a vein into the adjacent healthy tissue. Antineoplastic drugs are particularly damaging when extravasated due to their inherent properties. These medications are categorized by their potential for tissue damage: vesicants, irritants, and non-vesicants.
Vesicants cause severe blistering, necrosis, and tissue sloughing upon extravasation. Irritants, while less damaging than vesicants, cause localized pain, inflammation, and discomfort without tissue necrosis. Non-vesicants do not cause tissue damage. The mechanism of damage involves direct cellular toxicity, where the drug kills cells, or vasoconstriction, which reduces blood flow and oxygen to the area, contributing to tissue death.
Pre-Infusion Preparations for Prevention
Preventing antineoplastic extravasation begins with comprehensive patient assessment and meticulous site selection. This includes reviewing the patient’s medical history for factors like compromised circulation, fragile veins, or previous extravasation incidents. Nurses carefully assess potential intravenous (IV) sites, avoiding areas near joints, tendons, nerves, or previously irradiated areas, as these locations are more susceptible to damage.
Assess vein integrity and patency by observing for fragility, scarring, or phlebitis, and by ensuring a clear blood return from the chosen vein. For vesicant drugs, administering them via a central venous catheter (CVC) is recommended, especially for continuous infusions, as CVCs reduce the risk of extravasation compared to peripheral intravenous access. If peripheral access is necessary, the most distal site on the dorsum of the hand or forearm is preferred, avoiding the antecubital fossa due to its density of tendons and nerves. Patient education is also important, informing them about signs of extravasation (e.g., pain, burning, swelling) and instructing them to report any discomfort immediately.
Safe Administration and Vigilant Monitoring
During the antineoplastic infusion, proper administration techniques and continuous monitoring are important to preventing extravasation. When administering vesicant drugs peripherally, a slow push method or gravity infusion is preferred over infusion pumps, as pumps may continue to deliver the drug into the tissue after extravasation. The smallest appropriate gauge needle should be used for peripheral access to minimize vein trauma.
Continuous monitoring of the infusion site throughout the administration, observing for changes such as swelling, redness, pain, coolness, or a lack of blood return. Before and after drug administration, the IV line should be flushed with saline to confirm patency and clear any residual medication from the catheter. The IV site should be secured firmly, allowing direct and unobstructed visualization of the insertion area, enabling immediate detection of any signs of extravasation.
Immediate Response to Minimize Tissue Damage
If extravasation is suspected or observed, immediate action is required to minimize further tissue damage. Stop the infusion immediately and avoid applying pressure to the site. It is often recommended to leave the needle or catheter in place to aspirate any residual drug, which can help remove some extravasated medication.
Following aspiration, if an antidote is available, administer it through the existing IV line or subcutaneously around the site. Local treatments, such as warm or cold compresses, are used based on the specific drug. Some vesicants benefit from cold application to induce vasoconstriction and limit drug dispersion, while others benefit from warm compresses to promote vasodilation and drug dispersion. Elevate the affected limb for 24-48 hours to reduce edema and promote drainage. Document the event, including photographs, affected area delineation, and interventions taken, for monitoring and care.