Difference between revisions of "Vesicant & irritant chemotherapy"
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− | == | + | ==Chemotherapy vesicant & irritant properties and suggested management for extravasation== |
− | + | '''Always stop infusion of the causative medication first and, if appropriate, elevate the affected extremity.''' The venous access should not be removed immediately, since it can be used to attempt aspirating extravasated fluid and for administration of an antidote, if clinically appropriate. If an antidote is not going to be used, the venous access can be removed after aspiration of the extravasated fluid has been attempted. In general--aside from the exceptions listed below--keeping the extravasation cold is preferable to cause vasoconstriction, to prevent spread of the medication, and to decrease inflammation/pain. Some medications are more likely to have vesicant properties in high concentrations or large volumes. | |
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− | Some medications have vesicant properties in | ||
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− | + | The following information is a compilation from the various resources listed below<ref>[http://www.uptodate.com/contents/chemotherapy-extravasation-injury Chemotherapy extravasation injury (UpToDate)]</ref><ref>Beth Israel Deaconess Medical Center. ''Administration and Extravasation Management of Vesicant Chemotherapy Agents.'' 11/2010 revision.</ref><ref>Polovich M, Whitford JM, Olsen M. Chemotherapy and biotherapy guidelines and recommendations for practice, 3rd ed, Oncology Nursing Society, Pittsburgh, PA, 2009. Section V: Immediate Complications of cytotoxic therapy, p.105.</ref><ref>[http://www.ons.org/about/FAQ/Clinical/#extravasation ONS (Oncology Nursing Society) chemotherapy extravasation FAQs]</ref><ref>Wengström Y, Margulies A; European Oncology Nursing Society Task Force. European Oncology Nursing Society extravasation guidelines. Eur J Oncol Nurs. 2008 Sep;12(4):357-61. [http://www.ejoncologynursing.com/article/S1462-3889%2808%2900100-2/fulltext link to original article] [http://www.ncbi.nlm.nih.gov/pubmed/18765210 PubMed]</ref>. | |
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− | + | {| class="wikitable sortable" border="1" style="text-align:left;" | |
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− | {| border="1" | ||
!Drug | !Drug | ||
!Vesicant or Irritant | !Vesicant or Irritant | ||
!Apply Heat or Cold | !Apply Heat or Cold | ||
− | ! | + | !Additional treatment/antidote |
− | + | |- | |
+ | |[[Amsacrine (Amsidine)]] | ||
+ | |Vesicant | ||
+ | |Cold - 15-20 minutes at a time for at least four times per day for 24 hours | ||
+ | |None known | ||
|- | |- | ||
− | |Arsenic | + | |[[Arsenic trioxide (Trisenox)]] |
|Irritant | |Irritant | ||
− | |Cold | + | |Cold - 15-20 minutes at a time for at least four times per day for 24 hours |
− | |None | + | |None known |
− | |||
|- | |- | ||
− | |Bleomycin | + | |[[Bleomycin (Blenoxane)]] |
|Irritant | |Irritant | ||
− | |Cold | + | |Cold - 15-20 minutes at a time for at least four times per day for 24 hours |
− | |None | + | |None known |
− | |||
|- | |- | ||
− | |Bortezomib | + | |[[Bortezomib (Velcade)]] |
|Irritant | |Irritant | ||
− | |Cold | + | |Cold - 15-20 minutes at a time for at least four times per day for 24 hours |
− | |None | + | |None known |
− | |||
|- | |- | ||
− | |Busulfan | + | |[[Busulfan (Myleran)]] |
|Irritant | |Irritant | ||
− | |Cold | + | |Cold - 15-20 minutes at a time for at least four times per day for 24 hours |
− | |None | + | |None known |
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|- | |- | ||
− | | | + | |[[Carboplatin (Paraplatin)]] |
− | + | |Irritant | |
− | + | |Cold - Every 8 hours for 3 days; if using sodium thiosulfate, apply cold pack for 6-12 hours after administration of sodium thiosulfate | |
− | |Sodium Thiosulfate | + | |'''Sodium Thiosulfate''': Mix 4 mL of 10% sodium thiosulfate with 6 mL sterile water (yields 10mL of 1/6 molar sodium thiosulfate). Inject 5 mL subcutaneously using a 25 gauge needle, changing needles between each injection, into affected area in a pinwheel fashion.<br>'''OR DMSO (Dimethylsulfoxide) 99%''': 4 drops per 10 square centimeters of skin surface applied topically over area twice the size affected every 8 hours for 7 days. Allow to air dry. |
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|- | |- | ||
− | | | + | |[[Carmustine (BiCNU)]] |
− | | | + | |Vesicant/Irritant (depending on reference) |
+ | |Cold - 15-20 minutes at a time for at least four times per day for 24 hours | ||
+ | |Manage conservatively as first line option with supportive non-pharmacologic strategies. Hyaluronidase may be used in extreme scenarios such as large volume extravasation or severe irritation.<br>'''Hyaluronidase''': Inject a total of 1 mL (200 units) divided into 5-10 subcutaneous injections of 0.1-0.2 mL in a pinwheel fashion using a 25 gauge needle, changing needles between each injection, into affected area. May use up to 250 units if symptoms persist. | ||
|- | |- | ||
− | | | + | |[[Cisplatin (Platinol)]] |
− | | | + | |Vesicant (in concentrations =>0.5 mg/mL)<br>Irritant (in concentrations <0.5 mg/mL) |
− | + | |Cold - Every 8 hours for 3 days; if using sodium thiosulfate, apply cold pack for 6-12 hours after administration of sodium thiosulfate | |
− | | | + | |'''Sodium Thiosulfate''': Mix 4 mL of 10% sodium thiosulfate with 6 mL sterile water (yields 10mL of 1/6 molar sodium thiosulfate). Inject 5 mL subcutaneously using a 25 gauge needle, changing needles between each injection, into affected area in a pinwheel fashion.<br>'''OR DMSO (Dimethylsulfoxide) 99%''': 4 drops per 10 square centimeters of skin surface applied topically over area twice the size affected every 8 hours for 7 days. Allow to air dry. |
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|- | |- | ||
− | | | + | |[[Cladribine (Leustatin)]] |
− | | | + | |Irritant |
+ | |Cold - 15-20 minutes at a time for at least four times per day for 24 hours | ||
+ | |None known | ||
|- | |- | ||
− | + | |[[Cytarabine liposomal (DepoCyt)]] | |
− | + | |Irritant | |
− | + | |Cold - 15-20 minutes at a time for at least four times per day for 24 hours | |
− | + | |None known | |
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− | | | ||
|- | |- | ||
− | | | + | |[[Dacarbazine (DTIC)]] |
|Irritant | |Irritant | ||
− | |Cold | + | |Cold - If using sodium thiosulfate, apply cold pack for 6-12 hours after administration of sodium thiosulfate |
− | + | |Manage conservatively; shield exposed tissues from light.<br>'''OR Sodium Thiosulfate''': Mix 4 mL of 10% sodium thiosulfate with 6 mL sterile water (yields 10 mL of 1/6 molar sodium thiosulfate). Inject 5 mL subcutaneously using a 25 gauge needle, changing needles between each injection, into affected area in a pinwheel fashion. '''NOTE:''' Sodium thiosulfate is recommended only when '''concentrated dacarbazine''' is extravasated. There are no clinical reports of the use of sodium thiosulfate following dacarbazine extravasation. Its use for dacarbazine extravasation is based on evidence that it has worked as an antidote for dacarbazine-induced skin toxicity. | |
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− | |Manage conservatively | ||
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|- | |- | ||
− | |Dactinomycin | + | |[[Dactinomycin (Cosmegen)]] |
|Vesicant | |Vesicant | ||
− | |Cold | + | |Cold - 15-20 minutes at a time for at least four times per day for 24 hours |
− | |None | + | |None known |
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|- | |- | ||
− | |Daunorubicin | + | |[[Daunorubicin (Cerubidine)]] |
|Vesicant | |Vesicant | ||
− | |Cold | + | |Cold (different suggestions depending on reference): |
− | |Dexrazoxane | + | *Apply cold pack initially for 30-60 minutes, then repeat every 15 minutes on day 1 only. Remove cold pack at least 15 minutes before dexrazoxane therapy. |
− | + | *Apply cold pack intermittently for 15 minutes at a time, four times per day for 3 days | |
− | *Day one: 1000 mg/m² | + | |'''[[Dexrazoxane (Zinecard)]]''': Dexrazoxane should be administered over 1-2 hours IV at the recommended doses below, daily for 3 consecutive days. Site of administration should be in a large vein away from the extravasation. The first infusion should be initiated as soon as possible and within the first six hours after extravasation. |
− | *Day two: 1000 mg/m² | + | *Day one: 1000 mg/m² |
− | *Day three: 500 mg/m² | + | *Day two: 1000 mg/m² |
− | If cooling techniques are being used, withhold cooling 15 minutes before and after the infusion. Infuse in an extremity or area other than the one affected by | + | *Day three: 500 mg/m² |
+ | If cooling techniques are being used, withhold cooling 15 minutes before and after the infusion. Infuse in an extremity or area other than the one affected by extravasation. Reduce dose by 50% for patients with creatinine clearance <40 mL/min. | ||
|- | |- | ||
− | | | + | |[[Daunorubicin liposomal (DaunoXome)]] |
|Irritant | |Irritant | ||
− | |Cold | + | |Cold - 15-20 minutes at a time for at least four times per day for 24 hours |
− | | | + | |No additional treatment, e.g. [[Dexrazoxane (Zinecard)]], is recommended. |
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|- | |- | ||
− | | | + | |[[Docetaxel (Taxotere)]] |
− | |Vesicant | + | |Irritant (usually)<br>Vesicant (rare) |
− | |Cold | + | |Cold (different suggestions depending on reference): |
− | + | *Apply cold pack 15-20 minutes at a time for at least four times per day for 24 hours | |
− | + | *Apply ice to the area for 15-20 minutes each hour for 4 hours. Caution: excessive cold can cause tissue damage. | |
− | + | |'''Hyaluronidase''': Inject a total of 1 mL (200 units) divided into 5-10 subcutaneous injections of 0.1-0.2 mL in a pinwheel fashion using a 25 gauge needle, changing needles between each injection, into affected area. May use up to 250 units if symptoms persist. | |
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|- | |- | ||
− | | | + | |[[Doxorubicin (Adriamycin)]] |
|Vesicant | |Vesicant | ||
− | |Cold | + | |Cold (different suggestions depending on reference): |
− | |Dexrazoxane | + | *Apply cold pack initially for 30-60 minutes, then repeat every 15 minutes on day 1 only. Remove cold pack at least 15 minutes before dexrazoxane therapy. |
− | + | *Apply cold pack intermittently for 15 minutes at a time, four times per day for 3 days | |
− | *Day one: 1000 mg/m² | + | |'''[[Dexrazoxane (Zinecard)]]''': Dexrazoxane should be administered over 1-2 hours IV at the recommended doses below, daily for 3 consecutive days. Site of administration should be in a large vein away from the extravasation. The first infusion should be initiated as soon as possible and within the first six hours after extravasation. |
− | *Day two: 1000 mg/m² | + | *Day one: 1000 mg/m² |
− | *Day three: 500 mg/m² | + | *Day two: 1000 mg/m² |
− | If cooling techniques are being used, withhold cooling 15 minutes before and after the infusion. Infuse in an extremity or area other than the one affected by | + | *Day three: 500 mg/m² |
− | + | If cooling techniques are being used, withhold cooling 15 minutes before and after the infusion. Infuse in an extremity or area other than the one affected by extravasation. Reduce dose by 50% for patients with creatinine clearance <40 mL/min. | |
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|- | |- | ||
− | | | + | |[[Doxorubicin liposomal (Doxil)]] |
|Irritant | |Irritant | ||
− | |Cold | + | |Cold - 15-20 minutes at a time for at least four times per day for 24 hours |
− | | | + | |No additional treatment, e.g. [[Dexrazoxane (Zinecard)]], is recommended. |
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|- | |- | ||
− | | | + | |[[Epirubicin (Ellence)]] |
|Vesicant | |Vesicant | ||
− | |Cold | + | |Cold (different suggestions depending on reference): |
− | |Dexrazoxane | + | *Apply cold pack initially for 30-60 minutes, then repeat every 15 minutes on day 1 only. Remove cold pack at least 15 minutes before dexrazoxane therapy. |
− | + | *Apply cold pack intermittently for 15 minutes at a time, four times per day for 3 days | |
− | *Day one: 1000 mg/m² | + | |'''[[Dexrazoxane (Zinecard)]]''': Dexrazoxane should be administered over 1-2 hours IV at the recommended doses below, daily for 3 consecutive days. Site of administration should be in a large vein away from the extravasation. The first infusion should be initiated as soon as possible and within the first six hours after extravasation. |
− | *Day two: 1000 mg/m² | + | *Day one: 1000 mg/m² |
− | *Day three: 500 mg/m² | + | *Day two: 1000 mg/m² |
− | If cooling techniques are being used, withhold cooling 15 minutes before and after the infusion. Infuse in an extremity or area other than the one affected by | + | *Day three: 500 mg/m² |
+ | If cooling techniques are being used, withhold cooling 15 minutes before and after the infusion. Infuse in an extremity or area other than the one affected by extravasation. Reduce dose by 50% for patients with creatinine clearance <40 mL/min. | ||
|- | |- | ||
− | | | + | |[[Etoposide (Vepesid)]] |
|Irritant | |Irritant | ||
− | | | + | |Heat (different suggestions depending on reference): |
− | | | + | *15-20 minutes at a time for at least four times per day for 24-48 hours |
− | + | *warm compresses for 30-60 minutes, then alternate off/on every 15 minutes for 1 day | |
+ | |'''Hyaluronidase''': Inject a total of 1 mL (200 units) divided into 5-10 subcutaneous injections of 0.1-0.2 mL in a pinwheel fashion using a 25 gauge needle, changing needles between each injection, into affected area. May use up to 250 units if symptoms persist. | ||
|- | |- | ||
− | | | + | |[[Fluorouracil (5-FU)]] |
|Irritant | |Irritant | ||
− | |Cold | + | |Cold - 15-20 minutes at a time for at least four times per day for 24 hours |
− | |None | + | |None known |
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|- | |- | ||
− | | | + | |[[Gemcitabine (Gemzar)]] |
|Irritant | |Irritant | ||
− | |Cold | + | |Cold - 15-20 minutes at a time for at least four times per day for 24 hours |
− | |None | + | |None known |
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|- | |- | ||
− | | | + | |[[Idarubicin (Idamycin)]] |
− | | | + | |Vesicant |
− | |Cold | + | |Cold (different suggestions depending on reference): |
− | | | + | *Apply cold pack initially for 30-60 minutes, then repeat every 15 minutes on day 1 only. Remove cold pack at least 15 minutes before dexrazoxane therapy. |
− | + | *Apply cold pack intermittently for 15 minutes at a time, four times per day for 3 days | |
+ | |'''[[Dexrazoxane (Zinecard)]]''': Dexrazoxane should be administered over 1-2 hours IV at the recommended doses below, daily for 3 consecutive days. Site of administration should be in a large vein away from the extravasation. The first infusion should be initiated as soon as possible and within the first six hours after extravasation. | ||
+ | *Day one: 1000 mg/m² | ||
+ | *Day two: 1000 mg/m² | ||
+ | *Day three: 500 mg/m² | ||
+ | If cooling techniques are being used, withhold cooling 15 minutes before and after the infusion. Infuse in an extremity or area other than the one affected by extravasation. Reduce dose by 50% for patients with creatinine clearance <40 mL/min. | ||
|- | |- | ||
− | | | + | |[[Ifosfamide (Ifex)]] |
|Irritant | |Irritant | ||
− | |Cold | + | |Cold (different suggestions depending on reference): |
− | + | *60 minutes every 8 hours for 3 days | |
− | | | + | *15-20 minutes at a time for at least four times per day for 24 hours |
+ | |'''DMSO (Dimethylsulfoxide) 99%''': 4 drops per 10 square centimeters of skin surface applied topically over area twice the size affected every 8 hours for 7 days. Allow to air dry. | ||
|- | |- | ||
− | | | + | |[[Irinotecan (Camptosar)]] |
|Irritant | |Irritant | ||
− | |Cold | + | |Cold - 15-20 minutes at a time for at least four times per day for 24 hours |
− | |None | + | |None known |
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|- | |- | ||
− | |Mechlorethamine | + | |[[Mechlorethamine (Mustargen)]] |
|Vesicant | |Vesicant | ||
− | |Cold | + | |Cold - for 6-12 hours after administration of sodium thiosulfate |
− | |Sodium Thiosulfate | + | |'''Sodium Thiosulfate''': Mix 4 mL of 10% sodium thiosulfate with 6 mL sterile water (yields 10mL of 1/6 molar sodium thiosulfate). Administration varies depending on reference: |
− | + | *Inject 5 mL subcutaneously using a 25 gauge needle, changing needles between each injection, into affected area in a pinwheel fashion. | |
+ | *For every 1 mg of mechlorethamine suspected to have extravasated, inject 2 mL of the 1/6 molar sodium thiosulfate solution subcutaneously into the extravasation site using a 25 gauge or smaller needle. | ||
|- | |- | ||
− | |Melphalan | + | |[[Melphalan (Alkeran)]] |
|Irritant | |Irritant | ||
− | |Cold | + | |Cold - 15-20 minutes at a time for at least four times per day for 24 hours |
− | |None | + | |None known |
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|- | |- | ||
− | |Mitomycin | + | |[[Mitomycin (Mutamycin)]] |
|Vesicant | |Vesicant | ||
− | |Cold | + | |Cold - 15-20 minutes at a time for at least four times per day for 24 hours |
− | |Sodium Thiosulfate | + | |'''Sodium Thiosulfate''': Mix 4 mL of 10% sodium thiosulfate with 6 mL sterile water (yields 10mL of 1/6 molar sodium thiosulfate). Inject 5 mL subcutaneously using a 25 gauge needle, changing needles between each injection, into affected area in a pinwheel fashion. |
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|- | |- | ||
− | |Mitoxantrone | + | |[[Mitoxantrone (Novantrone)]] |
− | |Irritant | + | |Irritant (usually)<br>Vesicant (rare) |
|Cold - Apply cold packs for 15-20 minutes 4 times per day for 1-2 days. | |Cold - Apply cold packs for 15-20 minutes 4 times per day for 1-2 days. | ||
− | |None | + | |None known |
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|- | |- | ||
− | |Oxaliplatin | + | |[[Oxaliplatin (Eloxatin)]] |
− | |Vesicant | + | |Irritant (usually)<br>Vesicant (rare) |
|Heat - Apply warm compresses to extravasation site for 1 hour. Caution: excessive heat can cause tissue damage. | |Heat - Apply warm compresses to extravasation site for 1 hour. Caution: excessive heat can cause tissue damage. | ||
− | |Sodium Thiosulfate | + | |'''Sodium Thiosulfate''': Mix 4 mL of 10% sodium thiosulfate with 6 mL sterile water (yields 10mL of 1/6 molar sodium thiosulfate). Inject 5 mL subcutaneously using a 25 gauge needle, changing needles between each injection, into affected area in a pinwheel fashion.<br>'''Corticosteroids''': For large extravasations, dexamethasone 8 mg PO BID for up to 14 days is recommended to help mitigate the local inflammatory reaction. |
− | + | |- | |
+ | |[[Paclitaxel (Taxol)]] | ||
+ | |Irritant (usually)<br>Vesicant (rare) | ||
+ | |'''Cold generally recommended''' (different suggestions depending on reference): | ||
+ | *Apply cold pack 15-20 minutes at a time for at least four times per day for 24 hours | ||
+ | *Apply ice to the area for 15-20 minutes each hour for 4 hours. Caution: excessive cold can cause tissue damage. | ||
+ | '''Controversial use of heat''': EONS (European Oncology Nurses Society) suggests application of heat to encourage circulation and to dilute & diffuse the chemotherapy. | ||
+ | |'''Hyaluronidase''': Inject a total of 1 mL (200 units) divided into 5-10 subcutaneous injections of 0.1-0.2 mL in a pinwheel fashion using a 25 gauge needle, changing needles between each injection, into affected area. May use up to 250 units if symptoms persist. | ||
|- | |- | ||
− | |Paclitaxel | + | |[[Paclitaxel, nanoparticle albumin-bound (Abraxane)]] |
|Irritant | |Irritant | ||
− | |Cold - Apply ice to the area for 15-20 minutes each hour for 4 hours. Caution: excessive cold can cause tissue damage. | + | |Cold (different suggestions depending on reference): |
− | | | + | *Apply cold pack 15-20 minutes at a time for at least four times per day for 24 hours |
− | | | + | *Apply ice to the area for 15-20 minutes each hour for 4 hours. Caution: excessive cold can cause tissue damage. |
+ | |None known | ||
+ | |- | ||
+ | |[[Plicamycin (Mithracin)]] | ||
+ | |Vesicant/Irritant (depending on reference) | ||
+ | |Cold - 15-20 minutes at a time for at least four times per day for 24 hours | ||
+ | |None known | ||
+ | |- | ||
+ | |[[Streptozocin (Zanosar)]] | ||
+ | |Vesicant | ||
+ | |Cold - 15-20 minutes at a time for at least four times per day for 24 hours | ||
+ | |None known | ||
|- | |- | ||
− | | | + | |[[Teniposide (Vumon)]] |
|Irritant | |Irritant | ||
− | |Cold | + | |Cold - 15-20 minutes at a time for at least four times per day for 24 hours |
− | | | + | |'''Hyaluronidase''': Inject a total of 1 mL (200 units) divided into 5-10 subcutaneous injections of 0.1-0.2 mL in a pinwheel fashion using a 25 gauge needle, changing needles between each injection, into affected area. May use up to 250 units if symptoms persist. |
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|- | |- | ||
− | | | + | |[[Thiotepa (Thioplex)]] |
|Irritant | |Irritant | ||
− | |Cold | + | |Cold - 15-20 minutes at a time for at least four times per day for 24 hours |
− | |None | + | |None known |
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|- | |- | ||
− | | | + | |[[Topotecan (Hycamtin)]] |
|Irritant | |Irritant | ||
− | |Cold | + | |Cold - 15-20 minutes at a time for at least four times per day for 24 hours |
− | + | |None known | |
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|- | |- | ||
− | | | + | |[[Trabectedin (Yondelis)]] |
− | | | + | |Vesicant |
− | |Cold | + | |Cold - 15-20 minutes at a time for at least four times per day for 24 hours |
− | |None | + | |None known |
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|- | |- | ||
− | | | + | |[[Vinblastine (Velban)]] |
− | | | + | |Vesicant |
− | | | + | |Heat - 15-20 minutes at a time for at least four times per day for 24-48 hours |
− | | | + | |'''Hyaluronidase''': Inject a total of 1 mL (200 units) divided into 5-10 subcutaneous injections of 0.1-0.2 mL in a pinwheel fashion using a 25 gauge needle, changing needles between each injection, into affected area. May use up to 250 units if symptoms persist. |
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|- | |- | ||
− | | | + | |[[Vincristine (Oncovin)]] |
|Vesicant | |Vesicant | ||
− | |Heat | + | |Heat - 15-20 minutes at a time for at least four times per day for 24-48 hours |
− | |Hyaluronidase | + | |'''Hyaluronidase''': Inject a total of 1 mL (200 units) divided into 5-10 subcutaneous injections of 0.1-0.2 mL in a pinwheel fashion using a 25 gauge needle, changing needles between each injection, into affected area. May use up to 250 units if symptoms persist. |
− | |Inject a total of 1 mL (200 units) divided into 5-10 subcutaneous injections of 0.1-0.2 mL in a pinwheel fashion using a 25 gauge needle, changing needles between each injection, into affected area up to 250 units | + | |- |
+ | |[[Vincristine liposomal (Marqibo)]] | ||
+ | |Irritant | ||
+ | |Heat - 15-20 minutes at a time for at least four times per day for 24-48 hours | ||
+ | |No formal recommendation, but depending on clinical condition could consider extrapolating from management of other vinca alkaloids: '''Hyaluronidase''': Inject a total of 1 mL (200 units) divided into 5-10 subcutaneous injections of 0.1-0.2 mL in a pinwheel fashion using a 25 gauge needle, changing needles between each injection, into affected area. May use up to 250 units if symptoms persist. | ||
|- | |- | ||
− | | | + | |[[Vindesine (Eldisine)]] |
|Vesicant | |Vesicant | ||
− | |Heat | + | |Heat - 15-20 minutes at a time for at least four times per day for 24-48 hours |
− | |Hyaluronidase | + | |'''Hyaluronidase''': Inject a total of 1 mL (200 units) divided into 5-10 subcutaneous injections of 0.1-0.2 mL in a pinwheel fashion using a 25 gauge needle, changing needles between each injection, into affected area. May use up to 250 units if symptoms persist. |
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|- | |- | ||
− | |Vinorelbine | + | |[[Vinorelbine (Navelbine)]] |
|Vesicant | |Vesicant | ||
− | |Heat | + | |Heat - 15-20 minutes at a time for at least four times per day for 24-48 hours |
− | |Hyaluronidase | + | |'''Hyaluronidase''': Inject a total of 1 mL (200 units) divided into 5-10 subcutaneous injections of 0.1-0.2 mL in a pinwheel fashion using a 25 gauge needle, changing needles between each injection, into affected area. May use up to 250 units if symptoms persist. |
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|- | |- | ||
|} | |} | ||
+ | |||
+ | ==Definitions== | ||
+ | *Extravasation: Leakage of a medication into tissue or extravascular space around the infusion site. May be due to direct leakage from the venous access device or from elsewhere in the vessel (such as from previous phlebotomy). | ||
+ | *Flare reaction: A skin reaction to a medication which is an allergic response. | ||
+ | *Vesicant: Medication that may causes severe and/or irreversible tissue injury and necrosis. | ||
+ | *Irritant: Medication that can cause local inflammatory reactions at the infusion site, which may include: burning, swelling, pain, inflammation, tightness, or phlebitis. Clinical exam may reveal warmth, erythema, or tenderness. | ||
==Reference== | ==Reference== | ||
− | + | <references/> |
Revision as of 21:01, 21 February 2012
Chemotherapy vesicant & irritant properties and suggested management for extravasation
Always stop infusion of the causative medication first and, if appropriate, elevate the affected extremity. The venous access should not be removed immediately, since it can be used to attempt aspirating extravasated fluid and for administration of an antidote, if clinically appropriate. If an antidote is not going to be used, the venous access can be removed after aspiration of the extravasated fluid has been attempted. In general--aside from the exceptions listed below--keeping the extravasation cold is preferable to cause vasoconstriction, to prevent spread of the medication, and to decrease inflammation/pain. Some medications are more likely to have vesicant properties in high concentrations or large volumes.
The following information is a compilation from the various resources listed below[1][2][3][4][5].
Drug | Vesicant or Irritant | Apply Heat or Cold | Additional treatment/antidote |
---|---|---|---|
Amsacrine (Amsidine) | Vesicant | Cold - 15-20 minutes at a time for at least four times per day for 24 hours | None known |
Arsenic trioxide (Trisenox) | Irritant | Cold - 15-20 minutes at a time for at least four times per day for 24 hours | None known |
Bleomycin (Blenoxane) | Irritant | Cold - 15-20 minutes at a time for at least four times per day for 24 hours | None known |
Bortezomib (Velcade) | Irritant | Cold - 15-20 minutes at a time for at least four times per day for 24 hours | None known |
Busulfan (Myleran) | Irritant | Cold - 15-20 minutes at a time for at least four times per day for 24 hours | None known |
Carboplatin (Paraplatin) | Irritant | Cold - Every 8 hours for 3 days; if using sodium thiosulfate, apply cold pack for 6-12 hours after administration of sodium thiosulfate | Sodium Thiosulfate: Mix 4 mL of 10% sodium thiosulfate with 6 mL sterile water (yields 10mL of 1/6 molar sodium thiosulfate). Inject 5 mL subcutaneously using a 25 gauge needle, changing needles between each injection, into affected area in a pinwheel fashion. OR DMSO (Dimethylsulfoxide) 99%: 4 drops per 10 square centimeters of skin surface applied topically over area twice the size affected every 8 hours for 7 days. Allow to air dry. |
Carmustine (BiCNU) | Vesicant/Irritant (depending on reference) | Cold - 15-20 minutes at a time for at least four times per day for 24 hours | Manage conservatively as first line option with supportive non-pharmacologic strategies. Hyaluronidase may be used in extreme scenarios such as large volume extravasation or severe irritation. Hyaluronidase: Inject a total of 1 mL (200 units) divided into 5-10 subcutaneous injections of 0.1-0.2 mL in a pinwheel fashion using a 25 gauge needle, changing needles between each injection, into affected area. May use up to 250 units if symptoms persist. |
Cisplatin (Platinol) | Vesicant (in concentrations =>0.5 mg/mL) Irritant (in concentrations <0.5 mg/mL) |
Cold - Every 8 hours for 3 days; if using sodium thiosulfate, apply cold pack for 6-12 hours after administration of sodium thiosulfate | Sodium Thiosulfate: Mix 4 mL of 10% sodium thiosulfate with 6 mL sterile water (yields 10mL of 1/6 molar sodium thiosulfate). Inject 5 mL subcutaneously using a 25 gauge needle, changing needles between each injection, into affected area in a pinwheel fashion. OR DMSO (Dimethylsulfoxide) 99%: 4 drops per 10 square centimeters of skin surface applied topically over area twice the size affected every 8 hours for 7 days. Allow to air dry. |
Cladribine (Leustatin) | Irritant | Cold - 15-20 minutes at a time for at least four times per day for 24 hours | None known |
Cytarabine liposomal (DepoCyt) | Irritant | Cold - 15-20 minutes at a time for at least four times per day for 24 hours | None known |
Dacarbazine (DTIC) | Irritant | Cold - If using sodium thiosulfate, apply cold pack for 6-12 hours after administration of sodium thiosulfate | Manage conservatively; shield exposed tissues from light. OR Sodium Thiosulfate: Mix 4 mL of 10% sodium thiosulfate with 6 mL sterile water (yields 10 mL of 1/6 molar sodium thiosulfate). Inject 5 mL subcutaneously using a 25 gauge needle, changing needles between each injection, into affected area in a pinwheel fashion. NOTE: Sodium thiosulfate is recommended only when concentrated dacarbazine is extravasated. There are no clinical reports of the use of sodium thiosulfate following dacarbazine extravasation. Its use for dacarbazine extravasation is based on evidence that it has worked as an antidote for dacarbazine-induced skin toxicity. |
Dactinomycin (Cosmegen) | Vesicant | Cold - 15-20 minutes at a time for at least four times per day for 24 hours | None known |
Daunorubicin (Cerubidine) | Vesicant | Cold (different suggestions depending on reference):
|
Dexrazoxane (Zinecard): Dexrazoxane should be administered over 1-2 hours IV at the recommended doses below, daily for 3 consecutive days. Site of administration should be in a large vein away from the extravasation. The first infusion should be initiated as soon as possible and within the first six hours after extravasation.
If cooling techniques are being used, withhold cooling 15 minutes before and after the infusion. Infuse in an extremity or area other than the one affected by extravasation. Reduce dose by 50% for patients with creatinine clearance <40 mL/min. |
Daunorubicin liposomal (DaunoXome) | Irritant | Cold - 15-20 minutes at a time for at least four times per day for 24 hours | No additional treatment, e.g. Dexrazoxane (Zinecard), is recommended. |
Docetaxel (Taxotere) | Irritant (usually) Vesicant (rare) |
Cold (different suggestions depending on reference):
|
Hyaluronidase: Inject a total of 1 mL (200 units) divided into 5-10 subcutaneous injections of 0.1-0.2 mL in a pinwheel fashion using a 25 gauge needle, changing needles between each injection, into affected area. May use up to 250 units if symptoms persist. |
Doxorubicin (Adriamycin) | Vesicant | Cold (different suggestions depending on reference):
|
Dexrazoxane (Zinecard): Dexrazoxane should be administered over 1-2 hours IV at the recommended doses below, daily for 3 consecutive days. Site of administration should be in a large vein away from the extravasation. The first infusion should be initiated as soon as possible and within the first six hours after extravasation.
If cooling techniques are being used, withhold cooling 15 minutes before and after the infusion. Infuse in an extremity or area other than the one affected by extravasation. Reduce dose by 50% for patients with creatinine clearance <40 mL/min. |
Doxorubicin liposomal (Doxil) | Irritant | Cold - 15-20 minutes at a time for at least four times per day for 24 hours | No additional treatment, e.g. Dexrazoxane (Zinecard), is recommended. |
Epirubicin (Ellence) | Vesicant | Cold (different suggestions depending on reference):
|
Dexrazoxane (Zinecard): Dexrazoxane should be administered over 1-2 hours IV at the recommended doses below, daily for 3 consecutive days. Site of administration should be in a large vein away from the extravasation. The first infusion should be initiated as soon as possible and within the first six hours after extravasation.
If cooling techniques are being used, withhold cooling 15 minutes before and after the infusion. Infuse in an extremity or area other than the one affected by extravasation. Reduce dose by 50% for patients with creatinine clearance <40 mL/min. |
Etoposide (Vepesid) | Irritant | Heat (different suggestions depending on reference):
|
Hyaluronidase: Inject a total of 1 mL (200 units) divided into 5-10 subcutaneous injections of 0.1-0.2 mL in a pinwheel fashion using a 25 gauge needle, changing needles between each injection, into affected area. May use up to 250 units if symptoms persist. |
Fluorouracil (5-FU) | Irritant | Cold - 15-20 minutes at a time for at least four times per day for 24 hours | None known |
Gemcitabine (Gemzar) | Irritant | Cold - 15-20 minutes at a time for at least four times per day for 24 hours | None known |
Idarubicin (Idamycin) | Vesicant | Cold (different suggestions depending on reference):
|
Dexrazoxane (Zinecard): Dexrazoxane should be administered over 1-2 hours IV at the recommended doses below, daily for 3 consecutive days. Site of administration should be in a large vein away from the extravasation. The first infusion should be initiated as soon as possible and within the first six hours after extravasation.
If cooling techniques are being used, withhold cooling 15 minutes before and after the infusion. Infuse in an extremity or area other than the one affected by extravasation. Reduce dose by 50% for patients with creatinine clearance <40 mL/min. |
Ifosfamide (Ifex) | Irritant | Cold (different suggestions depending on reference):
|
DMSO (Dimethylsulfoxide) 99%: 4 drops per 10 square centimeters of skin surface applied topically over area twice the size affected every 8 hours for 7 days. Allow to air dry. |
Irinotecan (Camptosar) | Irritant | Cold - 15-20 minutes at a time for at least four times per day for 24 hours | None known |
Mechlorethamine (Mustargen) | Vesicant | Cold - for 6-12 hours after administration of sodium thiosulfate | Sodium Thiosulfate: Mix 4 mL of 10% sodium thiosulfate with 6 mL sterile water (yields 10mL of 1/6 molar sodium thiosulfate). Administration varies depending on reference:
|
Melphalan (Alkeran) | Irritant | Cold - 15-20 minutes at a time for at least four times per day for 24 hours | None known |
Mitomycin (Mutamycin) | Vesicant | Cold - 15-20 minutes at a time for at least four times per day for 24 hours | Sodium Thiosulfate: Mix 4 mL of 10% sodium thiosulfate with 6 mL sterile water (yields 10mL of 1/6 molar sodium thiosulfate). Inject 5 mL subcutaneously using a 25 gauge needle, changing needles between each injection, into affected area in a pinwheel fashion. |
Mitoxantrone (Novantrone) | Irritant (usually) Vesicant (rare) |
Cold - Apply cold packs for 15-20 minutes 4 times per day for 1-2 days. | None known |
Oxaliplatin (Eloxatin) | Irritant (usually) Vesicant (rare) |
Heat - Apply warm compresses to extravasation site for 1 hour. Caution: excessive heat can cause tissue damage. | Sodium Thiosulfate: Mix 4 mL of 10% sodium thiosulfate with 6 mL sterile water (yields 10mL of 1/6 molar sodium thiosulfate). Inject 5 mL subcutaneously using a 25 gauge needle, changing needles between each injection, into affected area in a pinwheel fashion. Corticosteroids: For large extravasations, dexamethasone 8 mg PO BID for up to 14 days is recommended to help mitigate the local inflammatory reaction. |
Paclitaxel (Taxol) | Irritant (usually) Vesicant (rare) |
Cold generally recommended (different suggestions depending on reference):
Controversial use of heat: EONS (European Oncology Nurses Society) suggests application of heat to encourage circulation and to dilute & diffuse the chemotherapy. |
Hyaluronidase: Inject a total of 1 mL (200 units) divided into 5-10 subcutaneous injections of 0.1-0.2 mL in a pinwheel fashion using a 25 gauge needle, changing needles between each injection, into affected area. May use up to 250 units if symptoms persist. |
Paclitaxel, nanoparticle albumin-bound (Abraxane) | Irritant | Cold (different suggestions depending on reference):
|
None known |
Plicamycin (Mithracin) | Vesicant/Irritant (depending on reference) | Cold - 15-20 minutes at a time for at least four times per day for 24 hours | None known |
Streptozocin (Zanosar) | Vesicant | Cold - 15-20 minutes at a time for at least four times per day for 24 hours | None known |
Teniposide (Vumon) | Irritant | Cold - 15-20 minutes at a time for at least four times per day for 24 hours | Hyaluronidase: Inject a total of 1 mL (200 units) divided into 5-10 subcutaneous injections of 0.1-0.2 mL in a pinwheel fashion using a 25 gauge needle, changing needles between each injection, into affected area. May use up to 250 units if symptoms persist. |
Thiotepa (Thioplex) | Irritant | Cold - 15-20 minutes at a time for at least four times per day for 24 hours | None known |
Topotecan (Hycamtin) | Irritant | Cold - 15-20 minutes at a time for at least four times per day for 24 hours | None known |
Trabectedin (Yondelis) | Vesicant | Cold - 15-20 minutes at a time for at least four times per day for 24 hours | None known |
Vinblastine (Velban) | Vesicant | Heat - 15-20 minutes at a time for at least four times per day for 24-48 hours | Hyaluronidase: Inject a total of 1 mL (200 units) divided into 5-10 subcutaneous injections of 0.1-0.2 mL in a pinwheel fashion using a 25 gauge needle, changing needles between each injection, into affected area. May use up to 250 units if symptoms persist. |
Vincristine (Oncovin) | Vesicant | Heat - 15-20 minutes at a time for at least four times per day for 24-48 hours | Hyaluronidase: Inject a total of 1 mL (200 units) divided into 5-10 subcutaneous injections of 0.1-0.2 mL in a pinwheel fashion using a 25 gauge needle, changing needles between each injection, into affected area. May use up to 250 units if symptoms persist. |
Vincristine liposomal (Marqibo) | Irritant | Heat - 15-20 minutes at a time for at least four times per day for 24-48 hours | No formal recommendation, but depending on clinical condition could consider extrapolating from management of other vinca alkaloids: Hyaluronidase: Inject a total of 1 mL (200 units) divided into 5-10 subcutaneous injections of 0.1-0.2 mL in a pinwheel fashion using a 25 gauge needle, changing needles between each injection, into affected area. May use up to 250 units if symptoms persist. |
Vindesine (Eldisine) | Vesicant | Heat - 15-20 minutes at a time for at least four times per day for 24-48 hours | Hyaluronidase: Inject a total of 1 mL (200 units) divided into 5-10 subcutaneous injections of 0.1-0.2 mL in a pinwheel fashion using a 25 gauge needle, changing needles between each injection, into affected area. May use up to 250 units if symptoms persist. |
Vinorelbine (Navelbine) | Vesicant | Heat - 15-20 minutes at a time for at least four times per day for 24-48 hours | Hyaluronidase: Inject a total of 1 mL (200 units) divided into 5-10 subcutaneous injections of 0.1-0.2 mL in a pinwheel fashion using a 25 gauge needle, changing needles between each injection, into affected area. May use up to 250 units if symptoms persist. |
Definitions
- Extravasation: Leakage of a medication into tissue or extravascular space around the infusion site. May be due to direct leakage from the venous access device or from elsewhere in the vessel (such as from previous phlebotomy).
- Flare reaction: A skin reaction to a medication which is an allergic response.
- Vesicant: Medication that may causes severe and/or irreversible tissue injury and necrosis.
- Irritant: Medication that can cause local inflammatory reactions at the infusion site, which may include: burning, swelling, pain, inflammation, tightness, or phlebitis. Clinical exam may reveal warmth, erythema, or tenderness.
Reference
- ↑ Chemotherapy extravasation injury (UpToDate)
- ↑ Beth Israel Deaconess Medical Center. Administration and Extravasation Management of Vesicant Chemotherapy Agents. 11/2010 revision.
- ↑ Polovich M, Whitford JM, Olsen M. Chemotherapy and biotherapy guidelines and recommendations for practice, 3rd ed, Oncology Nursing Society, Pittsburgh, PA, 2009. Section V: Immediate Complications of cytotoxic therapy, p.105.
- ↑ ONS (Oncology Nursing Society) chemotherapy extravasation FAQs
- ↑ Wengström Y, Margulies A; European Oncology Nursing Society Task Force. European Oncology Nursing Society extravasation guidelines. Eur J Oncol Nurs. 2008 Sep;12(4):357-61. link to original article PubMed