Chemotherapy Extravasation Management

Algorithm Steps

1. ▶

   Start

   Suspected Chemotherapy Extravasation

   Leakage of antineoplastic agent into surrounding tissue

   1. ●

      Action

      Immediate Actions

      Stop infusion, do not remove cannula yet

      • 1. STOP infusion immediately
      • 2. Leave cannula/needle in place initially
      • 3. Attempt to aspirate residual drug (3-5 mL)
      • 4. Mark the extravasation area with pen
      • 5. Remove cannula after aspiration attempts
      • 6. Elevate affected limb
      • 7. Notify physician immediately
      1. ◆

         Decision

         Classify the Extravasated Agent

         Vesicant, Irritant, or Non-vesicant

         • VESICANTS (cause necrosis):
         • • Anthracyclines: doxorubicin, daunorubicin, epirubicin
         • • Vinca alkaloids: vincristine, vinblastine, vinorelbine
         • • Nitrogen mustards: mechlorethamine
         • • Taxanes: paclitaxel, docetaxel (debated)
         • IRRITANTS (inflammation, no necrosis):
         • • Etoposide, teniposide, irinotecan
         • • Carboplatin, oxaliplatin (cold sensitive)
         • NON-VESICANTS:
         • • Cyclophosphamide, methotrexate, 5-FU
         1. ●

            Action

            Anthracycline Extravasation

            Dexrazoxane is antidote of choice

            • DEXRAZOXANE PROTOCOL:
            • • Day 1: 1000 mg/m² IV (max 2000mg)
            • • Day 2: 1000 mg/m² IV (max 2000mg)
            • • Day 3: 500 mg/m² IV (max 1000mg)
            • Start within 6 hours of extravasation
            • Give in large vein AWAY from extravasation site
            • CRITICAL: Do NOT use DMSO with dexrazoxane
            • Do NOT apply ice during dexrazoxane (remove 15 min before)
            1. ●

               Action

               Documentation & Follow-up

               Thorough documentation essential

               • DOCUMENT:
               • • Drug name, concentration, volume estimated
               • • Time of extravasation and detection
               • • Description of area (size, erythema, pain)
               • • Photograph if possible
               • • Treatment administered
               • FOLLOW-UP:
               • • Daily assessment for first 7 days
               • • Watch for: blistering, ulceration, necrosis
               1. ◆

                  Decision

                  Surgical Consultation Needed?

                  Assess tissue viability

                  • CONSULT SURGERY/PLASTICS IF:
                  • • Ulceration develops
                  • • Necrosis present
                  • • Large volume vesicant extravasation
                  • • Pain persisting >10 days
                  • • No improvement with conservative management
                  • Early surgical debridement may prevent spread
                  1. ●

                     Action

                     Surgical Management

                     For severe tissue injury

                     • Debridement of necrotic tissue
                     • May require skin grafting
                     • Early intervention better outcomes
                     • Consider liposuction/saline flush technique
                     • Wound care and rehabilitation
                     1. ✓

                        Outcome

                        Extravasation Resolved

                        Resume chemotherapy via different access

                  2. ●

                     Action

                     Conservative Management

                     Continue monitoring and local care

                     • Continue topical treatments as prescribed
                     • Pain management
                     • Physical therapy if contracture develops
                     • Most heal within 2-4 weeks
                     • Patient education on signs of worsening
         2. ●

            Action

            Vinca Alkaloid Extravasation

            Hyaluronidase + warm compress

            • HYALURONIDASE PROTOCOL:
            • • Inject 150-1500 units (diluted) SC
            • • Multiple injections around extravasation site
            • • 0.2 mL per injection, clockface pattern
            • WARM COMPRESSES:
            • • Apply dry warm compresses
            • • 15-20 min QID for 24-48 hours
            • • Heat disperses drug and increases absorption
            • NEVER use cold for vinca alkaloids
         3. ●

            Action

            Other Vesicants / DNA-Binding Agents

            DMSO + cold compress (if dexrazoxane not available)

            • DMSO 99% topical:
            • • Apply to affected area
            • • Cover twice the extravasation area
            • • Allow to air dry (do not cover)
            • • Apply every 8 hours for 7-14 days
            • COLD COMPRESSES:
            • • Apply for 15-20 min QID
            • • For 24-48 hours
            • Localize drug, reduce cellular uptake
         4. ●

            Action

            Taxane Extravasation

            Management controversial

            • Paclitaxel and docetaxel: debated severity
            • Some guidelines: hyaluronidase + cold
            • Others: warm compresses only
            • No clear consensus
            • Conservative management often sufficient
            • Monitor closely for tissue damage
         5. ●

            Action

            Irritant Extravasation

            Supportive care, rarely causes necrosis

            • Apply cold or warm compresses as appropriate
            • Elevate limb
            • Pain management (NSAIDs, topical steroids)
            • Monitor for worsening
            • Usually resolves without intervention