Extravasation Evidence Based Care Chemotherapy

Extravasation Evidence Based Care Chemotherapy

Extravasation Evidence Based Care Chemotherapy

Introduction

This paper considers the problem of extravasation within nursing practice. It explores a collaborative approach between nurse educationalists and clinical nurses offering the potential to inform and change practice. The conclusion was the development of pre- and post-registration programmes designed to meet the needs of a specialist area. Extravasation within chemotherapy is a specialist problem requiring urgent treatment. A critical incident concerning extravasation has been utilised to highlight the need for this specialist information within pre- and post-registration programmes.

Problem of extravasation

Extravasation exists in all areas where drugs are administered intravenously and is therefore not confined to chemotherapeutics. General definitions of extravasation found in the literature describe an inadvertent infiltration or leakage of intravenous fluids from the vein into the perivascular or surrounding subcutaneous tissues (Holmes, 1997). However, in the case of chemotherapy the impact of extravasation is dependent upon four factors (Allwood et al., 1997) including human error, equipment error, and the patient's underlying medical condition. The fourth factor is the classification of the agent i.e. whether it is irritant, non-vesicant, or vesicant to cells. An irritant is described as a Group 3 drug ( NEIS, 2000) and as a drug capable of producing venous pain directly at the venepuncture site or along it, occasionally with an inflammatory response. A non-vesicant is a Group 3 drug which refers to drugs that have extravasated in large volumes, where quick dispersal is encouraged. A vesicant however can cause local tissue destruction both within and outside the venous system and are categorised as belonging to Group 1 drugs because of their potential to cause serious necrosis when extravasation occurs ( Allwood et al., 1997; NEIS, 2001). The mechanisms of the damage are uncertain but a possible explanation is that the vesicant binds irreversibly to the subcutaneous tissue resulting in pain, oedema, erythema and tissue necrosis ( Berman et al., 1993) with the possibility of a significant loss of function for the patient, all of which add to the patient's suffering at a time when minimising further suffering is the priority. The effect of vesicant extravasation may not be noted immediately but may happen within 48 h (delayed extravasation) or as late as 4-6 weeks post infusion. Furthermore, severe (albeit rare) consequences of extravasation may include loss of function and even ambutation. Injuries may require skin grafting or surgical debridement.

The need to monitor, detect and successfully manage any potential extravasation is essential in patient care in order to try and minimise adverse side effects such as necrosis and/or tissue damage. With reference to the practice incident described in this article Mitomycin-C is classified as a vesicant in both Allwood et al. (1997) and the NEIS (2001) categories. The type of extravasation produced would easily be classified as delayed extravasation. Venous access devices such as central lines can malfunction, often leading to infiltration of the surrounding tissue. This can present as delayed extravasation. Webster and D'Souza (1995) have reported delayed presentations of Epirubicin ...