Extravasation of chemotherapy

A Retrospective Study of Chemotherapy-Related Extravasation Events in Dogs and Cats

BACKGROUND

Chemotherapy extravasation is a potentially serious complication. There is a paucity of information in the veterinary literature investigating extravasation events, treatments, and outcomes.

OBJECTIVE

Evaluate chemotherapy extravasation events and treatments in dogs and cats, adverse events (AEs), and overall outcomes.

ANIMALS

Twenty dogs and three cats were included.

METHODS

Retrospective, multicenter, descriptive study including dogs or cats with suspected extravasation from chemotherapy. Information obtained included: signalment, extravasation details and treatment provided, AEs graded according to VCOG-CTCAE v2 criteria, and outcome.

RESULTS

The most common drug extravasated was doxorubicin, followed by carboplatin. Carboplatin extravasation (n = 5) resulted in Grades III-IV AEs, all of which required surgical debridement. Doxorubicin extravasation (n = 9) resulted in Grades 0-V AEs, two of which amputation was ultimately recommended, and one of those two was euthanized instead. Extravasation of vinca alkaloids (n = 5) and rabacfosadine (n = 1) resulted in Grades II-III AEs, all managed in the outpatient setting. Mitoxantrone (n = 2) and dacarbazine (n = 1) extravasation resulted in no clinical signs associated with extravasation injury. Seventy-eight percent (18/23) cases had extravasation occur during one of the first four treatments of chemotherapy, with 30% (7/23) occurring during the first chemotherapy treatment.

CONCLUSIONS AND CLINICAL IMPORTANCE

Most cases (20/23) had mild to moderate or no AEs. Findings support that carboplatin should be considered a vesicant.

Oncological Emergencies from Pathophysiology and Diagnosis to Treatment: A Narrative Review

Oncological emergencies are defined as any acute possible morbid or life-threatening events in patients with cancer either because of the malignancy or because of their treatment. These events may occur at any time during malignancy, from symptoms present to end-stage disease. The aim of this study is the review of urgent conditions results from cancer or cancer treatment side effects that need to be addressed immediately. In this study, a comprehensive and in-depth narrative review was carried out by searching the databases of PubMed, Scopus, Science Direct, Google Scholar with the keywords of "cancer, emergency, metabolic emergency, neutropenic fever" along with the words, "tumor lysis syndrome, chemotherapeutic emergency, diagnosis, treatment " in last two decades. Patients suffering from cancer mostly face the challenges that we are classified in different categories, including metabolic, hematologic, cardiovascular, neurologic, respiratory, infectious, and chemotherapeutic emergencies. These patients mostly complain of headaches, nausea, pain, and fever. In conclusion, knowledge of oncology emergencies and palliative care as part of a team approach is critical for treating cancer patients. In this light, it is pivotal for physicians to focus on the early detection of oncological emergencies. Moreover, training programs for cancer patients help them to timely recognize and report the oncologic emergency symptoms, leading to avoid deleterious consequences and unnecessary healthcare costs as well as improve the quality of life in these patients.

Guidelines for the management of extravasation

The purpose of these practice guidelines is to offer and share strategies for preventing extravasation and measures for handling drugs known to cause tissue necrosis, which may occur even with the most skilled experts at intravenous (IV) injection. Herein, general knowledge about extravasation is first described, including its definition, incidence, risk factors, diagnosis, differential diagnosis, and extravasation injuries. Management of extravasation includes nursing intervention and thermal application. At the first sign of extravasation, nursing intervention with following steps is recommended: stop administration of IV fluids immediately, disconnect the IV tube from the cannula, aspirate any remaining drug from the cannula, administer drug-specific antidote, and notify the physician. Local thermal treatments are used to decrease the site reaction and absorption of the infiltrate. Local cooling (ice packs) aids in vasoconstriction, theoretically limiting the drug dispersion. Although clear benefit has not been demonstrated with thermal applications, it remains a standard supportive care. The recommended application schedule for both warm and cold applications is 15 to 20 minutes, every 4 hours, for 24 to 48 hours. For prevention of extravasation, health professionals should be familiar with the extravasation management standard guidelines. They should regularly check the extravasation kit, assess patients’ sensory changes, tingling or burning, and always pay attention to patients’ words. The medical team’s continuous education on extravasation is essential. With the practical use of these guidelines, it is expected to reduce the occurrence rate of extravasation and contribute to patient care improvement.

Suspected Carboplatin Extravasation Reactions in Seven Dogs

Carboplatin is a platinum chemotherapeutic agent commonly used in veterinary oncology that is currently classified as an irritant to local tissues when extravasated. To the authors' knowledge, there are no reports of vesicant injuries associated with carboplatin administration reported in the veterinary literature. In this case series, seven dogs are described to have experienced injuries following a suspected carboplatin extravasation resembling vesicant injuries a median of 7 days after carboplatin administration (range 4-15 days). Wounds healed with a variety of treatments, including medical management and/or surgical debridement, a median of 25.5 days (range 7-49 days) after observation of the suspected extravasation injury. There were no obvious similarities involving carboplatin administration among patients to explain why these reactions occurred. Extravasation injury should be considered a possible local complication associated with carboplatin chemotherapy.

Pharmacokinetics of the Cardioprotective Drug Dexrazoxane and Its Active Metabolite ADR-925 with Focus on Cardiomyocytes and the Heart

Dexrazoxane (DEX), the only cardioprotectant approved against anthracycline cardiotoxicity, has been traditionally deemed to be a prodrug of the iron-chelating metabolite ADR-925. However, pharmacokinetic profile of both agents, particularly with respect to the cells and tissues essential for its action (cardiomyocytes/myocardium), remains poorly understood. The aim of this study is to characterize the conversion and disposition of DEX to ADR-925 in vitro (primary cardiomyocytes) and in vivo (rabbits) under conditions where DEX is clearly cardioprotective against anthracycline cardiotoxicity. Our results show that DEX is hydrolyzed to ADR-925 in cell media independently of the presence of cardiomyocytes or their lysate. Furthermore, ADR-925 directly penetrates into the cells with contribution of active transport, and detectable concentrations occur earlier than after DEX incubation. In rabbits, ADR-925 was detected rapidly in plasma after DEX administration to form sustained concentrations thereafter. ADR-925 was not markedly retained in the myocardium, and its relative exposure was 5.7-fold lower than for DEX. Unlike liver tissue, myocardium homogenates did not accelerate the conversion of DEX to ADR-925 in vitro, suggesting that myocardial concentrations in vivo may originate from its distribution from the central compartment. The pharmacokinetic parameters for both DEX and ADR-925 were determined by both noncompartmental analyses and population pharmacokinetics (including joint parent-metabolite model). Importantly, all determined parameters were closer to human than to rodent data. The present results open venues for the direct assessment of the cardioprotective effects of ADR-925 in vitro and in vivo to establish whether DEX is a drug or prodrug.

The management of cytotoxic chemotherapy extravasation: a systematic review of the literature to evaluate the evidence underpinning contemporary practice

Management of cytotoxic drug extravasation remains contentious, with differing views on the most effective management strategy. With the increasing drive to provide effective, evidence-based healthcare, while ensuring the patient experience of the treatment provided plays a significant part in the development of clinical practice guidelines, the purpose of this literature review was to both critically analyse the quality of evidence that underpins contemporary practice and to determine if the patient experience is taken into account. A literature search was undertaken sourcing publications from the 1960s to July 2014 identifying all studies detailing strategies aimed at preventing the need for surgical debridement and all studies evaluating extravasation management from the patient's perspective. No conclusive evidence was found to suggest one clinical strategy as more effective than the other. No studies were identified that evaluated outcome from the patient's perspective. It is therefore suggested that outcomes-based research should underpin contemporary extravasation management guidelines to determine what the final outcome or 'end result' is and how this impacts on the patient and that the current lack of research into the patient experience of extravasation management is an area that needs to be addressed.

Medication wrong route administration: a poisons center-based study

OBJECTIVES

To describe clinical effects, circumstances of occurrence, management and outcomes of cases of inadvertent administration of medications by an incorrect parenteral route.

METHODS

Retrospective single-center consecutive review of parenteral route errors of medications, reported to our center between January 2006 and June 2010. We collected demographic data and information on medications, route and time of administration, severity of symptoms/signs, treatment, and outcome.

RESULTS

Seventy-eight cases (68 adults, 10 children) were available for analysis. The following wrong administration routes were recorded: paravenous (51%), intravenous (33%), subcutaneous (8%), and others (8%). Medications most frequently involved were iodinated x-ray contrast media (11%) and iron infusions (9%). Twenty-eight percent of the patients were asymptomatic and 54% showed mild symptoms; moderate and severe symptoms were observed in 9% and 7.7%, respectively, and were mostly due to intravenous administration errors. There was no fatal outcome. In most symptomatic cases local nonspecific treatment was performed.

CONCLUSIONS

Enquiries concerning administration of medicines by an incorrect parenteral route were rare, and mainly involved iodinated x-ray contrast media and iron infusions. Most events occurred in adults and showed a benign clinical course. Although the majority of exposures concerned the paravenous route, the occasional severe cases were observed mainly after inadvertent intravenous administration.

Dexrazoxane treatment of doxorubicin extravasation injury in four dogs

CASE DESCRIPTION

4 dogs were treated with dexrazoxane for known or suspected doxorubicin extravasation. Records were retrospectively reviewed. Doses and number of doses of dexrazoxane were variable. Dexrazoxane was administered within 2 hours after known extravasation in 3 dogs and 48 hours after suspected extravasation in 1 dog. Additional medical treatments included tissue cooling in all dogs, topically administered dimethyl sulfoxide ointment in 3, and orally administered piroxicam in 1.

CLINICAL FINDINGS

Mild erythema and edema at the extravasation site developed within 1 to 6 days after extravasation in the 3 dogs that received dexrazoxane within 2 hours after extravasation. Extensive tissue necrosis occurred in the dog treated 48 hours after suspected extravasation.

TREATMENT AND OUTCOME

Only the dog with severe tissue necrosis required surgical intervention. Lesions in the other 3 dogs resolved with medical management alone. All dogs survived the event.

CLINICAL RELEVANCE

To date, use of dexrazoxane in the management of doxorubicin extravasation has not been reported in dogs. Treatment was successful in 3 of 4 patients. The most effective dosage and timing of administration are unknown; however, there is evidence to suggest that administration within 6 hours after the event is warranted. Further studies are needed to confirm efficacy and to optimize use of this drug in the prevention and treatment of anthracycline extravasation injury in veterinary patients.

Oncologic emergencies: Pathophysiology, presentation, diagnosis, and treatment

Oncologic emergencies can occur at any time during the course of a malignancy, from the presenting symptom to end-stage disease. Although some of these conditions are related to cancer therapy, they are by no means confined to the period of initial diagnosis and active treatment. In the setting of recurrent malignancy, these events can occur years after the surveillance of a cancer patient has been appropriately transferred from a medical oncologist to a primary care provider. As such, awareness of a patient's cancer history and its possible complications forms an important part of any clinician's knowledge base. Prompt identification of and intervention in these emergencies can prolong survival and improve quality of life, even in the setting of terminal illness. This article reviews hypercalcemia, hyponatremia, hypoglycemia, tumor lysis syndrome, cardiac tamponade, superior vena cava syndrome, neutropenic fever, spinal cord compression, increased intracranial pressure, seizures, hyperviscosity syndrome, leukostasis, and airway obstruction in patients with malignancies. Chemotherapeutic emergencies are also addressed.