Dimethylsulphoxide and cooling after extravasation of antitumour agents

[Establishing Evidence for Use of Appropriate Medicines in the Operating Room]

Various issues related to clinical use of medicines remain unclear, and pharmacists are expected to establish evidence for appropriate use of medicines. The present review summarizes our findings from three areas of research regarding the use of medicines in the operating room: 1) We evaluated the extent of extravasation injury due to thiopental (2.5 mg/100 μL) and propofol (1.0 mg/100 μL) at the macroscopic and histopathologic levels in a rat model. Thiopental, which causes tissue necrosis, can be classified as a "vesicant", and propofol can be classified as an "irritant". Moreover, warming strongly exacerbated the degeneration or necrosis induced by extravasation of thiopental. 2) The cytotoxicity of povidone-iodine solution (PVP-I) for ophthalmic use and that of polyvinyl alcohol-iodine solution (PAI) was compared using a human corneal epithelial cell line. Despite exhibiting equivalent antiseptic effects, the cytotoxicity of PVP-I diluted 16-fold was greater than that of PAI diluted 6-fold. After inactivation of iodine, the cytotoxicity of PVP-I persisted; therefore, to avoid corneal damage, antisepsis should be achieved with PAI. 3) The stability of 1 μg/mL adrenaline when used as an intraocular irrigating solution to maintain pupil dilation was evaluated. After mixing for 6 h, the adrenaline concentration was 65.2% (pH 8.0) of the initial concentration. Moreover, the low concentration of sodium bisulfite in the irrigating solution could have caused adrenaline reduction. Our results strongly suggest that intraocular irrigation solution containing adrenaline should be prepared just prior to use in surgery.

Anthracycline Extravasation: A Comprehensive Review of Experimental and Clinical Treatments

An accidental extravasation of anthracycline-containing chemotherapy is a feared complication that may lead to necrosis and severe tissue destruction. For four decades, much effort has been done to prevent and treat this devastating condition. Savene™ has recently been proved to be very effective, and is the only approved treatment against anthracyline extravasation. It is thus now widely recommended. The present article represents a comprehensive review of, and historical insight to, the experimental and clinical studies of surgical and non-surgical treatments of extravasation during forty years of clinical anthracycline treatment.

Injury due to extravasation of thiopental and propofol: Risks/effects of local cooling/warming in rats

Inadvertent leakage of medications with vesicant properties can cause severe necrosis in tissue, which can have devastating long-term consequences. The aim of this study was to evaluate the extent of extravasation injury induced by thiopental and propofol, and the effects of cooling or warming of local tissue on extravasation injury at macroscopic and histopathologic levels. Rats were administered intradermally thiopental (2.5 mg/100 µL) or propofol (1.0 mg/100 µL). Rats were assigned randomly to three groups: control (no treatment), cooling and warming. Local cooling (18-20 °C) or warming (40-42 °C) was applied for 3 h immediately after agent injection. Lesion sizes (erythema, induration, ulceration, necrosis) were monitored after agent injection. Histopathology was evaluated in skin biopsies taken 24 h after agent injection. Thiopental injection induced severe skin injury with necrosis. Peak lesions developed within 24 h and healed gradually 18-27 days after extravasation. Propofol induced inflammation but no ulceration, and lesions healed within 1-2 days. Local cooling reduced thiopental- and propofol-induced extravasation injuries but warming strongly exacerbated the skin lesions (e.g., degeneration, necrosis) induced by extravasation of thiopental and propofol. Thiopental can be classified as a "vesicant" that causes tissue necrosis and propofol can be classified as an "irritant". Local cooling protects (at least in part) against skin disorders induced by thiopental and propofol, whereas warming is harmful.

Role of dimethylsulfoxide for management of chemotherapy extravasation

Extravasation of anthracyclines is a rare complication that can lead to severe tissue necrosis and ulceration. With conservative measures (e.g., limb elevation, cooling), ulceration may develop in 28% of patients. Topical dimethylsulfoxide is commonly suggested as an antidote. However, there are inconsistent and sometimes conflicting animal data on its efficacy and safety. Ovid Medline (1966 to April 2004) was searched using the medical subject headings of ‘Dimethyl Sulfoxide’ and ‘Extravasation of Diagnostic and Therapeutic Materials’, and limited to English language and human articles. There have been no controlled trials on dimethylsulfoxide comparing its efficacy with cooling alone. Of a total of 147 patients, ulceration was uncommon after anthracycline extravasation when patients were managed with dimethylsulfoxide with or without cooling. Dimethylsulfoxide was well tolerated, with the most common toxicities being early mild reversible burning sensation, blistering, followed later by itch, erythema and superficial scaling. Dimethylsulfoxide is probably effective in preventing ulceration in patients who may not respond to cooling alone. When applied appropriately, dimethylsulfoxide seems well tolerated, with self-limiting local irritation to be the most common adverse effect. Hence, it is reasonable to consider topical dimethylsulfoxide 99% solution when managing extravasation of anthracyclines and mitomycin.

Review : Utilization of dimethyl sulfoxide for treating anthracycline extravasation

Objective. To review the literature available on the use of dimethyl sulfoxide (DMSO) to treat anthracy cline extravasation.

Data Sources. English-language literature was gathered using Medline, EMBASE International Phar maceutical Abstracts, CINAHL, and references from bibliographies.

Study Selection. Studies selected for review included controlled animal studies and any available human studies, including case reports and case series. All studies must have used DMSO in the treatment of an anthracycline extravasation.

Data Extraction. Data extracted from animal studies included the animal model used; method of doxorubicin and DMSO administration; ulcer out come ; and statistical significance. Individual case re ports and case series were abstracted for the anti neoplastic agent extravasated; associated symptoms; DMSO administration; concurrent therapies; and short- and long-term results (symptoms, functional damage).

Data Synthesis. One of six animal studies indi cated a significant difference in peak lesion size and area under the curve between DMSO and control. However, local cooling resulted in less toxicity as compared with DMSO, and the time to ulcer healing was actually prolonged in the DMSO-treated group. Clinical experience with DMSO has resulted in no surgical intervention and no residual function impair ment after anthracycline extravasation.

Conclusion. The controversial animal data and the lack of controlled clinical experience with DMSO should preclude its use as the sole initial therapy of anthracycline extravasations. A comparison study be tween topical DMSO and local cooling versus local cooling alone would aid in determining the true benefit of DMSO in the treatment of anthracycline extravasation.

Current recommendations for prevention and therapy of extravasation reactions in dermato-oncology

Despite the introduction of many targeted therapies, a wide variety of cytostatic agents are still frequently used in dermato-oncology. In order to avoid further morbidity in tumor patients, prevention of extravasation reactions is of highest importance. The optimal management of extravasation requires an early diagnosis, the application of specific antidotes and a well-trained oncology team.

Toxicity to topical dimethyl sulfoxide (DMSO) when used as an extravasation antidote

DMSO is a dipolar, aprotic, hygroscopic solvent for which a large number of pharmacologic properties have been claimed. Topical DMSO is considered an effective and safe antidote to be used with topical cooling after extravasations of vesicant drugs. A case of toxicity after its use as an antidote is described. Furthermore, the increasing importance of DMSO pharmacology, as its use in haematologic patients is spreading, is reviewed.

Treatment of extravasation of both doxorubicin and vincristine administration in a Y-site infusion

OBJECTIVE

To describe a patient treated with vincristine, doxorubicin, and dexamethasone who experienced extravasation of both doxorubicin and vincristine during a Y-site infusion.

CASE SUMMARY

A 74-year-old white woman was diagnosed with multiple myeloma IgA kappa in stage IIA. One year after a complete remission she relapsed. Her treatment included daily doxorubicin 16 mg in 500 mL of dextrose 5% and vincristine 0.4 mg in 500 mL of dextrose 5% administered in a Y-site continuous infusion into a peripheral vein of her left forearm. Extravasation occurred during administration of these drugs. Immediately, chondroitinsulfatase, a mucopolysaccharidase similar to hyaluronidase, was administered subcutaneously around the extravasation area and repeated 24 hours later. Furthermore, dimethyl sulfoxide 90% v/v was applied topically on the area four times daily for 2 weeks. All inflammatory signs resolved and no necrosis developed.

DISCUSSION

Ths is the first report of an extravasation of two cytotoxic drugs. Doxorubicin and vincristine have different antidotes and opposite physical treatments for their extravasation. The antidotes dimethyl sulfoxide and chondroitinsulfatase have different mechanisms of action, but both cause uptake of the cytotoxic agent from the tissue and are likely to be administered together. No warming or cooling was performed.

CONCLUSIONS

Topical dimethyl sulfoxide four times daily for 14 days plus subcutaneous chondroitinsulfatase in one or two applications effectively treated an extravasation of both doxorubicin and vincristine in our patient.

Prevention and management of extravasation of cytotoxic drugs

Extravasation of certain cytotoxic agents during peripheral intravenous administration may cause severe local injuries. Most extravasation can be prevented with the systematic implementation of careful administration techniques. However, the management of this complication, the aim of which is to prevent progression to tissue necrosis and ulceration, remains an important challenge in the care of cancer patients. Many antidotes have been evaluated experimentally and a few may be able to reduce the local toxicity of the more common vesicant cytotoxic drugs. Because no randomised trial on the management of cytotoxic drug extravasation in humans has ever been completed, recommendations must be based on the more consistent experimental evidence and on cumulative clinical experience from available case reports and uncontrolled studies, which are reviewed in this article. Empirical guidelines recommend the use of topical dimethylsulfoxide (DMSO) and cooling after extravasation of anthracyclines or mitomycin, locally injected hyaluronidase after extravasation of vinca alkaloids, and locally injected sodium thiosulfate (sodium hyposulfite) after extravasation of chlormethine (mechlorethamine; mustine). Plastic surgery may be necessary when conservative treatment fails to prevent ulceration. The possibility of late local reactions must also be considered in the management of patients receiving chemotherapy.

Combined management in the treatment of epidoxorubicin extravasation. A case report

Inadvertent extravasation during intravenous antitumor therapy is not an unusual complication and can cause damage ranging from minor erythema to severe local necrosis. The appropriate management of these iatrogenic accidents as a part of supportive care in oncology has been addressed by several experimental studies, but there has been little clinical study and no conclusive evidence on the best therapeutic strategies to adopt. The case reported here of a patient suffering from severe soft-tissue injury caused by extravasation of epidoxorubicin demonstrates the usefulness of a combined management (medical, surgical and rehabilitative) in the appropriate care of extravasation.

Ifosfamide extravasation

OBJECTIVE

To report a case in which a local reaction is attributed to an ifosfamide extravasation. Previously, extravasated ifosfamide has been considered a nonirritant.

CASE SUMMARY

A 54-year-old woman with a non-Hodgkin's lymphoma in stage IV B developed a local reaction in her right arm after an ifosfamide extravasation. No pressure was prescribed, no bandaging was applied on the affected area, and the limb was elevated to the heart level. In addition, chondroitinsulfatase 150 turbidity-reducing units was administered subcutaneously around the area. This procedure was repeated 12 hours later, resulting in a satisfactory decrease in the inflammatory signs and pain.

DISCUSSION

The local reaction in the patient's arm cannot be attributed to the hypertonicity of the infusing solution or to the vehicle of the infusate. The antidote used was chondroitinsulfatase, an enzyme similar to hyaluronidase. It enhances the systemic uptake of the drug from the tissue.

CONCLUSIONS

Extravasated ifosfamide is a potential irritant. General measures applied after its extravasation can be potentiated strongly by local subcutaneous administration of chondroitinsulfatase or hyaluronidase, repeated if necessary.