Guidelines for the management of extravasation

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.

Silver Sulfadiazine and Recombinant Human Epidermal Growth Factor Treatment for Neonatal Extravasation: A Case Report

BACKGROUND

Neonates are at high risk of intravenous extravasation, which can cause severe tissue necrosis. However, few studies have combined silver sulfadiazine (SSD) with recombinant human epidermal growth factor (rh-EGF), which has limited application in neonatal patients, to treat extravasation. This report describes the case of a female neonate treated with SSD and rh-EGF for a skin injury caused by epinephrine extravasation.

CLINICAL FINDINGS

The patient (gestational age: 33 + 5 weeks) experienced extravasation during epinephrine hydrochloride infusion on the first day of hospitalization in the neonatal intensive care unit (NICU).

PRIMARY DIAGNOSIS

Extravasation was diagnosed 6 hours following initiation of epinephrine hydrochloride infusion, which led to specific signs, including erythema, swelling, and pain.

INTERVENTIONS

The patient suffered an extravasation injury in her right lower limb. Sterile puncture points were made from the edge of the leak toward the puncture center. Phentolamine was administered at the puncture site. SSD and rh-EGF were applied to the injured area and covered with Vaseline gauze.

OUTCOMES

After treatment, the extravasation injury in the right lower limb resolved without any debridement or noticeable signs of infection. The black and purple skin discoloration decreased gradually, achieving normalization 13 days post-injury. The patient recovered completely with no scarring and was subsequently discharged.

PRACTICE RECOMMENDATIONS

Patients receiving infusions with high extravasation risk should be continuously and carefully evaluated for signs of dislocation, leakage swelling, or extravasation to quickly identify and prevent further injury. Combining SSD and rh-EGF may be an alternative treatment for advanced extravasation lesions in the NICU.

Systematic Risk Analysis and Mitigation Strategies for Near-Miss Events in Interventional Operating Room Nursing

Purpose

The aim of this study is to examine the characteristics of intraoperative nursing near-miss events in interventional operating rooms, systematically identify and analyze associated risks, and propose effective mitigation strategies.

Patients and Methods

A retrospective study was conducted using a specially designed survey focused on nursing near-miss events in Interventional operating rooms. Records of intraoperative near-miss events voluntarily reported by medical and nursing staff between January 2023 and March 2024 were analyzed. Grey relational analysis was used to evaluate and identify the associated risk factors.

Results

A total of 81 near-miss events were reported, with the majority (50%) occurring after 8 PM. These events were categorized into 6 main types: medication errors (60.49%), issues with consumables (16.05%), tubing-related incidents (8.64%), specimen handling errors (7.4%), transfer handover issues (4.93%), and patient transport problems (2.46%). Grey relational analysis identified air embolism formation during pressurized fluid administration as the highest risk event (ξ1 = 0.369). The risk factors were ranked as follows: weak coordination ability and lack of responsibility among nurses > operational interruptions > inadequate professional capability > poor communication between medical staff and nurses > equipment malfunction > frequent emergency surgeries and a fast paced working environment.

Conclusion

Medication administration errors are frequently encountered, with air embolisms during pressurized fluid infusion representing the most significant risk. Operational interruptions are major contributors to these errors, often influenced by the coordination skills and professional competencies of nurses. Clinically, it is crucial to enhance the identification and management of near-miss events to reduce the incidence of adverse outcomes during surgical procedures.

Doxorubicin treatment has a biphasic effect over time on dopamine release and impulsive behavior in Wistar rats

Doxorubicin (Dox) is a chemotherapy agent commonly used to treat multiple types of cancers and is associated with cognitive impairment. The goal of this work was to determine the effect of Dox treatment on dopamine release and uptake and behavior in rats. Rats received one dose per week of Dox (2.5 mg/kg, I.V.) and were sacrificed after two or four weeks. Dopamine release and uptake was measured in brain slices with fast-scan cyclic voltammetry (FSCV). A set of rats that received treatment also underwent behavioral testing with the 5-choice serial reaction timed task (5CSRTT) to measure degree of impulsiveness and attention throughout the course of treatment. Dopamine release and uptake increased substantially after treatment with Dox for two weeks compared to controls. After four weeks of treatment, release levels decreased to less than controls while there were no differences in uptake. Treatment of brain slices with pramipexole revealed that dopamine release was equally sensitive to autoregulation after two weeks of Dox treatment, but less sensitive after four weeks. Measurements from the 5CSRTT indicated that, while Dox did not affect attention, it increased impulsiveness after two and three weeks of treatment, but not after four weeks. Treatment with Dox for a short time may elevate dopamine system activity and increase impulsiveness, while longer administration then leads to an underactive dopamine system. To our knowledge this work demonstrates for the first time that Dox can have a biphasic neurochemical and behavioral effect.

Multicenter retrospective evaluation of norepinephrine extravasation in dogs and cats (2015-2021): 14 cases

OBJECTIVE

To document clinical complications and intervention options associated with norepinephrine (NE) extravasation in dogs and cats.

DESIGN

Cases were identified between 2015 and 2021. Because this is an uncommon complication, the findings are compiled as a descriptive retrospective study.

SETTING

Cases were provided from 4 universities and 2 private practice groups in the United States, Canada, and Australia.

ANIMALS

Fourteen patients (13 dogs, 1 cat) that experienced extravasation events (16 total).

INTERVENTIONS

Small animal patients were included where extravasation of a NE constant rate infusion (CRI) was documented. Records were reviewed for information, including suspected underlying condition, description of the interventions pursued after identification of extravasation, clinical signs after extravasation, and survival to discharge or reason for patient death or euthanasia. When available, information was collected pertaining to the NE dose, dilution, total duration of CRI, and duration of CRI before extravasation was recognized.

MEASUREMENTS AND MAIN RESULTS

The most commonly reported clinical signs after extravasation of NE were skin necrosis (n = 9 [64.3%]) and swelling (n = 6 [42.9%]). In 10 of 16 events (62.5%), discontinuation of the NE CRI and/or application of a warm compress to the extravasation site were performed; these were the most common nonpharmacological rescue measures. Two patients received subcutaneous phentolamine, and 1 patient underwent hyperbaric oxygen therapy. While surgical intervention was recommended for 4 dogs, 2 improved without surgical debridement. The overall survival rate from underlying disease processes was 57% (n = 8), with only 1 patient (7%) euthanized due to an injury from the extravasation.

CONCLUSIONS

Severe lesions can result from NE extravasation in dogs and cats, leading to euthanasia. Although phentolamine remains the treatment of choice, lesions may heal with alternative supportive measures.

Extravasation Identification and Management in Neonates and Pediatrics: A Cross Sectional Survey

OBJECTIVE

To explore current practice and guidelines surrounding the identification and management of extravasation injuries in Australian and New Zealand neonatal and pediatric settings.

METHODS

Between February and September 2023, an internet-based descriptive cross-sectional survey was distributed to Australian and New Zealand neonatal and pediatric clinicians using exponential nondiscriminative snowball sampling. Survey data domains included demographics, extravasation identification, management, local guidelines, and resources.

RESULTS

Of the 141 responses, the majority of respondents were registered nurses (n = 96, 68.1%), with greater than 20 years of experience (n = 51, 36.2%). Over two-thirds of respondents had no extravasation identification and management training (n = 98, 69.5%). Half of the respondents (n = 70, 49.6%) reported that increased presentation of risk factors did not alter monitoring frequency. Extravasations were primarily associated with the hand and wrist region (n = 118, 43.7%). Maintenance fluids, antibiotics and parenteral nutrition accounted for extravasation events. Acute management practices (immediate cessation of infusion) showed consistency (n = 124, 87.9%), whereas varying degrees of adoption were observed for aspirating the residual fluid. The majority of respondents (n = 119, 84%) reported the absence of a formal grading scale for extravasation severity.

CONCLUSIONS

Clinicians reported challenges and inconsistencies in neonatal and pediatric extravasation injury identification and management. This underscores the need for effective monitoring and identification, standardized management practices, and education to minimize the burdens of extravasation for patients, families, and the health care system.

Addressing Venous Extravasation, a Concern in Intravenous Iron Administration

Intravenous iron is commonly used to treat anemia related to chronic illnesses, but venous extravasation, an uncommon side effect of intravenous iron, can result in persistent skin discoloration. This report presents the case of a female patient who experienced venous extravasation following intravenous iron administration, with data collected from her patient record. Although venous extravasation is a rare adverse effect, it is important for both patients and healthcare providers to recognize this potential complication. Adhering to established criteria to minimize the occurrence of extravasation and its associated risks is essential for improving patient outcomes.

Management of Iron Deficiency in Heart Failure: Practical Considerations and Implementation of Evidence-Based Iron Supplementation

Iron deficiency (ID) is present in approximately 50% of patients with heart failure (HF) and even higher prevalence rate up to 80% in post-acute HF setting. The current guidelines for HF recommend intravenous (IV) iron replacement in HF with reduced or mildly reduced ejection fraction and ID based on clinical trials showing improvements in quality of life and exercise capacity, and an overall treatment benefit for recurrent HF hospitalization. However, several barriers cause challenges in implementing IV iron supplementation in practice due, in part, to clinician knowledge gaps and limited resource availability to protocolize routine utilization in appropriate patients. Thus, the current review will discuss practical considerations in ID treatment, implementation of evidence-based ID treatment to improve regional health disparities with toolkits, inclusion/exclusion criteria of IV iron supplementation, and clinical controversies in ID treatment, as well as gaps in evidence and questions to be answered.

Addressing and mitigating the high costs of extravasation and infiltration to patients and healthcare organisations

Infiltration and extravasation injuries are a common complication of intravenous therapy and vascular access practice. However, there remains a lack of awareness and understanding surrounding these injuries. The first of two articles (Barton, 2024) reported on data from a study showing that the use of ivWatch infusion site surveillance technology can dramatically reduce the number of infiltration and extravasation injures with peripheral intravenous infusions of vesicant preparations, which can improve patient safety and have a positive financial impact. This second of two articles on infiltration and extravasation examines the financial and academic burdens.

Extravasation associated with cancer drug therapy: multidisciplinary guideline of the Japanese Society of Cancer Nursing, Japanese Society of Medical Oncology, and Japanese Society of Pharmaceutical Oncology

BACKGROUND

Extravasation (EV), or the leakage of anticancer drugs into perivascular and subcutaneous tissues during intravenous administration, can cause serious conditions that may require surgical intervention. Therefore, updated guidelines for EV based on systematic review are needed. Additionally, classifications for anticancer drugs that cause EV are not standardized across the current guidelines, and some novel drugs have not been classified. Therefore, this study aimed to formulate guidelines using evidence-based information for shared decision making on prevention, early detection, treatment, and care for EV in Japan and provide additional classification for tissue injury based on systematic review.

MATERIALS AND METHODS

The members of the Japanese Society of Cancer Nursing (JSCN), Japanese Society of Medical Oncology (JSMO), and Japanese Society of Pharmaceutical Oncology (JASPO) were surveyed about significant clinical challenges related to EV, and 17 clinical questions (CQs) were formulated. PubMed and ICHUSHI Web were searched using the Patient, Intervention, Comparison, and Outcomes terms listed in each CQ as key words. For the classification of new drugs, articles published through February 2021 were selected using the search terms 'extravasation', 'injection-site reaction', 'adverse events', and the names of individual drugs as key words.

RESULTS

Recommendations based on the results of randomized controlled trials (RCTs) were made with regard to the selection of central venous (CV) devices (CQ2, CQ3a, CQ3b, and CQ3c), regular replacement of peripheral venous catheters (CQ5), and use of fosaprepitant (CQ7). These CQs are novel and were not mentioned in previous guidelines. Warm compression monotherapy (CQ10b) and local injection of steroids (CQ12) are discouraged for the management of EV. Ten new drugs were classified for EV tissue injury.

CONCLUSIONS

This study provides updated guidelines for the prevention and treatment of EV, which can be used to help health care providers and patients and their families practice better EV management.

A large forearm subcutaneous hematoma after contrast extravasation requires surgical managements: A case report

RATIONALE

Large extremity hematoma can rarely happen after contrast extravasation during a contrast-enhanced computed tomography scan. Some hematomas need prompt surgical managements.

PATIENT CONCERNS

A 77-year-old man had acute ischemic stroke and received the thrombolytic and antiplatelet therapies. He had a contrast extravasation during the computed tomography scan and developed a large hematoma in the right forearm, despite without evidence of compartment syndrome.

DIAGNOSIS

Right forearm hematoma, status post contrast extravasation.

INTERVENTIONS

The patient responded poorly to the routine care with arm elevation, cold pack, and wet dressing, and was finally treated by the surgical debridement, vacuum sealing drainage, fascioplasty, and skin flap repair.

OUTCOMES

Right forearm wound healed with a scar.

LESSONS

Large extremity hematoma can happen after contrast extravasation during computed tomography scan, which may require surgical treatments. Careful preparation, close monitor, and prompt managements should be applied in high-risk patients.

Vascular access devices for prolonged intravenous therapy regimens in people diagnosed with cancer

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the relative effectiveness and vascular access device (VAD)-related complications of VADs in people requiring prolonged systemic anti-cancer treatment.

A temperature-responsive intravenous needle that irreversibly softens on insertion

The high stiffness of intravenous needles can cause tissue injury and increase the risk of transmission of blood-borne pathogens through accidental needlesticks. Here we describe the development and performance of an intravenous needle whose stiffness and shape depend on body temperature. The needle is sufficiently stiff for insertion into soft tissue yet becomes irreversibly flexible after insertion, adapting to the shape of the blood vessel and reducing the risk of needlestick injury on removal, as we show in vein phantoms and ex vivo porcine tissue. In mice, the needles had similar fluid-delivery performance and caused substantially less inflammation than commercial devices for intravenous access of similar size. We also show that an intravenous needle integrated with a thin-film temperature sensor can monitor core body temperature in mice and detect fluid leakage in porcine tissue ex vivo. Temperature-responsive intravenous needles may improve patient care.

Integrating human expertise & automated methods for a dynamic and multi-parametric evaluation of large language models' feasibility in clinical decision-making

BACKGROUND

Recent enhancements in Large Language Models (LLMs) such as ChatGPT have exponentially increased user adoption. These models are accessible on mobile devices and support multimodal interactions, including conversations, code generation, and patient image uploads, broadening their utility in providing healthcare professionals with real-time support for clinical decision-making. Nevertheless, many authors have highlighted serious risks that may arise from the adoption of LLMs, principally related to safety and alignment with ethical guidelines.

OBJECTIVE

To address these challenges, we introduce a novel methodological approach designed to assess the specific feasibility of adopting LLMs within a healthcare area, with a focus on clinical nursing, evaluating their performance and thereby directing their choice. Emphasizing LLMs' adherence to scientific advancements, this approach prioritizes safety and care personalization, according to the "Organization for Economic Co-operation and Development" frameworks for responsible AI. Moreover, its dynamic nature is designed to adapt to future evolutions of LLMs.

METHOD

Through integrating advanced multidisciplinary knowledge, including Nursing Informatics, and aided by a prospective literature review, seven key domains and specific evaluation items were identified as follows:A Peer Review by experts in Nursing and AI was performed, ensuring scientific rigor and breadth of insights for an essential, reproducible, and coherent methodological approach. By means of a 7-point Likert scale, thresholds are defined in order to classify LLMs as "unusable", "usable with high caution", and "recommended" categories. Nine state of the art LLMs were evaluated using this methodology in clinical oncology nursing decision-making, producing preliminary results. Gemini Advanced, Anthropic Claude 3 and ChatGPT 4 achieved the minimum score of the State of the Art Alignment & Safety domain for classification as "recommended", being also endorsed across all domains. LLAMA 3 70B and ChatGPT 3.5 were classified as "usable with high caution." Others were classified as unusable in this domain.

CONCLUSION

The identification of a recommended LLM for a specific healthcare area, combined with its critical, prudent, and integrative use, can support healthcare professionals in decision-making processes.

Identification of Drugs and Patient Profiles at Risk for Severe Skin Injuries Due to Extravasation: Analysis of a Spontaneous Reporting System

This study aimed to identify risk factors and combinations thereof that are associated with severe skin injuries due to the extravasation of injectable drugs. A cross-sectional study using the Japanese Adverse Drug Event Report database was conducted according to the RECORD-PE checklist. Adverse event reports related to necrosis, ulcers, or erosions due to extravasation were considered "with severe skin injury," and others were considered "without severe skin injury." Approximately 255 cases "with" and 260 cases "without" severe skin injury were identified. The relationship between the incidence of severe skin injury and age, sex, drugs, and primary disease was evaluated using the χ2 test. Association rule mining was used to evaluate the correlation between each combination of factors and skin injury. Nine factors were identified as independent risk factors for severe skin injury, including age (<10 or ≥70 years), peripheral parenteral nutrition use, and mental disorders. The association rule mining results suggested that a combination of specific patient backgrounds and drug use was associated with the incidence of necrosis or ulcers. The findings of this study reiterate that nurses might consider closely observing patients with the risk factors identified in this study for the prevention and early detection of extravasation-related skin injuries.

Redefining the Classification of Extravasation Severity Using CLIP Linear Probe with Few-shot Instances

This study addresses extravasation, a critical issue requiring prompt detection for effective management to avoid severe complications. This work harnesses the capability of zero-shot capabilities from pre-trained vision transformer models-specifically, GroundingDINO and Segment Anything Model (SAM) for segment human skin regions, and Contrastive Language-Image Pretraining (CLIP) for extracting rich features from these regions using its frozen image encoder. Our methodology applies linear probe techniques to feature vectors obtained from CLIP using few-shot instances. The results demonstrate accurate classification of extravasation severities with training using only 64 instances per class, achieving average F1macro scores of 74.08% for GroundingDINO-CLIP. This marks an improvement result to the previous study which utilized dual U-Nets for skin and lesion segmentation alongside DenseNet-121 models for classification with training using 975 instances. Notably, this approach increases previous F1macro scores by 3.27% in mild extravasation cases. This research advances fine-grained extravasation classification, specifically in early detection, achieved through few-shot models in a unique context.

Exploring Extravasation in Cancer Patients

Extravasation, the unintended leakage of intravenously administered substances, poses significant challenges in cancer treatment, particularly during chemotherapy and radiotherapy. This comprehensive review explores the pathophysiology, incidence, risk factors, clinical presentation, diagnosis, prevention strategies, management approaches, complications, and long-term effects of extravasation in cancer patients. It also outlines future directions and research opportunities, including identifying gaps in the current knowledge and proposing areas for further investigation in extravasation prevention and management. Emerging technologies and therapies with the potential to improve extravasation prevention and management in both chemotherapy and radiotherapy are highlighted. Such innovations include advanced vein visualization technologies, smart catheters, targeted drug delivery systems, novel topical treatments, and artificial intelligence-based image analysis. By addressing these aspects, this review not only provides healthcare professionals with insights to enhance patient safety and optimize clinical practice but also underscores the importance of ongoing research and innovation in improving outcomes for cancer patients experiencing extravasation events.

Acyclovir extravasation in a newborn: a case report

OBJECTIVE

Extravasation of infused drugs is not a rare problem in medical practice. Acyclovir is a vesicant and an antiviral medication commonly used for young children. In the present study, we presented a neonate with soft tissue damage due to acyclovir extravasation.

CASE REPORT

A female newborn (Iranian, Asian) with gestational age 37+2 weeks and breech presentation was born by Cesarean delivery from a mother with a recent history of Herpes simplex virus (HSV) infection (Yas Women's Hospital, Tehran, Iran). Intravenous administration of acyclovir was initiated through a peripheral catheter inserted on the dorsal side of the left hand. A few minutes after the second dose, the patient showed a diffused firm swelling, local discoloration, and induration in the dorsum of the hand. The peripheral catheter was removed immediately. Hyaluronidase was injected subcutaneously in five different regions around the catheterization site. Intermittent limb elevation and cold compression (for 10 minutes) were applied. Serial follow-ups and examinations were performed hourly to check limb inflammation, ischemia, and compartment syndrome. The limb swelling and discoloration significantly improved 4 hours after the second dose of hyaluronidase.

CONCLUSION

Early diagnosis of acyclovir extravasation and immediate management could prevent severe complications in neonates. Further studies are needed to suggest a standard approach and treatment protocol for acyclovir extravasation.

Safe and Informed Use of Gadolinium-Based Contrast Agent in Body Magnetic Resonance Imaging: Where We Were and Where We Are

Gadolinium-based contrast agents (GBCAs) have helped to improve the role of magnetic resonance imaging (MRI) for the diagnosis and treatment of diseases. There are currently nine different commercially available gadolinium-based contrast agents (GBCAs) that can be used for body MRI cases, and which are classifiable according to their structures (cyclic or linear) or biodistribution (extracellular-space agents, target/specific-agents, and blood-pool agents). The aim of this review is to illustrate the commercially available MRI contrast agents, their effect on imaging, and adverse reaction on the body, with the goal to lead to their proper selection in different clinical contexts. When we have to choose between the different GBCAs, we have to consider several factors: (1) safety and clinical impact; (2) biodistribution and diagnostic application; (3) higher relaxivity and better lesion detection; (4) higher stability and lower tissue deposit; (5) gadolinium dose/concentration and lower volume injection; (6) pulse sequences and protocol optimization; (7) higher contrast-to-noise ratio at 3.0 T than at 1.5 T. Knowing the patient's clinical information, the relevant GBCAs properties and their effect on body MRI sequences are the key features to perform efficient and high-quality MRI examination.

Extravasation and infiltration: under-recognised complications of intravenous therapy

Occasionally, the administration of intravenous (IV) therapies can go wrong. Infiltration or extravasation is a complication when a drug or IV therapy leaks into the tissues surrounding the vascular access device. Extravasation can cause serious and often life-changing injuries. Extravasation is often associated with systemic anti-cancer therapy but non-chemotherapy drugs have been reported as having a greater risk of serious complications. This study outlines the first UK Infusion unit evaluation of the ivWatch infusion monitoring device which was undertaken from August 2023 to January 2024. Out of 2254 infusions monitored with ivWatch, the device prevented 122 cases of infiltration and extravasation from causing any harm to the patient, corresponding to a 5.4% 'check IV' notification rate.

Addressing and mitigating the high costs of extravasation and infiltration to patients and healthcare organisations

Infiltration and extravasation injuries are a common complication of intravenous therapy and vascular access practice. However, there remains a lack of awareness and understanding surrounding these injuries. The first of two articles (Barton, 2024) reported on data from a study showing that the use of ivWatch infusion site surveillance technology can dramatically reduce the number of infiltration and extravasation injures with peripheral intravenous infusions of vesicant preparations, which can improve patient safety and have a positive financial impact. This second of two articles on infiltration and extravasation examines the financial and academic burdens.

Extravasation and infiltration: under-recognised complications of intravenous therapy

Occasionally, the administration of intravenous (IV) therapies can go wrong. Infiltration or extravasation is a complication when a drug or IV therapy leaks into the tissues surrounding the vascular access device. Extravasation can cause serious and often life-changing injuries. Extravasation is often associated with systemic anti-cancer therapy but non-chemotherapy drugs have been reported as having a greater risk of serious complications. This study outlines the first UK Infusion unit evaluation of the ivWatch infusion monitoring device which was undertaken from August 2023 to January 2024. Out of 2254 infusions monitored with ivWatch, the device prevented 122 cases of infiltration and extravasation from causing any harm to the patient, corresponding to a 5.4% 'check IV' notification rate.

Extravasation of monoclonal antibodies commonly used in oncology: Classification, management and the role of the pharmacist

INTRODUCTION

Extravasation by conventional cytotoxics has been well documented. While monoclonal antibodies are not considered to have the necrotic potential of some cytotoxic medicines, they require appropriate management in case of extravasation. However, fewer data are available on their classification and appropriate management when extravasation occurs. As monoclonal antibodies are being more commonly used in current daily oncology practice, this is an issue that cannot be ignored.

METHODS

A scientific literature review on PubMed was conducted. All findings were critically appraised independently by 6 clinical pharmacists in order to provide a classification according to the extravasation hazard.

RESULTS

A classification of non-conjugated and conjugated monoclonal antibodies according to extravasation hazard has been elaborated for different molecules frequently used in oncology. In addition, general management, in case extravasation of monoclonal antibodies occurs, has been proposed and the role of the pharmacist in the extravasation process has been described.

CONCLUSION

A classification of hazard extent of extravasation of monoclonal antibodies with concurrent management based on literature data and expert consensus has been elaborated. In addition, the role of the oncology pharmacist is crucial in terms of follow-up and documentation of the extravasated monoclonal antibody and management is described.

Exploring the multifaceted effects of Ammi visnaga: subchronic toxicity, antioxidant capacity, immunomodulatory, and anti-inflammatory activities

Ammi visnaga (A. visnaga) is an annual herb that has been used in traditional medicine to treat various ailments attributed to the presence of its bioactive compounds. The purpose of this study was to identify and examine the phytochemical properties of the hydroalcoholic extract of A. visnaga using in vitro and in vivo models. Our findings demonstrated that the extract contained a variety of beneficial components, including phenols, flavonoids, tannins, coumarins, saponins, khellin, and visnagin. The total polyphenolic content and total flavonoid content were 23.26 mg/GAE/g dry weight and 13.26 mg/GAE/g dry weight, respectively. In vitro tests demonstrated that the extract possessed antioxidant properties as evidenced by the ability to scavenge free radicals, including DPPH, ABTS, nitric oxide (NO), phosphomolybdate, and ferric-reducing antioxidant power (FRAP). Further, the extract was found to inhibit hydrogen peroxide (H2O2)-induced hemolysis. In a 90-d in vivo study, female Wistar rats were administered 1 g/kg of A. visnaga extract orally resulting in a significant increase in total white blood cell count. Although morphological changes were observed in the liver, no marked alterations were noted in kidneys and spleen. In a female Swiss albino mice model of acetic acid-induced vascular permeability, A. visnaga significantly inhibited extravasations of Evans blue at doses of 0.5 or 1 g/kg with inhibition percentages of 51 and 65%, respectively, blocking tissue necrosis. The extract also demonstrated potential immunomodulatory properties in mice by enhancing antibody production in response to antigens. In silico molecular docking studies demonstrated a strong affinity between khellin or visnagin and immunomodulatory proteins, NF-κB, p52, and TNF-α. These findings suggest that A. visnaga may be considered a beneficial antioxidant with immunomodulatory properties and might serve as a therapeutic agent to combat certain diseases.

Predictors of central line-associated bloodstream infections in cancer patients undergoing chemotherapy through implanted venous access ports: a retrospective, observational study

Background

Central venous catheters (CVCs) are sometimes superior to peripheral vascular access for chemotherapy. Central line-associated bloodstream infections (CLABSIs) are an important complication of CVCs in chemotherapy.

Methods

A retrospective, observational study was conducted to investigate patients with implanted venous access ports (PORTs) from July 2010 to June 2021 in a teaching hospital. General conditions of the PORTs, backgrounds, and characteristics of patients were compared between CLABSI cases and uninfected cases to identify predictors of CLABSI.

Results

A total of 566 patients with PORTs who underwent chemotherapy were enrolled in this study, with CLABSI identified in 41 patients, for a total of 436,597 catheter-days. The median duration of PORT use was 26 vs. 494 days (P<0.001) in the CLABSI and uninfected groups, respectively. There were no significant differences in tumor classification, staging, white blood cell (WBC) count, neutrophil proportion, lymphocyte proportion, albumin, C-reactive protein (CRP), and performance status between the CLABSI and uninfected groups. Multivariable analysis showed that antibiotic usage within the previous week, total protein (TP), and immediate PORT use were independently associated with CLABSI, and their odds ratios (ORs) were 4.89 [95% confidence interval (CI): 1.67, 14.35], 1.95 (95% CI: 1.14, 3.53), and 3.13 (95% CI: 1.18, 8.30), respectively. The area under the curve (AUC) of the receiver-operating characteristic curve for TP was 0.63, and the cutoff value was 5.9 g/dL.

Conclusions

PORT implantation should be avoided in patients who had antibiotic treatment episodes within 1 week, especially for those with low serum TP levels.

Progress in Research on the Mechanisms and Interventions of Phlebitis from the Perspective of Vascular Endothelial Cell and Signaling Pathway

Background

Phlebitis is a common complication of intravenous administration and greatly affects clinical outcomes, patient satisfaction, and health-care expenditure. Numerous studies have revealed venous injuries only through visual and histopathological examination. Although sporadic studies have explored the cellular and molecular biological mechanisms of phlebitis and the outcomes of pharmacological interventions, an updated review over the last decade is not available.

Methods

Progress in research on the mechanisms and interventions of phlebitis was summarized from the perspective of endothelial cells and signaling pathways by retrieving the PubMed, Web of Science Core Collection, MEDLINE, Embase, and CNKI.

Results

Phlebitis involves multiple signaling pathways (eg, nuclear factor kappa B, Wnt/β-catenin, focal adhesion kinase/protein kinase B, Toll-like receptor, protein kinase C beta/NADPH oxidase, PI3K/AKT/TNF, and JAK2/STAT3), upregulation of E-selectin, GBP5/NLRP3 inflammasome axis, cell apoptosis, intracellular ROS generation, SOD reduction, stimulation of angiogenesis, and induction of autophagy-associated cell death. Preventive and curative interventions included α-solanine, baicalein, escin, intermedin, Y15, micro-ribonucleic acid-223, sotrastaurin, cimetidine, aescin, resveratrol, α-chaconine, Chahuang ointment, QingLuoTongMai, Mailuo Shutong, and N-acetylcysteine. Laboratory models included vascular endothelial cells, real-time cell-monitoring analysis, network pharmacology analysis and experimental verification in vivo, animal models of phlebitis (rat, rabbit, and mouse), rabbit models with peripherally inserted central catheters (PICC) catheterization, models of PICC/central venous catheter indwelling with combined drugs in human umbilical vein endothelial cells, and compatibility with endothelial cells. Factors affecting vascular endothelial cell injury include difference in the same class of drugs, concentration and exposure time of precipitant, and infusion strategy.

Conclusion

Phlebitis is accompanied by endothelial dysfunction and may involve multiple molecular and cellular mechanisms. These findings improve our understanding of the molecular targets of interventions and help identify effective candidates for the prophylaxis and treatment of phlebitis. Vascular health and risk management should be considered when initiating intravenous administration.

Effect of Pharmacoprophylaxis on Postoperative Outcomes in Adult Elective Colorectal Surgery: A Multi-Center Retrospective Cohort Study within an Enhanced Recovery after Surgery Framework

BACKGROUND

The application of enhanced recovery after surgery principles decreases postoperative complications (POCs), length of stay (LOS), and readmissions. Pharmacoprophylaxis decreases morbidity, but the effect of specific regimens on clinical outcomes is unclear.

METHODS AND MATERIALS

Records of 476 randomly selected adult patients who underwent elective colorectal surgeries (ECRS) at 10 US hospitals were abstracted. Primary outcomes were surgical site infection (SSI), venous thromboembolism (VTE), postoperative nausea and vomiting (PONV), pain, and ileus rates. Secondary outcomes included LOS and 7- and 30-day readmission rates.

RESULTS

POC rates were SSI (3.4%), VTE (1.5%), PONV (47.9%), pain (58.1%), and ileus (16.1%). Cefazolin 2 g/metronidazole 500 mg and ertapenem 1 g were associated with the shortest LOS; cefotetan 2 g and cefoxitin 2 g with the longest LOS. No SSI occurred with ertapenem and cefotetan. More Caucasians than Blacks received oral antibiotics before intravenous antibiotics without impact. Enoxaparin 40 mg subcutaneously daily was the most common inpatient and discharge VTE prophylaxis. All in-hospital VTEs occurred with unfractionated heparin. Most received rescue rather than around-the-clock antiemetics. Scopolamine patches, spinal opioids, and IV lidocaine continuous infusion were associated with lower PONV. Transversus abdominis plane block with long-acting local anesthetics, celecoxib, non-anesthetic ketamine bolus, ketorolac IV, lidocaine IV, and pregabalin were associated with lower in-hospital pain severity rates. Gabapentinoids and alvimopan were associated with lower ileus rates. Acetaminophen, alvimopan, famotidine, and lidocaine patches were associated with shorter LOS.

CONCLUSIONS

Significant differences in pharmacotherapy regimens that may improve primary and secondary outcomes in ECRS were identified. In adult ECRS, cefotetan or ertapenem may be better regimens for preventing in-hospital SSI, while ertapenem or C/M may lead to shorter LOS. The value of OA to prevent SSI was not demonstrated. Inpatient enoxaparin, compared to UFH, may reduce VTE rates with a similar LOS. A minority of patients had a documented PONV risk assessment, and a majority used as-needed rather than around-the-clock strategies. Preoperative scopolamine patches continued postoperatively may lower PONV and PDNV severity and shorter LOS. Alvimopan may reduce ileus and shorten LOS. Anesthesia that includes TAP block, ketorolac IV, and pregabalin use may lead to reduced pain rates. Acetaminophen, alvimopan, famotidine, and lidocaine patches may shorten LOS. Given the challenges of pain management and the incidence of PONV/PDNV found in this study, additional studies should be conducted to determine optimal opioid-free anesthesia and the benefit of newer antiemetics on patient outcomes. Moreover, future research should identify latent pharmacotherapy variables that impact patient outcomes, correlate pertinent laboratory results, and examine the impact of order or care sets used for ECRS at study hospitals.

Extravasation of Non-Cytotoxic Drugs in Older People

Objective To describe the risk factors of extravasation, its impact on the pharmacokinetics of non-cytotoxic drugs, and management of extravasation in older individuals. Extravasation occurs when vesicants leak from blood vessels into surrounding tissue causing severe injury such as tissue necrosis while infiltration is caused by leakage of an irritant that causes injury but does not lead to tissue necrosis. Extravasation occurs in approximately 0.01% to 6% of patients, particularly with cytotoxic agents. However, there is limited documentation about extravasation of non-cytotoxic agents, particularly in older people. Data Sources A literature search of Pubmed and Medline was performed using the following search items: "extravasation," "infiltration," "elderly," and "non-cytotoxic drugs," as well as a combination of these terms. Conclusion It is important to recognize, identify, and manage extravasation early since it can have deleterious consequences for older people. It is more important to prevent extravasation than manage it using standardized evidence-based protocols, and this can be implemented in the nursing facility and acute care setting.

Radiopharmaceutical extravasation in bone scintigraphy: a cross-sectional study

OBJETIVES

Tc-99m Hydroxymethylene diphosphonate (HMDP) bone scintigraphy is commonly used to diagnose bone disorders. We aimed to quantify and characterize the occurrence of radiopharmaceutical extravasation in bone scintigraphy, using Tc-99m HMDP, as well as to compare the visual classification of the events with an independent analysis using image processing software.

METHODS

We conducted a cross-sectional study, using data from a total of 400 (9.1%) exams, randomly selected from all the procedures performed in 2018 in the Portuguese Institute of Oncology of Porto, Portugal. Prevalence estimate and the corresponding 95% confidence interval (CI) was computed for the presence of extravasation. Odds ratios and 95% CI were computed to quantify the association between demographic and clinical characteristics, and the occurrence of extravasation.

RESULTS

The prevalence of Tc-99m HMDP extravasation was 26.5% (95% CI: 22.4-31.0). Those from an inpatient setting had almost seven-fold higher odds of extravasation than those from an outpatient setting. When the wrist was used for administration, there was three times more odds of extravasation when compared to the use of hand. There were statistically significant differences in the median scores of extravasations severity obtained from image processing software according to the different grades attributed by visual appreciation ( P  < 0.001).

CONCLUSION

Tc-99m HMDP extravasation occurred in one out of four patients, being more frequent among those from an inpatient setting and when the wrist was used for administration. Visual appreciation of the extravasation seems to be acceptable to classify its severity.

Profiles and Outcomes of Skin Injuries Caused by Injectable Drug Extravasation: An Analysis of the Japanese Adverse Drug Event Report Database

Extravasation occurs when injectable drugs leak out of the blood vessels, damaging the surrounding tissues and causing a variety of skin injuries. This study aimed to comprehensively analyze extravasation risk, skin injury profiles, and outcomes for suspect drugs from the Japanese Adverse Drug Event Report (JADER) database. Adverse events were defined according to the Medical Dictionary for Regulatory Activities/Japanese version; the term extravasation (Standardized MedDRA Query Code: 20000136) was used in this analysis. The names of adverse events were entered as unified preferred terms and redefined to evaluate skin injury profiles. In addition, skin injury outcomes were divided into 2 broad categories: "improvement" and "no improvement." Reporting odds ratios were used to detect signals for adverse events. A total of 656 cases of extravasation-related adverse events were reported between April 2004 and January 2022. Signals for extravasation-related adverse events were detected from 11 drugs. Then, their respective skin injury profiles and outcomes were determined. These results suggest a relationship between adverse events associated with extravasation and 11 drugs and identify the characteristics of each skin injury and their outcomes. These findings will contribute to improving the quality of infusion management in clinical practice.

Compartment Syndrome Secondary to Calcium Gluconate Extravasation

This case report highlights a rare yet severe complication of calcium gluconate extravasation, namely, compartment syndrome. We present the case of an 86-year-old female who developed compartment syndrome following an extravasation of intravenously administered calcium gluconate for the management of hyperkalemia. Initially, mild erythema and edema were observed at the site of extravasation, which eventually progressed to severe pain, a reduction in the joint range of motion due to increased compartment pressure. Despite undergoing a series of fasciotomies, the patient's condition did not improve, and extensive tissue necrosis and gangrene necessitated amputation. This case emphasizes that calcium gluconate extravasation can lead to life-threatening complications, such as compartment syndrome, underscoring the critical importance of employing proper infusion techniques.

Nurses' knowledge and experience related to short peripheral venous catheter extravasation

BACKGROUND

The majority of hospitalized patients receive a Peripheral Venous Catheter (PVC) in the course of their treatment. Extravasation injury is a serious complication of intravenous treatment.

OBJECTIVE

This cross-sectional survey designed study aims to investigate nurses' knowledge and experience related to short peripheral venous catheter extravasation.

METHOD

The study sample included 145 nurses working in a university hospital in the west of Turkey. A questionnaire developed in accordance with the literature was used for data collection. The data were assessed by frequency and proportions.

RESULTS

Of the nurses included in this study, 26.2% reported they had experienced extravasation injury in a patient; 74.5% said they had received no instruction in the management of extravasation during their in-service training program; and 85.5% stated they did not keep a record of extravasation. 89.7% of the nurses reported infused medications as a cause of extravasation, and 81.4% reported catheter sites as a cause. Among the medications reported by the nurses as causing extravasation: 89.7% reported contrast agents; 84.8% TPN solutions; 71.0% cytotoxic agents; and 65.1% mannitol. The symptoms of extravasation reported by nurses included: swelling (97.9%), redness (97.2%), pain (92.4%), rise in temperature (65.5%), and ulceration (60.0%). In responding to the occurrence of extravasation, interventions reported by the nurses included: stopping the flow of fluid (98.6%), elevation (89.7%), cold application (76.6%), and aspiration of drug (40.7%).

CONCLUSION

Based on these results, it is recommended that guidelines are developed for the management of extravasation, that periodic in-service training programs are provided and that observational studies are carried out into the administration of vesicant drugs.

Sensing Technologies for Extravasation Detection: A Review

Peripheral intravenous catheters are administered for various purposes, such as blood sampling or the infusion of contrast agents and drugs. Extravasation happens when the catheter is unintentionally directed outside of the vein due to movement of the intravascular catheter, enhanced vascular permeability, or occlusion of the upstream vein. In this article, extravasation and its mechanism are discussed. Subsequently, the sensorized devices (e.g., single sensor and multimodal detection) to identify the extravasation phenomena are highlighted. In this review article, we have shed light on both physiological and engineering points of view of extravasation and its detection approaches. This review provides an overview on the most recent and relevant technologies that can help in the early detection of extravasation.

An updated narrative review on the management of the most common oncological and hematological emergencies

Oncological emergencies are defined as an acute life-threatening event in a patient with a tumor occurring as part of their complex treatment regimen or secondarily to their underlying malignancy. These events can occur at any time from the initial diagnosis of their cancer to end-stage disease. These oncological emergencies are broadly classified into four major categories; metabolic, structural, hematological and treatment-related causes; and can be encountered in any clinical setting, ranging from primary care physician and emergency department visits to a variety of subspecialty environments. This study aims to cover an in-depth review of the underlying pathogenesis, clinical presentation, and updated management protocol of most common emergencies belonging to the above-mentioned categories. An all-language literature search was conducted on 15th October 2021 and 10th March 2022, limited to 5 years on PubMed database using the following search strings: oncological emergencies, malignant spinal cord compression, febrile neutropenia, hyperviscosity syndrome, superior vena cava syndrome, immune related adverse events, tumor lysis syndrome, hypercalcemia of malignancy, corrected calcium, malignant pericardial effusion and chemotherapy extravasation.

Skin Staining Following Intravenous Iron Extravasation in a Patient With Chronic Kidney Disease: A Case Report

Rationale

Intravenous iron is commonly use in anemia related to chronic kidney disease. Skin staining due to iron extravasation is a rare adverse reaction that can leave a long-term staining of the skin.

Presenting Concerns of the Patients

During iron derisomaltose infusion, patient reported iron extravasation. Five months after the incident, the skin stain related to the extravasation was still present.

Diagnosis

A case of skin staining due to iron derisomaltose extravasation was diagnosed.

Interventions/Outcomes

She was reviewed by dermatology and laser therapy was offered.

Teaching Points

Patients and clinicians need to be aware of this complication, and protocol needs to be put in place to minimize extravasation and its complication.

Effects of photobiomodulation (660 nm laser) on anthracycline extravasation: An experimental study

OBJECTIVE

to investigate the effect of using different agents (topical hyaluronidase, photobiomodulation, and the association of photobiomodulation with topical hyaluronidase) in preventing the formation of lesions caused by doxorubicin extravasation, as well as in the reduction of lesions formed by extravasation of this drug.

METHOD

a quasi-experimental study conducted with 60 Wistar rats, randomized into four groups with 15 animals each. Group 1 (Control); Group 2 (Hyaluronidase); Group 3 (Photobiomodulation); and Group 4 (Hyaluronidase + Photobiomodulation). A wound was induced by applying 1 mg of doxorubicin to the subcutaneous tissue of the back of the animals. The concentration of topical hyaluronidase was 65 turbidity units/g and the energy employed was 1 joule of 100 mW red laser per square centimeter. With macroscopic evaluation every two days for 28 days, the following variables were observed: skin integrity, presence of blisters, hyperemia, exudate, bleeding, edema, crust, peeling and granulation tissue.

RESULTS

the animals from the groups subjected to photobiomodulation obtained better results in the assessment of the following variables: bleeding, hyperemia, exudate, intact skin and edema.

CONCLUSION

it was evidenced that the association of photobiomodulation with topical hyaluronidase was effective in reducing the local effects and assisted in the wound healing process, and that PBM alone was able to prevent appearance of lesions.

Interplay between exosomes and autophagy machinery in pain management: State of the art

Despite recent progress regarding inexpensive medical approaches, many individuals suffer from moderate to severe pain globally. The discovery and advent of exosomes, as biological nano-sized vesicles, has revolutionized current knowledge about underlying mechanisms associated with several pathological conditions. Indeed, these particles are touted as biological bio-shuttles with the potential to carry specific signaling biomolecules to cells in proximity and remote sites, maintaining cell-to-cell communication in a paracrine manner. A piece of evidence points to an intricate relationship between exosome biogenesis and autophagy signaling pathways at different molecular levels. A close collaboration of autophagic response with exosome release can affect the body's hemostasis and physiology of different cell types. This review is a preliminary attempt to highlight the possible interface of autophagy flux and exosome biogenesis on pain management with a special focus on neuropathic pain. It is thought that this review article will help us to understand the interplay of autophagic response and exosome biogenesis in the management of pain under pathological conditions. The application of therapies targeting autophagy pathway and exosome abscission can be an alternative strategy in the regulation of pain.

Effects of high-quality nursing on complications of peripherally inserted central catheter placement in patients with leukemia

OBJECTIVE

To determine the effects of high-quality nursing on negative emotions, treatment compliance, and complications of peripherally inserted central catheter (PICC) placement in patients with leukemia.

METHODS

A total of 87 patients with leukemia treated in our hospital from May 2018 to May 2020 were retrospectively enrolled and their clinical data were analyzed. The patients were assigned to a routine group (n=40) and a high-quality group (n=47) based on different nursing schemes. The self-rating depression scale (SDS) and self-rating anxiety scale (SAS) were used to compare the negative emotional changes in patients of the two groups, and the visual analogue scale (VAS) was used to analyze the degree of pain. The two groups were compared in treatment compliance, quality of life, incidence of complications of PICC placement, and nursing satisfaction.

RESULTS

After intervention, the high-quality group got significantly lower SDS and SAS scores than the routine group (both P<0.05). Compared with the routine group, the high-quality group showed higher treatment compliance and nursing satisfaction, experienced higher quality of life (all P<0.05), with also a lower total incidence of complications of PICC placement (P<0.01).

CONCLUSION

For patients with leukemia, high-quality nursing can substantially improve their psychological state, treatment compliance and nursing satisfaction, and reduce the incidence of complications of PICC placement.

Cutaneous Management after Extravasation of High-Concentrated Amino Acid Solution Administered for Renal Protection in PRRT

High-concentrated amino acid solution is used to protect the kidneys during peptide receptor radionuclide therapy (PPRT) in patients with neuroendocrine tumors (NETs). Extravasation of the solution can cause cutaneous complications. In this study, we described a 66-year-old man with metastatic medullary thyroid cancer and a 32-year-old woman with metastatic pancreatic NET who developed cutaneous lesions caused by the extravasation of an amino acid solution (25 g of lysine and 25 g of arginine in 1 L of normal saline) during PRRT with [¹⁷⁷Lu]Lu-DOTA-TATE. Both were treated conservatively, and these cutaneous lesions gradually improved. The patient with metastatic pancreatic NET rejected the amino acid infusion in subsequent cycles of PRRT and therefore received [¹⁷⁷Lu]Lu-DOTA-TATE alone, and her serum creatinine level and estimated glomerular filtration rate (eGFR) remained normal for 2 months after the last treatment. These two cases revealed cutaneous complications resulting from high-concentrated amino acid solution during PRRT because of hyperosmolarity. Health care providers should be aware of this complication to ensure its prevention and appropriate management. Preserved renal function was demonstrated after [¹⁷⁷Lu]Lu-DOTA-TATE treatment in the absence of the infusion of a high-concentrated amino acid solution. However, long-term follow-up of renal function is suggested.

Drug Extravasation in a Large General Hospital in Hunan, China: A Retrospective Survey

Background and Aim

Drug extravasation is one of the most common complications of intravenous therapy, which can lead to severe tissue injury if inappropriately treated. This study analyzes the current situation of extravasation and the risk factors affecting the severity of extravasation to provide a theoretical basis for carrying out prospective research, reducing the severity of drug extravasation, and strengthening the management of drug extravasation.

Materials and Methods

We retrieved the data on extravasation from January 2016 to December 2020 from the hospital’s safe infusion management system. We used nonparametric tests to assess the differences in the severity of drug extravasation among each variable and performed a multivariate analysis using multivariate ordered logistic regression.

Results

Extravasation occurred in 0.038% (263/694,043) of patients, including 203 cases of mild extravasation (77.2%), 57 cases of moderate extravasation (21.7%), and 3 cases of severe extravasation (1.1%). The main diseases of the patients with extravasation were cancer (24.7%), neurological-related diseases (19.4%), circulatory-related diseases (14.8%), and digestive-related diseases (14.1%); the main extravasated drugs were hypotonic or hypertonic drugs (31.9%) and contrast media (27.8%); the infusion tools of extravasation were indwelling needles (92.0%) and steel needles (8.0%). The multi-factor analysis showed that close to joints, patients’ age ≤6 or age >65, cancer, neurological-related diseases, circulatory-related diseases, antineoplastic agents, hypotonic or hypertonic drugs and strong acid or alkali drugs were independent risk factors for more severe extravasation. The nurses’ age and first identified by nurse were nurse-related factors that influenced the severity of drug extravasation.

Conclusion

To prevent the occurrence of drug extravasation and reduce its severity, the nurses should strengthen the learning of emergency plans related drug extravasation, strengthen inspections of high-risk patients. Besides, the managers should strengthen the risk warning management of high-risk extravasated drugs.

Chemotherapy Extravasation: Incidence of and Factors Associated With Events in a Community Cancer Center

BACKGROUND

The administration of chemotherapy is a high-risk and nurse-sensitive practice. One complication is extravasation.

OBJECTIVES

The purpose of this study was to determine the incidence of and iatrogenic factors associated with extravasation in the ambulatory and inpatient settings of a community cancer center.

METHODS

Events were reviewed by agent, route of administration, patient characteristics, and RNs administering the agent. A one-year, retrospective review of electronic health records and pharmacy and nursing reports was conducted.

FINDINGS

The number of vesicants, irritants, and irritants with vesicant properties administered was 12,260 in the ambulatory setting and 612 on the inpatient unit, with 21 and 1 extravasation events, respectively. Incidence rates for both settings were 0.001%. The most common agent to extravasate was docetaxel, and all events occurred via peripheral route. The incidence of events was lower than the reported benchmark for National Cancer Institute-designated cancer centers.

Tissue distribution of epirubicin after severe extravasation in humans

PURPOSE

As critical parameter after extravasation of cytotoxic vesicants, anthracyclines were determined in removed tissue from patients requiring surgical intervention due to tissue necrosis. We monitored their distribution within the affected lesion to establish a possible dose-toxicity relation.

METHODS

From six patients scheduled for surgery, removed tissue flaps were systematically analysed by HPLC (epirubicin: 5 subjects; doxorubicin: 1 subject).

RESULTS

After extravasation, tissue concentrations were highly variable with an individual anthracycline distribution pattern ranging from a few nanograms up to 17 µg per 100 mg tissue, which indicated a substantial difference in tissue sensitivity among patients. The resection borders coincided with the extension of the erythema and guided the surgical intervention after demarcation of the lesion, which occurred usually 2 or 3 weeks after extravasation. At that time, drug was hardly detected at the resection borders. Wound drains were negative for the extravasated drugs while showing a time profile of vascular growth factors and inflammatory cytokines, which was highly similar to routine surgery. In all six patients, surgical debridement with immediate wound closure led to healing within approximately 2 weeks, when therapy was resumed in all patients with reasonable time delay.

CONCLUSION

Surgical intervention after demarcation of the extravasation lesion allows for almost uninterrupted continuation of treatment independent of the amount of extravasated anthracycline. As even minor amounts of the vesicants may trigger tissue necrosis, preventive measures merit the highest priority.

[Guidelines for neonatal skin management in the neonatal intensive care unit (2021)]

Neonates are easily suffering from local or systematic infections due to their vulnerable skin barrier function, which leads to the increasing risk of death. Therefore, it is important to protect neonatal skin integrity and prevent neonatal skin injury in the neonatal intensive care unit (NICU). Based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) and current evidence, the guidelines for neonatal skin management in the NICU were developed to provide recommendations on routine skin care and prevention and treatment of iatrogenic skin injury of neonates for health care providers.

[Guidelines for neonatal skin management in the neonatal intensive care unit (2021)]

Neonates are easily suffering from local or systematic infections due to their vulnerable skin barrier function, which leads to the increasing risk of death. Therefore, it is important to protect neonatal skin integrity and prevent neonatal skin injury in the neonatal intensive care unit (NICU). Based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) and current evidence, the guidelines for neonatal skin management in the NICU were developed to provide recommendations on routine skin care and prevention and treatment of iatrogenic skin injury of neonates for health care providers.

Measuring the Validity and Reliability of the Vascular Access Complication Staging and Treatment Instrument in a Pediatric Population

A multiphase study designed with Delphi and observational components was conducted to establish the preliminary validity and reliability of the 2018 Vascular Access Complication Staging and Treatment Instrument in pediatric and neonatal populations from a single, free-standing academic children's hospital. The instrument uses objective measurement criterion to determine the severity of swelling and tissue damage to inform treatment decisions. The results of the study provided preliminary empirical evidence to support a pediatric and neonatal intravenous complication staging instrument to assess degree of swelling and severity of tissue injury. The study also offered preliminary evidence that the instrument was perceived by the nurses who participated in the study to be efficient and easy to use.

Elaboration and validation of an algorithm for treating peripheral intravenous infiltration and extravasation in children

OBJECTIVE

to elaborate and validate the content and appearance of an algorithm for treating infiltration and extravasation of non-chemotherapy drugs and solutions administered to children.

METHOD

a methodological study of the technology formulation and validation type. To elaborate the algorithm, a bibliographic review was carried out to list the scientific evidence on the treatment of infiltration and extravasation. Content and appearance validation was in charge of 14 specialists in pediatric nursing, using the Delphi technique, adopting a value equal to or greater than 0.80 as Content Validation Index.

RESULTS

the algorithm was validated in the third evaluation by the judges, reaching a Global Content Validation Index of 0.99, being composed by the perception of the occurrence of the complication; discontinuation of intravenous therapy infusion; verification of signs and symptoms; measurement of edema; application of an infiltration and extravasation assessment scale and conduits to be used according to the characteristics of the fluid administered and the type of complication.

CONCLUSION

the algorithm was validated and can be used in a practical and objective way by health professionals, in order to promote safety in the care of hospitalized children, with regard to reducing harms caused by infiltration and extravasation.

Efficacy of combination of localized closure, ethacridine lactate dressing, and phototherapy in treatment of severe extravasation injuries: A case series

BACKGROUND

The management of severe extravasation injuries is still controversial. Extravasation injuries can be treated in many ways.

AIM

To present a series of patients with severe extravasation injuries due to infusion who were managed with ethacridine lactate dressing combined with localized closure and phototherapy.

METHODS

In this study, we evaluated the data of eight patients, including six from the Department of Burn, one (with colorectal carcinoma) from the Veteran Cadre Department, and one (with leukemia) from the Hematology Department. Of these, three patients were male and five were female. Age of the patients ranged from 10 mo to 72 years, including two children (10 and 19 mo of age). In this study, the infusion was stopped immediately when the extravasation was identified. The extravasation event was managed routinely using a blocking solution. A ring-shaped localized closure was performed using the blocking agents. Moreover, ethacridine lactate dressing and phototherapy were applied for 3-5 d.

RESULTS

In this study, the drugs contained in the infusates were iodixanol, norepinephrine, alprostadil, amino acids, fat emulsion, cefoselis, cefoxitin, and potassium chloride + concentrated sodium chloride. All of the patients achieved complete healing after treatment and no obvious adverse reactions were observed.

CONCLUSION

The treatment of severe extravasation injuries using a combination of localized closure, ethacridine lactate dressing, and phototherapy resulted in satisfactory outcomes in patients.