Local Care:

1. If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity.

2. May be managed with sodium thiosulfate in the same manner as mechlorethamine extravasation (see #3 and #4 below) (Schulmeister 2011).

3. Isotonic sodium thiosulfate may be used as an antidote. Prepare 1/6 molarolar solution.

a. If a 10% sodium thiosulfate solution: mix 4 ml with 6 ml sterile water for injection.

b. If a 25% sodium thiosulfate solution: mix 1.6 ml with 8.4 ml of sterile water for injection.

4. Inject 1/6 molar sodium thiosulfate subcutaneously into extravasation area using 2 mL for each mg of mechlorethamine suspected to have extravasated (Perez Fidalgo, 2012; Polovich, 2009). Apply ice for 6 to 12 hours after sodium thiosulfate administration (Mustargen prescribing information, 2013; Polovich, 2009).

Nursing Considerations:

⇰ Apply dry cold compresses for 20 minutes, 4 times daily, for 1 to 2 days (Perez Fidalgo, 2012).

⇰ Avoid alcohol compresses.

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Local Care:

1. Apply dry local compresses.

Local Care:

1. Apply dry local compresses.

Local Care:

1. Apply dry local compresses.

Nursing Considerations:

⇰ Irritant: Irritants cause short lived and limited irritation to the vein.

⇰ Apply dry warm compresses for 20 minutes, 4 times daily, for 1 to 2 days (Perez Fidalgo, 2012).

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Nursing Considerations:

⇰ Apply dry cold compresses for 20 minutes, 4 times daily, for 1 to 2 days (Perez Fidalgo, 2012).

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Notes:

★ Known to cause chemical phlebitis.

Local Care:

1. If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); initiate sodium thiosulfate antidote; elevate extremity.

2. Isotonic sodium thiosulfate may be used as an antidote. Prepare 1/6 molar solution.

a. If a 10% sodium thiosulfate solution: mix 4 ml with 6 ml sterile water for injection.

b. If a 25% sodium thiosulfate solution: mix 1.6 ml with 8.4 ml of sterile water for injection.

3. Inject 2 mL of 1/6 molar sodium thiosulfate into existing IV line for each 100 mg of cisplatin extravasated. Remove needle.

4. Then consider also injecting 1 mL of 1/6 molar sodium thiosulfate as 0.1 mL subcutaneous injections (clockwise) around the area of extravasation, may repeat subcutaneous injections several times over the next 3 to 4 hours (Ener 2004).

5. Dimethyl sulfoxide (DMSO) may also be considered an option: Apply to a region covering twice the affected area every 8 hours for 7 days; begin within 10 minutes of extravasation; do not cover with a dressing (Perez Fidalgo 2012).

Nursing Considerations:

⇰ Use of sodium thiosulfate requires MD order.

⇰ Vesicant > 0.4 mg/ml

⇰ Irritant ≤ 0.4 mg/ml

⇰ If irritant: apply dry warm compresses for 20 minutes, 4 times daily, for 1 to 2 days; elevate (Perez Fidalgo, 2012)

⇰ Use 25-gauge needle or smaller to inject antidote.

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Notes:

★ Known to cause local skin reactions.

★ Known to cause chemical phlebitis.

Local Care:

1. Apply dry local compresses.

Nursing Considerations:

⇰ Protect exposed tissue from light following extravasation.

⇰ Apply dry cold compresses for 20 minutes, 4 times daily, for 1 to 2 days (Perez Fidalgo, 2012).

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Notes:

★ Known to cause chemical phlebitis.

Local Care:

1. If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity.

Nursing Considerations:

⇰ Apply dry cold compresses for 20 minutes, 4 times daily, for 1 to 2 days (Perez Fidalgo, 2012).

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Nursing Considerations:

⇰ May cause pain or burning at IV site.

⇰ Little information is known.

⇰ Apply dry cold compresses for 20 minutes, 4 times daily, for 1 to 2 days (Perez Fidalgo, 2012).

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Notes:

★ Known to cause local skin reactions.

Local Care:

1. If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity.

2. Information conflicts regarding the use of warm or cold compresses (Perez Fidalgo, 2012; Polovich, 2009).

Nursing Considerations:

⇰ Apply dry warm compresses for 20 minutes, 4 times daily, for 1 to 2 days (Perez Fidalgo, 2012).

⇰ Single case reports describe both irritant and vesicant properties.

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Local Care:

1. If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in elevate extremity.

2. Withhold cooling beginning 15 minutes before dexrazoxane infusion; continue withholding cooling until 15 minutes after infusion is completed. Topical DMSO should not be administered in combination with dexrazoxane; may lessen dexrazoxane efficacy.

3. Initiate antidote (dexrazoxane or dimethyl sulfate [DMSO]).

4. Dexrazoxane: Adults: 1,000 mg/M² (maximum dose: 2,000 mg) IV (administer in a large vein remote from site of extravasation) over 1 to 2 hours days 1 and 2, then 500 mg/M² (maximum dose: 1,000 mg) IV over 1 to 2 hours day 3; begin within 6 hours of extravasation. Day 2 and day 3 doses should be administered at approximately the same time (±3 hours) as the dose on day 1 (Perez Fidalgo, 2012; Mouridsen, 2007).

a. Note: Reduce dexrazoxane dose by 50% in patients with moderate to severe renal impairment (CrCl <40 mL/minute).

5. Dimethyl sulfoxide (DMSO): Children and Adults: Apply topically (ie: paint on the skin) to a region covering twice the affected area every 8 hours for 7 days; begin within 10 minutes of extravasation; do not cover with a dressing (Perez Fidalgo, 2012).

Nursing Considerations:

⇰ Use of dexrazoxane requires MD order.

⇰ Apply dry cold compresses for 20 minutes, 4 times daily, for 1 to 2 days (Perez Fidalgo, 2012).

⇰ Extravasations of less than 1 to 2 ml often heal spontaneously. If greater than 3 ml, ulcerations often result (Goodman, 2000).

⇰ Protect area of extravasation from sunlight and heat.

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Notes:

★ Known to cause local skin reactions.

Local Care:

1. If extravasation, infiltration, or burning/stinging sensation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity (Perez Fidalgo, 2012; Polovich, 2009).

2. Do not apply pressure to the site. Apply ice to the site for 15 minutes, 4 times daily, for 3 days.

Nursing Considerations:

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Local Care:

1. If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity.

2. Withhold cooling beginning 15 minutes before dexrazoxane infusion; continue withholding cooling until 15 minutes after infusion is completed. Topical DMSO should not be administered in combination with dexrazoxane; may lessen dexrazoxane efficacy.

3. Initiate antidote (dexrazoxane or dimethyl sulfate [DMSO]).

4. Dexrazoxane: Adults: 1,000 mg/M² (maximum dose: 2,000 mg) IV (administer in a large vein remote from site of extravasation) over 1 to 2 hours days 1 and 2, then 500 mg/M² (maximum dose: 1,000 mg) IV over 1 to 2 hours day 3; begin within 6 hours of extravasation. Day 2 and day 3 doses should be administered at approximately the same time (±3 hours) as the dose on day 1 (Perez Fidalgo, 2012; Mouridsen, 2007).

a. Note: Reduce dexrazoxane dose by 50% in patients with moderate to severe renal impairment (CrCl <40 mL/minute).

5. Dimethyl sulfoxide (DMSO): Children and Adults: Apply topically (ie: paint on the skin) to a region covering twice the affected area every 8 hours for 7 days; begin within 10 minutes of extravasation; do not cover with a dressing (Perez Fidalgo, 2012).

Nursing Considerations:

⇰ Use of dexrazoxane requires MD order

⇰ Apply dry cold compresses for 20 minutes, 4 times daily, for 1 to 2 days (Perez Fidalgo, 2012).

⇰ Extravasations of less than 1 to 2 ml often heal spontaneously. If greater than 3 ml, ulcerations often result (Goodman, 2000).

⇰ Protect area of extravasation from sunlight and heat.

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Notes:

★ Known to cause local skin reactions.

★ Known to cause chemical phlebitis.

Nursing Considerations:

⇰ May be an irritant.

⇰ No specific treatment for extravasation — if occurs discontinue immediately, administer into another vein.

⇰ Apply dry cold compresses for 20 minutes, 4 times daily, for 1 to 2 days (Perez Fidalgo, 2012).

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Nursing Considerations:

⇰ May be an irritant.

⇰ No specific antidote.

⇰ Apply dry cold compresses for 20 minutes, 4 times daily, for 1 to 2 days (Perez Fidalgo, 2012).

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Local Care:

1. Apply dry local compresses.

Notes:

★ Known to cause chemical phlebitis.

Local Care:

1. If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity.

2. Withhold cooling beginning 15 minutes before dexrazoxane infusion; continue withholding cooling until 15 minutes after infusion is completed. Topical DMSO should not be administered in combination with dexrazoxane; may lessen dexrazoxane efficacy.

3. Initiate antidote (dexrazoxane or dimethyl sulfate [DMSO]).

4. Dexrazoxane: Adults: 1,000 mg/M² (maximum dose: 2,000 mg) IV (administer in a large vein remote from site of extravasation) over 1 to 2 hours days 1 and 2, then 500 mg/M² (maximum dose: 1,000 mg) IV over 1 to 2 hours day 3; begin within 6 hours of extravasation. Day 2 and day 3 doses should be administered at approximately the same time (±3 hours) as the dose on day 1 (Perez Fidalgo, 2012; Mouridsen, 2007).

a. Note: Reduce dexrazoxane dose by 50% in patients with moderate to severe renal impairment (CrCl <40 mL/minute).

5. Dimethyl sulfoxide (DMSO): Children and Adults: Apply topically (ie: paint on the skin) to a region covering twice the affected area every 8 hours for 7 days; begin within 10 minutes of extravasation; do not cover with a dressing (Perez Fidalgo, 2012).

Nursing Considerations:

⇰ Use of dexrazoxane requires MD order

⇰ Apply dry cold compresses for 20 minutes, 4 times daily, for 1 to 2 days (Perez Fidalgo, 2012).

⇰ Extravasations of less than 1 to 2 ml often heal spontaneously. If greater than 3 ml, ulcerations often result (Goodman, 2000).

⇰ Protect area of extravasation from sunlight and heat.

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Nursing Considerations:

⇰ Irritant: Irritants cause short lived and limited irritation to the vein.

⇰ Apply dry cold compresses for 20 minutes, 4 times daily, for 1 to 2 days (Perez Fidalgo, 2012).

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Local Care:

1. If extravasation occurs, flush site with sterile water for injection, elevate extremity and apply ice.

Nursing Considerations:

⇰ May be an irritant.

⇰ Apply dry cold compresses for 20 minutes, 4 times daily, for 1 to 2 days (Perez Fidalgo, 2012).

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Local Care:

1. If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity.

Nursing Considerations:

⇰ Apply dry cold compresses for 20 minutes, 4 times daily, for 1 to 2 days (Perez Fidalgo, 2012).

⇰ Avoid alcohol compresses.

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Local Care:

Extravasation may cause local tissue damage; administration by slow injection into a fast running IV solution into an injection port or via a central line is recommended; do not administer by direct injection into a peripheral vein.

Nursing Considerations:

⇰ Irritant - see local care for administration recommendations.

⇰ Apply dry cold compresses for 20 minutes, 4 times daily, for 1 to 2 days (Perez Fidalgo, 2012).

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Notes:

★ Known to cause local skin reactions.

Local Care:

1. Apply dry local compresses.

Local Care:

1. If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity.

2. Initiate dimethyl sulfate (DMSO) antidote.

a. Apply topically to a region covering twice the affected area every 8 hours for 7 days; begin within 10 minutes of extravasation; do not cover with a dressing (Perez Fidalgo, 2012).

Nursing Considerations:

⇰ Apply dry cold compresses for 20 minutes, 4 times daily, for 1 to 2 days (Perez Fidalgo, 2012).

⇰ Protect area of extravasation from sunlight.

⇰ Delayed skin reactions have occurred in areas far from the original IV site.

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Local Care:

1. If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity.

2. Information conflicts regarding use of warm or cold compresses. Cold compresses could potentially precipitate or exacerbate peripheral neuropathy (de Lemos, 2005).

Nursing Considerations:

⇰ Irritant with vesicant-like properties.

⇰ Single case reports describe both irritant and vesicant properties.

⇰ Apply dry warm compresses for 20 minutes, 4 times daily, for 1 to 2 days (Perez Fidalgo, 2012).

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Local Care:

1. If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; initiate antidote (hyaluronidase); remove needle/cannula; elevate extremity.

2. Hyaluronidase: If needle/cannula still in place: Administer 1 to 6 mL (150 units/mL) into existing IV line; usual dose is 1 mL for each 1 mL of extravasated drug; if needle/cannula has been removed, inject subcutaneously in a clockwise manner around area of extravasation; may repeat several times over the next 3 to 4 hours (Ener, 2004).

3. Information conflicts regarding the use of warm or cold compresses (Perez Fidalgo, 2012; Polovich, 2009).

Nursing Considerations:

⇰ Apply dry warm compresses for 20 minutes, 4 times daily, for 1 to 2 days (Perez Fidalgo, 2012).

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Local Care:

1. Apply dry local compresses.

Nursing Considerations:

⇰ Little information is known.

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Local Care:

1. If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula (see #4 prior to removal).

2. Remaining portion of the vinblastine dose should be infused through a separate vein.

3. Initiate hyaluronidase antidote.

4. Hyaluronidase: If needle/cannula still in place, administer 1 to 6 mL hyaluronidase (150 units/mL) into the existing IV line; the usual dose is 1 mL hyaluronidase for each 1 mL of extravasated drug (Perez Fidalgo, 2012; Schulmeister, 2011). If needle/cannula was removed, inject 1 to 6 mL (150 units/mL) subcutaneously in a clockwise manner using 1 mL for each 1 mL of drug extravasated (Schulmeister, 2011) or administer 1 mL (150 units/mL) as 5 separate 0.2 mL injections (using a 25-gauge needle) subcutaneously into the extravasation site (Polovich, 2009).

Nursing Considerations:

⇰ Use of hyaluronidase requires MD order.

⇰ Apply dry warm compresses for 20 minutes, 4 times daily, for 1 to 2 days (Perez Fidalgo, 2012).

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Local Care:

1. If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula (see #4 prior to removal).

2. Remaining portion of the vincristine dose should be infused through a separate vein.

3. Initiate hyaluronidase antidote.

4. Hyaluronidase: If needle/cannula still in place, administer 1 to 6 mL hyaluronidase (150 units/mL) into the existing IV line; the usual dose is 1 mL hyaluronidase for each 1 mL of extravasated drug (Perez Fidalgo, 2012; Schulmeister, 2011). If needle/cannula was removed, inject 1 to 6 mL (150 units/mL) subcutaneously in a clockwise manner using 1 mL for each 1 mL of drug extravasated (Schulmeister, 2011) or administer 1 mL (150 units/mL) as 5 separate 0.2 mL injections (using a 25-gauge needle) subcutaneously into the extravasation site (Polovich, 2009).

Nursing Considerations:

⇰ Use of hyaluronidase requires MD order.

⇰ Apply dry warm compresses for 20 minutes, 4 times daily, for 1 to 2 days (Perez Fidalgo, 2012).

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Local Care:

1. If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula (see #4 prior to removal).

2. Remaining portion of the vindesine dose should be infused through a separate vein.

3. Initiate hyaluronidase antidote.

4. Hyaluronidase: If needle/cannula still in place, administer 1 to 6 mL hyaluronidase (150 units/mL) into the existing IV line; the usual dose is 1 mL hyaluronidase for each 1 mL of extravasated drug (Perez Fidalgo, 2012; Schulmeister, 2011). If needle/cannula was removed, inject 1 to 6 mL (150 units/mL) subcutaneously in a clockwise manner using 1 mL for each 1 mL of drug extravasated (Schulmeister, 2011) or administer 1 mL (150 units/mL) as 5 separate 0.2 mL injections (using a 25-gauge needle) subcutaneously into the extravasation site (Polovich, 2009).

Nursing Considerations:

⇰ Use of hyaluronidase requires MD order.

⇰ Apply dry warm compresses for 20 minutes, 4 times daily, for 1 to 2 days (Perez Fidalgo, 2012).

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Local Care:

1. If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula (see #4 prior to removal).

2. Remaining portion of the vinorelbine dose should be infused through a separate vein.

3. Initiate hyaluronidase antidote.

4. Hyaluronidase: If needle/cannula still in place, administer 1 to 6 mL hyaluronidase (150 units/mL) into the existing IV line; the usual dose is 1 mL hyaluronidase for each 1 mL of extravasated drug (Perez Fidalgo, 2012; Schulmeister, 2011). If needle/cannula was removed, inject 1 to 6 mL (150 units/mL) subcutaneously in a clockwise manner using 1 mL for each 1 mL of drug extravasated (Schulmeister, 2011) or administer 1 mL (150 units/mL) as 5 separate 0.2 mL injections (using a 25-gauge needle) subcutaneously into the extravasation site (Polovich, 2009).

Nursing Considerations:

⇰ Use of hyaluronidase requires MD order.

⇰ Apply dry warm compresses for 20 minutes, 4 times daily, for 1 to 2 days (Perez Fidalgo, 2012).

⇰ Assess all patients for pain, blisters, sloughing frequently. Instruct patient to report fever chills, blistering, sloughing, increased pain swelling or stiffness.

Notes:

★ Known to cause chemical phlebitis.