Managing Extravasation During Chemotherapy Administration

Chemotherapy extravasation occurs when a vesicant medication leaks out of a vein into the surrounding soft tissues during an intravenous (IV) infusion. Vesicants and irritants with vesicant potential are chemotherapy medications that can cause significant damage to the soft tissue surrounding a vein and can include blistering, sloughing, and tissue necrosis. Extravasation injuries can cause permanent and potentially disfiguring damage, and may require surgical intervention to manage.

Examples of vesicants include anthracyclines (epirubicin, doxorubicin), vinca alkaloids (vinblastine, vincristine), and mitomycin. Examples of irritants with vesicant potential include taxanes (paclitaxel, docetaxel), platinum-based agents (cisplatin, oxaliplatin), gemcitabine, and etoposide.¹

Extravasation may occur for multiple reasons, and risk factors associated with the medication, the patient, or the procedure can contribute to the development of extravasation. High doses or concentrations of vesicants or irritants with vesicant potential may increase the risk of extravasation. If a patient has small or difficult-to-access veins, or if chemotherapy has been given through the vein previously, extravasation may be more likely to occur. Inexperience in chemotherapy administration may also make extravasation more likely to happen if a nurse chooses the incorrect cannula size for an IV needle .²

Signs/Symptoms

Signs and symptoms of extravasation may vary depending on the medication and the volume of vesicant that extravasated. Although some symptoms may develop quickly, it is possible that symptoms may not develop until days or weeks following an infusion. The first symptom experienced by the patient may be discomfort near the IV site. The patient also may develop redness or swelling around the peripheral IV. If a central line is used, redness or swelling around the insertion site may be seen, and the patient may complain of pain or numbness.³ Other symptoms that may develop later include skin discoloration, blisters, and damage to deeper tissues such as tendons, muscles, and nerves.

Levels of Severity

Extravasation severity is defined using the Common Terminology Criteria for Adverse Events (CTCAE) grades, and are described as follows:

• Grade 1 extravasation: Edema without pain or discomfort;
• Grade 2 extravasation: Erythema and other symptoms such as pain, swelling, or phlebitis;
• Grade 3 extravasation: Severe tissue damage such as blistering, ulcers, or necrosis;
• Grade 4 extravasation: Life-threatening tissue damage; or
• Grade 5 extravasation: Death.⁴