Appendix B: Extravasation Risk of Chemotherapeutic Agents

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Vesicants	Irritants
Dactinomycin* Daunorubicin*‡ Doxorubicin*‡ Epirubicin*‡ Idarubicin*‡ Liposomal vincristine†$ Mechlorethamine*# Mitomycin* Mitoxantrone* Vinblastine†$ Vincristine†$ Vinorelbine†$	Abraxane (paclitaxel albumin bound)* Ado-trastuzumab* Arsenic trioxide* Bendamustine*# Busulfan* Cabazitaxel Carboplatin* Carmustine (BCNU)*^ Cladribine* Cisplatin*# Dacarbazine* Docetaxel* Doxorubicin liposomal* Etoposide†$ Fluorouracil Gemcitabine Ixabepilone Ifosfamide*^ Irinotecan* Melphalan Oxaliplatin†# Paclitaxel* Streptozocin Teniposide†$ Topotecan*

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Antidote and local care: *topical cooling, ^†topical heat, ^‡dexrazoxane, ^#sodium thiosulfate, ^$hyaluronidase, ^{^}topical dimethyl sulfoxide (DMSO).

Management of Extravasation

  1.  Stop infusion and intravenous (IV) fluids. Leave IV catheter in place. Do not flush the extravasated IV catheter

  2.  Disconnect IV tubing from IV catheter

  3.  Attach small syringe and attempt to aspirate as much fluid as possible (drug, fluid in tissue) to clear IV catheter of chemotherapy

  4.  Estimate amount of drug that was extravasated

  5.  If peripheral IV, remove IV catheter—avoid pressure to site of extravasation; mark area of induration or swelling

  6.  Administer appropriate antidote, if needed. Apply topical cooling or heat if indicated as well (see table in preceding text). Rest and elevate extremity

  7.  Consider plastic surgery expert consultation depending on severity and agent extravasated

Specific Extravasation Interventions

  1.  Dexrazoxane

       a.  Dose: 1,000 mg/m² (max 2,000 mg) IV daily days 1 to 2,500 mg/m² (max 1,000 mg) day 3

       b.  Administration:

             i.   First dose should be given within 6 hours of extravasation

            ii.   IV infusion over 1 hour into a functioning IV line that is not affected by the extravasation (ideally in the opposite arm)

           iii.   Avoid cooling procedures within 15 minutes of dexrazoxane administration

           iv.   Do NOT use topical dimethyl sulfoxide (DMSO) if using dexrazoxane

  2.  DMSO (topical)

       a.  Dose/administration:

           i.   50% solution, 1 to 2 mL onto a sterile gauze pad and gently apply to the skin surface of extravasated site every 8 hours × 7 days

  3.  Hyaluronidase

       a.  Dose: 150 international units subcutaneously

       b.  Administration:

             i.   Administer subcutaneously with a small needle (eg, 25 gauge), distributing dose around the perimeter of the extravasation site in four or more equal injections, pointing the medication inward toward the center of the extravasated site

            ii.   Do not rub site; use new needle for each injection given

  4.  Sodium thiosulfate

       a.  Dose: 10% solution, 4 mL diluted with 6 mL sterile water; 2 mL of a solution for:

             i.   Each mg of mechlorethamine or bendamustine suspected of extravasating

            ii.   Each 100 mg of cisplatin suspected of extravasating

       b.  Administration:

             i.   Administer subcutaneously with a small needle (eg, 25 gauge), distributing dose around the perimeter of the extravasation site in four or more equal injections, pointing the medication inward toward the center of the extravasated site

            ii.   Do not rub site; use new needle for each injection given

           iii.   Avoid pressure to site; allow to air-dry—do not cover the site

           iv.   Do not use topical DMSO if using dexrazoxane