Management of Extravasation

Prevention

Use large veins in the forearm for peripheral administration and avoid cannulation over joints, inner wrist, and lower extremities, as recommended by the European Society for Medical Oncology 1
Use flexible cannulae instead of winged steel infusion devices and check for blood return before drug administration, as recommended by the European Society for Medical Oncology 1
Monitor the cannulation site regularly during infusion, as suggested by the European Society for Medical Oncology 1
Apply firm pressure to the injection site for 5-10 seconds immediately after injection to minimize bruising, as recommended by the Mayo Clinic Proceedings 2
Use the shortest available needle (4mm recommended) with the highest gauge number to reduce bruising, as suggested by the Mayo Clinic Proceedings 2
Proper needle removal, counting to 10 after fully depressing the plunger before removing the needle from the skin, is advised by the Mayo Clinic Proceedings to minimize bruising 2

Administer dexrazoxane IV in a 3-day schedule (1000, 1000, and 500 mg/m²) starting within 6 hours of extravasation, with a reduced dose to 50% if creatinine clearance is less than 40 ml/min, as recommended by the European Society for Medical Oncology 1
Apply DMSO 99% at four drops per 10 cm² of skin surface, covering twice the affected area, and apply every 8 hours for 7 days, allowing to air dry without dressing, and ideally administering within 10 minutes after extravasation for best results, as recommended by the European Society for Medical Oncology 1
Apply dry cold compresses for 20 minutes several times daily for 1-2 days, as recommended by the European Society for Medical Oncology 1
Elevate the affected limb to reduce swelling, and apply dry cold compresses for 20 minutes several times daily for 1-2 days to reduce swelling and pain, as recommended by the European Society for Medical Oncology 1
Administer analgesia as needed to manage pain, as recommended by the European Society for Medical Oncology 1
Alternative treatment options include topical DMSO 99% and hyaluronidase (1-6 ml of 150 U/ml solution injected through existing IV line), according to the American Society of Clinical Oncology 1

Use acetaminophen 650 mg every 4-6 hours (maximum 4000 mg/day) for pain management in patients with extravasation, as suggested by the American Society of Clinical Oncology 3
Use ibuprofen 400-600 mg every 6-8 hours for pain management in patients with extravasation, with caution in patients with GI and renal toxicity, as recommended by the European Society for Medical Oncology 4

Surgical intervention is indicated for unresolved tissue necrosis, pain lasting more than 10 days, or failed conservative therapy, and involves wide three-dimensional excision of all involved tissue, temporary coverage with biologic dressing, and delayed application of split-thickness skin graft (2-3 days), as recommended by the Society of Surgical Oncology 1
Subcutaneous wash-out procedure is an alternative technique for delayed presentations (2-14 days) and involves flushing the infiltrated area with 300-500 ml normal saline through multiple stab incisions, but is not recommended as routine management in non-experienced surgical units, as recommended by the European Society for Medical Oncology 1

Document the extravasation area with photographs if possible, including patient information, date and time of extravasation, name of drug extravasated and diluent used, signs and symptoms reported by patient, description of the IV access used, estimated extravasation area and amount, management steps with time and date, as recommended by the European Society for Medical Oncology and the National Comprehensive Cancer Network 1
Schedule follow-up within 7 days for reassessment and continue monitoring for 3-4 weeks as chemotherapy agents are classified as irritants with potential for delayed tissue damage, as recommended by the European Society for Medical Oncology 1
Evaluate for signs of tissue necrosis or progressive damage, document wound healing progress, and assess pain levels using validated pain scales, as suggested by the American College of Physicians 5

Applying manual pressure over the extravasated area, using subcutaneous corticosteroids, inadequate documentation, delayed recognition and treatment, and using alcohol compresses are all contraindicated and may worsen the injury, according to the European Society for Medical Oncology 1
Subcutaneous corticosteroid injection is not recommended as it may increase the need for surgical debridement, as advised by the European Society for Medical Oncology 1