Many patients receive anthracycline chemotherapy (daunorubicin, doxorubicin, epirubicin, and idarubicin). Anthracyclines have the potential to cause tissue necrosis when they extravasate from a vein or are inadvertently administered into the tissue. The incidence of anthracycline extravasation is estimated to be 0.01-6%1,2. However, extravasation is a known risk of anthracycline administration so patients are at risk for extravasation every time an anthracycline is administered.
Anthracyclines bind to nucleic acids in DNA. When they extravasate, they bind to the DNA in the cells of healthy tissue and promptly and directly cause cell death. DNA-anthracycline complexes are released from dead cells in the tissue and spread to adjacent healthy cells by endocytosis. This process creates a continuing cycle of tissue damage as the anthracycline in the tissue is essentially “recirculated” in the surrounding healthy tissue. Consequently, these extravasation injuries become larger in size, deeper in depth, and more painful over time.
Full thickness anthracycline extravasation injuries extend beyond the dermis into the subcutaneous tissue and may involve muscles, tendons, ligaments, and nerves. These wounds may heal by filling with granulation tissue, contraction, and epitheliallization from the wound edges, but often require surgical debridement and skin grafting or myocutaneous flap placement. Anthracycline extravasation may cause septicemia, permanent sensory loss, joint stiffness and contractures, and disfigurement.
Extravasation treatment may take weeks to months and often delays or interrupts subsequent chemotherapy treatment. Patients may require multiple surgical procedures, wound care, and physical therapy. Many are unable to work, including work around the home, while undergoing anthracycline extravasation treatment.
Various anthracycline extravasation treatment approaches are used in clinical practice. A few have been studied in animals and small clinical studies. Anecdotal reports also have been published; however, none of the commonly used treatments, such as topical application of dimethyl sulfoxide (DMSO), hydrocortisone injection, local and systemic antibiotic therapy, early surgical intervention, and saline washout of the affected area, has proven efficacy in reducing anthracycline-induced tissue necrosis.2-4
References
1. Langstein HN et al. Retrospective study of the management of chemotherapeutic extravasation injury. Ann Plat Surgery 2002;49:369-374.
2. Barlock AL et al. Nursing management of adriamycin extravasation. Am J Nurs 1979;79:94-96.
3. Goolsby TV et al. Extravasation of chemotherapeutic agents: prevention and treatment. Semin Oncol. 2006;33:139-143.
4. Langer SW, et al. Treatment of anthracycline extravasation in mice with dexrazoxane with or without DMSO and hydrocortisone. Cancer Chemother Pharmacol. 2006;57:125-128. |
Signs and symptoms of an anthracycline extravasation include: swelling redness (usually, but not always) a stinging or burning sensation (usually, but not always) loss of a blood return from the IV device an IV flow rate that slows or stops resistance felt when administering a vesicant via IV bolus (push)
If any of these signs or symptoms occurs, immediately stop administering the anthracycline and assess the patient and the patient’s IV device. Because anthracycline extravasations have a high propensity to cause tissue necrosis, when in doubt, it is better to err on the side of caution and presume that an extravasation has occurred. |
Determine the vesicant(s) suspected to extravasate. Estimate the maximum amount suspected to extravasate by measuring the amount of the vesicant remaining in the syringe or infusion bag (use a syringe to withdraw the vesicant from infusion bag rather than ‘eye balling’ the amount remaining). Note the concentration of the vesicant (milligrams per milliliter). Note the patient’s position (e.g. supine, sitting) and location of the infusion site. The full extent of tissue damage often is gravity dependent. Inspect the infusion site. If an area of redness or swelling is apparent, use a pen to mark the area and record observations and measurements. Obtain the patient’s consent to photograph the area and include the date in the photographs. Ask the patient to rate discomfort at the infusion site on a 0-10 scale. Have the patient describe sensations experienced during chemotherapy administration in his/her own words. Gently palpate the infusion site and ask the patient to rate discomfort on a 0-10 scale. Note patient factors that may impact outcome (e.g. age, comorbidities, etc). Note other factors to consider such as vesicant administration site in area of flexion, area prone to mechanical friction from a bra strap, or moisture-prone area (e.g. groin, near underarm). Assess the patient’s lifestyle (the patient may not be able to work while undergoing extravasation treatment, may not be allowed to work with an open wound, may not be able to perform work duties, such as lifting, because of injury, etc.)
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