Extravasation

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Classification according to ICD-10
T80.8 Other complications following infusion, transfusion, or injection for therapeutic purposes
ICD-10 online (WHO version 2019)

In medicine, extravasation means that either a bodily fluid (e.g. blood, urine) or cells that are normally in this bodily fluid have leaked from the bodily vessel intended for this fluid into the surrounding tissue. In the context of inflammation , extravasation means that leukocytes have emerged from the capillaries , see leukodiapedesis . In the context of cancer , extravasation means that cancer cells have leaked out of the capillaries, which can lead to metastasis .

Much more often, however, extravasation in medicine means that a medical infusion that the patient receives has incorrectly not run into the vein intended for this infusion , but into the surrounding arm tissue.

The leaked or misplaced liquid is as extravasation designated. In most languages, e.g. B. in English or Italian , extravasation is called extravasation . The German medical terminology is an exception here.

Overview of extravasation during an infusion

Extravasation can be a dangerous side effect of IV infusions. Extravasation is the accidental administration of an intravenous (iv) infusion into the surrounding arm tissue instead of the designated vein. This inadvertent giving can happen through leakage, e.g. B. in elderly patients with very permeable veins, or because the infusion needle has pierced the vein. The exit opening is then in the actual arm tissue and the infusion runs directly into the arm tissue. This can e.g. This can happen, for example, with children who move their arm too much, or because the infusion needle was not very well placed from the start, or when the patient falls asleep lying on his arm, etc.

Extravasation during an infusion is a side effect that can and must be avoided.

In moderate cases, extravasation causes pain, redness, irritation, and swelling on the arm with the infusion needle. In severe cases, arm tissue necrosis occurs. In very rare, extremely severe cases, it can even mean the loss of the arm.

Extent of damage

The damage after extravasation can be mild, moderate, or severe. If only the pure carrier solution (mostly either saline = 0.9% NaCl solution or sugar solution = 5% glucose solution) has been infused, the damage will be minor.

Some drugs cause only moderate damage to the arm with the infusion needle after extravasation; they are called "irritating". Other medicines cause serious damage to the arm with the infusion needle; they are called "vesicant".

Damage is particularly evident after extravasation of cytostatics , i.e. H. during chemotherapy , feared. However, damage can also occur after extravasation from all other drugs, not just after extravasation from cytostatic drugs.

frequency

The proportion of patients who have had an extravasation is not exactly known, since an extravasation, especially a slight extravasation, is often not recognized and / or not documented, but overall it is probably 10%.

In recent years, health professionals have become much more aware of the problem of extravasation.

Treatment of extravasation

The best "treatment" for extravasation is prevention, as there is no specific treatment for extravasation. Although the effectiveness of various measures is not very high, they should always be carried out after an extravasation.

  1. Immediately stop the infusion. This should happen if the area around the infusion needle turns red, becomes hot, burns, or swells.
  2. Replace the infusion tube with a disposable syringe and aspirate the infusion fluid
  3. Remove the infusion needle from the arm.
  4. Keep the arm in the raised position. If there are blisters on the arm, use a new, thin needle to remove the contents of the blisters.
  5. If substance-specific measures are recommended for the extravased drug, carry out these measures, e.g. B. local cooling, local heating, DMSO, hyaluronidase or dexrazoxane.

New clinical studies show that dexrazoxane is effective after extravasation of anthracyclines d. that is, can prevent tissue necrosis from occurring. In two multicenter, open-label, non-controlled, small phase II clinical studies, 98% of patients did not develop tissue necrosis after extravasation of an anthracycline after the use of dexrazoxane. (The anthracyclines include daunorubicin, doxorubicin, epirubicin, idarubicin, etc.)

Pain management and other follow-up measures

Effective pain management is very important for the patient, as is complete documentation and prevention against infection and superinfection . If such a situation arises, request an antibiogram and consult an infectious disease specialist. Regular checks and follow-up care are necessary.

Measures if the extravasated drug is "vesicant" (tissue necrotizing)

  • Do not flush the IV access.
  • No wet compresses, no alcoholic compresses, no bandages.
  • Call in a senior physician who has experience in the treatment of extravasation and a reconstructive surgeon at an early stage.
  • Such cases sometimes require skin grafts and intensive physiotherapy.

Prevention of extravasation

  • IV access should only be established by experienced staff, if possible, at least for patients who are particularly at risk, e.g. B. very fat patients, very young patients, very old patients and patients with barely visible veins.
  • In the case of IV access, do not make multiple attempts to pierce the same area.
  • Use of thin cannulas. Before the infusion, the position of the cannula should be checked by aspirating blood and flushing through with carrier solution.
  • Close observation of the infusion.
  • The iv infusion must consist of the appropriate carrier solution with the correctly dissolved cytostatic / drug.
  • After the IV infusion, flush the vein with only the carrier solution.
  • A placed central access ( central venous catheter, CVC) during the infusion of vesicant drugs is advantageous if the patient is suitable for a central access.

Examples of vesicant drugs

Cytostatics

  • Amsacrine
  • Cisplatin (if> 0.4 mg / mL)
  • Dactinomycin
  • Daunorubicin
  • Docetaxel
  • Doxorubicin
  • Epirubicin
  • Idarubicin
  • Mechlorethamine
  • Mitomycin C
  • Mitoxantrone
  • Oxaliplatin
  • Paclitaxel
  • Vinblastine
  • Vincristine
  • Vindesine
  • Vinorelbine

Other medicines

  • alcohol
  • Aminophyllins
  • Chlordiazepoxide
  • Diazepam
  • Digoxin
  • Nafzillin
  • Sodium bicarbonate
  • Nitroglycerin
  • Phenytoin
  • Propylene glycol
  • Sodium thiopental
  • Tetracyclines

Web links

Individual evidence

  1. ↑ C. Sauerland, C. Engelking, R. Wickham, D. Corbi: Vesicant extravasation part I: Mechanisms, pathogenesis, and nursing care to reduce risk. In: Oncol Nurs Forum. 2006 Nov 27; 33 (6), pp. 1134-1141. Review.
  2. ^ R. Wickham, C. Engelking, C. Sauerland, D. Corbi: Vesicant extravasation part II: Evidence-based management and continuing controversies. In: Oncol Nurs Forum. 2006 Nov 27; 33 (6), pp. 1143-1150. Review.
  3. ^ TV Goolsby, FA Lombardo: Extravasation of chemotherapeutic agents: prevention and treatment. In: Semin Oncol . 2006 Feb; 33 (1), pp. 139-143. Review.
  4. ↑ RA Ener, SB Meglathery, M. Styler: extravasation of systemic hemato-oncological therapies. In: Ann Oncol. 2004 Jun; 15 (6), pp. 858-862. Review.
  5. ^ DL Schrijvers: Extravasation: a dreaded complication of chemotherapy. In: Ann Oncol . 2003; 14 Suppl 3, pp. Iii26-30. Review.
  6. ^ I. Mader: Extravasation of cytostatics: A compendium for prevention and therapy. Springer publishing house.
  7. ↑ HT Mouridsen, SW Langer, J. Buter, H. Eidtmann, G. Rosti, M. de Wit, P. Knoblauch, A. Rasmussen, K. Dahlstrom, PB Jensen, G. Giaccone: Treatment of anthracycline extravasation with Savene ( dexrazoxane): results from two prospective clinical multicenter studies. In: Ann Oncol. 2007 Mar; 18 (3), pp. 546-550.