Preventing and managing vesicant chemotherapy extravasations The complexity of administration of antineoplastic agents and the potential safety issues involved are unique to oncology care and require careful consideration. If using a peripheral vein, allow the infusion to flow via gravity. endobj The venous access should not be removed immediately, since it can be used to attempt aspirating extravasated fluid and for administration of an antidote, if clinically appropriate. %PDF-1.7 David V, Christou N, Etienne P, et al. Since 1975, ONS has provided a professional community for oncology nurses, developed evidence-based education programs and treatment information, and advocated for patient care, all in an effort to improve the quality of life and outcomes for patients with cancer and their families. PDF Chemotherapy Drugs for Cancer Treatment: Administration, Safe Handling Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. Always stop infusion of the causative medication first and, if appropriate, elevate the affected extremity. HHS Vulnerability Disclosure, Help Clinicians considering drug administration via this VAD should review the chemical properties of the drug under consideration from reputable resources (eg, prescribing information) to compare them with the guidance above. No current standard or scoring system exists for the . Extravasation of antineoplastic agents: prevention and treatments. The Hospira Brand of vinCRIStine sulfate injection, USP (preservative-free) 1 mg/mL vial package insert2 states: Unable to load your collection due to an error, Unable to load your delegates due to an error. Table 7 in Chemotherapy and Biotherapy Guidelines and Recommendations for Practice discusses special features required for administration, but package inserts should be referred to for the most up-to-date information. Therefore, questions often arise regarding the appropriateness of administering specific drugs via midline catheter. Eur J Oncol Nurs. 2016 Updated American Society of Clinical Oncology/Oncology Including Your institution can use them to inform practice policies and procedures, internal quality assessment, and external quality monitoring. Front Oncol. Gorski L, Hadaway L, Hagle ME, McGoldrick M, Orr M, Doellman D. Infusion therapy standards of practice. Venous irritation (chemical phlebitis) that occurs with drug administration into a vein that remains intact (eg, vinorelbine and epirubicin), and other cutaneous complications of chemotherapy are discussed elsewhere. If cooling techniques are being used, withhold cooling 15 minutes before and after the infusion. The Oncology Nursing Society (ONS) is a professional association that represents 100,000 nurses and is the professional home to more than 35,000 members. 866-257-4ONS (866-257-4667). Your IP: Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. Management of Chemotherapy Extravasations - U.S. Pharmacist Accessibility Midline catheters differ from other VADs with regard to their insertion and termination sites.1,3Midline catheters are inserted peripherally into the antecubital fossa or upper arm via the basilic, cephalic, or brachial vein, and extend from 8 to 20 cm centrally, where the catheter tip terminates at or below the axillary vein. Also, dilution of the vinca alkaloid likely reduces the impact of any extravasation that might occur. This article describes manufacturers' recommendations, lists antidotes and treatments approved by the FDA, and reviews published guidelines and recommendations. Monitor for extravasation according to hospital policy. 2013;1(1):9- 16. If not clearly defined in the literature. If chemical phlebitis occurs, consideration should be given to the need for alternative vascular access, an alternative medication, a slower infusion rate, or further dilution of the medication.6. ONS is committed to promoting excellence in oncology nursing and the transformation of cancer care. A study in Australia involving 68 cancer centers evaluated more than 44,000 doses of vinca alkaloids administered via syringe or minibag to adult and pediatric patients, found that the extravasation rates were similar and low0.03% with syringes and 0.04% with minibags.1 Preliminary data from another study conducted in children and adults found no cases of extravasation during administration via minibags.2 These data strongly support the safe use of minibags in adults and children.3 The risk of extravasation injury doesnt compare to the risk of severe neurological injury and near certain death resulting from the intrathecal administration of vinca alkaloids. 2012;18(suppl):16-7. 2021 Update: What are considerations for determining whether a drug may be administered via a midline catheter? Vesicant chemotherapy extravasation antidotes and treatments. Clinical exam may reveal warmth, erythema, or tenderness. <> 866-257-4ONS (866-257-4667). Since 1975, ONS has provided a professional community for oncology nurses, developed evidence-based education programs and treatment . 2088 0 obj <> endobj Chemotherapy Extravasation | PSNet - Agency for Healthcare Research and Controversial use of heat: EONS (European Oncology Nurses Society) suggests application of heat to encourage circulation and to dilute & diffuse the chemotherapy. UIC's seven health sciences colleges and health care delivery enterprise. Special Considerations When Administering IV Chemotherapy - ONS Voice 4. Apply ice to the area for 15 to 20 minutes each hour for 4 hours. Taxanes: vesicants, irritants, or just irritating? References: 1. National Library of Medicine Introduction. Antidote and treatment recommendations of vesicant chemotherapy manufacturers, antidotes and treatments approved by the U.S. Food and Drug Administration (FDA), and guidelines and recommendations Answer:Yes, the product is stable in a minibag. Irritant: Medication that can cause local inflammatory reactions at the infusion site, which may include: burning, swelling, pain, inflammation, tightness, or phlebitis. Copyright 2023 Oncology Nursing Society. Griffiths V. Midline catheters: indications, complications and maintenance. Package insert for vinCRIStine sulfate injection, USP (preservative-free) 1 mg/mL vial. The vinCRIStine is infused via gravity through the peripheral line. Sodium Chloride. Safe administration of vancomycin through a novel midline catheter: a randomized, prospective clinical trial. Once the infusion is complete, the short set is dropped to backfill the line with saline and then the remaining drug is infused. Adams DZ, Little A, Vinsant C, Khandelwal S. The midline catheter: A clinical review. J Oncol Pharm Pract. J Pediatr Oncol. Clinical Associate Professor, Drug Information Specialist, Updated by: Midline catheters have properties that differ from both those of traditional peripheral IV catheters and central venous catheters (CVCs). References and bibliography updated. European Oncology Nursing Society extravasation guidelines. Extravasation is defined as the leakage or inadvertent administration of a vesicant drug or solution from a vein into the extravascular space. 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Braun Recalls Certain Lots of Blood Administration Sets, FDA Approves Sunitinib Malate for Adjuvant Treatment of Renal Cell Carcinoma, News, Views, and Advocacy From the Oncology Nursing Society, Copyright 2023 Oncology Nursing Society, ONSs Chemotherapy and Biotherapy Guidelines and Recommendations for Practice, ONS and American Society of Clinical Oncology standards, Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. Cold (different suggestions for anthracyclines depending on reference): (off-label, based on general management strategies for anthracyclines), Cold - 15 to 20 minutes at a time for at least four times per day for 24 hours, Irritant or neutral, depending on reference, Cold - Every 8 hours for 3 days; if using sodium thiosulfate, apply cold pack for 6 to 12 hours after administration of sodium thiosulfate, Vesicant/Irritant (depending on reference). Nonetheless, a review of literature of known vesicants and drugs reported to cause vascular injury or extravasation indicates some drugs that may present higher risk when administered via midline catheter. Calcium Chloride. 3. Plymouth Meeting, PA 19462. $on8+i5BqlA/K>I,ELi{z292%4ImIK=EYG[tlX5l6XjVYU>WyAfb;%a@ Potassium Chloride. Boulanger J, Ducharme A, Dufour A, et al. Find the answers to questions regarding symptoms, side effects, and more. 6. The Oncology Nursing Society and Infusion Nurses Society have published guidelines for vesicant administration and extravasation management. Additionally, the risk of cytotoxicity is reduced by intermittent compared with continuous infusion, as well as by dilution of vancomycin to concentrations of 2 to 5 mg/mL. PDF Guidelines on treatment of extravasation - Thames Valley Cancer Alliance Use of an infusion pump is discouraged because it increases the amount of pressure on the vein, which raises the risk of extravasation. The Oncology Nursing Society4 recommends administering IV vinCRIStine and other vinca alkaloids via a minibag to prevent errors with intrathecal chemotherapy administration. 9fGr,zGa$9:WSs["8d/#'K f.'nw_EET Preventing and Managing Vesicant Chemotherapy Extravasations Hospira. Lu H, Hou Y, Chen J, et al. 2. Please. Cold - Apply cold packs for 15 to 20 minutes four times per day for 1 to 2 days. Gorski LA, Stranz M, Cook LS, et al. Furthermore, in vitro evidence suggested that vancomycin-associated endothelial damage is caused by factors other than pH. However, the INS Task Force identified limited literature describing extravasation of vancomycin. Use a central venous catheter or implanted device for continuous vesicant infusions or for any vesicant infusion lasting longer than 30 minutes. 2. References: 1. References: 1. Question:Is it just as safe to prepare vinCRIStine in a large volume (30-50 mL) syringe as in a minibag? 1990 Mar;4(1):41-60. doi: 10.1016/0268-960x(90)90015-k. Wang Y, Tian H, Chen X, Zhang J, Wang L, Fan H, Zhang Y, Qi X, Hu S, Yang Y. In addition, whenever an extravasation occurs or is suspected, vesicant administration must immediately cease, and the appropriate antidote or treatment needs to be promptly administered. <> Based on the range of pH values generally considered appropriate for midline administration, vancomycin would be excluded because of its pH of 4. In 2021 the Infusion Nurses Society (INS) updated their 2016 guidelines and recommended consideration of midline catheters when the anticipated duration of therapy was 5 to 14 days with a preference for peripheral catheters for shorter durations of therapy and CVCs when longer durations of therapy are required.6 A recent study supports use of midline catheters for prolonged courses of therapy up to 14 days, but there remains limited data for use of midline catheters beyond 2 weeks.7 Currently, the CDC recommends consideration of midline catheters when the duration of IV therapy is likely to exceed 6 days.1,8, Considerations for drugs administered via midline catheter Treatment of cutaneous injuries of neonates induced by drug extravasation with hyaluronidase and hirudoid. The main consideration in determining whether a drug is appropriate for administration via midline catheter is its propensity for causing phlebitis.2Phlebitis is inflammation of a vein caused by damage to the tunica intima, which may be accompanied by erythema, swelling, pain, heat, and a palpable cord if thrombosis is present. Seo H, Altshuler D, Dubrovskaya Y, et al. University of Illinois at Chicago College of Pharmacy. HHS Vulnerability Disclosure, Help (An infusion pump is not recommended by the Oncology Nurses Society (ONS) to administer vinCRIStine in this situation1 .) ASCO/ONS Chemotherapy Administration Safety Standards The organization also recommends a multidisciplinary review of the process regarding the preparation and administration of vinCRIStine in each practice setting. American College of Radiology. Vesicant Chemotherapy Extravasation Antidotes and Treatments Lu H, Yang Q, Yang L, et al. Unauthorized use of these marks is strictly prohibited. Lastly, they recommend avoidance of midline catheters in patients with a history of thrombosis, hypercoagulability, venous stasis, or with a need to preserve vein integrity, such as in patients with end-stage renal disease. The flush line can be used before, during, and after the infusion to verify line patency and blood return for a flush solution if the chemotherapy must be stopped because of an adverse reaction. Avoid the "blame game.". 1,2 Recognize that when a vinca alkaloid is prepared in a minibag, it is likely more dilute than in a syringe, and thus the impact of tissue injury is even less if extravasation should occur. Bookshelf Oncologist. Caparas JV, Hu JP. Question:Wouldnt the administration of vinCRIStine IV push using a syringe be much shorter in duration and with less chance of extravasation than administration using a minibag? 2006;12(2):113-8. endstream endobj 2089 0 obj <. This site needs JavaScript to work properly. % 3/26/2014, 4. PMC Not a current ONS member or journal subscriber? 2008 Sep;12(4):357-61. Pittsburgh, PA 15275 Vesicant: Medication that may causes severe and/or irreversible tissue injury and necrosis. 15 to 20 minutes at a time for at least four times per day for 24-48 hours, warm compresses for 30 to 60 minutes, then alternate off/on every 15 minutes for 1 day, 15 to 20 minutes at a time for at least four times per day for 24 hours. UN vR7. 2017 Jan-Mar;4(1):61-68. doi: 10.4103/2347-5625.199081. When assessing a chemotherapy extravasation, it is important to understand the classification of the chemotherapeutic agent in terms of its potential to cause cellular damage if extravasated. Depending on treatment complexity, ONS's Chemotherapy and Biotherapy Guidelines and Recommendations for Practice state that chemotherapy agents being administered by infusion "may be connected directly to the IV catheter or to a line of compatible maintenance solution." For example, many cytotoxic agents (ie, chemotherapy) are considered vesicants and should not be administered via midline catheters according to INS standards.10,11Additionally, in 2017, the INS assigned a Vesicant Task Force to publish a list of noncytotoxic vesicant medications and solutions.11The Table below, while not exhaustive, details drugs from this list, as well as drugs that have extremes of pH or osmolarity that have been associated with vascular injury or extravasation.8,9, One drug that has generated controversy regarding its appropriateness for administration via midline catheter is vancomycin. 1 Infiltration, often used in reference to extravasation, refers to leakage of a non-vesicant drug or solution. Question: We are trying to implement Best Practice #1 to dispense vinCRIStine (and other vinca alkaloids) in a minibag. Heat - Apply warm compresses to extravasation site for 1 hour. Would you like email updates of new search results? Section V: Immediate Complications of cytotoxic therapy, p.105. No solid research exists regarding IV chemotherapy administration setups, because they can vary greatly based on the regimen, equipment availability, and patient status. 125 Enterprise Drive Epub 2014 Jul 3. To update the ASCO/Oncology Nursing Society (ONS) Chemotherapy Administration Safety Standards and to highlight standards for pediatric oncology. Unable to load your collection due to an error, Unable to load your delegates due to an error. Please include what you were doing when this page came up and the Cloudflare Ray ID found at the bottom of this page. PDF NCCN Chemotherapy Order Templates If an antidote is not going to be used, the venous access can be removed after aspiration of the extravasated fluid has been attempted. Cold (different suggestions depending on reference): Heat (different suggestions depending on reference): Cold - for 6 to 12 hours after administration of sodium thiosulfate. The action you just performed triggered the security solution. When administering chemotherapy, nurses should always be able to say that safe handling has been considered and opportunity for exposure has been limited, but also that clinical staff have accounted for ensuring the dose is received in its entirety and they can rapidly intervene should an adverse event or complication occur. Vesicants and irritants with vesicant . Yan YM, Fan QL, Li AQ, Chen JL, Dong FF, Gong M. Iran J Pediatr. You can email the site owner to let them know you were blocked. Clinical exam may reveal warmth, erythema, or tenderness. Accessed August 2, 2021. https://www.acr.org/-/media/ACR/Files/Clinical-Resources/Contrast_Media.pdf. Prior to initiation of a vesicant, the VAD tip must be verified &checked for blood Polovich M, Whitford JM, Olsen M. Chemotherapy and biotherapy guidelines and recommendations for practice, 3rd ed, Oncology Nursing Society, Pittsburgh, PA, 2009. Assessment of the risk of extravasation with the introduction of vincristine mini-bags to eliminate inadvertent intrathecal administration. A central line is always required for vesicant or any chemotherapy in the home. There are several actions that could trigger this block including submitting a certain word or phrase, a SQL command or malformed data. Knowledge Level on Administration of Chemotherapy through Peripheral and Central Venous Catheter among Oncology Nurses. 2012;18(1):155-7. 2016 Feb 10; 7(1): 8797. Disclaimer. The following information is a compilation from the various resources listed below.[1][2][3][4][5][6][7][8]. Bethesda, MD 20894, Web Policies References: 1. 2. To report a content error, inaccuracy, or typo, email pubONSVoice@ons.org. In, For more information on nurses, chemotherapy, and pregnancy, watch. Properties of midline catheters Infuse in an extremity or area other than the one affected by extravasation. Clipboard, Search History, and several other advanced features are temporarily unavailable. Vesicant & irritant chemotherapy - A Hematology Oncology Wiki official website and that any information you provide is encrypted The incidence of extravasation of vinca alkaloids supplied in syringes or mini-bags. Manage conservatively as first line option with supportive non-pharmacologic strategies. Flare reaction: A skin reaction to a medication which is an allergic response. eCollection 2022. Please enable it to take advantage of the complete set of features! This section focuses on drug administration, including cycle definition (which contains the cycle length, number of cycles, and other schedule-related information), dosing, frequency, and routes of administration. PDF Irritants and Vesicants Guide to Intravenous Administration via Midline Clin J Oncol Nurs. The site is secure. Before J Oncol Pharm Pract. These include engaging patients in extravasation-prevention efforts, thoroughly assessing patients receiving vesicants, selecting an appropriate administration site for peripheral vesicant administration, and checking for a blood return prior to and during vesicant administration. 2008 Sep;12(4):357-61. doi: 10.1016/j.ejon.2008.07.003. (K k0|hzv 6gN5UzVa+91C+yTOOcV^t^IjpiOROeutcI9GOqs'."XA*c2@GfK!rKP;{4?|h=,G _wyNdfSc#A]LHq#@Gtn[YWk%1o*Bbyk'82h6~IOvvi2`6 Current ASCO/ONS standards address the safety of all routes of chemotherapy administration to adult patients in the outpatient and inpatient settings. Safety and feasibility assessment of extending the flushing interval in totally implantable venous access port flushing during the non-treatment stage for patients with breast cancer. Administering Vesicants | ONS Your institution can use them to inform practice policies and procedures, internal quality assessment, and external quality monitoring. Management of the extravasation of anti-neoplastic agents. eCollection 2012 Jul 31. What do you recommend? MeSH Gilbar P, Chambers CR, Larizza M. Medication safety and the administration of intravenous vincristine: International survey of oncology patients. The procedure includes connecting the bag of saline to a long straight infusion set. Institutional policies and procedures used in hospitals, clinics, and office settings should be written in accordance with these . Pittsburgh, PA 15275 Note: Do not use an infusion pump when administering a vesicant via a peripheral intravenous. (Closed system devices are also utilized to ensure the vinCRIStine does not leak out of the system.) Polovich M, Olsen M, LeFebvre KB, eds. By using this site, you agree to theTerms of Use, Privacy Policy, andTerms and Conditions for ONS Guidelines, as applicable. and transmitted securely. FOIA The .gov means its official. 3/10/2014, Institute for Safe MedicationPractices Email ONSs clinical inbox at clinical@ons.org to reach one of our oncology clinical specialists, who can advise on ONS recommendations, best practices, and evidence support. Courtney Krueger, PharmD, BCPS The Oncology Nursing Society (ONS) is a professional association that represents 100,000 nurses and is the professional home to more than 35,000 members. Click to reveal Cold - If using sodium thiosulfate, apply cold pack for 6 to 12 hours after administration of sodium thiosulfate. Question:How do you recommend that we verify blood return when administering vinCRIStine in a minibag? Reduce dose by 50% for patients with creatinine clearance less than 40 mL/min. Updated January 2021. In some regimens, enough data support sequencing of agents, but in others, data are lacking. ACR manual on contrast media. Answer:In regard to duration of administration: It is true that the process of administering a vinca alkaloid via a syringe is probably of shorter duration when compared to administering via a minibag. Clinimix 4.25/5 Vesicant Yes Yes Yes Guidelines allow if 10% dextrose, Peripheral PN (PPN) Vesicant . Tubing features can present another challenge when considering how to best administer chemotherapy agents. Extravasation of noncytotoxic drugs.

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