Extravasation

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A small number of chemotherapy drugs can cause irritation and tissue damage if they leak out of the vein whilst being injected. This is called extravasation.

All nurses who administer chemotherapy have completed an intensive training programme and are fully aware of which drugs are more likely to cause these problems and what to do if extravasation occurs. Rarely problems can start after patients have left the unit. If patients complain of pain, redness, swelling, stinging or burning at the injection site unit contact the clinic via emergency numbers you have been given. In the mean time keep the arm raised and place a cool (not ice) pack on the area.

• Pain, stinging or burning sensation
• Redness or swelling around the area where the chemotherapy is being/or was given

It is very important that you tell your chemotherapy Nurse or Doctor immediately if you experience any of these symptoms, to enable them to start the appropriate treatment. This will help to prevent any further problems.

If you develop any of the symptoms described above and receive treatment for these, you will be given specific instructions of what to do when you leave hospital. However, if you experience any further problems at home or have concerns, please contact the hospital on the telephone number you have been given and ask to speak to a chemotherapy Nurse or Doctor explaining-

• Your name and hospital number
• Your Consultant’s name
• The symptoms you are experiencing
• When you received your chemotherapy
• If possible, what drugs you were given

Extravasation is an extremely rare side effect of chemotherapy and can be treated effectively if it does occur.  Whenever possible patients or their carers are taught to care for their own lines.  If this is not possible the following guidelines should apply:

When not in regular use, lumens should be flushed once per week with 10mls saline and 1.6mls hepsal.

When not in regular use, should be flushed once per week with saline. (The manufacturers say that heparin products are not required, but if an individual patient’s line has a tendency to block then hepsal may be used).

When not in regular use should be flushed once per week with 10mls saline and 1.6 mls of hepsal.

When not in regular use should be flushed 3 times per week with 10mls saline and 1.6 mls of hepsal

When not in regular use should be flushed three times per week with 10 mls saline and 1.5mls of heparin 1000 IU.

Equipment needed

• 3 x 10ml syringe ]

• 2 x needle – green ] multiply these

• 1 x 10ml ampoule of saline for injection 0.9% ] depending on the

• 1 x bung ] number of lumens

• 2 x streets ] on the line

• 1 x ampoule of Hepsal ]

• 1 x pair of sterile gloves

• 1 x sharps bin

• Chlorhexidine spray

Preparation

1. Clear away an area of table and clean it well

2. Wash hands

3. Draw up the saline into 10ml syringe

4. Draw up 1.6 ml Hepsal (Central, Hickman and PICC lines only) into the 10 ml syringe

5. Assemble 10 ml syringe, two streets and bung and place all equipment in IV injection tray

1. Spray hands with chlorhexidine spray. Allow them to dry.

2. Put on gloves and place sterile sheet under the line.

3. Make sure the clamp is on (Central, Hickman and Quintin lines only)

4. Remove bung and clean end of line with street and allow to dry.

5. Attach the 10ml syringe, open clamp and draw back on the syringe. If you get blood back remove 2 mls. If you do not get blood back refer to the problem list.

6. Reclamp and remove the 10 ml syringe

7. Attach the 10 ml saline syringe. Open clamp, Instil the saline gently. Close the clamp and remove the 10ml syringe.

8. Attach the 10ml syringe containing 1.6 mls Hepsal. Open clamp. Instil the Hepsal (Central, Hickman and PICC lines only)

9. Close the clamp using postitive pressure on the syringe.

10. Clean the end of the line with a new street and allow to dry. Attach new bung after each use (unless using a bionector, which should be changed every 7 days)

11. Repeat the procedure with any remaining lines.

Dressing change

Dressing change should be undertaken on a regular basis depending on the dressing used.

Once the sutures have been removed and the exit site is healed a dressing is not require although some patients may prefer to cover the exit site.

If the line is newly placed a mepore dressing under a Air occlusive dressing is appropriate and changed every other day or whenever soiled until blood leakage stops.

Then the following guidelines apply: -

Permeable dressing (e.g. mepore) Central, Hickman and Groshong lines only change every other day or after a shower or bath. (if having a bath it is important that you do not soak the dressing as this can lead to infection)

Transparent dressing (e.g. IV 3000) PICC, Central, Hickman or Groshong lines.

Change every 7 days or whenever loosened.

These dressings are waterproof therefore do not need changing after a bath or shower.

• Appropriate dressing
• Chlorhexidine skin spray
• Gloves
• Hibirub hand prep
• Tape

1. Wash hands
2. Remove old dressing ensuring the catheter is not pulled
3. Apply hibirub to hands
4. Don gloves
5. Inspect the catheter site for - Redness

- Oozing

- Red tracking up the line

1. Don not touch the exit site with hands
2. Cover exit site with chosen dressing
3. Loop the catheter once over the dressing or on the chest and tape in position.

Sutures

For Hickman and Groshong lines there are two sites that have sutures

The top site sutures should be removed after 7 days

The exit site sutures should be removed after 3 days

Line problems can occur. Here are some of helpful hints.

No blood bleeds back -. Make sure the clamp is open and that the line is not kinked.

If you still do not get blood back ask the patient to cough or take a deep breath.

For Central, Hickman and Groshong lines, ask the patient to raise their arms above their head or change position (lean forward or extend their neck) as it may move the line tip away from the vein wall and allow blood flash back.

If you still do not get any blood back just continue with the flushing procedure. Not all lines will produce blood all the time.

Difficulty instilling the saline – Make sure the clamp is open and that the line is not kinked.

Do not force the saline in. If you need resistance it may mean that there may be a clot or fibrin sheath at the end of the line. Stop the procedure and phone the Chemotherapy Day Unit or wards C10, D9.

A stitch has come out – If the line is a tunneled and has been in 3 weeks or more the stitch does not need to be replaced. If the line is newly placed, replace the dressing and phone the ward.

The line has moved or come out – If the line has moved, replace the dressing carefully and phone the ward.

If the line has come out put a waterproof plaster over the entrance site and phone the ward. If the patient experiences problems with bleeding or breathing phone the ward. (Problems are unlikely but air may have entered as the line came out)

The entrance site is red, inflamed or oozing – Spray with chlorhexidine, replace the dressing and phone the ward.

The line leaks as you instill the saline or has a crack in it – stop the flushing procedure and phone the ward.

As you instill the saline the patient feels unwell and develops rigors – Stop the flushing procedure and phone the ward.

This could happen if there is infection in the line and as you flush it, you flush the infection into the venous system. The symptoms may settle down on their own but it is important that you let the hospital know as you may need to be seen in the Chemotherapy Day Unit or non the ward

Further general information Your doctors and specialist nurses are in an ideal position to give you relevant information on your disease and treatment as they know your individual circumstances. Cancerbackup has a help line (0808 800 1234) and a prize winning video available in English, Italian, Urdu, Bengali, Gujarati & Hindi explaining Radiotherapy & Chemotherapy. Cancernet.co.uk has over 500 pages describing cancer, its management, practical tips and tool which patients, their carers and their doctors have found helpful during the cancer journey.