1 Vesicant Infusions A presentation for King Edward VII Memorial Hospital, Bermuda 23 January, 2012 Kristen Bodnaruk, RN, BSDenise Dreher, RN, CRNI, VA-BCMary McCormick-Gendzel, RN, MS, CRNI, RN-BC
2 Today’s Discussion: Definitions Patient safety Peripheral and central VAD assessmentsEquipmentHealthcare worker safetyDrug administrationExtravasation
3 DefinitionsIrritant: medication that may cause itching, phlebitis, or reaction along the vessel or at the injection site.Vesicant: any IV drug that can cause blistering, severe tissue injury or tissue necrosis when extravasated. These may be chemotherapeutic or non-chemotherapeutic medications.
4 Peripheral IV (PIV) Access Gauge of catheter:---bigger is not always better---use smallest gauge possible to meetinfusion needs---smaller gauge decreases intimal damageand promotes hemodilutionPlacement of catheter: avoid areas of flexion such as the hand, wrist, or antecubital fossaConsider new PIV insertion daily if patient receiving daily vesicantsStart PIV insertions distally on arm and move proximally as therapy regimen progresses
5 Risk Factors Patient age, condition, or acuity Large gauge, location, and/or length of catheterInfusion historyPoor VAD insertion techniquePoor care and maintenance practicesExtended dwell timeChemical makeup of drug: pH <5 or >9, osmolarity >600mOsm, or final dextrose concentration > 10%Recent proximal peripheral venipunctures, or other existing PIVs in the same extremity
6 Risk FactorsRecent proximal peripheral venipunctures, or other existing PIVs in the same extremityInadequate device securementConfused or active patients could dislodge or damage accessImproper length of non-coring needle used with port access.
7 VAD Assessment Patient comments/complaints What is insertion date? (for PIVs)Any swelling/edema noted…is transparent dressing looking taut?...is ID bracelet tight?Is skin blanched or cool to touch?Positive blood return?Any redness (erythema) or leaking at insertion site?Any difficulty flushing?Radiological confirmation of central line catheter tip placement
8 Some Potential Complications of Central Venous Access Devices (CVADs) Catheter occlusionVessel occlusionCatheter rupture/fractureDevice rotationCatheter migrationFor implanted ports: improper insertion of non-coring needle or needle dislodgement
9 EquipmentIV tubing containing DEHP: (di-2-ethylhexylphthalate) is a plasticizer added to PVC-based plastics to make them soft and pliable.There is evidence that certain drugs cause more leaching of DEHP.Increased amounts of DEHP in humans is concerning for its carcinogenic or hepatotoxic effects.
10 Personal Protective Equipment (PPE) Long-sleeved protective gown or cover-up should be lint-free and made of a low-permeability fabric. Gown should have a solid front, back closure, and tight cuffs.Powder-free long-cuffed gloves designed specifically for chemotherapy should be worn. Gloves should be changed after each use, after 30 minutes of wear, or if they become torn or exposed to chemotherapy.Face shield, goggles, or safety glasses should be worn
11 Healthcare Worker Safety Proper handling of infusates and administration setsCaution with connecting and disconnectingProper use of PPEExercise caution when handling patient’s emesis, urine, or fecesDisposal of equipment into the appropriate biohazard bag or containerFollow established protocols and use a chemotherapy spill kit when cleaning up spills
13 General Points of Emphasis Continuous vesicants are given via central access.Pre-filled administration sets versus backpriming of tubingsVesicants are administered FIRST in a multiple chemo regimenPatient education!!
14 Pre-infusion Informed consent? Patient education: including signs/symptoms to notify RN if they feel any pain, burning, cool sensation, tingling, etc… at insertion site.Gather supplies:---clean pad or ‘chux’ to place supplies on at bedside---PPE---medication---alcohol wipes---empty 10ml syringe---bag of 0.9% saline (NS) with tubing
15 Pre-infusionCheck/double-check of correct medication and dosage per facility policies and proceduresReview of patient’s height, weight, body surface area (BSA), and any pertinent lab valuesPatient identification using two verifiers
16 InfusionDo you have “the three C’s?”…. correct patient, correct medication and dose, and correct VAD?Connect NS to VAD. Fluid should be fast and free-flowing. Chemotherapy should be connected at the lowest port closest to IV insertion site. Technique is known as “free-flowing side arm”.
17 InfusionWhen giving an IVP medication, blood return must be assessed every 2-3ml of infusate given. It should be given in a slow, steady push.The NS should be free-flowing the entire time.Site assessment should be on-going during administration.End with NS flush of ml.
21 ExtravasationInadvertent administration of vesicant medication or solution into the surrounding tissue (INS, 2011)
22 ExtravasationAny grade 4 infiltrate of a vesicant is considered an extravasationIncidence is similar for peripheral and central line administrationRisk factors, such as fragile vessels, location of peripheral IV, or catheter integrity are things to considerAntidotes may be used, but are considered controversial in some circlesMany non-chemotherapy agents have vesicant properties (e.g., Dopamine, Epinephrine, Gentamycin, Mannitol)Reference: MGH NPROM
23 Early warning signs of possible extravasation SwellingStinging, burning, or pain at insertion siteIV flow that stops or slowsResistance when pushing medicationLeaking around the port needleLack of blood returnErythema, inflammation, or blanching
24 Other symptoms/damage resulting from extravasation IndurationVesicle formationNecrotic tissue damage can progress for six monthsTissue sloughingTendon, nerve, joint damageBlistering at insertion siteUlceration is usually seen 2-3 days to weeks following extravasation
25 Treatment of Extravasation IMMEDIATELY STOP INFUSIONRemove tubing from VAD, attach syringe to VAD, and aspirate drugIf via PIV, elevate extremityNotify physician ASAPLocate your institution’s policies or call Pharmacy for specific antidoteApplication of heat or coldDocumentation in patient’s medical recordDocumentation via safety report
26 DNA-binding agentsBind to the DNA in healthy cells when they extravasate into the tissue and cause cell death.Retained in the tissue for long periods of time and cause progressive tissue necrosis.Examples: anthracyclines (daunorubicin,doxorubicin, epirubicin, and idarubicin)Application of cold minutes for four to six times daily for 24 to 48 hours
27 Non-DNA binding agents Do not bind to the DNA in healthy cells, and are metabolized in the tissueExamples: plant alkaloids (vincristine, vinblastine, and vindesine)Application of heat 15 to 20 minutes for four to six times daily for 24 to 48 hours
28 Some Available Antidotes Totect (dexrazoxane) for anthracycline extravasationSodium thiosulfate for nitrogen mustard extravasationHyaluronidase for vinca alkaloid extravasation