1. Vesicant Infusions A presentation for King Edward VII Memorial Hospital, Bermuda 23 January, 2012
Kristen Bodnaruk, RN, BS
Denise Dreher, RN, CRNI, VA-BC
Mary McCormick-Gendzel, RN, MS, CRNI, RN-BC

2. Today’s Discussion: Definitions Patient safety
Peripheral and central VAD assessments
Equipment
Healthcare worker safety
Drug administration
Extravasation

3. Definitions
Irritant: 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 meet
infusion needs
---smaller gauge decreases intimal damage
and promotes hemodilution
Placement of catheter: avoid areas of flexion such as the hand, wrist, or antecubital fossa
Consider new PIV insertion daily if patient receiving daily vesicants
Start 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 catheter
Infusion history
Poor VAD insertion technique
Poor care and maintenance practices
Extended dwell time
Chemical 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 Factors
Recent proximal peripheral venipunctures, or other existing PIVs in the same extremity
Inadequate device securement
Confused or active patients could dislodge or damage access
Improper 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 occlusion
Vessel occlusion
Catheter rupture/fracture
Device rotation
Catheter migration
For implanted ports: improper insertion of non-coring needle or needle dislodgement

9. Equipment
IV 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 sets
Caution with connecting and disconnecting
Proper use of PPE
Exercise caution when handling patient’s emesis, urine, or feces
Disposal of equipment into the appropriate biohazard bag or container
Follow established protocols and use a chemotherapy spill kit when cleaning up spills

12. Vesicant Administration

13. General Points of Emphasis
Continuous vesicants are given via central access.
Pre-filled administration sets versus backpriming of tubings
Vesicants are administered FIRST in a multiple chemo regimen
Patient 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-infusion
Check/double-check of correct medication and dosage per facility policies and procedures
Review of patient’s height, weight, body surface area (BSA), and any pertinent lab values
Patient identification using two verifiers

16. Infusion
Do 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. Infusion
When 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.

18. Peripheral IV Extravasation

19. Port Extravasation

20. Port Extravasation

21. Extravasation
Inadvertent administration of vesicant medication or solution into the surrounding tissue (INS, 2011)

22. Extravasation
Any grade 4 infiltrate of a vesicant is considered an extravasation
Incidence is similar for peripheral and central line administration
Risk factors, such as fragile vessels, location of peripheral IV, or catheter integrity are things to consider
Antidotes may be used, but are considered controversial in some circles
Many non-chemotherapy agents have vesicant properties (e.g., Dopamine, Epinephrine, Gentamycin, Mannitol)
Reference: MGH NPROM

23. Early warning signs of possible extravasation
Swelling
Stinging, burning, or pain at insertion site
IV flow that stops or slows
Resistance when pushing medication
Leaking around the port needle
Lack of blood return
Erythema, inflammation, or blanching

24. Other symptoms/damage resulting from extravasation
Induration
Vesicle formation
Necrotic tissue damage can progress for six months
Tissue sloughing
Tendon, nerve, joint damage
Blistering at insertion site
Ulceration is usually seen 2-3 days to weeks following extravasation

25. Treatment of Extravasation
IMMEDIATELY STOP INFUSION
Remove tubing from VAD, attach syringe to VAD, and aspirate drug
If via PIV, elevate extremity
Notify physician ASAP
Locate your institution’s policies or call Pharmacy for specific antidote
Application of heat or cold
Documentation in patient’s medical record
Documentation via safety report

26. DNA-binding agents
Bind 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 tissue
Examples: 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 extravasation
Sodium thiosulfate for nitrogen mustard extravasation
Hyaluronidase for vinca alkaloid extravasation

29. Helpful Websites

30. References
Alexander, M., et al., Infusion Nursing. An Evidence-Based Approach. INS, Saunders, 2010.
Policies and Procedures for Infusion Nursing. INS, fourth edition, 2011.
Infusion Nursing Standards of Practice. INS, Lippincott, 2011.
Terry, et al. Intravenous Therapy: Clinical Principles and Practice. INS. WB Saunders, 2001
Oncology Nurses Society (ONS) website
MGH Nursing Procedure Manual (NPROM)
MGH Clinical Policies and Procedures
MGH Infection Control Manual