vesicant chemotherapy administration guidelines

These medications are generally considered to be unlikely to cause injury when extravasation occurs: These medications are generally described as causing mild to moderate inflammation when extravasation occurs. Avoid the "blame game.". Irritant: Medication that can cause local inflammatory reactions at the infusion site, which may include: burning, swelling, pain, inflammation, tightness, or phlebitis. Conclusion Inject 5 mL subcutaneously using a 25 gauge needle, changing needles between each injection, into affected area in a pinwheel fashion. Treatment of cutaneous injuries of neonates induced by drug extravasation with hyaluronidase and hirudoid. Please refer to FAQ Question #1 and the ONS guidelines 1 for special considerations for vesicant administration through a peripheral IV site. Do not pinch the IV administration tubing because this can cause the vein to rupture. Prior to initiation of a vesicant, the VAD tip must be verified &checked for blood Generally, drugs that are vesicants or have extremes of pH or osmolarity should not be administered via midline catheters. Before Copyright 2023 Oncology Nursing Society. The incidence of extravasation of vinca alkaloids supplied in syringes or mini-bags. Question:How do you recommend that we verify blood return when administering vinCRIStine in a minibag? 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. The https:// ensures that you are connecting to the Rev. 1995 Jan-Feb;22(1):57-67. doi: 10.4081/pr.2012.e28. Question:Will administering vinCRIStine in a minibag increase the risk of extravasation? Based on the range of pH values generally considered appropriate for midline administration, vancomycin would be excluded because of its pH of 4. References: 1. 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. Always double check information at the primary references linked below. Pittsburg, PA: Oncology Nursing Society; 2014. 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 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 Some references primarily classify drugs as vesicants or irritants, so those categories will preferentially be used below over classifying as inflammitants and exfoliants. Chemotherapeutics can be classified into three categories: vesicants, irritants, and non-irritants. 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 made by professional oncology organizations are useful resources in this process. 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. Vesicant Administration Guidelines 1. 1 Note: for sterility reasons, USP 797 recommends a beyond-use date, which is less than the maximum stability above. 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 made by professional oncology organizations are useful resources in this process. Gorski LA, Stranz M, Cook LS, et al. Bethesda, MD 20894, Web Policies American College of Radiology. Package insert for vinCRIStine sulfate injection, USP (preservative-free) 1 mg/mL vial. The minibag of vinCRIStine, using a short infusion set, is connected to the Y-site closest to the patient. Use of an infusion pump is discouraged because it increases the amount of pressure on the vein, which raises the risk of extravasation. Calcium Chloride. Infusion therapy standards of practice. 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. 2017 Jan-Mar;4(1):61-68. doi: 10.4103/2347-5625.199081. Accessibility In general--aside from the exceptions listed below--keeping the extravasation cold is preferable to cause vasoconstriction, to prevent spread of the medication, and to decrease inflammation/pain. 3/10/2014, 6. What are other facilities doing to avoid excessive drug loss in the tubing? Nurses play an integral role in determining whether an infusion is appropriate for primary or secondary infusion. Federal government websites often end in .gov or .mil. J Intraven Nurs. Unauthorized use of these marks is strictly prohibited. Caution: excessive heat can cause tissue damage. A central line is always required for vesicant or any chemotherapy in the home. Disclaimer. Although vesicant chemotherapy extravasations cannot be entirely prevented, the risk of extravasation can be reduced by adhering to guidelines for safe vesicant administration. Current ASCO/ONS standards address the safety of all routes of chemotherapy administration to adult patients in the outpatient and inpatient settings. Plymouth Meeting, PA 19462. 2013;1(1):9- 16. Handbook of Injectable Drugs 17th Edition. TheAmerican Society of Clinical Oncology (ASCO)and ONS are conducting an ongoing collaborative project to use a rigorous, consensus-based process to develop standards for the safe administration of chemotherapy. Gilbar P. Inadvertent intrathecal administration of vincristine: has anything changed? Safe Administration of Chemotherapy: Safety During Chemotherapy Ordering, Transcribing, Dispensing, and Patient Identification Safe Administration of Systemic Cancer Therapy: Administration of Chemotherapy and Management of Preventable Adverse Event Clinical Assistant Professor, Drug Information Specialist Extravasation is defined as the leakage or inadvertent administration of a vesicant drug or solution from a vein into the extravascular space. The risk of venous thromboembolism associated with midline catheters compared with peripherally inserted central catheters: A systematic review and meta-analysis [published online ahead of print, 2021 May 15]. Bethesda, MD: American Society of Healthsystem Pharmacists; 2012:1104-5. %PDF-1.7 Managing Extravasation During Chemotherapy Administration Best Practice #1 FAQ | Institute For Safe Medication Practices Extravasation of antineoplastic agents: prevention and treatments. 2012;18(1):155-7. References: 1. Question: Is the dilution of vinCRIStine in a minibag stable? PDF Irritants and Vesicants Guide to Intravenous Administration via Midline Listed below are a few non-chemo agents: Vancomycin. It is also important to note that some medications are classified differently by different references. An official website of the United States government. Version number changed to v.5. Oncol Nurs Forum. PDF BC Cancer Extravasation Hazard Table Minor updates to administration and patient education. For definitions of different categories of extravasation hazard and the details on management of extravasation, see BC Cancer Systemic Therapy Policy III-20 1990 Mar-Apr;13(2):111-4. Central VADs may also be more appropriate in patients needing longer-term therapy.3 Although some evidence has supported lower thrombosis risk with midline catheters compared with CVCs,1 a recent systematic review of 12 studies in 40,871 patients found that risk of venous thromboembolism was significantly higher with a midline catheter compared with a PICC (3.97% versus 2.29%; relative risk, 1.53; 95% CI, 1.33 to 1.76; p<0.00001).4 However, evidence evaluating the risk of catheter-related bloodstream infections (CRBSI) continues to find similar or improved rates of infection with midline catheters compared with PICCs.5, Compared with midline catheters, peripheral IV catheters are inserted more distally and most often utilize veins of the dorsum of the hand for cannulation.1-3Peripheral IV catheters have high first-attempt failure rates (26% in adults, 54% in children) and often require recannulation in larger more proximal sites.1,2Therefore, midline catheters may reduce the need for recannulation and thereby afford a longer dwell time. 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. Vesicant Chemotherapy Extravasation Antidotes and Treatments 2014;(Epub ahead of print). endobj PDF Appendix B: Vesicant/Irritant and Extravasation Management Guidelines MeSH Trissel LA. J Oncol Pharm Pract. 139.59.111.99 Pediatr Rep. 2012 Aug 1;4(3):e28. J Oncol Pharm Pract. The following information is a compilation from the various resources listed below.[1][2][3][4][5][6][7][8]. Oncology nurses and pharmacists often are given the responsibility of developing or updating institutional policies to manage vesicant chemotherapy extravasations. 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. Abstract. Preventing and managing vesicant chemotherapy extravasations www.hospira.com/Images/434047_32-91799_1.pdf, http://opp.sagepub.com/content/early/2014/01/13/1078155213517729, Medication Safety Officers Society (MSOS). Management of Chemotherapy Extravasations - U.S. Pharmacist May be due to direct leakage from the venous access device or from elsewhere in the vessel (such as from previous phlebotomy). There are several actions that could trigger this block including submitting a certain word or phrase, a SQL command or malformed data. FOIA This review provides an overview of midline catheters and a summary of properties that influence the determination of whether a drug is appropriate for administration via midline catheter. This site needs JavaScript to work properly. Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. Antidotes to vesicant chemotherapy extravasations. Flare reaction: A skin reaction to a medication which is an allergic response. Properties of midline catheters Vesicant: Medication that may causes severe and/or irreversible tissue injury and necrosis. eCollection 2012 Jul 31. 2021 Update: What are considerations for determining whether a drug may Front Oncol. <> Vesicant: Medication that may causes severe and/or irreversible tissue injury and necrosis. Therefore, questions often arise regarding the appropriateness of administering specific drugs via midline catheter. Development of an evidence-based list of noncytotoxic vesicant medications and solutions. Introduction. Having practitioners spend a few additional minutes during the administration step using a minibag is the only safe choice to be made. PDF Antineoplastic Drug Administration: Vesicant and Irritant Agents Rev.12/2/2014. Developing extravasation protocols and monitoring outcomes. 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. Available antidote and treatment formulations and their preparation and administration also are discussed. Overview, prevention and management of chemotherapy extravasation. Nurgat Z, Smythe MP, Aljedai A. % Hemonc Today | During the past several years, the Oncology Nursing Society developed and maintained Chemotherapy and Biotherapy Guidelines and Recommendations for Practice, providing a unique and . Nafcillin. 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. Centers for Disease Control and Prevention. Introduction HHS Vulnerability Disclosure, Help 5-Safe administration of anti-cancer drugs | eviQ If cooling techniques are being used, withhold cooling 15 minutes before and after the infusion. If an antidote is not going to be used, the venous access can be removed after aspiration of the extravasated fluid has been attempted. Pittsburg, PA: Oncology Nursing Society; 2014. Blood Rev. Exfoliants:An agent that is capable of causing inflammation and skin shedding, but less likely to cause tissue damage. Always stop infusion of the causative medication first and, if appropriate, elevate the affected extremity. The 2008 European Oncology Nursing Society extravasation guidelines recommend this management for the following medications: From HemOnc.org - A Hematology Oncology Wiki, Chemotherapy vesicant & irritant properties and suggested management for extravasation, "Localize and neutralize" or "disperse and dilute". 2. **Some case reports of extravasation and injection site reactions or inflammation have been reported. What do you recommend? All rights reserved. Accessed August 2, 2021. https://www.acr.org/-/media/ACR/Files/Clinical-Resources/Contrast_Media.pdf. 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. European Oncology Nursing Society extravasation guidelines. Errors have still been reported with the use of large volume syringes, although usually with 10 or 20 mL syringes. For primary infusions, the agents should be administered by direct connection to the access site using primary tubing, a Luer lock connection should be used, and a compatible IV flush solution should be readily available for emergent administration issues and to clear the line after completion. Clin J Oncol Nurs. There is not a comprehensive list of drugs that are appropriate for administration via midline catheter. 2008 Sep;12(4):357-61. doi: 10.1016/j.ejon.2008.07.003. Adams DZ, Little A, Vinsant C, Khandelwal S. The midline catheter: A clinical review. Management of the extravasation of anti-neoplastic agents. 2022 Dec 2;12:1021488. doi: 10.3389/fonc.2022.1021488. Ryan Rodriguez, PharmD, BCPS Pittsburg, PA: Oncology Nursing Society; 2014. Oncologist. 6 Although the "extremes" are not further defined, the guidelines specifically recommend central lines for parenteral nutrition formulas . Kapucu S, zkaraman A, Uysal N, Bagcivan G, eref F, Elz A. Asia Pac J Oncol Nurs. Reduce dose by 50% for patients with creatinine clearance less than 40 mL/min. 3/10/2014, Institute for Safe MedicationPractices Sauerland C, Engelking C, Wickham R, Corbi D. Oncol Nurs Forum. Vesicant extravasation: myths and realities. Taxanes: vesicants, irritants, or just irritating? Preventing and Managing Vesicant Chemotherapy Extravasations In regard to the risk of extravasation: There have been studies comparing extravasation rates between these two administration techniques, which have similar results. HHS Vulnerability Disclosure, Help The 2021 INS guidelines recommend against the use of midline catheters for continuous administration of vesicant therapy, parenteral nutrition, or other infusates with "extremes" of pH or osmolarity. Knowledge Level on Administration of Chemotherapy through Peripheral and Central Venous Catheter among Oncology Nurses. There are non-chemo medications and solutions that have vesicant properties as well and can cause extravasation. NCI's Dictionary of Cancer Terms provides easy-to-understand definitions for words and phrases related to cancer and medicine. 2. 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. Clinical Associate Professor, Drug Information Specialist, Updated by: Unauthorized use of these marks is strictly prohibited. Hospira. 2. MeSH Your institution can use them to inform practice policies and procedures, internal quality assessment, and external quality monitoring. To report a content error, inaccuracy, or typo, email pubONSVoice@ons.org. The ASCO/ONS Chemotherapy Administration Safety Standards are intended to reduce the risk of error when providing adult patients with chemotherapy, and to provide a framework for best practices in cancer care. Infuse in an extremity or area other than the one affected by extravasation. Calcium Gluconate. R*#;Wv777UtB4o"*v fgf?m[q\.>:TM=U)!f7STG.(Ky\B/Uc>L3}4d##0 ~!m I/>fwo8X p#D:}(edI? *(rC?Qe<=O%cfkkdsWq(u ?|b1k#^b!*tne{R^i5 }ikSbRI{xlQYSgAoKmgx~f However, data suggests that the risk of extravasation is low, regardless of the method used to administer the drug. Wengstrm Y, Margulies A; European Oncology Nursing Society Task Force. This website is using a security service to protect itself from online attacks. Performance & security by Cloudflare. Secondary infusions are safest administered with the use of secondary tubing attached with a Luer lock connector to the primary line containing a compatible IV solution. 833 S. Wood St., Suite B12, College of Pharmacy, (MC 886), Chicago, IL 60612, 2023 The Board of Trustees of the University of Illinois, UI Health is UICs academic health enterprise. {M@C:NiD(mXx?0/a`1Y$,X6iF ~,e!|;b`H30dhfN@+T@ 8 Caparas JV, Hu JP. Most importantly, organizations must weigh the risk of possible extravasation versus certain death from the accidental administration of vinCRIStine by the intrathecal route when making decisions about changing 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. Accidental administration of vincristine in pediatric patients. Another option is to aspirate with a syringe via the lowest Y-site and clamp off fluid from the minibag. Eur J Oncol Nurs. Polovich M, Olsen M, LeFebvre KB, eds. %%EOF Furthermore, in vitro evidence suggested that vancomycin-associated endothelial damage is caused by factors other than pH. Vesicant & irritant chemotherapy - A Hematology Oncology Wiki 1. Safe administration of vancomycin through a novel midline catheter: a randomized, prospective clinical trial. Hyaluronidase may be used in extreme scenarios such as large volume extravasation or severe irritation. However, the INS Task Force identified limited literature describing extravasation of vancomycin. Intravascular catheter-related infection (BSI). Please enable it to take advantage of the complete set of features! To update the ASCO/Oncology Nursing Society (ONS) Chemotherapy Administration Safety Standards and to highlight standards for pediatric oncology. Vesicant Chemotherapy Extravasation Antidotes and Treatments Polovich M, Olsen M, LeFebvre KB, eds. 2008 Sep;12(4):357-61. doi: 10.1016/j.ejon.2008.07.003. Gilbar P, Chambers CR, Larizza M. Medication safety and the administration of intravenous vincristine: International survey of oncology patients. PDF Chemotherapy Drugs for Cancer Treatment: Administration, Safe Handling PMC 2108 0 obj <>/Filter/FlateDecode/ID[<79BA663E75301A408346CF53CE9BCBB7><05BE28B3380661489955B8DFD5505C1D>]/Index[2088 54]/Info 2087 0 R/Length 102/Prev 343790/Root 2089 0 R/Size 2142/Type/XRef/W[1 3 1]>>stream Your IP: UN vR7. Tubing features can present another challenge when considering how to best administer chemotherapy agents. 2. The action you just performed triggered the security solution. 3. Clinical exam may reveal warmth, erythema, or tenderness. Heat - Apply warm compresses to extravasation site for 1 hour. Nurses, Chemotherapy, and Pregnancy: What Do We Know? 2016 Updated American Society of Clinical Oncology/Oncology Including National Library of Medicine Extravasation of noncytotoxic drugs. <>/Metadata 1012 0 R/ViewerPreferences 1013 0 R>> All rights reserved. Your institution can use them to inform practice policies and procedures, internal quality assessment, and external quality monitoring. Facebook - National Cancer Institute Remove cold pack at least 15 minutes before dexrazoxane therapy. The .gov means its official. Irritant: Medication that can cause local inflammatory reactions at the infusion site, which may include: burning, swelling, pain, inflammation, tightness, or phlebitis. e.YvIQ|!C2\@&;:8 h qF . uDX i! Use a central venous catheter or implanted device for continuous vesicant infusions or for any vesicant infusion lasting longer than 30 minutes. 2088 0 obj <> endobj eCollection 2012 Jul 31. Avoid continuous vesicants or irritants (chemotherapy, vasopressors) . Reference: 1. Content on this site is protected by U.S. and international copyright laws. Answer:Yes, the product is stable in a minibag. This site needs JavaScript to work properly. 2008 Sep;12(4):357-61. Cloudflare Ray ID: 7c0b26d1e9b36bd5 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. x][8~Gi"K6$Yd cG_")X=@zdbXb"f]FyMQrt2i[Fl')o:{pO^}~[~9>aP,p"yKxb}t+~{x:?OA9?tvK:0+M*7y wg|[]okN(6cw1gQX$|6x5Q^Xn{~(8klFaL8?k|9}YjO"?}M8OC?}T-Qezi^D1@olKSw8E[D7:z,eQ,rY!'HT|9,}O$. A similar sized bag for the back flushing, such as a 25 mL bag of 0.9% saline is used for both adults and pediatric patients. A subsequent 2013 revision J Oncol Pharm Pract. The tubing contains 7 mL of volume and that is more than 10% of the 50 mL for an adult dose. By using this site, you agree to theTerms of Use, Privacy Policy, andTerms and Conditions for ONS Guidelines, as applicable. Bookshelf ONS is committed to promoting excellence in oncology nursing and the transformation of cancer care. You can email the site owner to let them know you were blocked. Please enable it to take advantage of the complete set of features! Oncology Nursing Society releases updated guidelines on - Healio Unable to load your collection due to an error, Unable to load your delegates due to an error. Rev. Would you like email updates of new search results? 866-257-4ONS (866-257-4667). 8600 Rockville Pike 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. For every 1 mg of mechlorethamine suspected to have extravasated, inject 2 mL of the 1/6 molar sodium thiosulfate solution subcutaneously into the extravasation site using a 25 gauge or smaller needle. Clinical exam may reveal warmth, erythema, or tenderness. Also, dilution of the vinca alkaloid likely reduces the impact of any extravasation that might occur. This decision must be weighed in light of certain death if the drug is administered via the wrong route. Managing Vesicant Extravasations | The Oncologist | Oxford Academic 2008 Mar;13(3):284-8. doi: 10.1634/theoncologist.2007-0191. Please. stream 2023 Institute for Safe Medication Practices. Acknowledgement: MiKaela M.Olsen RN, MS, AOCNS, Oncology and Hematology Clinical Nurse Specialist; Johns Hopkins Hospital Potassium Chloride. doi: 10.1097/GOX.0000000000001743. In some regimens, enough data support sequencing of agents, but in others, data are lacking. Careers. 1 0 obj Advocating for the Provision of Alternate Responsibilities for Nurses Who Are Pregnant, Breastfeeding, or Trying to Conceive, Medical surveillance programs are recommended to detect changes in the health status of those working with hazardous drugs. VinCRIStine administration and the back flushing method are done by gravity when administered through a peripheral line. Extravasation injury from chemotherapy and other non - UpToDate Vesicant chemotherapy extravasation antidotes and treatments The 2021 INS guidelines recommend against the use of midline catheters for continuous administration of vesicant therapy, parenteral nutrition, or other infusates with extremes of pH or osmolarity.6 Although the extremes are not further defined, the guidelines specifically recommend central lines for parenteral nutrition formulas with osmolarity exceeding 900 mOsm/L. Eur J Oncol Nurs. 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. Although vesicant chemotherapy extravasations cannot be entirely prevented, the risk of extravasation can be reduced by adhering to guidelines for safe vesicant administration.