Treating Extravasation Injuries

The many papers on this subject present a diversity of views but there is not enough consensus to formulate an algorithmic approach to treatment based on the physicochemical properties of the groups of agents or to predict which cases may progress to significant tissue necrosis. The following information is based on current available evidence. Units are advised to formulate a policy to deal promptly with extravasation which is relevant to the drugs and infusates used regularly.

To view the West Midlands Regional Chemotherapy Services extravasation treatment protocol, formulated by St. Chad's Unit, City Hospital, Birmingham UK, click here

To view details of David Gault's 'flush-out' technique, please click here

Heat and Cold                                                                       

8,13,14,16,20,23,30,36,45,78,79

These have been used on the principle that:

• Heat induces vasodilation, increasing drug distribution and absorption 60,88 and decreasing local drug concentrations.59,64
• Cold causes vasoconstriction, localising the extravasation 60 and allowing time for local vascular and lymphatic systems to disperse the agent.88
• With the exception of vinca alkaloids, topical cooling seems to be more effective than topical warming in the management of cytotoxic and non-cytotoxic vesicants.88 In practice, the application of moist heat has lead to maceration and necrosis.62

Corticosteroids

• As intradermal or subcutaneous injections and topically as steroid creams.
• As single treatments and in combination with other agents.
• Evidence suggests that corticosteroids are not helpful in the extravasation of antineoplastic agents because inflammation is not prominent in the aetiology of tissues necrosis.

Antidotes

Some of these are recommended by the drug manufacturers.

• Phentolamine (an alpha-adrenergic blacking agent relaxing smooth vascular muscles) has been used as an antidote to vasopressor extravasation. (ABPI Compendium 1998-9)
• Topical glyceryl trinitrate (vasodilator) for parenteral nutrition. 93
• Sodium thiosulphate (direct inactivation) for mustine.(ABPI Compendium 1998-9)
• Dimethyl sulphoxide (an oxygen-free radical scavenger) for daunorubicin, 11 mitomycin 4 and doxorubicin. 94
• Dexrazoxane (Savene TM) for anthracycline extravasation

Surgery

Indications for surgical excision of the extravasated area:

• Clear cut full-thickness skin necrosis with or without frank ulceration 92 or intractable pain. 95
• Wide excision including a margin of normal tissue ensures a satisfactory graft or flap 61although deep ulceration may involve tendons or nerves. 92
• Patients frequently end up with extension contractures regardless of how wound closure is achieved. 92
• Early surgical excision is controversial since only about a third of known vesicant extravasations will ulcerate.96