Chemotherapy Extravasation

Introduction:

• It is escape of a chemotherapeutic agent from a vessel into the surrounding tissues by leakage or involuntary injection of a drug into tissues.
• 2 types of cytotoxic agents
  • Vesicants- Anthracyclines, vinca alkaloids, taxanes
  • Irritants- Alkylating agents, antimetabolites
• Occurs with daunorubicin, doxorubicin, vincristine, vindesin, etoposide

Clinical features:

• Aching, swelling, pain or phlebitis at injection site
• Sclerosis and hyperpigmentation along the vein
• Vesicants cause tissue damage and necrosis of overlying tissue

Prevention:

• Use CVC/PICC line while administering chemotherapy
• Do not administer chemotherapy distal to the site of recent venipuncture
• Get access into easily visualized vein in forearm (as damage to nerves, tendons and ligaments is minimized).Avoid small and fragile veins.
• Do not use butterfly needles
• Adequate dilution
• Before administering cytotoxic agent, the catheter should be flushed with free-flowing infusion of 100ml NS.
• Watch for local reaction. Inform patient that, in case of pain or other discomfort, the nurse should be informed immediately.
• Stop infusion immediately upon extravasation, but leave canula in situ

Treatment:

• Aspirate 3-5ml of blood via original canula
• Aspirate contents of blister
• Elevate arm
• If vinca extravasation-Elevate the limb, apply warm pack for 15-20min-every 4 hrs for 24-48hrs. Inj. Hyaluronidase (150-1500 units) through canula if available/ subcutaneously near the extravasation site.
• For daunorubicin/ doxorubicin- Ice packs- 15min- every 4-6hrs- for 24 to 48 hrs. Administer dexrazoxane (1000mg/m2- IV within 5 hrs of extravasation on day 1, 1000mg/m2 on day 2 and 500mg/m2 on day 3) if available. DMSO may be applied topically 3 times a day for 7 days
• Etoposide- Dry heat for 1-2hrs, hydrocortisone cream- LA
• Anti-inflammatory drugs- Steroids 
• Analgesics for pain
• Cover lesion with sterile, dry dressing
• If gangrenous changes- Plastic surgery

Bisphosphonate Induced Osteonecrosis of Jaws

Introduction:

• It is presence of an exposed necrotic bone in the mandible or maxilla, which does not heal after 2 months in a patient receiving a bisphosphonate.
• Other cause for this condition is radiotherapy.
   

Predisposing factors:

• Dental infection
• Dental extraction
• IV administration of bisphosphonates

Pathogenesis:

• Vascular insufficiency within microcirculation

Clinical features:

• Pain
• Loosening of teeth
• Spontaneous avulsion and soft tissue ulceration
• Sinus formation

Prevention:

• Tooth extraction should be done prior to starting bisphosphonates

Treatment:

• Supportive: Good oral care with/ without antibiotics
• Limited debridement of bone
• Stop bisphosphonate use