Extravasation injuries are among the most consequential local toxic events. When the vesicant chemotherapeutics leak into the perivascular space, significant necrosis of skin, muscles, and tendons occurs, with resultant loss of function, infection, and deformity. Typical initial manifestations include swelling, pain, and a burning sensation that can last for hours. Days later, the area becomes erythematous and indurated, followed by resolution or progression to ulceration and necrosis. These early findings are often difficult to distinguish from other forms of local drug toxicity, such as irritation and hypersensitivity, which can result from the chemotherapeutic or its vehicle (ethanol, propylene glycol) and do not progress to ulceration and necrosis. For example, fluorouracil, carmustine, cisplatin, and dacarbazine are local irritants. The local irritation and hypersensitivity manifestations are self-limiting and typified by an immediate onset of a burning sensation, pruritus, erythema, and a flare reaction of the vein receiving the infused. The extravasation of monoclonal antibodies causes minimal discomfort and inflammation.15,37,49 When a hypersensitivity reaction or an irritation to the vessel cannot be differentiated from extravasation, it is prudent to presume extravasation and manage the situation accordingly.
The occurrence of extravasations appears to be more frequent with inexperienced clinicians.19 Factors associated with extravasation injuries from peripheral intravenous lines include (1) poor vessel integrity and blood flow, such as those found in the elderly and in patients with numerous venipuncture attempts or who have received radiation therapy to the site; (2) limited venous and lymphatic drainage caused by either obstruction or surgical resection; and (3) the use of venous access overlying a joint, which increases the risk of dislodgments because of movement.18,40
In children, the use of a steel needle (butterfly) or a small catheter that easily allows blood to flow around the catheter increases the risk for an extravasation.10 Children require frequent monitoring of the intravenous site for possible extravasation. Extravasation injuries from implanted ports in central veins occurs from inadequate placement of the needle, needle dislodgment, damaged septum, fibrin sheath formation around the catheter, perforation of the superior vena cava, and fracture of the catheter.44 When extravasation from a central venous access device is suspected and plain radiographic studies are not diagnostic, a contrast-enhanced CT scan of the anatomic location is necessary for evaluation because the extent of the injury is often underestimated at the bedside.1,2,37
The factors associated with a poor outcome from extravasation injuries include (1) areas of the body with little subcutaneous tissue, such as the dorsum of the hand, volar surface of the wrist, and the antecubital fossa, where healing is poor and vital structures are more likely to be involved; (2) increased concentrations of extravasate; (3) increased volume and duration of contact with tissue; and (4) the type of chemotherapeutic.40,41
Vesicants, such as doxorubicin, daunorubicin, dactinomycin, epirubicin, idarubicin, mechlorethamine, ...