What Is Extravasation? What Should Be Done When a Cancer Drug Leaks Under the Skin?

What Is Extravasation?

When a drug is given through a venous cannula (into a vein), leakage of the solution or infusion fluid out of the blood vessels and into surrounding tissue is called extravasation. This risk is very low when a healthcare professional administers medication through an infusion, but it can still occur rarely. Infusions containing chemotherapy are of particular concern because some chemotherapy drugs can damage tissue; these drugs are called vesicants.

Which Chemotherapy Drugs Cause Problems if Extravasation Occurs?

If chemotherapy is vesicant—meaning it can cause tissue damage through blistering and ulceration—extravasation can cause a serious complication.

Chemotherapy drugs are listed below according to their vesicant potential:

What Causes Extravasation?

Extravasation may occur if a drug is administered too quickly, if it is too acidic or alkaline, or if there is a blockage in the intravenous (IV) line.

What Are the Symptoms of Extravasation?

Symptoms of extravasation include:

• a painful stinging or burning sensation at the IV site,
• swelling and
• skin discoloration

The severity of extravasation depends on how much medication has entered the surrounding tissue and how strongly the tissue reacts to it. Very severe cases can cause loss of a limb, tissue or function.

4 degrees are used to describe the severity of extravasation

First Degree

First-degree extravasation is mild, with symptoms including:

• discomfort or pain around the needle site
• medication that does not pass easily through the cannula
• minimal swelling without skin discoloration

Second Degree

Second-degree extravasation is more serious than first-degree extravasation and includes additional symptoms such as:

• slightly more pain around the needle site
• medication flowing more slowly through the cannula
• mild swelling
• mild redness

Third Degree

If a person shows signs of third-degree extravasation, a doctor or nurse must intervene immediately.

Symptoms include:

• severe pain around the needle site
• a blocked cannula
• swelling
• skin that is paler or grayer than normal, with or without nearby discoloration

Pallor can be difficult to detect in dark skin, so healthcare professionals may check the eyes, palms and nail beds for signs of discoloration.

Fourth Degree

A person should immediately alert the medical team if they notice the following symptoms:

• intense pain around the injection or needle site
• marked swelling
• patches of paler skin that feel cold, possibly with nearby areas of skin that are darker than normal
• blistering

At this stage, a person shows signs of severe tissue damage and loss.

Extravasation or Infiltration?

The difference between extravasation and infiltration is the type of solution or drug that leaks into nearby tissue. Vesicant drugs can cause tissue death, whereas nonvesicant drugs do not have this effect.

Extravasation

Extravasation occurs when a vesicant drug leaks out of a vein into surrounding tissue. When this happens, a person will suffer severe tissue damage, including ulceration and tissue death, if treatment is not received in time.

Infiltration (Seepage)

This complication occurs when a nonvesicant drug leaks out of a vein into nearby tissue. The leakage may cause symptoms and discomfort in the affected area, but any damage is usually less severe than in extravasation.

Causes of Extravasation

Among adults receiving cancer treatment, extravasation occurs at a rate of 0.1–6%. However, improvements in infusion techniques and greater awareness of the early signs of extravasation among healthcare professionals are reducing this rate.

There are many possible causes of extravasation, including:

• repeatedly using the same veins for cannulation
• fragile veins
• drugs with a pH below 5 or above 9
• drugs that cause a vein to constrict or go into spasm
• differences in osmotic pressure
• poor injection or cannulation technique
• a blockage in the IV line

To prevent permanent tissue and limb damage, it is important for the person receiving the medication or the medical team to recognize the signs and symptoms of extravasation early.

How Is Extravasation Treated?

Oncology nurses and doctors diagnose extravasation by examining the skin around the cannula.

• If extravasation is suspected, the drug infusion should be stopped and the affected limb elevated. Doing this as soon as possible may prevent serious complications and stop extravasation from progressing to a higher degree.
• The medical team should continue monitoring the skin for 24 hours after stopping the infusion to check for signs of infection.
• The degree of extravasation determines the intervention required. Third- and fourth-degree cases require more intensive treatment than first- and second-degree cases.

As soon as a doctor or nurse suspects extravasation, they should follow these steps:

1. Stop the infusion and leave the cannula in place.
2. Using a 10-20 milliliter syringe attached to the cannula, remove or withdraw as much of the drug as possible.
3. Relieve any pressure on the affected area.
4. Then remove the cannula and mark the affected area with a pen.
5. Notify the doctor, if this has not already been done, so treatment can begin.
6. Elevate the limb.
7. Give pain relief if the person needs it.
8. Monitor the area for infection or further progression of tissue injury.

The healthcare team will continue monitoring the person and may take photographs to document healing.

Depending on the type of drug that has leaked into the tissue, doctors may warm or cool the affected area to stop the drug from spreading. Cold compresses are generally recommended for extravasation of all irritant and vesicant drugs except vinca alkaloids (vincristine, vinblastine, vinorelbine), epipodophyllotoxins (etoposide), oxaliplatin and vasopressors, because cold worsens the tissue ulceration caused by these drugs. Cold compresses cause vasoconstriction, limiting the spread of the extravasated drug. Cold also reduces local inflammation and pain. For extravasation of specific drugs such as vinca alkaloids, etoposide, vasopressors and oxaliplatin, increasing local blood flow and accelerating drug removal is the aim of warm compresses, which are preferred. Apply compresses for 20 to 60 minutes, 3 or 4 times a day, during the first 24 to 72 hours after extravasation occurs.

Healthcare professionals should use standardized, evidence-based techniques when inserting cannulas to minimize the risk of extravasation.

Other strategies for preventing extravasation include:

• avoiding needle insertion into joints or areas that are difficult to secure
• choosing a different IV (intravenous) route or alternative vein where possible
• removing and repositioning a cannula if it appears unstable
• watching for swelling while administering the drug
• asking whether a person feels any pain while administering a drug or solution
• administering drugs at the correct rate
• checking for blood flowing back through the cannula

A person should seek medical help if they experience pain and swelling where the cannula enters the skin. They should not wait for symptoms to worsen, because the earlier doctors treat extravasation, the better the outcome.

Summary

If healthcare teams do not treat extravasation promptly, a person may experience serious complications, such as loss of tissue and/or limb function.

Extravasation occurs when IV drugs capable of destroying tissue leak out of blood vessels into the surrounding skin and muscles.

First-degree extravasation is the least severe form, and if a person is treated at this stage, the risk of permanent tissue damage is low.

Fourth-degree extravasation is the most severe form. If the drug spreads from the infusion site to other areas, a person may lose limb function or the affected part of the limb.

A person should notify the healthcare team as soon as they feel any pain or swelling at the infusion site.

The earlier a person receives treatment, the greater the chance of a full recovery without permanent tissue damage.