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Course: Oncology Nursing

Topic: Nursing Management of Cancer

Treatment Related Extravasation and Peripheral Neuropathy

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Module Goals

Learners will be able to:

Describe extravasation and peripheral neuropathy as side-effects related to cancer and cancer treatment.
Identify risk factors, sign and symptoms of extravasation and peripheral neuropathy in cancer treatment.
Describe management of these side effects.
Describe the nurse’s role in management of these side-effects.

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Extravasation

Inadvertent infiltration of chemotherapy into the subcutaneous or subdermal tissues surrounding the intravenous or intra-arterial administration site¹
Classified according to drug’s potential for causing damage

Vesicant²: Capable of causing tissue destruction;
two types: DNA binding and Non-DNA binding
Irritant²: Causes stinging, aching, tightness, and phlebitis but without necrosis when extravasated
Non-vesicant: Does not cause tissue destruction when extravasated

Fidalgo et al. (2012)
New South Wales Government, eviQ (2019)

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Extravasation: Patient-Related Risk Factors

Small and fragile veins
Hard and/or sclerosed veins due to previous treatments
Prominent but mobile veins i.e elderly
Known diseases or situations associated with an altered or impaired circulation like advance diabetes
Predisposition to bleeding, increased vascular permeability or those with coagulation abnormalities
Obesity: difficult venous access
Impaired sensory ability to detect change in sensation
Hinder early reporting like young children, language barrier, sedation
Requiring prolonged infusion

Fidalgo et al. (2012).

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Extravasation: Procedure-Related Risk Factors

New South Wales Government, eviQ (2019)

Untrained or inexperienced staff
Multiple attempts at cannulation
Unfavorable cannulation site
Bolus injections
High flow pressure i.e infusion pump
Choice of equipment : type, size

(peripheral catheter, steel ‘Butterfly’ needle)

Inadequate dressings or poor cannula fixation
Poorly implanted CVAD

(too deep for cannula, difficult to secure cannula)

Displacement or migration of CVAD catheter from vein

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Extravasation : Preventive Protocols Minimize Risk

Site of insertion:

Use large veins in forearm recommended for peripheral administration
Cannulation avoided over joints and lymphoedema
Inner wrists and lower extremities to be avoided
Veins in antecubital fossa or in dorsum of hand not recommended for vesicant drugs
Central venous access highly recommended of prolonged infusion (12-24 hrs)

Cannula:

Butterfly needle to be avoided for infusion of vesicant drugs
Use flexible cannula

Fidalgo et al. (2012).

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Extravasation : Preventive Protocols Minimize Risk

Procedure:

After cannulation check for blood flow
then flush with 10-mL normal saline and check for signs of extravasation
Flushing with 10-20 ml of saline solution between different drugs infusions recommended
Always obtain blood return before drugs are administered
Continued monitoring of cannulation site for swelling, pain, redness, sluggish infusion rate
Bolus dosage of vesicant drugs may be administered concurrently with a fast running infusion of compatible I.V fluid

Fidalgo et al. (2012).

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Extravasation: Assessment

Early detection and treatment intervention is most crucial¹
Ongoing assessment necessary for early detection²:

Drug extravasated, dose, volume
Position and size of injury
Amount and type of exudate
Presence of swelling, oedema
Extent and spread of erythema

Differential diagnosis assessment should be carried out¹:

Sign/symptoms of local non-extravasation reaction include

Erythema around cannula site, along accessed vein
Urticaria and local itching

Fidalgo et al. (2012)
New South Wales Government, eviQ (2019)

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Extravasation

Another potential differential diagnosis is chemical phlebitis

Vein inflammation, frequently followed by thrombosis or sclerosis of veins.
May cause burning sensation at cannula site, cramping along the vein proximal to the cannula site.

Fidalgo et al. (2012).

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Extravasation: Management

Patient education crucial for prompt identification
Initiation of general non-specific measures soon after diagnosis is highly recommended
Trained person in extravasation management must be available with extravasation kit

Should contain instructions, materials, medications

Fidalgo et al. (2012)

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What would the nurse do?

Once the nurse inserts the intravenous cannula into the vein, the nurse should perform all of the following steps to prevent extravasation of a chemotherapy drug? (Select all that apply)

The nurse should check for blood return in the cannula.
The nurse should flush 10 ml normal saline to check for signs of extravasation.
The nurse should proceed to give the medication immediately upon cannulation of the vein.
The nurse should secure the cannula in place with a transparent dressing.

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Extravasation : Management Protocol

Step 1: Stop and disconnect infusion. Leave the venous access device (VAD) in place.

Step 2: Identify the extravasated drug

Step 3: Gently aspirate residual drug from VAD using sterile syringe. Remove the VAD. Avoid direct pressure over the area.

Step 4: Mark outline of the extravasated area with a pen.

Step 5: Notify physician. Start specific measures as soon as possible.

(Illustrated in Step 5A and 5B in the next slide)

Step 6: Elevate the limb. Administer analgesia if necessary

Fidalgo et al. (2012)
New South Wales Government, eviQ (2019)

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Fidalgo et al. (2012)

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Extravasation: Management

Surgical debridement is the treatment option of unresolved tissue necrosis or pain lasting more than 10 days¹

Documentation necessary for extravasation incident include:

Patient name and identification number
Date and time of extravasation
Name of drug extravasated as well as diluent used (if applicable)
Signs and symptoms including those reported by patient
Description of the venous access
Extravasation area with approximate amount of drug

Fidalgo et al. (2012)

.

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Extravasation: Follow-up Care

Fidalgo et al. (2012)

.

Subtle signs/symptoms of extravasation can increase in intensity on the days that follow

Blister may appear, inflammation may evolve to a necrosis

Advise patient

To monitor affected area, inform of any changes immediately
About follow-up policy before leaving treatment area

Patient reviewed by the healthcare professional

Daily or every 2 days for first week
Then weekly after, until resolution of symptoms

If required referral to plastic surgeon

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Nurse’s Role in Extravasation

Patient counselling before drug administration¹:

Early sign/symptoms of extravasation
Immediate report:

Any changes in sensations- tingling/burning/discomfort/pain.
Swelling, redness, wetness at cannulation site.
Sluggish infusion rate.

Limit movement of cannulation site, prevent tugging on IV line.

Practice prevention measures:

Choose appropriate cannulation site and appropriate cannula.
Ensure blood return after cannulation/before administering drugs.
Keep the cannulation site patent by flushing with normal saline.

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Nurse’s Role in Extravasation

Management of Extravasation:

Monitor cannulation site for signs of extravasation during and after chemotherapy drug administration.
Assess for patency of venous access before administering drugs.
Provide prompt care, support when extravasation occur.
Provide follow-up policy and follow-up care of extravasation.
Document and report extravasation incident.

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What Would the Nurse Do?

Nurse collected the prescribed vesicant drug, other necessary equipment for the drug administration, and proceeded to the patient’s bedside. Prior to the administration of the medication what patient education is the most vital regarding the administration of a vesicant drug?

The nurse should inform the patient about signs/symptoms of extravasation and to report these sign/symptoms immediately.
The nurse should inform the patient that during the administration of the drug, all family members must leave the room to avoid potential exposure.
The nurse should inform the patient that if the vesicant begins to leak at the site, that this is not considered an extravasation event.
The nurse should inform the patient can adjust the infusion the medication as desired.

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Peripheral Neuropathy

Damage to the nerves of the peripheral nervous system^1,2
Caused by cancer/it’s treatment^1,2

Some chemotherapy drugs, targeted therapy drugs¹
Tumor growing into/pressing on peripheral nerve¹
Radiation therapy¹
Surgery¹
Poor nutrition¹
Paraneoplastic syndrome¹
Substances released by cancer cells disrupt

the normal function of nearby/distant organs or tissues

Canadian Cancer Society, n.d., Peripheral nerve damage (peripheral neuropathy).
National Cancer Institute, 2020, Nerve Problems

(Peripheral Neuropathy) and Cancer Treatment

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Peripheral Neuropathy: Risks

Cancer patients are at higher risk of developing peripheral neuropathy if:

Diabetic
Consumes large amount of alcohol
Have autoimmune conditions such as rheumatoid arthritis or lupus
Have an underactive thyroid (hypothyroidism)
Have kidney problems
Are experiencing extreme pain

Canadian Cancer Society, n.d., Peripheral nerve damage (peripheral neuropathy)

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Peripheral Neuropathy: Sign/symptoms

Sign/symptoms depend on peripheral nerves affected:-

Damage to sensory nerves:

Tingling, numbness, or a pins-and-needles feeling in feet and hands, may spread to legs and arms
Inability to feel hot, cold, or pain sensation

Damage to motor nerves:

Weak/achy muscles-difficult to button shirts or open jars
Swallowing or breathing difficulties if chest or throat muscles affected
Loose balance, trip easily
Twitching/cramping/wasting of muscle

National Cancer Institute, 2020, Nerve Problems

(Peripheral Neuropathy) and Cancer Treatment

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Peripheral Neuropathy: Signs/symptoms

Damage to autonomic nerves (blood pressure, digestion, heart rate, temperature, and urination):

Digestive changes such as constipation or diarrhea
Dizzy or faint feeling-due to low blood pressure
Sexual problems-men may be unable to get an erection and women may not reach orgasm
Sweating problems (either too much or too little sweating)
Urination problems, such as leaking urine or difficulty emptying bladder

National Cancer Institute, 2020, Nerve Problems (Peripheral Neuropathy) and Cancer Treatment

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Peripheral Neuropathy: Diagnosis

Monitoring signs of nerve damage before initiating treatments known to cause peripheral neuropathy
Tests to check nerve function:

Check reflexes, muscle strength, signs of numbness
Nerve conduction studies for severity/location of nerve damage
Electromyography (EMG) – checks the electrical signals of the nerves to the muscles

Tests to check for patient’s-

Balance and coordination
Hearing
Vision

Canadian Cancer Society, n.d., Peripheral nerve

damage (peripheral neuropathy)

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Peripheral Neuropathy: Management

According to ASCO Guideline Update by Loprinzi and his friends (2020):

Assess risks and benefits of agents known to cause peripheral neuropathy in patients with
Should not offer, and should discourage use of acetyl-L-carnitine for prevention of chemotherapy-induced peripheral neuropathy
Patients with intolerable neuropathy, discuss the appropriateness of:

Dose delaying
Dose reduction
Stopping chemotherapy
Substituting with agents that do not cause peripheral neuropathy

Loprinzi et al. (2020)

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Peripheral Neuropathy: Management

According to Jordan and his friends in ESMO–EONS–EANO Clinical Practice Guidelines:

Medical exercise to improve muscular strength and sensorimotor functions can be offered to patient at risk of peripheral neuropathy
Focus on reduction/relief of neuropathic pain in patients with chronic chemotherapy-induced peripheral neuropathy

Duloxetine is the only agent for treatment
Venlafaxine, pregabalin, amitriptyline, tramadol or strong opioids can be considered

Jordan et al (2020)

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Peripheral Neuropathy: Management

Cryotherapy with frozen socks and gloves
Compression therapy using surgical gloves
Local intervention: topical low-concentration menthol cream
Physical exercise and functional training (e.g. vibration training) recommended
Acupuncture might be considered in selected patients to treat CIPN symptoms
For early detection of ototoxicity in adults receiving platinum agents, a pure tone audiometry is recommended

Jordan et al (2020)

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Figure: Algorithm for Nursing Assessment and Management of Chemotherapy-Induced Peripheral Neuropathy

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Nurse’s Role in Management of Peripheral Neuropathy

Assess for signs/symptoms of peripheral neuropathy in patients being treated with potentially neurotoxic regimen

Assess at every visit
Ask about new numbness, tingling, or uncomfortable sensation

positive response warrants further neurologic and falls-risk assessment

Provide prescribed medications to manage neuropathic pain and numbness/tingling
Make appropriate referrals to physiotherapist/occupational therapist

Provides strategies to improve functionality and assistive devices to improve balance and prevent falls

Bitterice & Mazanec (2013)

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Nurse’s Role in Management of Peripheral Neuropathy

Bitterice & Mazanec (2013)

Provide psychological, social support where possible
Assess impact on patients psychological, social, and spiritual domains

Can impact on work and family roles
Inability to walk/stand for long, participate in social activities can lead to feelings of isolation
Lead to distress, anxiety, depression

Make referrals to address psychological and spiritual distress
Identify social support to help patients with activities of daily living at home

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Nurse’s Role in Management of Peripheral Neuropathy

Provide patient education/counseling:

Information about prescribed medications and how to safely take them
Strategies to prevent injuries and falls

Careful with sharp, hot, cold or dangerous objects if fingers are numb
Check arms, legs, feet regularly for cuts/wounds
Use dishes that won’t break
Use potholders in the kitchen
Clean up spills right away, remove objects that could cause to trip/fall

Canadian Cancer Society, n.d., Peripheral nerve

damage (peripheral neuropathy)

Contact info: info@nursesinternational.org

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Nurse’s Role in Management of Peripheral Neuropathy

Keep rooms, stairway, hallways well lit
Use handrails on the stairs, grab bars and skid-free bath mats for showers/tub
Using cane or walker
Wear comfortable shoes, socks, gloves
Move slowly so the body has time to adjust to the change in position
Consume diet high in fiber ease constipation
Sharing feelings with someone close might help cope with emotionally
Counseling/support groups for psychological support

Canadian Cancer Society, n.d., Peripheral nerve

damage (peripheral neuropathy)

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Case Study/Critical Thinking Question/What would the Nurse do?

What is the following is true with respect to cancer treatment-related peripheral neuropathy?(Select all that apply)

Diabetic cancer patient is more at risk
Signs of peripheral neuropathy are assessed at every visit
Acetyl-L-carnitine should not be prescribed
Stopping chemotherapy is not an option

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Reference:

Bettrice, A. & Mazanec, P. (2013). Managing Chemotherapy-Induced Peripheral Neuropathy. Oncology Nursing News, 7(4). Accessed from: https://www.oncnursingnews.com/view/managing-chemotherapy-induced-peripheral-neuropathy

Canadian Cancer Society (n.d). Peripheral nerve damage (peripheral neuropathy). Accessed from: https://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/managing-side-effects/peripheral-nerve-damage-peripheral-neuropathy/?region=on

eviQ (April 2019). Extravasation management. Government of New South Wales. Accessed from: https://www.eviq.org.au/clinical-resources/extravasation/157-extravasation-management#assessment

Contact info: info@nursesinternational.org

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Reference:

Fidalgo, J. A. P., Fabregat, L. G, Cervantes, A., Margulies, A., Vidall, C., & Roila, F. (2012). Management of chemotherapy extravasation: ESMO– EONS Clinical Practice Guidelines. Annals of Oncology, 23 (Supplement 7): vii167–vii173. Accessed from: https://www.annalsofoncology.org/article/S0923-7534(19)37675-6/fulltext

Jordan, B., Margulies, A.,Cardoso, F., Cavaletti, G., Haugnes, H.S., Jahn, P., Le Rhun, E., Preusser, M., Scotté, F. , Taphoorn, M.J.B., & Jordan, K. (2020). Systemic anticancer therapy-induced peripheral and central neurotoxicity: ESMO–EONS–EANO Clinical Practice Guidelines for diagnosis, prevention, treatment and follow-up. Annals of Oncology, 31(10): 1306-1319. Accessed from: https://www.annalsofoncology.org/article/S0923-7534(20)39938-5/fulltext

Contact info: info@nursesinternational.org

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Reference:

Loprinzi, C.L., Lacchetti, C., Bleeker, J., Cavaletti, G., Chauhan, C., Hertz, D.L, Kelley, M.R., Lavino, A., Lustberg, M.B, et al. (2020). Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. Journal of Clinical Oncology, 38 (28): 3325-3348. Accessed from: https://ascopubs.org/doi/10.1200/JCO.20.01399

National Cancer Institute (January 2020). Nerve Problems (Peripheral Neuropathy) and Cancer Treatment. Accessed from: https://www.cancer.gov/about-cancer/treatment/side-effects/nerve-problems

Contact info: info@nursesinternational.org

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Reference:

Souza, P.L., Dionello, C.F., Sá-Caputo, D.D C., Marconi, E.M., Frederico, E.H.F.F., Marchon, R.M., Bergmann, A., Furness, T., & Filho, M.B. (2018). Whole body vibration exercise in the management of cancer therapy-related morbidities: A systematic review. Drug Discoveries & Therapeutics, 12(4):239-247. Accessed from: https://www.jstage.jst.go.jp/article/ddt/12/4/12_2018.01039/_article

Tofthagen, C., Visovsky, C. M., & Hopgood, R. (2013). Chemotherapy-induced peripheral neuropathy: an algorithm to guide nursing management. Clinical journal of oncology nursing, 17(2), 138–144. Accessed from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5469440/

Contact info: info@nursesinternational.org

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