Ryan Rodriguez, PharmD, BCPS The risk of venous thromboembolism associated with midline catheters compared with peripherally inserted central catheters: A systematic review and meta-analysis [published online ahead of print, 2021 May 15]. Rev. Gorski L, Hadaway L, Hagle ME, McGoldrick M, Orr M, Doellman D. Infusion therapy standards of practice. To discuss the information in this article with other oncology nurses, visit the ONS Communities. {M@C:NiD(mXx?0/a`1Y$,X6iF ~,e!|;b`H30dhfN@+T@ 8 Due to some references not using this classification, the only drugs listed in this section are ones which were unclassified by some resources, yet classified by others as inflammitants. The site is secure. Prepared by: An official website of the United States government. The site is secure. The .gov means its official. When assessing a chemotherapy extravasation, it is important to understand the classification of the chemotherapeutic agent in terms of its potential to cause cellular damage if extravasated. Properties of midline catheters http://opp.sagepub.com/content/early/2014/01/13/1078155213517729. The complexity of administration of antineoplastic agents and the potential safety issues involved are unique to oncology care and require careful consideration. Remove cold pack at least 15 minutes before dexrazoxane therapy. Accessed August 2, 2021. https://www.cdc.gov/infectioncontrol/guidelines/BSI/index.html. Extravasation: Leakage of a medication into tissue or extravascular space around the infusion site. %PDF-1.7 But chemo agents are not the only vesicants that cause extravasation injuries. The loss of drug in the tubing exceeds the 5% dose variability acceptable for our chemotherapy doses per our hospital policy. Extravasation is defined as the leakage or inadvertent administration of a vesicant drug or solution from a vein into the extravascular space. Rev. The following information is a compilation from the various resources listed below.[1][2][3][4][5][6][7][8]. 2009]. J Pediatr Oncol. In order from most likely to least likely to cause damage when extravasation occurs: vesicants (most likely), exfoliants, irritants, inflammitants, and neutrals (least likely). General recommendations for midline administration: A. HHS Vulnerability Disclosure, Help 2.13.2 Vesicant chemotherapy administered through a peripheral intravenous must be infused IV push as ordered or via a short-term gravity intravenous line. In general--aside from the exceptions listed below--keeping the extravasation cold is preferable to cause vasoconstriction, to prevent spread of the medication, and to decrease inflammation/pain. 2141 0 obj <>stream Clipboard, Search History, and several other advanced features are temporarily unavailable. Apply cold pack intermittently for 15 minutes at a time, four times per day for 3 days, Apply cold pack 15 to 20 minutes at a time for at least four times per day for 24 hours. Antidote and treatment recommendations of vesicant chemotherapy manufacturers, antidotes and treatments approved by the U.S. Food and Drug Administration (FDA), and guidelines and recommendations made by professional oncology organizations are useful resources in this process. Preparation for flexible plastic container VinCRIStine sulfate injection, USP when diluted with 0.9% sodium chloride injection in concentrations from 0.0015 mg/mL to 0.08 mg/mL is stable for up to 24 hours when protected from light or 8 hours under normal light at 25C. and transmitted securely. Eur J Oncol Nurs. In some regimens, enough data support sequencing of agents, but in others, data are lacking. Accessibility Vesicant: Medication that may causes severe and/or irreversible tissue injury and necrosis. Additionally, the risk of cytotoxicity is reduced by intermittent compared with continuous infusion, as well as by dilution of vancomycin to concentrations of 2 to 5 mg/mL. TheAmerican Society of Clinical Oncology (ASCO)and ONS are conducting an ongoing collaborative project to use a rigorous, consensus-based process to develop standards for the safe administration of chemotherapy. 125 Enterprise Drive Minor updates to administration and patient education. Before Gilbar P, Chambers CR, Larizza M. Medication safety and the administration of intravenous vincristine: International survey of oncology patients. For example, many cytotoxic agents (ie, chemotherapy) are considered vesicants and should not be administered via midline catheters according to INS standards.10,11Additionally, in 2017, the INS assigned a Vesicant Task Force to publish a list of noncytotoxic vesicant medications and solutions.11The Table below, while not exhaustive, details drugs from this list, as well as drugs that have extremes of pH or osmolarity that have been associated with vascular injury or extravasation.8,9, One drug that has generated controversy regarding its appropriateness for administration via midline catheter is vancomycin. <> Please. Extravasation of antineoplastic agents: prevention and treatments. 1998 Jul-Aug;21(4):232-9. University of Illinois at Chicago College of Pharmacy. Rev. Gilbar PJ. Updated July 2017. Introduction. Question:Wouldnt the administration of vinCRIStine IV push using a syringe be much shorter in duration and with less chance of extravasation than administration using a minibag? Pittsburg, PA: Oncology Nursing Society; 2014. The Oncology Nursing Society and Infusion Nurses Society have published guidelines for vesicant administration and extravasation management. Pittsburgh, PA 15275 Vesicant extravasation part I: Mechanisms, pathogenesis, and nursing care to reduce risk. 125 Enterprise Drive 1. It is also important to note that some medications are classified differently by different references. Always double check information at the primary references linked below. A Primer on the Acute Management of Intravenous Extravasation Injuries for the Plastic Surgeon. Answer:ISMP does not recommend the use of large volume syringes as an acceptable alternative to the minibag. ONS is committed to promoting excellence in oncology nursing and the transformation of cancer care. Since 1975, ONS has provided a professional community for oncology nurses, developed evidence-based education programs and treatment . Unauthorized use of these marks is strictly prohibited. The 2008 European Oncology Nursing Society extravasation guidelines recommend this management for the following medications: From HemOnc.org - A Hematology Oncology Wiki, Chemotherapy vesicant & irritant properties and suggested management for extravasation, "Localize and neutralize" or "disperse and dilute". Griffiths V. Midline catheters: indications, complications and maintenance. eCollection 2022. 2006;12(2):113-8. Accidental administration of vincristine in pediatric patients. Disclaimer. Current ASCO/ONS standards address the safety of all routes of chemotherapy administration to adult patients in the outpatient and inpatient settings. 2108 0 obj <>/Filter/FlateDecode/ID[<79BA663E75301A408346CF53CE9BCBB7><05BE28B3380661489955B8DFD5505C1D>]/Index[2088 54]/Info 2087 0 R/Length 102/Prev 343790/Root 2089 0 R/Size 2142/Type/XRef/W[1 3 1]>>stream Vesicant: An agent that has the potential to cause pain, inflammation, blistering and irreversible tissue damage, including necrosis and loss of limb function and mobility. 8}-Fb}" "R5xPQ%Flm^%/jV Table 7 in Chemotherapy and Biotherapy Guidelines and Recommendations for Practice discusses special features required for administration, but package inserts should be referred to for the most up-to-date information. FOIA 2 0 obj endstream endobj startxref Heat - 15 to 20 minutes at a time for at least four times per day for 24 to 48 hours. Clipboard, Search History, and several other advanced features are temporarily unavailable. Pittsburg, PA: Oncology Nursing Society; 2014. Lu H, Hou Y, Chen J, et al. Nurgat Z, Smythe MP, Aljedai A. Multiagent regimens add another level of complexity, and nurses must not only ensure patient safety but maintain safe handling principles and confirm agent compatibility. Manage conservatively as first line option with supportive non-pharmacologic strategies. e.YvIQ|!C2\@&;:8 h qF . uDX i! eCollection 2012 Jul 31. Calcium Chloride. Bookshelf Cold (different suggestions for anthracyclines depending on reference): (off-label, based on general management strategies for anthracyclines), Cold - 15 to 20 minutes at a time for at least four times per day for 24 hours, Irritant or neutral, depending on reference, Cold - Every 8 hours for 3 days; if using sodium thiosulfate, apply cold pack for 6 to 12 hours after administration of sodium thiosulfate, Vesicant/Irritant (depending on reference). Since 1975, ONS has provided a professional community for oncology nurses, developed evidence-based education programs and treatment information, and advocated for patient care, all in an effort to improve the quality of life and outcomes for patients with cancer and their families. Once the infusion is complete, the short set is dropped to backfill the line with saline and then the remaining drug is infused. Before For standardization, regimens with continuous daily dosing are represented using a 28-day cycle length. The Oncology Nursing Society (ONS) is a professional association that represents 100,000 nurses and is the professional home to more than 35,000 members. Cold - Apply cold packs for 15 to 20 minutes four times per day for 1 to 2 days. This page was last edited 14:24, 26 April 2023 by. Section V: Immediate Complications of cytotoxic therapy, p.105. Vesicant extravasation: myths and realities. Vesicant chemotherapy extravasation antidotes and treatments. References: 1. These . This site needs JavaScript to work properly. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Answer: To prevent excessive drug loss, some organizations are utilizing a back flushing method to infuse the remaining volume of drug that may remain in the IV tubing. Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. The procedure includes connecting the bag of saline to a long straight infusion set. Furthermore, in vitro evidence suggested that vancomycin-associated endothelial damage is caused by factors other than pH. ONS is committed to promoting excellence in oncology nursing and the transformation of cancer care. 3. Clinicians considering drug administration via this VAD should review the chemical properties of the drug under consideration from reputable resources (eg, prescribing information) to compare them with the guidance above. 3/10/2014, Institute for Safe MedicationPractices Note: Do not use an infusion pump when administering a vesicant via a peripheral intravenous. When the institution implements the use of minibags to administer vinCRIStine, the following nursing guidelines should be followed to further reduce the risk of harm from extravasation. 3/26/2014, 4. This section focuses on drug administration, including cycle definition (which contains the cycle length, number of cycles, and other schedule-related information), dosing, frequency, and routes of administration. This review provides an overview of midline catheters and a summary of properties that influence the determination of whether a drug is appropriate for administration via midline catheter. Clinical exam may reveal warmth, erythema, or tenderness. Patients often seek explanations for why their extravasations occurred. www.hospira.com/Images/434047_32-91799_1.pdf The 2021 INS guidelines recommend against the use of midline catheters for continuous administration of vesicant therapy, parenteral nutrition, or other infusates with extremes of pH or osmolarity.6 Although the extremes are not further defined, the guidelines specifically recommend central lines for parenteral nutrition formulas with osmolarity exceeding 900 mOsm/L. Tubing features can present another challenge when considering how to best administer chemotherapy agents. A subsequent 2013 revision The vinCRIStine is infused via gravity through the peripheral line. Oncologist. Cold (different suggestions depending on reference): Heat (different suggestions depending on reference): Cold - for 6 to 12 hours after administration of sodium thiosulfate. stream Management of the extravasation of anti-neoplastic agents. We recommend using the latest version of IE11, Edge, Chrome, Firefox or Safari. Firas Y Kreidieh, Hiba A Moukadem, and Nagi S El Saghir. Hemonc Today | During the past several years, the Oncology Nursing Society developed and maintained Chemotherapy and Biotherapy Guidelines and Recommendations for Practice, providing a unique and . Institutional policies and procedures used in hospitals, clinics, and office settings should be written in accordance with these . The .gov means its official. The 2021 INS guidelines recommend against the use of midline catheters for continuous administration of vesicant therapy, parenteral nutrition, or other infusates with "extremes" of pH or osmolarity. For definitions of different categories of extravasation hazard and the details on management of extravasation, see BC Cancer Systemic Therapy Policy III-20 3. Since 1975, ONS has provided a professional community for oncology nurses, developed evidence-based education programs and treatment information, and advocated for patient care, all in an effort to improve the quality of life and outcomes for patients with cancer and their families. Clinical exam may reveal warmth, erythema, or tenderness. The practice of monitoring the administration of vinCRIStine and other vinca alkaloids in a minibag to avoid extravasation via a peripheral IV is essentially the same as if it was administered IV push. 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Braun Recalls Certain Lots of Blood Administration Sets, FDA Approves Sunitinib Malate for Adjuvant Treatment of Renal Cell Carcinoma, News, Views, and Advocacy From the Oncology Nursing Society, Copyright 2023 Oncology Nursing Society, ONSs Chemotherapy and Biotherapy Guidelines and Recommendations for Practice, ONS and American Society of Clinical Oncology standards, Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. 1 Because this termination site is distal to those of CVCs and peripherally inserted central catheters (PICCs), midline catheters are not considered to dwell in the central circulation.1Whereas the central termination site of CVCs and PICCs provide the ability to administer a wider range of infusates (eg, vesicants), this is not recommended with VADs terminating distal to the central circulation. Please refer to FAQ Question #1 and the ONS guidelines 1 for special considerations for vesicant administration through a peripheral IV site. The https:// ensures that you are connecting to the The main consideration in determining whether a drug is appropriate for administration via midline catheter is its propensity for causing phlebitis.2Phlebitis is inflammation of a vein caused by damage to the tunica intima, which may be accompanied by erythema, swelling, pain, heat, and a palpable cord if thrombosis is present. Wengstrm Y, Margulies A; European Oncology Nursing Society Task Force. Plast Reconstr Surg Glob Open. Careers. Safe Administration of Chemotherapy: Safety During Chemotherapy Ordering, Transcribing, Dispensing, and Patient Identification Safe Administration of Systemic Cancer Therapy: Administration of Chemotherapy and Management of Preventable Adverse Event Please enable it to take advantage of the complete set of features! Most importantly, organizations must weigh the risk of possible extravasation versus certain death from the accidental administration of vinCRIStine by the intrathecal route when making decisions about changing practice. Therefore, questions often arise regarding the appropriateness of administering specific drugs via midline catheter. There are several actions that could trigger this block including submitting a certain word or phrase, a SQL command or malformed data. Introduction Question: Our pediatric department is reluctant to administer vinCRIStine via a minibag through a peripheral IV line since many of our patients do not have a peripherally inserted central catheter (PICC) or central venous access device. Antidotes to vesicant chemotherapy extravasations. This site needs JavaScript to work properly. This information is intended as an educational piece and should not be used as the sole source for clinical decision making. %%EOF However, data suggests that the risk of extravasation is low, regardless of the method used to administer the drug. Additionally, patient mobility is greater with midline catheters because of the location of their insertion site.2 Lastly, compared with drug administration via peripheral IV catheter, the risk of phlebitis may be reduced with administration via midline catheter because of its termination in an area with a higher rate of blood flow.2The rates of CRBSI have also been reported to be lower with midline versus peripheral catheters (0 to 0.2 versus 0.5 per 1,000 catheter days).1, Overall, the properties of midline catheters may make them preferable for specific durations of therapy. An official website of the United States government. 1995 Jan-Feb;22(1):57-67. 2. David V, Christou N, Etienne P, et al. Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. Polovich M, Whitford JM, Olsen M. Chemotherapy and biotherapy guidelines and recommendations for practice, 3rd ed, Oncology Nursing Society, Pittsburgh, PA, 2009. <>/Metadata 1012 0 R/ViewerPreferences 1013 0 R>> Determinations regarding the administration of drugs via midline catheter should consider properties of each drug individually because no definitive guidance is available to list the appropriateness of all drugs. FOIA Although relevant guidelines and policy statements existed (e.g., OSHA'sControlling Occupational Exposure to Hazardous Drugs, Chapter 2: Safe Handling of Chemotherapy Drugs, the ONSChemotherapy and Biotherapy Guidelines and Recommendations for Practice, ASCO'sCriteria for Facilities and Personnel for the Administration of Parenteral Systemic Antineoplastic Therapy), specific requirements to promote patient safety had not been well-defined by key stakeholders. Depending on treatment complexity, ONSs Chemotherapy and Biotherapy Guidelines and Recommendations for Practice state that chemotherapy agents being administered by infusion may be connected directly to the IV catheter or to a line of compatible maintenance solution. Therefore, critical and collaborative consideration of the components of each regimen and the clinical presentation of the patient should be part of the treatment planning process. Hyaluronidase may be used in extreme scenarios such as large volume extravasation or severe irritation. 2008 Sep;12(4):357-61. doi: 10.1016/j.ejon.2008.07.003. Caution: excessive heat can cause tissue damage. hbbd```b`` "_HR, Iejw\Xo b&mQs8DbCC ; UIC's seven health sciences colleges and health care delivery enterprise. Click to reveal Infuse in an extremity or area other than the one affected by extravasation. Reference: 1. 9fGr,zGa$9:WSs["8d/#'K f.'nw_EET For primary infusions, the agents should be administered by direct connection to the access site using primary tubing, a Luer lock connection should be used, and a compatible IV flush solution should be readily available for emergent administration issues and to clear the line after completion. PMC If an antidote is not going to be used, the venous access can be removed after aspiration of the extravasated fluid has been attempted. 1 0 obj Polovich M, Olsen M, LeFebvre KB, eds. eCollection 2018 Apr. endobj Polovich M, Olsen M, LeFebvre KB, eds. Prior to initiation of a vesicant, the VAD tip must be verified &checked for blood official website and that any information you provide is encrypted All rights reserved. What are other facilities doing to avoid excessive drug loss in the tubing? Intermountain Medical Center . The tubing contains 7 mL of volume and that is more than 10% of the 50 mL for an adult dose. Midline catheters represent a unique vascular access device (VAD) for patients requiring intravenous (IV) administration of drugs or other infusates.1,2After their introduction in the 1950s, hypersensitivity and phlebitis reactions to the manufacturing materials led to a temporary decline in the use of midline catheters through the 1990s; however, a redesign of these products in recent years has led to their renewed adoption. 2006 Nov 27;33(6):1134-41. doi: 10.1188/06.ONF.1134-1141. 1 Infiltration, often used in reference to extravasation, refers to leakage of a non-vesicant drug or solution. Another option is to aspirate with a syringe via the lowest Y-site and clamp off fluid from the minibag. Federal government websites often end in .gov or .mil. Apply ice to the area for 15 to 20 minutes each hour for 4 hours. Answer:For those patients who do not have a PICC or central venous access device, a peripheral IV line can still be used to administer vinCRIStine in a minibag. Bethesda, MD 20894, Web Policies Epub 2014 Jul 3. J Oncol Pharm Pract. The information presented is current as of August 2, 2021. 3. European Oncology Nursing Society extravasation guidelines. 3/10/2014, 7. Clinical Assistant Professor, Drug Information Specialist Abstract. Advocating for the Provision of Alternate Responsibilities for Nurses Who Are Pregnant, Breastfeeding, or Trying to Conceive, Medical surveillance programs are recommended to detect changes in the health status of those working with hazardous drugs. Pittsburg, PA: Oncology Nursing Society; 2014. Cold - If using sodium thiosulfate, apply cold pack for 6 to 12 hours after administration of sodium thiosulfate. 2008 Mar;13(3):284-8. doi: 10.1634/theoncologist.2007-0191. Question:Is it just as safe to prepare vinCRIStine in a large volume (30-50 mL) syringe as in a minibag? The incidence of extravasation of vinca alkaloids supplied in syringes or mini-bags. Assessment of the risk of extravasation with the introduction of vincristine mini-bags to eliminate inadvertent intrathecal administration. Clin J Oncol Nurs. In addition, whenever an extravasation occurs or is suspected, vesicant administration must immediately cease, and the appropriate antidote or treatment needs to be promptly administered. Rev.12/2/2014. Treatment of cutaneous injuries of neonates induced by drug extravasation with hyaluronidase and hirudoid. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). The Independent Clinical Oncology Network's Chemotherapy Administration. doi: 10.1097/GOX.0000000000001743. Disclaimer. Always stop infusion of the causative medication first and, if appropriate, elevate the affected extremity. 1990 Mar-Apr;13(2):111-4. doi: 10.4081/pr.2012.e28. May be due to direct leakage from the venous access device or from elsewhere in the vessel (such as from previous phlebotomy). Developing extravasation protocols and monitoring outcomes. For permissions, please contacthelp@ons.org. If cooling techniques are being used, withhold cooling 15 minutes before and after the infusion. References: 1. Although vesicant chemotherapy extravasations cannot be entirely prevented, the risk of extravasation can be reduced by adhering to guidelines for safe vesicant administration. No formal recommendation, but depending on clinical condition could consider extrapolating from management of other vinca alkaloids: Apply cold pack initially for 30 to 60 minutes, then repeat every 15 minutes on day 1 only. (An infusion pump is not recommended by the Oncology Nurses Society (ONS) to administer vinCRIStine in this situation1 .) UN vR7. 15 to 20 minutes at a time for at least four times per day for 24-48 hours, warm compresses for 30 to 60 minutes, then alternate off/on every 15 minutes for 1 day, 15 to 20 minutes at a time for at least four times per day for 24 hours. Oncologist. Sodium Chloride. There is not a comprehensive list of drugs that are appropriate for administration via midline catheter. Although vesicant chemotherapy extravasations cannot be entirely prevented, the risk of extravasation can be reduced by adhering to guidelines for safe vesicant administration. A similar sized bag for the back flushing, such as a 25 mL bag of 0.9% saline is used for both adults and pediatric patients.

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