The following information is a compilation from the various resources listed below.[1][2][3][4][5][6][7][8]. Midline catheters have properties unique from those of peripheral and central VADs. A Primer on the Acute Management of Intravenous Extravasation Injuries for the Plastic Surgeon. A subsequent 2013 revision ACR Committee on Drugs and Contrast Media. J Oncol Pharm Pract. Vesicant chemotherapy extravasation antidotes and treatments. Sauerland C, Engelking C, Wickham R, Corbi D. Oncol Nurs Forum. Conclusion 8600 Rockville Pike Depending on treatment complexity, ONS's 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." Prevention is the most important approach to extravasation management. By using this site, you agree to theTerms of Use, Privacy Policy, andTerms and Conditions for ONS Guidelines, as applicable. Methods The ASCO/ONS Chemotherapy Administration Safety Standards were rst published in 2009 and updated in 2011 to include inpatient settings. Introduction. doi: 10.1097/GOX.0000000000001743. www.hospira.com/Images/434047_32-91799_1.pdf, http://opp.sagepub.com/content/early/2014/01/13/1078155213517729, Medication Safety Officers Society (MSOS). 3/26/2014, 5. In regard to the risk of extravasation: There have been studies comparing extravasation rates between these two administration techniques, which have similar results. Clipboard, Search History, and several other advanced features are temporarily unavailable. ONS is committed to promoting excellence in oncology nursing and the transformation of cancer care. 3/26/2014 5. 1,2 Recognize that when a vinca alkaloid is prepared in a minibag, it is likely more dilute than in a syringe, and thus the impact of tissue injury is even less if extravasation should occur. Safety and feasibility assessment of extending the flushing interval in totally implantable venous access port flushing during the non-treatment stage for patients with breast cancer. 6. ACR manual on contrast media. Of the utmost importance is that the administration setup ensures chemotherapy is given safely and allows for prompt nursing intervention in the event of an adverse reaction or infiltration. 2. 1 HHS Vulnerability Disclosure, Help If cooling techniques are being used, withhold cooling 15 minutes before and after the infusion. Front Oncol. 2017 Jan-Mar;4(1):61-68. doi: 10.4103/2347-5625.199081. endstream endobj startxref 2141 0 obj <>stream Developing extravasation protocols and monitoring outcomes. Accessibility Copyright 2023 Oncology Nursing Society. J Oncol Pharm Pract. Vesicant: Medication that may causes severe and/or irreversible tissue injury and necrosis. PMC 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. A description of the ASCO/ONS Chemotherapy Administration Safety Standards process for development, consensus, and refinement, as well as a discussion of the standards and results, is available on theASCO website. The Oncology Nursing Society and Infusion Nurses Society have published guidelines for vesicant administration and extravasation management. European Oncology Nursing Society extravasation guidelines. Gilbar PJ. Prior to initiation of a vesicant, the VAD tip must be verified &checked for blood Copyright 2023 Oncology Nursing Society. Bethesda, MD 20894, Web Policies 1 Infiltration, often used in reference to extravasation, refers to leakage of a non-vesicant drug or solution. Chemotherapeutics can be classified into three categories: vesicants, irritants, and non-irritants. 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. Answer:ISMP does not recommend the use of large volume syringes as an acceptable alternative to the minibag. Gilbar P. Inadvertent intrathecal administration of vincristine: has anything changed? Cold - If using sodium thiosulfate, apply cold pack for 6 to 12 hours after administration of sodium thiosulfate. Exfoliants:An agent that is capable of causing inflammation and skin shedding, but less likely to cause tissue damage. Management of the extravasation of anti-neoplastic agents. We recommend using the latest version of IE11, Edge, Chrome, Firefox or Safari. When this complication occurs, or is suspected, be truthful and avoid minimizing the situationor worse, fabricating an explanation for the extravasation. However, the INS Task Force identified limited literature describing extravasation of vancomycin. Calcium Gluconate. 2008 Sep;12(4):357-61. Disclaimer. Gorski LA, Hadaway L, Hagle ME, et al. Plast Reconstr Surg Glob Open. This decision must be weighed in light of certain death if the drug is administered via the wrong route. Firas Y Kreidieh, Hiba A Moukadem, and Nagi S El Saghir. Rev. Polovich M, Olsen M, LeFebvre KB, eds. 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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. Ensure the best possible outcomes with ONS standards. American College of Radiology. 2008 Sep;12(4):357-61. doi: 10.1016/j.ejon.2008.07.003. $on8+i5BqlA/K>I,ELi{z292%4ImIK=EYG[tlX5l6XjVYU>WyAfb;%a@ Wengstrm Y, Margulies A; European Oncology Nursing Society Task Force. The site is secure. Epub 2014 Jul 3. Trissel LA. Please refer to FAQ Question #1 and the ONS guidelines 1 for special considerations for vesicant administration through a peripheral IV site. Bethesda, MD 20894, Web Policies 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. endobj MeSH Your institution can use them to inform practice policies and procedures, internal quality assessment, and external quality monitoring. Having practitioners spend a few additional minutes during the administration step using a minibag is the only safe choice to be made. Careers. Pittsburgh, PA 15275 *Follow guidelines and treat like a vesicant. This article describes manufacturers' recommendations, lists antidotes and treatments approved by the FDA, and reviews published guidelines and recommendations. 2018 Apr 19;6(4):e1743. In 2021 the Infusion Nurses Society (INS) updated their 2016 guidelines and recommended consideration of midline catheters when the anticipated duration of therapy was 5 to 14 days with a preference for peripheral catheters for shorter durations of therapy and CVCs when longer durations of therapy are required.6 A recent study supports use of midline catheters for prolonged courses of therapy up to 14 days, but there remains limited data for use of midline catheters beyond 2 weeks.7 Currently, the CDC recommends consideration of midline catheters when the duration of IV therapy is likely to exceed 6 days.1,8, Considerations for drugs administered via midline catheter Answer:Some practitioners have expressed concern that administering diluted IV vinCRIStine via a minibag might increase the risk of extravasation and subsequent tissue injury. References: 1. Reference Eur J Oncol Nurs. According to Trissels Handbook on Injectable Drugs 17th Edition, vinCRIStine is stable at a concentration of 20 mg/L in dextrose 5% in water, Lactated Ringers, and 0.9% sodium chloride for at least 24 hours and up to 21 days with little or no drug loss (under 10%) at 4C and 25C when in the dark. e.YvIQ|!C2\@&;:8 h qF . uDX i! and transmitted securely. Use a central venous catheter or implanted device for continuous vesicant infusions or for any vesicant infusion lasting longer than 30 minutes. 3. Caution: excessive cold can cause tissue damage. 2006 Nov 27;33(6):1134-41. doi: 10.1188/06.ONF.1134-1141. Extravasation is defined as the leakage or inadvertent administration of a vesicant drug or solution from a vein into the extravascular space. 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. Available antidote and treatment formulations and their preparation and administration also are discussed. When administering chemotherapy, nurses should always be able to say that safe handling has been considered and opportunity for exposure has been limited, but also that clinical staff have accounted for ensuring the dose is received in its entirety and they can rapidly intervene should an adverse event or complication occur. Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. Vesicant: Medication that may causes severe and/or irreversible tissue injury and necrosis. If using a peripheral vein, allow the infusion to flow via gravity. Pediatr Rep. 2012 Aug 1;4(3):e28. 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. sharing sensitive information, make sure youre on a federal The incidence of extravasation of vinca alkaloids supplied in syringes or mini-bags. Watch for signs of extravasation; stay with the patient and verify blood return every 5 to 10 minutes. Furthermore, in vitro evidence suggested that vancomycin-associated endothelial damage is caused by factors other than pH. official website and that any information you provide is encrypted Always stop infusion of the causative medication first and, if appropriate, elevate the affected extremity. 2. 2006;12(2):113-8. Risk of catheter-related bloodstream infection associated with midline catheters compared with peripherally inserted central catheters: A meta-analysis [published online ahead of print, 2020 Dec 29]. Manage conservatively as first line option with supportive non-pharmacologic strategies. Polovich M, Olsen M, LeFebvre KB, eds. 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. Remove cold pack at least 15 minutes before dexrazoxane therapy. These include engaging patients in extravasation-prevention efforts, thoroughly assessing patients receiving vesicants, selecting an appropriate administration site for peripheral vesicant administration, and checking for a blood return prior to and during vesicant administration. Irritant: Medication that can cause local inflammatory reactions at the infusion site, which may include: burning, swelling, pain, inflammation, tightness, or phlebitis. %%EOF The Independent Clinical Oncology Network's Chemotherapy Administration. Knowledge Level on Administration of Chemotherapy through Peripheral and Central Venous Catheter among Oncology Nurses. No solid research exists regarding IV chemotherapy administration setups, because they can vary greatly based on the regimen, equipment availability, and patient status. 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. Email ONSs clinical inbox at clinical@ons.org to reach one of our oncology clinical specialists, who can advise on ONS recommendations, best practices, and evidence support. Please include what you were doing when this page came up and the Cloudflare Ray ID found at the bottom of this page. Secondary infusions are safest administered with the use of secondary tubing attached with a Luer lock connector to the primary line containing a compatible IV solution. 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 Acknowledgement: MiKaela M.Olsen RN, MS, AOCNS, Oncology and Hematology Clinical Nurse Specialist; Johns Hopkins Hospital Extravasation of antineoplastic agents: prevention and treatments. Tubing features can present another challenge when considering how to best administer chemotherapy agents. Updated January 2021. A study in Australia involving 68 cancer centers evaluated more than 44,000 doses of vinca alkaloids administered via syringe or minibag to adult and pediatric patients, found that the extravasation rates were similar and low0.03% with syringes and 0.04% with minibags.1 Preliminary data from another study conducted in children and adults found no cases of extravasation during administration via minibags.2 These data strongly support the safe use of minibags in adults and children.3 The risk of extravasation injury doesnt compare to the risk of severe neurological injury and near certain death resulting from the intrathecal administration of vinca alkaloids. 8600 Rockville Pike Question: We are trying to implement Best Practice #1 to dispense vinCRIStine (and other vinca alkaloids) in a minibag. 0 Inject 5 mL subcutaneously using a 25 gauge needle, changing needles between each injection, into affected area in a pinwheel fashion. Griffiths V. Midline catheters: indications, complications and maintenance. Clinimix 4.25/5 Vesicant Yes Yes Yes Guidelines allow if 10% dextrose, Peripheral PN (PPN) Vesicant . eCollection 2022. Careers. 1990 Mar;4(1):41-60. doi: 10.1016/0268-960x(90)90015-k. Wang Y, Tian H, Chen X, Zhang J, Wang L, Fan H, Zhang Y, Qi X, Hu S, Yang Y. Except as expressly stated on this site or as otherwise permitted by applicable law, no content on this site may be used or reproduced without the permission of the copyright holder. government site. Antidotes to vesicant chemotherapy extravasations. 833 S. Wood St., Suite B12, College of Pharmacy, (MC 886), Chicago, IL 60612, 2023 The Board of Trustees of the University of Illinois, UI Health is UICs academic health enterprise. Potassium Chloride. For permissions, please contacthelp@ons.org. 4 0 obj 2008 Sep;12(4):357-61. doi: 10.1016/j.ejon.2008.07.003. 3. Use VADs for vesicant administration, continuous infusions of vesicants, anticipated long-term administration of chemotherapy, poor venous access, and for children or older adult patients.a,b Ensure clear visualization of the site throughout the infusion. Generally, drugs that are vesicants or have extremes of pH or osmolarity should not be administered via midline catheters. Click to reveal 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 Two important safety features are important here. 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. <>/Metadata 1012 0 R/ViewerPreferences 1013 0 R>> There are several actions that could trigger this block including submitting a certain word or phrase, a SQL command or malformed data. Some references primarily classify drugs as vesicants or irritants, so those categories will preferentially be used below over classifying as inflammitants and exfoliants. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 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]. 125 Enterprise Drive J Pediatr Oncol. 139.59.111.99 2006;12(2):113-8. ONS is committed to promoting excellence in oncology nursing and the transformation of cancer care. 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". (An infusion pump is not recommended by the Oncology Nurses Society (ONS) to administer vinCRIStine in this situation1 .) Clinical exam may reveal warmth, erythema, or tenderness. 3/26/2014, 4. In some regimens, enough data support sequencing of agents, but in others, data are lacking. Properties of midline catheters The minibag of vinCRIStine, using a short infusion set, is connected to the Y-site closest to the patient. J Oncol Pharm Pract. COSA guidelines for the safe prescribing, dispensing and administration of systemic cancer therapy link and reference updated to new version. Intravascular catheter-related infection (BSI). Avoid the "blame game.". Midline catheters have properties that differ from both those of traditional peripheral IV catheters and central venous catheters (CVCs). Rev. Polovich M, Olsen M, LeFebvre KB, eds. Gorski LA, Stranz M, Cook LS, et al. www.hospira.com/Images/434047_32-91799_1.pdf 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. All rights reserved. Lastly, they recommend avoidance of midline catheters in patients with a history of thrombosis, hypercoagulability, venous stasis, or with a need to preserve vein integrity, such as in patients with end-stage renal disease. NCI's Dictionary of Cancer Terms provides easy-to-understand definitions for words and phrases related to cancer and medicine. Version number changed to v.5. %PDF-1.7 In December 2008, ASCO and ONS held a workshop to develop a consensus regarding standards for the safe administration of chemotherapy to adult patients in the outpatient setting. Clinical Associate Professor, Drug Information Specialist, Updated by: 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? World J Clin Oncol. Lu H, Hou Y, Chen J, et al. Disclaimer. These medications are generally considered to be unlikely to cause injury when extravasation occurs: These medications are generally described as causing mild to moderate inflammation when extravasation occurs. These . Wengstrm Y, Margulies A; European Oncology Nursing Society Task Force. Wengstrm Y, Margulies A; European Oncology Nursing Society Task Force. 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. The loss of drug in the tubing exceeds the 5% dose variability acceptable for our chemotherapy doses per our hospital policy. Another option is to aspirate with a syringe via the lowest Y-site and clamp off fluid from the minibag. ONS is committed to promoting excellence in oncology nursing and the transformation of cancer care. Content on this site is protected by U.S. and international copyright laws. 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. National Library of Medicine (K k0|hzv 6gN5UzVa+91C+yTOOcV^t^IjpiOROeutcI9GOqs'."XA*c2@GfK!rKP;{4?|h=,G _wyNdfSc#A]LHq#@Gtn[YWk%1o*Bbyk'82h6~IOvvi2`6 Introduction 2 0 obj Reynolds PM, MacLaren R, Mueller SW, Fish DN, Kiser TH. 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. 2008 Mar;13(3):284-8. doi: 10.1634/theoncologist.2007-0191. 2012;18(1):155-7. Nonetheless, a review of literature of known vesicants and drugs reported to cause vascular injury or extravasation indicates some drugs that may present higher risk when administered 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. Vesicants and irritants with vesicant . Yan YM, Fan QL, Li AQ, Chen JL, Dong FF, Gong M. Iran J Pediatr. The Hospira Brand of vinCRIStine sulfate injection, USP (preservative-free) 1 mg/mL vial package insert2 states: Development of an evidence-based list of noncytotoxic vesicant medications and solutions. 8}-Fb}" "R5xPQ%Flm^%/jV Bethesda, MD: American Society of Healthsystem Pharmacists; 2012:1104-5. 4. FOIA 2009]. Before Multiagent regimens add another level of complexity, and nurses must not only ensure patient safety but maintain safe handling principles and confirm agent compatibility. 2016 Feb 10; 7(1): 8797. Question:How do you recommend that we verify blood return when administering vinCRIStine in a minibag? Always obtain/ review MD order sent with delivery, identify patient with 2 identifiers. Clin J Oncol Nurs. 3/10/2014, 7. eCollection 2012 Jul 31. 1. Oncologist. Clipboard, Search History, and several other advanced features are temporarily unavailable. Accessibility Monitor for extravasation according to hospital policy. To update the ASCO/Oncology Nursing Society (ONS) Chemotherapy Administration Safety Standards and to highlight standards for pediatric oncology. Question:Is it just as safe to prepare vinCRIStine in a large volume (30-50 mL) syringe as in a minibag? 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. Accessed August 2, 2021. https://www.acr.org/-/media/ACR/Files/Clinical-Resources/Contrast_Media.pdf. Always double check information at the primary references linked below.

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