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Extravasation of Oxaliplatin

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Background

Extravasation is the inadvertent administration of a cytotoxic agent into the subcutaneous tissues. Cancer patients are at risk for extravasation, because their veins may be fragile from previous chemotherapy or radiation, poor nutrition, and multiple venipunctures.1

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Agents and Reactions

  • Vesicants cause blistering, tissue damage, or tissue necrosis referred to as chemical cellulitis.1 Cytotoxic agents include alkylating agents (cisplatin), antitumor antibiotics (doxorubicin, mitomycin, epirubicin), vinca alkaloids (vincristine, vinorelbine), and taxanes (paclitaxel).2
  • Irritants cause short-lived burning, with or without inflammation and pain, but not tissue necrosis. Examples are alkylating agents (carboplatin, ifosfamide, oxaliplatin) and liposomal doxorubicin.2

Oxaliplatin, recommended in chemotherapy regimens for treating CRC, has been described as both a vesicant and irritant.3-5 Several authors have reported oxaliplatin extravasation case studies. Kretzschmar and colleagues retrospectively reviewed 11 cases of oxaliplatin extravasation.3 Of the 11 patients, 6 experienced a small volume of infiltration. The physicians who were treating these patients reported that almost no symptoms occurred. These infiltrations were identified early in the infusion because of the presence of edema and one patient’s complaint of a mild burning sensation. In the remaining 5 patients, more than 40 mg of oxaliplatin infiltrated into the tissue. The authors concluded that even with the large extravasations of oxaliplatin, there was no evidence of tissue necrosis and the long-term outcomes were good. The authors also concluded that extravasation of oxaliplatin did not compare with that of the typical vesicants such as anthracyclines.

Foo and colleagues documented a case of peripheral oxaliplatin extravasation in which the patient developed erythema that formed a peau d’orange appearance.4 It progressed to form a red-brown and tender induration, which persisted over the next month. The patient developed paresthesias and had persistent skin fibrosis and numbness at the area of the extravasation. The authors concluded that oxaliplatin should be considered a vesicant.

Kennedy and coworkers reported significant muscle necrosis and fibrosis following antecubital extravasation of oxaliplatin.5 The patient declined surgical intervention and achieved return of function following physical therapy. The authors suggest that oxaliplatin may not be an appropriate agent for peripheral administration.

The package insert for oxaliplatin (Eloxatin, sanofi-aventis, Bridgewater, NJ) does not contain any specific information or treatment recommendations for oxaliplatin extravasation. It can be accessed here.

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Figures 1, 2.

Extravasation

From Foo et al4, with permission.

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Management of Oxaliplatin Extravasation

The extent of the insult depends on the agent, dose, concentration, and volume. It is advisable to administer vesicants through a central line.2,6 Extravasation via a central line is most commonly caused by a dislodged needle in the port. The most immediate nursing intervention is to stop the infusion. Oncology nurses should follow their institution’s protocol for extravasation management and assessment of central venous access if the extravasation occurred while using a central venous access device. General extravasation guidelines can be found in Oncology Nursing Society publications2 and in oncology nursing or medical textbooks. Management of oxaliplatin extravasation should include warm compresses, because cold may aggravate neuropathy.4

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References

  1. Apisarnthanarax N, Duvic MM. Dermatologic complications of cancer chemotherapy. In: Kufe DW, Pollock RE, Weichselbaum RR, et al, eds. Cancer Medicine 6. Vol. 2. Hamilton, Ont: BC Decker; 2003: 2469-2476.
  2. Polovich M, White JM, Kelleher LO, eds. Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. 2nd ed. Pittsburgh, Pa: Oncology Nursing Society; 2005: 78-80.
  3. Kretzschmar A, Pink D, Thuss-Patience P, et al. Extravasation of oxaliplatin. J Clin Oncol. 2003;21:4066-4069.
  4. Foo KF, Michael M, Toner G, et al. A case report of oxaliplatin extravasation. Ann Oncol. 2003;14:961-962.
  5. Kennedy JG, Donahue JP, Hoang B, et al. Vesicant characteristics of oxaliplatin following antecubital extravasation. Clin Oncol (R Coll Radiol). 2003;15:237-239.
  6. Martin VR, Walker FE, Goodman M. Delivery of cancer chemotherapy. In: McCorkle R, Grant M, Frank-Stromborg M, Baird SB, eds. Cancer Nursing. Philadelphia, Pa: WB Saunders; 1996: 395-433.

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