Extravasation and treatment-device complications

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Vesicants can cause blistering, ulceration and tissue necrosis; irritants usually cause pain and inflammation but less destructive injury. Some medicines bind DNA and persist in tissue, while others disperse and are managed differently. The bedside appearance may initially underestimate injury, especially with central-device extravasation into chest or mediastinal tissues. Prevention includes appropriate vessel selection, visible access, blood return and patient reporting.

Immediate management aims to stop further delivery and limit spread. The access is retained temporarily for aspiration and possible antidote. The team identifies the exact medicine and follows the UKONS agent-specific instruction for cooling, warming, antidote and surgical review. Limb elevation and analgesia may help. Unplanned massage, flushing or compress choice can worsen tissue exposure.

Devices also cause infection, thrombosis, occlusion, fracture, migration and air entry. Failure to aspirate may reflect tip position or fibrin sheath and is investigated before vesicant use. Fever during line access prompts paired cultures and sepsis treatment. A swollen arm requires ultrasound. A damaged catheter is clamped and specialist help sought; forceful flushing risks rupture or embolisation.

Key points

Extravasation is unintended leakage of a vesicant or irritant outside the vessel; injury depends on drug, concentration, volume, site and speed of recognition.
First actions are universal: stop the infusion, leave access in place, disconnect, aspirate where appropriate, mark and photograph the area, and obtain specialist advice.
Do not flush the line, apply pressure or remove access before checking the protocol, because these actions can spread drug or lose an antidote route.
Warm versus cold compresses and antidotes are agent-dependent; identify the exact medicine and use the current local cancer-network extravasation table rather than memory.
Central venous devices reduce repeated peripheral access but can still extravasate through malposition, fracture, disconnection or vessel erosion.
Line infection may present with fever, rigors during flushing, exit-site inflammation or unexplained sepsis; cultures and immediate sepsis care take priority.
Catheter-related thrombosis causes arm, neck or facial swelling, pain and collateral veins and needs imaging and anticoagulation review without automatic line removal.
Document drug, dose, estimated volume, site, actions, photographs and serial follow-up because necrosis can evolve after apparently mild early signs.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Peripheral access failure

Cannula displacement, fragile veins, repeated access or high-pressure infusion allows irritant or vesicant medicine to enter surrounding tissue.

Central device malfunction

Tip migration, catheter fracture, disconnection, needle misplacement or vessel erosion can release treatment into deep chest or soft tissues.

Device-associated infection or thrombosis

Foreign material, repeated access and cancer-related hypercoagulability promote biofilm infection and venous clot around long-term catheters.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Vesicant enters tissue
Concentrated anticancer medicine damages cells directly, and DNA-binding agents can persist locally and cause progressive necrosis.
2
Inflammation expands injury
Local vascular and cellular damage produces pain, oedema, blistering and impaired perfusion, sometimes evolving for days after exposure.
3
Biofilm sustains infection
Organisms adhere to catheter surfaces and resist clearance, seeding bloodstream infection during flushing or continuous device use.
4
Thrombus forms around catheter
Endothelial injury, flow disturbance and malignancy-associated coagulation create upper-limb or central venous thrombosis around the device.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Peripheral extravasation

Burning, pain, swelling, erythema, blanching, leakage, resistance or altered drip rate during infusion requires an immediate stop.

Central-device extravasationRed flag

Chest, shoulder or neck pain, swelling, dyspnoea or unexpected resistance during central infusion can indicate internal leakage.

Line-associated infection

Exit-site inflammation, purulence, fever or rigors during flushing suggests local or bloodstream infection and can progress to sepsis.

Catheter thrombosis

Unilateral arm, neck or facial swelling, heaviness, pain and collateral veins suggests catheter-associated venous thrombosis.

Mechanical failure

Loss of blood return, occlusion, leak, visible damage or change in external length indicates malposition, fibrin sheath or fracture.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Immediate site and infusion assessmentFirst step
Why
Identify the agent, access, symptoms and estimated tissue exposure.
Interpretation and limitations
Record dose delivered, residual volume, vessel and site, mark boundaries and photograph with consent before changes obscure progression.
02
Device blood return and imaging
Why
Assess patency and tip integrity before further vesicant use.
Interpretation and limitations
Do not force flush; chest radiography, contrast line study or other imaging is selected by the vascular-access team.
03
Paired blood cultures
Why
Investigate possible catheter-related bloodstream infection.
Interpretation and limitations
Take peripheral and line cultures promptly where feasible, but do not delay empirical sepsis antibiotics in an unstable patient.
04
Venous ultrasound
Why
Confirm catheter-associated upper-limb thrombosis safely.
Interpretation and limitations
Assess the involved deep veins; a negative limited study may need specialist review when central obstruction remains likely.
05
Serial tissue review
Why
Detect evolving blistering, necrosis, functional loss or compartment concern.
Interpretation and limitations
Follow at agent-specific intervals with measurements and photographs; early surgical review is needed for worsening pain, ulceration or high-risk exposure.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Infusion-site irritation

Mechanical pain or phlebitis can cause erythema without tissue vesicant exposure, but suspected extravasation is managed immediately until clarified.

Allergic infusion reaction

Generalised flushing, wheeze, urticaria or hypotension suggests systemic hypersensitivity rather than isolated local leakage, though both require stopping infusion.

Cellulitis

Progressive warmth, erythema, tenderness and fever outside infusion timing suggests infection, especially around an exit site or port.

Lymphoedema or tumour obstruction

Chronic limb swelling from nodal treatment or cancer can resemble catheter thrombosis and needs venous and oncological assessment.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01StopContain suspected extravasationFirst stepPain, swelling, leakage or access dysfunction develops during anticancer infusion.

1Stop infusion immediately, disconnect tubing and leave the cannula or device access in place without flushing.
2Identify the drug, aspirate residual medicine as the protocol directs, mark and photograph the site and call the trained chemotherapy team.
3Apply the implicated agent's compress and antidote strategy from the current cancer-network extravasation table, and arrange documented follow-up or plastic-surgical review according to injury risk.

02SepsisTreat possible line infectionFever, rigors or instability occurs with an indwelling treatment device.

1Use ABCDE and sepsis assessment, obtain paired cultures and start empirical antimicrobials promptly for an unstable or neutropenic patient.
2Examine tunnel, port and exit site and identify the organism and device type before deciding salvage or removal.
3AlternativeRemove urgently when mandated by instability, uncontrolled infection, tunnel involvement or organism-specific guidance, while securing alternative access safely.

03FunctionInvestigate thrombosis or mechanical failureThe line will not aspirate, appears damaged or the ipsilateral limb is swollen.

1Stop vesicant use and do not force flush; inspect clamps, connectors, external length and symptoms.
2Obtain vascular-access imaging or venous ultrasound and involve the line, radiology and oncology teams.
3Treat thrombosis, repair, replace or remove based on device need, infection, integrity and anticoagulation safety rather than a universal rule.

Key medicines and prescribing safety3 treatments · regimens, roles and cautions

Licensed antidote that reduces severe tissue injury after anthracycline extravasation when given promptly as a complete 3-day course.

Dexrazoxane for anthracycline extravasation

Start within 6 hours: 1,000 mg/m² intravenously on day 1, 1,000 mg/m² at 24 hours and 500 mg/m² at 48 hours, infused into an unaffected limb; maximum doses are 2,000 mg, 2,000 mg and 1,000 mg respectively. Reduce by 50% when creatinine clearance is below 40 mL/min.

Remove cooling at least 15 minutes before infusion and do not combine with topical dimethyl sulfoxide. Check pregnancy, marrow, renal and hepatic status and monitor additive cytotoxic and haematological toxicity.

Disperses selected extravasated medicines, including vinca alkaloids, when the agent-specific extravasation table indicates it.

Hyaluronidase for vinca-alkaloid extravasation

Within 1 hour, dilute 1,500 units in 1 mL water for injection and inject 0.2 mL intradermally or subcutaneously at 3–5 sites around the affected area, changing the needle each time, with the protocol-directed warm pack.

This technique is not interchangeable with anthracycline management. Stop but do not flush the infusion, preserve access for aspiration, identify the exact drug and follow trained-team documentation and serial tissue review.

Treats confirmed catheter-associated venous thrombosis in selected patients; a functional, well-positioned, uninfected and still-needed catheter does not require automatic removal.

Apixaban for confirmed catheter-associated deep-vein thrombosis

When a direct oral anticoagulant is appropriate, the licensed adult DVT regimen is 10 mg orally twice daily for 7 days, then 5 mg twice daily; catheter-associated thrombosis is normally treated for at least 3 months, with duration individualised to active cancer, catheter need, recurrence and bleeding risk.

Review active bleeding, platelet count, renal and hepatic function, gastrointestinal or genitourinary tumour bleeding, CYP3A4/P-glycoprotein interactions and procedures. Use LMWH or another strategy when a DOAC is unsuitable.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Skin necrosis and functional loss

Deep vesicant injury can ulcerate, expose tendon or nerve and require debridement, grafting and prolonged rehabilitation.

Bloodstream infection and sepsis

Catheter biofilm can seed recurrent bacteraemia, septic shock, endocarditis or metastatic infection in an immunocompromised patient receiving active treatment.

Venous thrombosis and embolism

Catheter-related clot can obstruct central veins, compromise future access and occasionally embolise to the pulmonary circulation.

Interrupted cancer treatment

Loss of safe vascular access, wound healing and infection can delay or prevent time-sensitive systemic therapy and reduce cancer-control options.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Review extravasation sites serially for boundary expansion, blistering, necrosis, pain, sensation, movement and infection until resolution.
Maintain dated photographs and exact treatment records, including compress, antidote, aspiration and referral actions.
For line infection trend cultures, fever, haemodynamics and metastatic foci and confirm clearance according to organism and device plan.
For thrombosis monitor swelling, pain, bleeding and line function and reassess anticoagulation around platelet nadir and procedures.
Audit device type, access technique, blood-return checks, extravasation events and delays to identify preventable system failures.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Keep access initially

The existing cannula may permit aspiration or antidote delivery; immediate removal can lose the only route to reduce local exposure.

Compresses are drug-specific

Cooling localises some vesicants while warming disperses others, so a generic ice-pack response can be harmful.

Central does not mean impossible

A port or central catheter can leak internally through migration, fracture or vessel erosion without obvious skin swelling.

No blood return matters

A vesicant should not be infused through unexplained absent aspiration simply because saline appears to run.

Thrombosis need not lose line

A needed, functioning, correctly positioned and uninfected catheter may remain while thrombosis is treated.

11Common pitfallsFrequent interpretation and management errors.

01
Flushing after suspected extravasation in clinical practice.
02
Removing access before aspiration and protocol review.
03
Choosing warm or cold compress from memory.
04
Assuming central access cannot extravasate.
05
Forcefully flushing an occluded catheter.
06
Removing every thrombosed line automatically.
07
Failing to arrange serial tissue follow-up.