Guidelines of extravasation, infection &pain management in Oncology Dr. O.P. Singh M.D.FICRO. Prof & H.O.D (Radiotherapy) Gandhi Medical College Bhopal , India Dr. Gopa Ghosh M.D, Associate prof (Radiotherapy)S.S. Medical College Rewa ,India
Jun 01, 2015
Guidelines of extravasation, infection &pain management in Oncology
Dr. O.P. Singh M.D.FICRO.Prof & H.O.D
(Radiotherapy)Gandhi Medical College Bhopal
, IndiaDr. Gopa Ghosh M.D,
Associate prof (Radiotherapy)S.S. Medical College Rewa ,India
Extravasation can be defined as leakage of drug in to subcutaneous tissue which leads to either irritation or vescication.
Classification of Cytotoxic drugs according to local site reaction
1.IrritantsInflammation,irritation,Pain
2.InflammitantsInflammation/flare
3.ExfoliantsShedding/Exfoliation of skin ,no necrosis
4.VescicantsTissueUlceration&necrosis
5.Neutrals do not cause any damage
Extravasation of a vescicant is a medical emergency hence calls for early detection &prompt action to prevent functional loss of limb involved.
Common Exfoliants & Vescicants
ExfoliantsLiposomal DaunorubicinLiposomal doxorubicinCisplatinMitoxantroneOxalaplatin
VescicantsDoxorubicinDaunorubicinEpirubicinDactinomycinMitomycin CVincristineVinblastinePaclitaxol
Probable risk factors for PeripheralExtravasation:
Thin fragile veins
Site of cannulation
Peripheral neuropathy(Diabetes)
Excessive movements due to altered mental status,vomitting,coughing
SVC Syndrome
Elderly/ Paediatric
Obese
Prior chemotherapy
Cause of Central venous catheter leakage
Backflow secondary to thrombosis in the catheter.
Needle dislodgement from the port
Damage of the catheter
Thrombocytopenia
Prevention of extravasationCareful assesment of cannulation site
Cannulation over joints to be avoided
Patients at increased risk of extravasation should be identified.
Vescicant drugs to be given before other drugs
Bolus doses are given via fast running infusion of compatible fluid
Continuous observation of cannulation site for signs of swelling ,pain inflammation, slowing of drip rate.
Opinion for placement of CVAD should be sought if Peripheral access difficult.
Extravastion can also occur in central access often of delayed onset .
Signs/Symptom'sBurning ,stinging ,pain at injection site
Swelling ,redness , blister.
Absence of free flow of infusion
Resistance on the plunger of the syringe in case of bolus drug infusion
No blood return in the cannula.
Steps in management of extravasation
Stop infusion ,disconnect tubing
Withdraw as much as drug possible via existing cannula or CVAD
Mark skin area with indelible pen
Take photograph of the area
Open extravasation kit
Apply hot/cold pack as applicable for the concerned drug.
Elevate the limb
Inform treating oncologist
Urgent assesment by oncologist regarding referral to plastic surgeon for saline flush out of extravasated area.
Follow up at regular intervals.
Contents of extravasation kit
Inj Hyaluronidase (1ampoule/1500iu)
Hydrocortisone 1%cream
S/w for injection
DMSO98%solution
Hot pack
Cold pack
Drugs vs. Warm/Cold packVinca alkoids, Paclitax, Oxaloplatin Hyaluronidase+ Warm pack
Anthracyclins,Mitoxantrone,Mitomycin,DactinomycinColdpack+DMSO+1%hudrocortisone creamCarboplat,Cisplat,Etoposide,5FU,Irrinotican,Mtx- Coldpack & Hydrocortisone cream
Regime of Warm & Cold pack
Warm1amp Hyaluronidase s.c. injWarm pack to aid in absorptionLeave warm pack in situ for 2-4hrs
Cold cold pack + Hydrocortison ecream × 3daysHydrocortisone 1%cream tds OR Cold pack + hydrocortisone cream + DMSO
DMSO application regimeThin layer 98% DMSO1%hydrocortisoneCold
compress
Rpt every2hr/24hrs
DMSO 6hrly×7days
Alt toDMSO1% Hydrocortisone 6 hrly×7days
Cancer pain a matter of concern
60-80% of terminal cancer patients have severe pain
Moderate pain exists in earlier course of the disease also.
QOL of such patients are significantly impaired due to pain.
Chronic pain expressed in vague terms (stiffness ,anxiety ,insomnia), actual prevalance underestimated
85% cases can be pain free with modern drugs & techniques.
Etiology1. Direct infiltration to mucosa, soft
tissues ,nerve &bone.
2.Treatment related (Sx/RT/CT) accounts for 20% pain cases.
Pain produced- stimulation of peripheral pain receptors.(nociceptive)
Neurogenic/Neuropathic-( involvement of afferent nerves or nerve pathways.)
Broad Principles of drug treatment
Simplest dosage and least invasive route to be used first
Analgesics to be given preferably around the clock basis than as need basis for more effective pain control.
Opioid dose till ultimate pain relief or unacceptable side effects.
NAIDS &adjuvant analgesics with ceiling effect, dose till upper limit of recommended dose
Switching of analgesics when required
Primary cause of pain i.e. tumour to be treated with palliative appropriate modality (RT/CT/Sx )
Adjuvants( Antidepressants, Anticonvulsants biphosphonates, steroids, etc)used when required to enhance efficacy of analgesia, treat concurrent symptoms ,independent analgesic effect for specific type of pain .
Reasons for Comprehensive pain assesment
1.Pain expression influenced by factors:
Cognitive status
Extreme of age
Psychological reasons(fear of morphine related side effects, progressive disease)
Religious beliefs
Communication barrier
2,Asses pain components: Bony
.Neuropathic
.Behavioral
.Somatic
3.Asses Comorbid conditions (Renal,hepatic,Coagulopathy,GI,Respiratory)
Some Pain assesment scale
1.Numeric scale(0-10) based on patients own pain report
2. Rupee scale.
Children : Face scale Happy to sad
2.Comprehensive pain evaluation:
By PQRST factor(Provocative, quality , referred/regional
severity, temporal factors like onset ,duration ,frequency etc.
WHO designed simple, effective ,well validated adjustment of pain therapy which results in pain relief in 90% cases, known as WHO pain ladder
Some common analgesics proposed for use:
NSAIDs-Aspirin, Ibuprofen , Naproxen , Piroxicam , Celecoxib
Weak Opioid-Codeine, dextropropoxyphine, Tramadol,
Strong opioid-Morphine, buprenorphine, transdermal Fentanyl
WHO LADDER OF PAIN(cont.)
1-3 ,NSAID+/-Adjuvant
4-6,WEAKOPIOID,+/-NONOPIOID+/- ADJUVANT
7-10,STRONG OPIOID=/-NONOPIOID+/-ADJUVANT
Pharmacologic Management Drug therapy remains the cornerstone of cancer
pain management reasons being:
safe
Inexpensive
Works fast
Better compliance
3 major classes of drugs are:
NSAIDS & Acetaminophen
Opioid analgesics
Adjuvant analgesic agents
Non Pharmacologic Techniques
Anesthetic - Local anesthetic
-Nerve block
Neurosurgical techniques-Nerve ablation
-Nerve division
- Implant of device for electrical stimulation
Physical methods-Heat ,cold, acupuncture , electrical stimuli
.Cognitive techniques
1-15% cases requires invasive technique.
Morphine dose/side effectsInexpensive opioid given commonly by oral route
Starting dose 10mg 4hrly,TDD usually 20-40mg , by 50% subsequently
Parenteral dose 1/3rd of OD
Breakthrough pain(10-15%) of daily dose.
No max. dose.
Extended release preparations when frequent dosing required
Side effects requiring dose modification ,adjuvants ,Switchin
g ,alternate routes
Constipation
Sedation
Myoclonus
Opioid toxicity syndrome(OTS)-RF ,dehydration, severe myoclonus
Withdrawal symptoms
Infection in oncology
Reason for significant morbidity & mortality
Oncologist should have thorough understanding of risk factors &common etiologic microbes
Prompt work up & therapy are key to successful management
Causes immunity-disease itself
-treatment induced neutropenia
.Protein malnutrition
Altered cellular/Humoral immunity
.Nosocomial
Post operative
.Secondary to obstruction & necrosis
.Exposure to community acquired pathogens(HSV,CMV)
.Reactivation of latent infections
Common Symptoms
Fever
Tachypnea
Tachycardia
Hypotension
Hypothermia
Organ specific
Organ failure
Routinely diagnosed by laboratory, microbial ,radiological tests
Guidelines for treatmentPrompt initiation of broad spectrum antimicrobial
empiric monotherapy in suspected infections without waiting for lab reports
Directed therapy against specific pathogens as per microbial culture report.
In case β-lactam allergy fluoroquinolone based therapy given.
Diagnosis of febrile neutropenia should be done in fever cases with ANC< 500/μl ,WBC <1000/μl.
Documented bacteremia treated at least for 14 days.
Common pathogensS.aureus
Enterococcus
Pseudomonas
C.difficle
Klebsiella
Proteus
E.coli
Candida
Aspergillus
CMV
Common Antimicrobials3rd /4th gen cephalosporins
Carbapenems(Imepenem/Merpenem)
Piperacillin-tazobactam
Amoxycillin-clavulanate
Fluoroquinolones
Aztreonam
Fluconazole
Voriconazole
Amphotericin-B
Acyclovir
Thank you