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

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.Irritan

ts

Inflamm

ation,irr

itation,

Pain

2.Inflam

mitants

Inflamma

tion/flare

3.Exfolia

nts

Shedding

/Exfoliati

on of

skin ,no

necrosis

4.Vescica

nts

Tissue

Ulceratio

n&necros

is

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

Exfoliants

Liposomal

Daunorubicin

Liposomal

doxorubicin

Cisplatin

Mitoxantrone

Oxalaplatin

Vescicants

Doxorubicin

Daunorubicin

Epirubicin

Dactinomycin

Mitomycin C

Vincristine

Vinblastine

Paclitaxol

Probable risk factors for

Peripheral

Extravasation: 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 extravasation

Careful 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's

Burning ,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 pack

Vinca alkoids, Paclitax, Oxaloplatin

Hyaluronidase+ Warm pack

Anthracyclins,Mitoxantrone,Mitomycin,Dacti

nomycinColdpack+DMSO+1%hudrocortis

one

cream

Carboplat,Cisplat,Etoposide,5FU,Irrinotican,

Mtx- Coldpack & Hydrocortisone cream

Regime of Warm & Cold pack

Warm

1amp Hyaluronidase

s.c. inj

Warm pack to aid in

absorption

Leave warm pack in

situ for 2-4hrs

Cold

cold pack +

Hydrocortison ecream

3days

Hydrocortisone

1%cream tds

OR

Cold pack +

hydrocortisone cream

+ DMSO

DMSO application regimeThin layer 98% DMSO1%hydrocortisoneCold

compress

Rpt every2hr/24hrs

DMSO 6hrly7days

Alt toDMSO1% Hydrocortisone 6 hrly7days

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 scale1.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 effects Inexpensive 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 ,Switching

,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 treatment Prompt 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 pathogens S.aureus

Enterococcus

Pseudomonas

C.difficle

Klebsiella

Proteus

E.coli

Candida

Aspergillus

CMV

Common Antimicrobials 3rd /4th gen cephalosporins

Carbapenems(Imepenem/Merpenem)

Piperacillin-tazobactam

Amoxycillin-clavulanate

Fluoroquinolones

Aztreonam

Fluconazole

Voriconazole

Amphotericin-B

Acyclovir

Thank you