Chemotherapy Extravasation Management
On this page
Direct answer
Cold for anthracyclines, warm for vinca alkaloids — the single most examinable line in chemotherapy extravasation. The universal first moves are identical: stop the infusion, leave the cannula in place, aspirate 5-10 mL of blood and drug, never flush the line, and elevate the limb. Anthracycline (doxorubicin, daunorubicin, epirubicin) and mitomycin spills then get cold compresses, topical DMSO, and — within the first six hours — intravenous dexrazoxane 1000 mg/m² on two days then 500 mg/m² on day three, the specific antidote. Vinca alkaloid and paclitaxel extravasations reverse the physics: warm compresses plus hyaluronidase 150-1500 units subcutaneously through the existing cannula disperse the drug and prevent the tissue necrosis that cold would worsen. Sodium thiosulfate follows mechlorethamine and concentrated cisplatin. Document, photograph, and review at 48-72 hours because anthracycline injury ulcerates for weeks.
What you must remember
- Immediate universal steps: stop, leave cannula, aspirate blood and residual drug, do not flush, remove the cannula, elevate, mark and photograph the margin.
- Vesicant roll-call: anthracyclines, mitomycin C, actinomycin D, vinca alkaloids, mechlorethamine, and paclitaxel (grouped with vesicants though technically an irritant at times).
- Cold-side antidotes: anthracyclines and mitomycin — cold compresses, topical DMSO (99%), dexrazoxane IV (1000 mg/m² days 1-2, 500 mg/m² day 3, first dose within 6 hours) as the definitive treatment.
- Warm-side antidotes: vinca alkaloids (vincristine, vinblastine) and paclitaxel — warm compresses plus hyaluronidase 150-1500 units, dispersing drug away from the site.
- Sodium thiosulfate: for mechlorethamine and concentrated cisplatin extravasation, as a 1/6 molar subcutaneous flush.
- Prevention beats cure: central venous access for continuous infusions and bolus vesicants; competent, running, freely flowing peripheral lines only; never administer vinca except as a short infusion through a verified line — fatal intrathecal vincristine is the companion never-event.
- Sequelae timeline: anthracycline damage (DNA-bound drug persists locally) progresses to ulceration over 1-4 weeks; surgery — debridement, grafting — is reserved for established necrosis.
Managing a doxorubicin spill minute by minute
A 52-year-old on adjuvant AC for breast cancer complains of burning above the cannula during doxorubicin push. The nurse stops. She aspirates 8 mL through the cannula before removing it. The arm is elevated; the margin of the 4 cm indurated area is marked with a pen and photographed. Cold compresses go on for 15-20 minutes hourly through the first day. Topical DMSO is applied to the marked area and allowed to dry, three to four times daily. Because the volume estimate approaches 10 mL, the oncology team administers dexrazoxane 1000 mg/m² IV within four hours, repeating the schedule over three days. Review at 72 hours shows dusky but intact skin; at two weeks a small eschar — plastics review, not more antidote. Every step generalises: the aspirate-first rule preserves the antidote window, and the documentation becomes the medico-legal record.
Contrast the same spill with vincristine: warm compress, hyaluronidase injected through the cannula and peripherally, cold explicitly avoided because it fixes the drug in tissue, worsening ulceration.
Where the exam sets its traps
Matching questions dominate: dexrazoxane pairs with anthracycline, hyaluronidase with vinca and taxane, thiosulfate with mechlorethamine and cisplatin, phentolamine with vasopressor extravasation (the non-chemo companion worth knowing). Two conceptual traps follow. First, "flush the line to dilute" — wrong; flushing drives more drug into tissue, which is why aspiration precedes cannula removal. Second, the phlebitis-versus-extravasation distinction: flare reactions to anthracyclines (immediate local urticarial streaking) resolve spontaneously without antidotes; calling every flare an extravasation wastes dexrazoxane. Indian context: day-care chemotherapy units in smaller centres rely on peripheral cannulae, extravasation kits are often incomplete (DMSO and hyaluronidide stock-outs are a real audit finding), and the practical viva answer is the protocol sequence — stop, aspirate, antidote, document — recited in order. The companion never-event, intrathecal vincristine, is asked as a one-liner: vincristine is for intravenous use only, always in a minibag in enlightened units.
Frequently asked questions
What are the first steps on suspecting chemotherapy extravasation?
Stop the infusion, aspirate blood and residual drug through the cannula, avoid flushing, remove the cannula, and elevate the limb.
Which antidote is specific for anthracycline extravasation?
Intravenous dexrazoxane, 1000 mg/m² on days 1 and 2 then 500 mg/m² on day 3, starting within six hours, alongside cold compresses and topical DMSO.
Why are warm compresses used for vinca alkaloid extravasation?
Heat with hyaluronidase disperses the drug through tissue, whereas cold localises it and deepens necrosis.
Which agent is treated with sodium thiosulfate?
Mechlorethamine and concentrated cisplatin extravasations, using a 1/6 molar subcutaneous flush.
What distinguishes an anthracycline flare reaction from extravasation?
Flare is immediate, urticarial, proximal to the vein and self-resolving, requiring observation rather than antidotes.