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