INFUSION RELATED RISKS ASSCOCIATED WITH CHEMOTHERAPY

CPD
CONTINUING
PROFESSIONAL
DEVELOPMENT
Infusion-related risks associated
with chemotherapy
NS831 Gallimore E (2016) Infusion-related risks associated with chemotherapy. Nursing Standard. 30, 25,
51-58. Date of submission: May 29 2015; date of acceptance: October 7 2015.
Aims and intended learning outcomes
Abstract
This article provides a comprehensive overview of the risks associated
with the administration of chemotherapy, monoclonal antibodies and
targeted or biological therapies in the management of solid tumours. The
main physiological actions of these agents are discussed, with reference
to the immediate infusion-related side effects and complications that may
arise from an extravasation injury. The article focuses on the identification
and early recognition of these risk factors to implement preventive
measures and appropriate management strategies.
Author
Elizabeth Gallimore Oncology research practitioner, Clatterbridge Cancer
Centre, Merseyside, England.
Correspondence to: [email protected]
Keywords
biological therapies, chemotherapy, extravasation, infusion reactions,
monoclonal antibodies, oncology, side effects
This article aims to improve nurses’
knowledge of the infusion-related risks of
chemotherapy and targeted therapies for
solid tumours. After reading this article and
completing the time out activities you should
be able to:
Describe the physiological action of
chemotherapy, monoclonal antibodies and
targeted therapies.
Recognise infusion-related risks and side
effects of chemotherapy and targeted
therapies.
Identify management strategies to reduce
the risk of infusion-related side effects and
complications.
Outline the implications of early recognition
and medical management of infusion-related
risks.
Review
Introduction
All articles are subject to external double-blind peer review and checked
for plagiarism using automated software.
Kang and Saif (2007) stated that ‘infusion
related reactions may be defined as any
signs or symptoms experienced by a patient
during the infusion of pharmacologic or
biologic agents or any event occurring
on the first day of drug administration.’
Zetka (2012) suggested that all systemic
anticancer therapies, whether chemotherapy,
monoclonal antibodies or novel agents, have
the potential to cause an infusion-related
reaction. It is essential to develop an
understanding of the presenting symptoms
and management strategies to promote early
recognition and prompt medical intervention
to minimise complications. Certain classes
of chemotherapy have a greater potential
to cause an infusion-related reaction; these,
in addition to the associated risks with
monoclonal antibodies, are discussed in
more detail.
Complete time out activity 1
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CPD oncology
Anticancer therapies
To fully appreciate the implications of
chemotherapy and targeted therapies,
including monoclonal antibodies, it is
important to define the action of these agents
and the physiological effect they have on
the cells, paying particular attention to the
mechanisms involved in infusion reactions
and extravasation injury.
Chemotherapy
1 Reflect on your
own practice.
List the most common
complications you
have experienced
when managing
patients undergoing
chemotherapy.
The term chemotherapy encompasses a range
of different cytotoxic agents used to target
and destroy cancer cells. Some cytotoxic
anticancer drugs may not have the potential
to cause cell death through their mechanism
of action; however, they have the ability to
induce mutations in the cancer cells. This
allows detection by the immune system, which
in turn triggers the physiological response of
apoptosis. Chemotherapy acts to limit tumour
growth and cause cell death through the
activation of apoptosis and the inhibition of
mitosis and proliferation. However, it does not
target other aspects of tumour progression,
including tissue invasion, angiogenesis,
metastases or loss of differentiation. This
means that, although cellular growth may
be contained, the chemotherapeutic agents
do not destroy those cells that have already
migrated outside the primary tumour (Payne
and Miles 2008).
A consequence, or rather a complication,
of chemotherapy regimens is the development
of resistance to chemotherapy. Resistance
occurs as a result of a cellular response to
drug exposure that limits the efficacy and
effectiveness of chemotherapy, leading to
tumour growth and disease progression
(Gatti and Zunino 2005). Dual therapy with
two cytotoxic agents is often used to target
high numbers of cancer cells and may be used
in conjunction with other targeted therapies
such as hormonal treatments or monoclonal
antibodies, in addition to surgical intervention
and the use of radiotherapy. However, this
largely depends on the type of cancer, the
rate of growth of cancer cells, and the aims
and implications of treatment. Combination
regimens may also help to delay the incidence
of resistance to chemotherapeutic agents
(Malhotra and Perry 2003).
Chemotherapy can be highly successful,
depending on several factors, including the
extent of the disease, nature of treatment,
presence of comorbidities and overall health
status of the patient. Chemotherapy is not
able to distinguish between healthy cells and
cancerous cells and therefore attacks both,
causing a number of side effects, including
bone marrow suppression, which can have
potentially fatal consequences. Both healthy
and cancerous cells with a high growth rate are
more sensitive to the actions of chemotherapy;
patients may experience side effects owing
to the damage to healthy cells as a result of
the cytotoxic agents, including cells in the
gastrointestinal tract, leading to mucositis,
nausea, vomiting, bowel complications,
damage to the hair follicles and, more
importantly, the bone marrow as mentioned
above. The distinguishing characteristic of this
process is the ability of healthy cells to repair
themselves and regenerate, whereas the cancer
cells die if they are unable to replicate (Payne
and Miles 2008).
The presence of comorbidities can
have a significant effect on whether the
patient is likely to tolerate the toxicities of
chemotherapy. Older people are compromised
as a result of age-related physiological changes
that affect their ability to tolerate the cytotoxic
effects on the body, in addition to the
associated complications of any concomitant
medications and coexisting medical problems
(Repetto 2003).
The different classes of chemotherapeutic
agents are not discussed in detail in this
article. Certain risk factors and toxicities
may be more prevalent depending on which
cytotoxic agent is used; the reader should refer
to their local policies and guidelines on the
administration of chemotherapy to ensure
safe and effective practice. Platinum-based
compounds and taxanes are the two most
common cytotoxic agents associated with
infusion-related reactions.
Targeted and biological therapies
The aim of this article is to discuss the
principles of infusion-related reactions linked
to the administration of chemotherapy agents.
However, it is important to mention that other
targeted and novel therapies also have the
potential to cause infusion-related reactions.
These agents are becoming more widely used
in conjunction with chemotherapy as a result
of their milder toxicity profiles and additional
potential benefits (Gerber 2008). It is beyond
the scope of this article to discuss each
targeted therapy in detail; however, reference
is made to ensure that the reader develops
an understanding of the potential risks of
administering these products.
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Targeted therapies and biological agents
act on specific molecules to inhibit tumour
growth and progression, and the spread of
cancerous cells. A broad range of targeted
therapies have been developed to work in
conjunction with chemotherapy agents and
form treatment pathways for several different
tumour groups. Transduction inhibitors
target epidermal growth factor receptors and
tyrosine kinase enzymes to prevent tumour
progression and growth. Other targeted
therapies focus on hormones, gene expression
modulators, apoptosis inducers and
angiogenesis inhibitors that target vascular
endothelial growth factors.
Immunotherapies and monoclonal
antibodies may trigger the immune system
to attack and kill the cancer cells, or they
may attach themselves to the cancer cells
to make them more visible to the immune
system. The action of these agents depends
on their specific pharmacodynamics; they
have the ability to block specific signalling
pathways that prevent the growth of cancer
cells (Gerber 2008).
Any pharmacological or biological agent
has the potential to cause an infusion-related
reaction, but there are clear documented
risks with specific agents. Among targeted
therapies, monoclonal antibodies in particular
carry an increased risk of infusion-related
reaction that is similar to a taxane response
(Chung 2008). Monoclonal antibodies are
classified as targeted therapies that have the
ability to recognise and attach to certain
proteins on the cancer cells. Each monoclonal
antibody has a specific mechanism of
action that depends on the cellular protein
it is designed to target; these agents differ
depending on the tumour and type of
cancer. Monoclonal antibodies encompass a
wide range of agents, including cetuximab,
rituximab, trastuzumab, bevacizumab and
panitunumab (Chung 2008).
It is also important to make reference to
novel therapies administered in a clinical
trial setting. These agents, especially in early
phase studies, do not have a fully developed
safety profile, so a high index of suspicion is
required when monitoring for infusion-related
reactions. It is essential to be aware of the
specific infusion reaction management
strategies for each agent as set out in the
study protocol, as well as any additional
safety concerns, to appropriately treat any
complications that arise.
Complete time out activity 2
Infusion reactions
One of the most prominent risks associated
with the administration of systemic
anticancer therapy is the possibility of an
allergic reaction. The mechanisms involved
in an immune-related response to both
chemotherapy agents and targeted therapy can
be treatment specific and depend on the class
of agent used (Castells and Matulonis 2015).
During initial exposure, immunoglobulin E
(IgE) antibodies are produced and bind to the
mast cells and basophils of the immune system.
As the infusion progresses, or on subsequent
infusions, the antibodies react to the antigen
and cause a hypersensitivity reaction, resulting
in the release of histamines, leukotrienes and
prostaglandins from mast cells in tissue and
basophils in peripheral blood. These reactions
are characterised by the contraction of smooth
muscle and dilation of the peripheral vessels.
The exact physiology of chemotherapy-related
reactions is unknown; some reactions occur
as a result of a direct effect on the immune
cells, while others may occur as a result of
an anaphylactoid response through direct
interaction with mast cells and basophils
(Lenz 2007). Collectively, the occurrence of
an allergic or hypersensitive reaction is the
response of the immune system to a cytotoxic
or biological agent considered a foreign protein.
Reactions are most commonly mild, but
they may develop into severe life-threatening
complications without prompt recognition
and implementation of management
strategies (Vogel 2010). The symptoms of an
infusion-related reaction to chemotherapy are
largely dependent on the severity of the reaction
and can be agent specific. Presenting symptoms
include facial flushing, nausea, urticarial rash,
back pain, chest pain, shortness of breath
resulting from angioedema and bronchospasm,
hypotension, tachycardia, drowsiness and
episodes of syncope (Gottlieb et al 2010).
When administering chemotherapy and
monoclonal antibodies, it is essential to have
an understanding of the risk factors associated
with that particular drug to acknowledge
whether an infusion-related reaction is likely to
occur. As previously mentioned, taxanes and
platinum-based compounds have the greatest
potential to cause infusion-related reactions;
however, the physiology differs somewhat
between these two classes.
Taxanes have the potential to cause a
reaction as a result of the immediate effect
of the biological agent on the immune
cells. Precautions are taken in the form of
2 Reflect on the
mechanism of action of
chemotherapy agents
and write brief notes on
the following:
How do they work?
What effect do they
have on the cancer
cells?
What is the rationale
behind the side
effects?
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CPD oncology
premedication to pre-empt and prevent
a reaction. Agents such as docetaxel and
paclitaxel pose a significant risk of allergic
reactions (Vogel 2010), and prophylactic
corticosteroids and antihistamines are used
to reduce this risk. The use of premedication
does not remove the risk of an infusion-related
reaction, but does help to minimise the
risk (Gottlieb et al 2010). The value of
premedication may significantly decrease with
further infusions of taxane agents, since the
risk of an infusion-related reaction decreases
with subsequent infusions (Chung 2008).
Most infusion-related reactions occur
within ten to 30 minutes of the initial or second
administration. Evidence suggests that most
reactions occur as a result of a direct effect on
the immune cells and may be classified as an
anaphylactoid response (Lenz 2007). In the
case of monoclonal antibodies, the physiology
behind an infusion-related reaction is not
clearly understood, but has been strongly
linked to the mechanisms involved in a reaction
to taxane chemotherapy agents; premedication
may also be used in the administration of
monoclonal antibodies.
Monoclonal antibodies interact with
their molecular targets on the tumour cells
and blood cells at the tumour site, resulting
in the release of cytokines. Cytokines are
hormone-like proteins that elicit an immune
response, leading to the symptoms associated
with a systemic infusion reaction (Pérez Fidalgo
2012). The presenting symptoms of a reaction
to a monoclonal antibody are similar to
a chemotherapy reaction, with a higher
prevalence of skin involvement in the form of
pruritus, rash and urticaria (Lenz 2007).
In contrast, certain other cytotoxic agents –
particularly platinum-based regimens with drugs
including carboplatin, cisplatin or oxaliplatin
– exhibit a classic IgE response. This response
is also seen with the monoclonal antibody
rituximab. These medications elicit a standard
IgE response, with a reaction likely to occur after
administration of multiple cycles, suggesting
previous sensitisation (Kang and Saif 2007).
Management strategies
It is important to be aware of the potential for a
reaction to take place and to have the knowledge,
resources and ability to administer remedial
therapy should a reaction occur. It is essential to
be familiar with local policies on anaphylaxis and
to have a good understanding of the principles
of management strategies (Vogel 2010). Most
chemotherapy units have an anaphylaxis kit to
manage such situations. Standard treatment of
a chemotherapy-related reaction is based on the
administration of remedial drug therapy. The use
of hydrocortisone and an antihistamine, usually
chlorphenamine maleate, to control and reverse
the immune response is highly effective, but
adrenaline (epinephrine) may be required. The
reader should refer to their local guidelines on
managing anaphylaxis. Vogel (2010) provides a
comprehensive algorithm for the management of
a hypersensitivity reaction.
The immediate response to a reaction is
to stop the chemotherapy and commence a
0.9% sodium chloride infusion to prevent
any further chemotherapy from being
administered. A fast-flowing infusion of 0.9%
sodium chloride should be administered to
ensure haemodynamic stability and to aid in
the administration of remedial drugs into the
bloodstream. The patient’s vital signs should be
monitored closely for any clinical deterioration,
and a full clinical assessment should be
performed. High-flow oxygen therapy is likely
to be administered to assist in the treatment of
the allergic reaction, but it should be noted that
some chemotherapy agents may be associated
with additional adverse reactions to the use of
oxygen. Oxaliplatin, for example, is sensitive
to cold air and may result in laryngeal spasms
in the event of oxygen administration, leading
to further complications and a potentially
dangerous situation for the patient (Castells
and Matulonis 2015). Preventive strategies
should be in place to reduce the risk of
laryngeal spasm. Avoiding cold food and
drinks, wrapping up warm and slowing down
the rate of administration of responsible agents
may all help to reduce the incidence of this
complication. If laryngeal spasm should occur,
it is important to keep the patient calm, apply
a warm compress to the area of the throat and
encourage the patient to sip a warm drink if
they are able. In severe cases, more definitive
measures may be required.
Allergic reactions are unpredictable and may
not respond to treatment, so close observation,
readiness to act and a comprehensive algorithm
are essential.
Patient education is another important
factor in the prevention and management of
these reactions. Educating the patient on the
side effects and risk factors associated with
their treatment emphasises the importance of
early recognition of infusion-related reactions
(Castells et al 2008). As mentioned, certain
medications, such as paclitaxel or docetaxel,
pose a significant risk within minutes of the
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first infusion, while others may present a
problem further along the treatment schedule.
Platinum-based therapies such as carboplatin
and cisplatin may cause an allergic reaction
after six cycles, which can be quite severe and
difficult to treat. Patients receiving multiple
doses of chemotherapy may become sensitised
to the drug, and subsequent exposure may
result in a hypersensitivity reaction (Castells
et al 2008). Education, close monitoring, early
recognition and a rapid response according
to a documented treatment algorithm with
best practice guidelines should be at the
forefront of nursing practice in relation to
infusion-related reactions to chemotherapy.
It is important to document the incidence
and severity of an allergic reaction accurately
to provide a detailed account. Incomplete
documentation or false representation of the
severity of the reaction may affect the patient’s
chance of being offered a re-challenge with
the same drug or similar classes of drugs, thus
limiting their treatment options. Safety concerns
may be raised about the use of subsequent
infusions, and additional precautions may be
taken to minimise further risk (Vogel 2010). The
decision to re-challenge depends on the aetiology
of the severe reaction and an understanding of
the mechanism of the individual agent.
A re-challenge is the re-administration of
a cytotoxic agent that previously caused an
infusion reaction, usually at a slower rate of
administration with the aid of premedication,
to promote desensitisation. The aim of
a re-challenge is to allow for treatment
administration of those chemotherapeutic
agents which cause an initial reaction but may
be tolerated with subsequent infusions.
Complete time out activity 3
Extravasation injury
Extravasation refers to the inadvertent
infiltration of cytotoxic agents into the
extravascular space and surrounding tissues.
Extravasation of targeted therapies does
not pose the same risk as chemotherapeutic
agents; the damage and potential for injury
is significantly increased with cytotoxic
medication. However, it is still important in
this setting to be aware of an extravasation risk
and the resulting complications (Pérez Fidalgo
et al 2012).
Misplacement of a peripheral cannula,
poor selection of venous access and accidental
damage to a cannula through movement may
cause an extravasation injury (Pérez Fidalgo
et al 2012). Chemotherapy agents are
classified by their potential to cause damage
should an extravasation injury occur and may
be subdivided into three categories:
Vesicant.
Irritant.
Non-vesicant.
Owing to their toxic nature, vesicant
chemotherapy drugs have the potential to cause
the most damage. A high index of suspicion
should be adopted when treating patients
with these drugs; first to assess for risk factors
and then to monitor actively for signs and
symptoms of an extravasation injury to ensure
prompt identification and implementation of
management strategies to limit damage.
Many, but not all, extravasation injuries
can be prevented through a thorough risk
assessment and the ‘systemic implementation
of careful, standardized, evidence-based
administration techniques’ (Pérez Fidalgo et al
2012). The insertion of a peripherally inserted
central catheter (PICC) can significantly
reduce the risk of an extravasation injury;
it is recommended and is hospital policy in
certain organisations for the administration
of vesicant chemotherapy agents. An
extravasation injury may still occur with a
PICC, but the risks are very low with correct
management and monitoring techniques
(Schulmeister 2010). Box 1 lists the risk
factors associated with an increased incidence
of extravasation injury; it should be noted that
this is not an exhaustive list.
3 Reflect on your
experience of an
infusion-related
reaction. What were
the main management
strategies? Locate
the clinical guidance
for the management
of infusion-related
reactions in your
practice area. Locate
the anaphylaxis kit and
familiarise yourself with
its contents.
BOX 1
Risk factors associated with extravasation injury
 Poor venous selection – small fragile veins or hard sclerosed veins.
 Poor site selection – an area that makes it difficult to detect the incidence
of an extravasation injury; previous multiple cannulation attempts, including
damage that occurred during previous treatment cycles.
 Poor insertion and management techniques and failure to adequately assess
patency – the use of inappropriate or inadequate equipment for the task and
fixation of the cannula once inserted may significantly increase the risk of an
extravasation injury.
 Untrained or inexperienced staff.
 Patient-associated factors – including obesity, history of comorbidities such
as peripheral vascular disease or diabetes, and the presence of lymphoedema
– that make the process of inserting a cannula more difficult.
 Lack of patient education regarding the implications of extravasation injuries
and difficulties in communication.
 Medical problems associated with altered peripheral sensation that can
impair the patient’s ability to recognise symptoms.
 Prolonged infusions, especially of vesicant and irritant agents.
 High flow pressure and the administration of bolus medication.
(Adapted from Pérez Fidalgo et al 2012)
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CPD oncology
4 Define extravasation
and list three known
risk factors. Locate
the extravasation
policy in your area and
become familiar with
the guidelines. Choose
one chemotherapy
agent and research
the extravasation
management of that
particular agent.
The degree of damage depends on the type
and concentration of chemotherapy, the length
of time the drug has leaked into the tissues
and the localisation of the area of
extravasation. For example, a vesicant
chemotherapy such as epirubicin given via
a peripheral cannula in the hand has the
potential for severe damage as a result of the
toxicity of the drug and the implications for
the surrounding area should an extravasation
occur (Pérez Fidalgo et al 2012).
Table 1 gives an overview of the different
classes of cytotoxic drugs and their potential
to cause an extravasation injury, making
reference to the most commonly used
chemotherapeutic agents. It should be noted
that this is not an exhaustive list.
Prompt recognition is essential to prevent
severe damage to the tissues and peripheries
surrounding the cannulation site. An
extravasation injury has the potential to cause
tissue necrosis, functional impairment and
permanent disfigurement if left untreated.
Surgical intervention may be required,
depending on the severity of the injury, which
may in turn result in a delay in planned
chemotherapy treatment with complications
lasting many months (Schulmeister 2010).
TABLE 1
Potential for extravasation injury associated with cytotoxic drugs
Class of agent
Potential for injury
Examples of agents
Vesicants
Capable of causing pain,
inflammation and blistering of
the local skin and underlying
structures. Extravasation of
this agent can result in tissue
death and necrosis.
Epirubicin, doxorubicin,
mitomycin,
dacarbazine, paclitaxel,
vinorelbine.
Exfoliants
Capable of causing
inflammation and shedding
of the skin; unlikely to cause
tissue necrosis.
Cisplatin, doxorubicin
liposomal, docetaxel,
oxaliplatin, topotecan.
Irritants
Capable of causing
inflammation, irritation or pain,
but rarely tissue necrosis.
Carboplatin, etoposide,
irinotecan.
Inflammatory
agents/
non-vesicants
Capable of causing
mild-to-moderate inflammation
and flare in local tissue.
Etoposide, fluorouracil,
methotrexate.
Neutrals
Do not cause peripheral
damage.
Bleomycin,
cyclophosphamide,
gemcitabine, rituximab,
trastuzumab, cisplatin,
pemetrexed.
(Hines 2011, Al-Benna et al 2013)
Box 2 lists the signs and symptoms of an
extravasation injury.
Management strategies
Management of these injuries depends on the
drug used. Application of topical heat or cooling
methods and extravasation antidotes are drug
specific, and different interventions are indicated
depending on the mechanism of action and the
response to treatment. Initial management is
to stop the infusion, keep the cannula in place,
raise the alarm to obtain assistance and follow
the local guidelines to manage the situation
(Schulmeister 2010). Any clinical environment
where cytotoxic agents are administered must
have an extravasation kit available immediately
should an incident occur. Local policies and
guidelines are kept with the extravasation kit,
in addition to essential information pertaining
to the management of different chemotherapy
extravasations, including the required
medications and evidence-based algorithms
(Figure 1).
Complete time out activity 4
Other infusion-related toxicities
There are other infusion-related side effects
and toxicities associated with administering
chemotherapy agents. The incidence of
chemotherapy-induced nausea and vomiting
and myelosuppression’s physiological effect are
two of the most prominent risks and can cause
significant complications. Myelosuppression
and the risk of infection in particular can lead to
fatal consequences if not identified and managed
appropriately. Side effects such as mucositis
can be severe and have detrimental effects on
overall health and nutritional status,requiring
medical intervention in extreme cases. Other
symptoms such as bowel disturbance can be
BOX 2
Signs and symptoms of an extravasation injury
 Altered sensation at the site of the cannula:
– Tingling.
– Burning.
– Discomfort or pain.
– Swelling.
– Redness.
 Interruption to intravenous flow, resistance
when administering a bolus injection and
the absence of blood return may signal an
extravasation injury.
 Late-stage symptoms may include blistering,
necrosis and ulceration.
(Schulmeister 2010)
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managed with prophylactic and therapeutic
medication. Longer term problems that may arise
and cause significant disruption to a patient’s
general wellbeing and quality of life include
hair loss, nail changes, peripheral neuropathy,
taste changes, and cognitive and emotional
problems. The more severe side effect of
an increased risk of a thrombus is widely
documented and can pose quite a significant
complication (Livshits 2014).
Patient education is essential to ensure an
understanding of these physiological effects,
FIGURE 1
Algorithm for the management of extravasation injuries during peripheral infusions
Step 1
Stop and disconnect infusion. Leave the cannula in place.
Step 2
Identify extravasated agent.
Step 3
Leaving the cannula in place, try to gently aspirate as much extravasated
solution as possible. Record volume removed in patient records.
Avoid manual pressure over the extravasated area.
Remove cannula.
Step 4
Mark with a pen an outline of the extravasated area.
Step 5
Notify physician. Start specific measures as soon as possible.
Non vesicant
Vesicant or irritant
Localise and neutralise
Agents:
Anthracyclines
Antibiotics (mitomycin/
dactinomycin)
Alkylating agents
Step 5A: Localise
Apply dry cold compresses for 20
minutes 4 times daily for 1-2 days.
Avoid alcohol compresses
Step 5B: Neutralise
Use specific antidotes
Anthracyclines
Topical DMSO
Dexrazoxane
Mitomycin C
Topical DMSO
Disperse and dilute
Agents:
Local dry cold compresses
Vinca alkaloids
Taxanes
Platinum salts
Step 5A: Disperse
Apply dry warm compresses for
20 minutes 4 times daily
for 1-2 days
Step 5B: Dilute
Administer agents
increasing resorption
Vinca alkaloids
and taxanes
Hyaluronidase
Step 6
Elevate the limb. Administer analgesia if necessary.
DMSO = Dimethyl sulfoxide
(Pérez Fidalgo et al 2012, © European Society for Medical Oncology www.esmo.org/Guidelines)
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CPD oncology
and a discussion of management strategies and
implications for treatment is a priority to
prepare patients for therapy. It is beyond the
scope of this article to provide detail on the
delayed toxicities. Macmillan Cancer Support
(2015) provides information on chemotherapy
administration and targeted therapy, associated
side effects and specific considerations. This
resource can be used for patient education.
Conclusion
It is important that nurses have an understanding
of the infusion-related risks associated with
chemotherapy to recognise symptoms and ensure
appropriate management strategies should
complications occur. It should be noted that the
information in this article provides an overview
of a diverse subject, and further reading can
provide additional knowledge NS
Complete time out activity 5
USEFUL RESOURCES
 Bovelli D, Plataniotis G, Roila F; ESMO Guidelines
Working Group (2010) Cardiotoxicity
of chemotherapeutic agents and
radiotherapy-related heart disease: ESMO
Clinical Practice Guidelines. Annals of Oncology.
21, Suppl 5, 277-282.
 Bracci L, Schiavoni G, Sistigu A, Belardelli F
(2014) Immune-based mechanisms of cytotoxic
chemotherapy: implications for the design of
novel and rationale-based combined treatments
against cancer. Cell Death and Differentiation.
21, 1, 15-25.
 Lyman GH, Abella E, Pettengell R (2014)
Risk factors for febrile neutropenia among
patients with cancer receiving chemotherapy:
a systematic review. Critical Reviews in Oncology/
Hemtaology. 90, 3, 190-199.
 Thompson N (2012) Optimizing treatment
outcomes in patients at risk for
chemotherapy-induced nausea and vomiting.
Clinical Journal of Oncology Nursing. 16, 3, 309-313.
5 Now that you have
completed the article,
you might like to write
a reflective account as
part of your revalidation.
Guidelines to help you
are on page 62.
References
Al-Benna S, O’Boyle C, Holley J
(2013) Extravasation injuries
in adults. ISRN Dermatology.
doi:10.1155/2013/856541.
Gerber DE (2008) Targeted
therapies: a new generation of
cancer treatments. American Family
Physician. 77, 3, 311-319.
Castells MC, Matulonis UA (2015)
Infusion Reactions to Systemic
Chemotherapy. www.uptodate.com/
contents/infusion-reactions-tosystemic-chemotherapy (Last
accessed: December 5 2015.)
Gottlieb GR, Bordoni RE,
Lawhead AR, Feinberg B
(2010) Successful outpatient
desensitization of cancer patients
with hypersensitivity reactions
to chemotherapy. Community
Oncology. 10, 7, 452-457.
Castells MC, Tennant NM,
Sloane DE et al (2008)
Hypersensitivity reactions to
chemotherapy: outcomes and
safety of rapid desensitization
in 413 cases. Journal of Allergy
and Clinical Immunology.
122, 3, 574-580.
Chung CH (2008) Managing
premedications and the risk
for reactions to infusional
monoclonal antibody therapy.
The Oncologist.
13, 6, 725-732.
Gatti L, Zunino F (2005) Overview
of tumor cell chemoresistance
mechanisms. Methods in Molecular
Medicine. 111, 127-148.
Hines A (2011) Network Guidance
for the Prevention and Management
of Extravasation Injuries. www.
mccn.nhs.uk/userfiles/documents/
MCCN%20Extravasation_
final_Oct11.pdf (Last accessed:
December 5 2015.)
Kang SP, Saif MW (2007)
Infusion-related and
hypersensitivity reactions of
monoclonal antibodies used to treat
colorectal cancer – identification,
prevention, and management.
Journal of Supportive Oncology.
5, 9, 451-457.
Lenz HJ (2007) Management and
preparedness for infusion and
hypersensitivity reactions.
The Oncologist. 12, 5, 601-609.
Livshits Z, Rao RB, Smith SW
(2014) An approach to
chemotherapy-associated toxicity.
Emergency Medicine Clinics of North
America. 32, 1, 167-203.
Macmillan Cancer Support (2015)
Chemotherapy. www.macmillan.
org.uk/information-and-support/
treating/chemotherapy/
chemotherapy-explained
(Last accessed: December 5 2015.)
Malhotra V, Perry MC (2003)
Models of anti-cancer therapy:
classical chemotherapy.
mechanisms, toxicities and the
therapeutic window.
Cancer Biology and Therapy. 2, 4,
Suppl 1, S2-S4.
Payne S, Miles D (2008)
Mechanisms of Anticancer
Drugs. http://cw.tandf.
co.uk/scottbrownent/
sample-material/Chapter-4Mechanisms-of-anticancer-drugs.
pdf (Last accessed:
December 5 2015.)
Pérez Fidalgo JA, García Fabregat L,
Cervantes A et al (2012)
Management of chemotherapy
extravasation: ESMO-EONS
Clinical Practice Guidelines.
Annals of Oncology. 23, Suppl
7, 167-173.
Repetto L (2003) Greater risks of
chemotherapy toxicity in elderly
patients with cancer. Journal of
Supportive Oncology. 4, Suppl 2,
18-24.
Schulmeister L (2010) Preventing
and managing vesicant
chemotherapy extravasations.
Journal of Supportive Oncology.
8, 5, 212-215.
Vogel WH (2010) Infusion
reactions: diagnosis, assessment,
and management. Clinical Journal
of Oncology Nursing. 14, 2,
E10-E21.
Zetka ES (2012) The essentials of
chemotherapy-induced infusion
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527-529.
58 february
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CPD assessment
Chemotherapy: infusion risks
TEST YOUR KNOWLEDGE BY COMPLETING SELF-ASSESSMENT QUESTIONNAIRE 831
1. Chemotherapy:
a) Distinguishes between healthy
and cancerous cells
❏
b) Causes cell death by inactivation
of apoptosis
❏
c) Encompasses a range of cytotoxic
agents to destroy cancer cells ❏
❏
d) Targets tissue invasion
7. Which chemotherapy agent may
result in laryngeal spasm following
oxygen administration to treat an
allergic reaction?
a) Rituximab
❏
b) Oxaliplatin
❏
❏
c) Taxane
❏
d) Etoposide
2. Which factor determines the
success of chemotherapy?
a) Presence of comorbidities
b) Extent of the disease
c) Overall patient health status
d) All of the above
8. Which is not a risk factor associated
with extravasation injury?
a) Bolus medication administration ❏
❏
b) Short infusion
c) Medical problems associated
with altered peripheral sensation ❏
d) Poor site selection
❏
3. Which cytotoxic agent is
most commonly associated with
infusion-related reactions?
a) Cetuximab
b) Rituximab
c) Paclitaxel
d) Bevacizumab
❏
❏
❏
❏
❏
❏
❏
❏
4. To prevent tumour progression
and growth in conjunction with
chemotherapy agents, transduction
inhibitors focus on:
a) Epidermal growth factor
receptors
❏
b) Gene expression modulators ❏
❏
c) Hormones
d) Apoptosis inducers
❏
5. A symptom of an infusion-related
reaction to chemotherapy is:
a) Facial pallor
❏
b) Rapid respiratory rate
❏
c) Nausea
❏
d) Hypertension
❏
6. When do most infusion-related
reactions occur?
a) Within 10 minutes of the initial
administration
❏
b) Within 30 minutes of the initial
administration
❏
c) Within 10 minutes of the initial
or second administration
❏
d) Within 10 to 30 minutes of the
initial or second administration ❏
9. The class of chemotherapy agent
with the potential to cause the most
extravasation damage is:
a) Vesicants
❏
b) Exfoliants
❏
❏
c) Irritants
❏
d) Neutrals
10. Which statement is correct?
a) Side effects such as mucositis
may have detrimental effects
on patients’ nutritional status ❏
b) Chemotherapy regimens
always result in resistance to
chemotherapy
❏
c) Monoclonal antibodies have
a small risk of infusion-related
reaction
❏
d) A n extravasation injury is
always caused by misplacement
of a peripheral cannula
❏
This self-assessment questionnaire
was compiled by Noreen Begley
The answers to this questionnaire will
be published on March 2
How to use this assessment
This self-assessment questionnaire (SAQ)
will help you to test your knowledge. Each
week you will find ten multiple-choice
questions that are broadly linked to the
CPD article. Note: there is only one
correct answer for each question.
You
could test your subject knowledge
by attempting the questions before
reading the article, and then go back
over them to see if you would answer
any differently.
might like to read the article to
You
update yourself before attempting
the questions.
When you have completed your
self‑assessment, add it to your professional
portfolio. You can record the amount of
time it has taken. Space has been provided
for comments.
You might like to consider writing a
reflective account, see page 62.
Report back
This activity has taken me _­­____ hours to
complete.
Other comments:
Now that I have read this article and
completed this assessment, I think
my knowledge is:
Excellent
Good
Satisfactory
Unsatisfactory
Poor
As a result of this I intend to:
❏
❏
❏
❏
❏
The answers to SAQ 829 on acute
pulmonary oedema, which appeared
in the February 3 issue, are:
1. d 2. c 3. b 4. a 5. c
6. b 7. d 8. a 9. c 10. d
60 february
17 from
:: volRCNi.com
30 no 25 by
:: 2016
STANDARD
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${individualUser.displayName} on Aug 08, 2016. For personal use only. NoNURSING
other uses without
permission.
Copyright © 2016 RCNi Ltd. All rights reserved.