An update on extravasation: basic knowledge for clinical pharmacists

Antineoplastic extravasation management: Consensus of the Spanish Oncology Pharmacy Group (GEDEFO)

“…For some LRI (CARBOplatin, etoposide, and fluorouracil) and one HRI (CISplatin) antidotes are recommended in situations of potential tissue damage severity considering drug concentration or extravasated volume. Other relevant variables include time elapsed from the moment of extravasation until detection, ph (≤ 5 or ≥ 9), osmolarity (≥ 500 mOsm/L), excipients (Cremophor ELR increase irritating properties) and formulation (liposomes) 20 . These relevant variables although may influence the final damage, are not always found in case reports or series.…”

Management of noncytotoxic extravasation injuries: A focused update on medications, treatment strategies, and peripheral administration of vasopressors and hypertonic saline

“…The physiological pH of human blood is approximately 7.35–7.45 with a buffering capacity using the acid–bicarbonate system to balance changes in pH when acidic or alkaline drugs are injected 48 . Although mechanisms of cellular injury with changes in pH are not well studied in humans, extravasation of agents with extreme pH's are caustic.…”

“…They should be used in conjunction with vasodilating antidotes in the treatment of vasopressor‐mediated extravasations and in cases of pH‐mediated, osmolarity‐mediated, or absorption refractory extravasations (Figure 1). 8 Alternatively, cold compresses should be used when the goal is to cause vasoconstriction and limit the spread of the agent to surrounding tissues for agents such as valproic acid and arginine 8,48,98,99 . Cold or warm compresses should be applied for 15–20 min four times daily for at least 24–48 h (Table 3).…”

“…4 In addition to the extent of injury being influenced by duration of exposure and type of tissue affected, the greater influence on pH by stronger acids and bases as determined by pKa also plays a role. 48 Treatment is generally limited to warm compresses and limb elevation with pharmacological options such as hyaluronidase for refractory cases (Table 2). Of note, it is important to avoid neutralization with exogenous acidic or basic products due to the exothermic chemical reaction causing gas and heat production that may worsen tissue damage.…”

“…Warm compresses cause vasodilation and allow for dispersion and reabsorption of the extravasated fluid. 8,48,98,99 They should be used in conjunction with vasodilating antidotes in the treatment of vasopressor-mediated extravasations and in cases of pH-mediated, osmolarity-mediated, or absorption refractory extravasations (Figure 1). 8 Alternatively, cold compresses should be used when the goal is to cause vasoconstriction and limit the spread of the agent to surrounding tissues for agents such as valproic acid and arginine.…”