Before administering a cytostatic drug, attention should be paid to the manufacturer's recommended dosage and the final concentration of the drug in the mixture. Therapy with drugs with potentially necrotic effects should take place in hospital, under the observation of qualified personnel. The patient should be aware of any possible symptoms, adverse effects of the drug itself or their associations. Rapid response plays a huge role in preventing distant complications of extravasation. From a technical point of view, thicker veins should be chosen for the venipuncture site for chemotherapy administration, avoiding the area around the joints. In patients who have undergone multiple insertions, where each successive insertion is difficult or to vessels that have been cannulated multiple times, a temporary central insertion should be considered. Equipment for administration of chemotherapy should be of the highest quality. Those made of flimsy materials that may irritate the vascular endothelium should not be used. In addition, needles, syringes, transfusion sets and IV fluid containers should be compatible with each other - so that there is no microleakage at the junctions between them. The supply of drugs to the peripheral vasculature should, if possible, be done each time through a new cannula, inserted in a different place - the wall of a repeatedly punctured vein becomes weaker and more susceptible to damage and rupture. If it is necessary to insert two punctures in quick succession, the vein should not be cannulated distal to the site of the last puncture. Transparent dressings should be used to secure the cannula, allowing observation of where it has penetrated under the skin. Chemotherapeutics should be given by slow infusion, at a constant rate, if possible after immobilisation of the limb. Changes in flow rate, acceleration, deceleration or resistance may suggest cannula dislocation or obstruction, in which case the infusion should be stopped. To minimise the risk of infusion infection, activities around the patient's vascular access should be carried out in accordance with current procedures, keeping the environment absolutely sterile.

Local effects of extravasation

Extravasation should be suspected if the patient reports a sensation of pain, burning, stinging or any discomfort in the area of the drug delivery site immediately after the start or during or even after the infusion. In addition, swelling, reddening of the skin, and serous blisters may appear in the area of administration as the first sign of a local inflammatory reaction. It is recommended that further intravenous drug administration be stopped immediately, leaving the cannula in place. The cannula should not be quickly removed; on the contrary, a disposable syringe should be inserted and as much of the cytotoxic drug solution as possible should be slowly aspirated into the vessel or tissue. For better control of the spread of the local inflammatory reaction, the area of primary extravasation can be marked on the skin (e.g. with a marker). The cannula is removed only after the residual drug has been aspirated from the vessel. Tissue compression should be avoided during all procedures so as not to further traumatise the tissue. It is also recommended to remain in a lying position, elevate the limb and immobilise it.

Management after extravasation

After extravasation of most cytotoxic drugs, a cool, dry compress is applied - moisture can cause tissue maceration and further intra-tissue spread of the infusion fluid. In addition, the toxic potential of chemotherapy is reduced at lower temperatures. Covering with cold compresses is recommended to be repeated several times a day. Over wide areas of the lesion, poultices with 99% dimethylsulphoxide (DMSO) are applied and allowed to dry (without covering) - this agent, as a powerful antioxidant (also an anti-inflammatory), reduces swelling, limits the local inflammatory reaction, improves the local blood supply and stimulates wound healing. The treatment of extravasation of dye alkaloid derivatives (e.g. vincristine) is different. Here, warm dry compresses are recommended - to increase blood flow and dilute the accumulated drug in the tissues. Sometimes techniques are practised to locally remove the cytostat from the extravasation site together with already damaged, necrotic tissues. In addition to the above, hydrocortisone, antihistamines, and, of course, analgesics may be used.

Distant complications

The extravasation site must be closely observed. If ulceration occurs despite the measures taken, the patient requires the consultation of a surgeon to assess the indications for local wound preparation. In the case of extensive necrosis, complicated by infection, multiple debridement procedures are carried out and antibiotic therapy is instituted, sometimes in a hospital setting. Finally, for a satisfactory cosmetic result, grafts are placed over extensive tissue defects after sterile cultures are obtained. Orthopaedic intervention is required for complicated or massive extravasations of the joint area, in close proximity to tendons and adhesions, giving contractures that limit the patient's activity in the long term. In order to reduce the risk of extravasation, implantation of vascular ports is considered in selected patients on long-term therapy, when it is difficult to provide reliable access. These are safer than typical peripheral catheters and allow multiple drug deliveries, including those that are highly toxic. They are implanted in specialist centres and surgical wards, usually during same-day hospitalisations.