Emergência oncológica: atuação dos enfermeiros no extravasamento de drogas quimioterápicas antineoplásicas / Oncological emergency: the work of nurses in the extravasation of antineoplastic chemotherapeutic drugs

Objetivo: Investigar a atuação dos enfermeiros no extravasamento de quimioterápicos antineoplásicos. Métodos: Estudo transversal, com abordagem quantitativa, realizado em um hospital de referência em oncologia, com uma amostra de 21 enfermeiros. Os dados foram coletados por meio da aplicação de questionário semiestruturado, nos meses de outubro e novembro de 2015, analisados por meio da frequência simples e percentual. Resultados: Os enfermeiros evidenciaram conhecimento suficiente quanto aos fatores de risco, prevenção e reconhecimento de sinais e sintomas da ocorrência de extravasamento por quimioterápicos. No entanto, o mesmo não foi verificado quanto às questões relacionadas a: classificação das drogas antineoplásicas e intervenções voltadas à ocorrência do agravo. Conclusão: Os resultados encontrados são importantes, vez que apontam para questões que devem ser refletidas por gestores hospitalares e de instituições formadoras, assim como profissionais preocupados com a melhoria da assistência à população acometida por essa patologia.

Level of adherence to an extravasation protocol over 10 years in a tertiary care hospital.

BACKGROUND: Extravasation of chemotherapy is an undesirable complication related to the administration of antineoplastic therapy. Establishing the real incidence is difficult. Because of the importance of a quick intervention after an extravasation, every hospital should have an extravasation protocol. OBJECTIVES: The purpose of this study was to determine the degree of observance of an extravasation protocol by nursing staff and to determine extravasation incidence. METHODS: This descriptive, longitudinal, retrospective study was set in a tertiary-level hospital. The researchers reviewed 117 extravasation notification forms received by the pharmacy department during a 10-year period. Nursing actuation, particularly observance of the extravasation protocol, was analyzed. FINDINGS: Protocol adherence was 89%. Twelve deviations from the protocol in the application of recommended measures were detected. An antidote was used in 41 patients, and temperature measures were applied in 14 cases. Ninety-nine patients had at least one episode of reported follow-up. No cases of necrosis or skin ulcers were described, except by one patient, who developed a delayed skin ulcer to vinorelbine. Drugs most frequently reported were etoposide, carboplatin, and paclitaxel. Nursing staff should be continuously trained in extravasation protocol because a rapid actuation can prevent skin lesions.

Treatment of skin lesions in newborn children: meeting the needs of nursing staff / Tratamiento de lesiones de piel en recién nacidos: conociendo las necesidades del equipo de enfermería / Tratamento de lesões de pele em recém-nascidos: conhecendo as necessidades da equipe de enfermagem

Objective To understand, together with nursing staff, the care needed to treat skin lesions in newborn children hospitalized in a neonatal unit. Method Qualitative research, of the convergent care type. The data was collected through semi-structured interviews, which were conducted from November to December 2012, in the neonatal unit of a hospital in southern Brazil. The participants were four auxiliary nurses, six nursing technicians and four nurses. Results The following three categories were designated: questions about what can be used in relation to newborn children; hospitalization can cause lesions on the skin of newborn children; and knowledge about care promotes professional autonomy. Conclusion There is an urgent need for staff to know more about the treatment of skin lesions, which would provide safer care for newborn children and would also support the autonomy of professional nurses in providing that care.
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Objetivo Conhecer, junto à equipe de enfermagem, os cuidados necessários para tratamento de lesões de pele em recém-nascidos internados em uma Unidade Neonatal. Método Pesquisa qualitativa do tipo Convergente Assistencial. Os dados foram obtidos por meio de entrevistas semiestruturadas, realizadas nos meses de novembro a dezembro de 2012, na Unidade Neonatal de um hospital do Sul do Brasil. Participaram da pesquisa quatro auxiliares de enfermagem, seis técnicos de enfermagem e quatro enfermeiras. Resultados Originaram-se três categorias: dúvidas sobre o que se pode utilizar no recém-nascido; a internação pode acarretar lesões na pele do recém-nascido; e o conhecimento do cuidado promove autonomia profissional. Conclusão Torna-se urgente a necessidade de conhecimento da equipe sobre o tratamento de lesões, propiciando o atendimento mais seguro ao recém-nascido e favorecendo a autonomia do profissional enfermeiro na realização do cuidado.

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Objetivo Conocer, junto al equipo de enfermería, los cuidados necesarios para el tratamiento de lesiones de piel en recién nacidos internados en una Unidad Neonatal. Método Investigación cualitativa del tipo Convergente Asistencial. Los datos fueron obtenidos por medio de entrevistas semiestructuradas, realizadas en los meses de noviembre a deciembre de 2012, en la Unidad Neonatal de un hospital del Sur de Brasil. Participaron de la investigación cuatro auxiliares de enfermería, seis técnicos de enfermería y cuatro enfermeras. Resultados Se originaron tres categorías: dudas acerca de lo que se puede utilizar en el recién nacido; la estancia hospitalaria puede causar lesiones en la piel del recién nacido; y el conocimiento del cuidado promueve autonomía profesional. Conclusión Se hace urgente la necesidad de conocimiento del equipo acerca del tratamiento de las lesiones, a fin de proporcionar una atención más segura al recién nacido y favorecer la autonomía del profesional enfermero en la puesta en marcha del cuidado. .

Dexrazoxane: a management option for anthracycline extravasations.

AIMS: This article reviews the efficacy and place in therapy of dexrazoxane (Savene®) for the treatment of anthracycline extravasation, highlighting the lack of inclusion of Savene in most UK cancer network and organisational treatment guidelines. Here we offer advice to nurses on making a case to ensure the availability of Savene. KEY FINDINGS: In 2010, the UK National Extravasation Information Service (NEXIS) green card scheme reported that anthracyclines were the second most common agent involved in extravasations, but they carry the greatest risk to the patient because of their potentially serious consequences. Anthracycline extravasations therefore require prompt and effective treatment. Due to the infrequent occurrence of anthracycline extravasations, their accidental nature and ethical considerations, conducting randomised controlled clinical trials in this therapy area is not possible. As treatment decisions should always be made on patient-specific factors, health professionals need to demonstrate the rationale for choosing a particular course of action when presented with an anthracycline extravasation, especially when we are moving into an era of increased medical litigation. There are several possible treatment options, some of which require demonstrable local core competencies in order to be considered for a particular patient. Based on the available evidence, Savene-the only licensed antidote-is recommended as an effective management strategy for anthracycline extravasation and should be made available in all settings where chemotherapy is administered. However, a high percentage of nurses administering chemotherapy still do not have access to Savene, as it has not been included in their local guidelines for the management of extravasations. Thus, in a large part of the UK, this important treatment option is not available, leaving a significant unmet need (Figure 1). CONCLUSIONS: As nurses play a key role in the prevention, detection, and management of extravasations, they should also assume a key role in ensuring that their local protocols include all appropriate management strategies. Where appropriate, if Savene is not included in the treatment guidelines, nurses should feel empowered to encourage their trust and Specialist Commissioning Groups (SCGs) to make it available, and thus minimise the serious risks associated with anthracycline extravasations.

A avaliação da rede venosa pela enfermagem em mulheres com câncer ginecológico durante o tratamento quimioterápico / Venous network assessment by nursing in women with gynecological cancer during chemotherapy treatment / Evaluación de la red venosa por la enfermería en mujeres con cáncer ginecológico durante el tratamiento de quimioterapia

Estudo de abordagem exploratória e descritiva que teve como objetivos: avaliar a rede venosa das mulheres com câncer cérvico uterino, no início e ao final do tratamento quimioterápico; analisar a ocorrência de flebite provocada pelas drogas utilizadas nos protocolos de quimioterapia neoadjuvante e adjuvante e relacionar os tipos de veia com os dispositivos mais utilizados, tempo de permanência e intercorrências. Utilizou-se um instrumento de avaliação da rede venosa para os membros superiores. Foram incluídas 20 mulheres atendidas em um hospital de ensino do interior do Estado de São Paulo. A avaliação da rede venosa demonstrou poucas alterações, e a intercorrência mais frequente foi o hematoma (60%). Os resultados deste estudo apontam para aspectos da prática de enfermagem relacionados à administração de quimioterápicos e ressaltam a necessidade de elaborar e implantar protocolos para o cuidado.

This descriptive and exploratory study aimed to evaluate the venous network of women with cervical uterine cancer, at the beginning and at the end of the chemotherapy treatment; to analyze the occurrence of phlebitis caused by the drugs used in protocols of neoadjuvant and adjuvant chemotherapy and to relate the types of vein with the most used devices, length of stay and complications. An instrument was used to evaluate the venous network for upper limbs. Participants were twenty women who received care at a teaching hospital in the interior of the state of Sao Paulo. The evaluation of the venous network presented little changes and hematoma was the most frequent complication (60%). The results point out aspects of the nursing practice, related to the administration of chemotherapeutic agents, and highlight the need to develop and implement care protocols.

Este estudio exploratorio y descriptivo tuvo como objetivos evaluar la red venosa de las mujeres con cáncer de cuello uterino en el comienzo y el final del tratamiento quimioterápico, analizar la ocurrencia de flebitis causada por los fármacos utilizados en los protocolos de quimioterapia neo adyuvante y adyuvante, y relacionar los tipos de venas con los dispositivos más utilizados, tiempo de permanencia y complicaciones. Se utilizó un instrumento para evaluar la red venosa de los miembros superiores. Participaron 20 mujeres tratadas en un hospital de enseñanza en el interior del estado de São Paulo. La evaluación de la red venosa mostró pocas alteraciones y la complicación más frecuente fue el hematoma (60%). Los resultados del estudio apuntan aspectos de la práctica de enfermería relacionados a la administración de agentes quimioterápicos y señalan la necesidad de desarrollar e implementar protocolos de atención.

Antineoplastic agents extravasation from peripheral intravenous line in children: a simple strategy for a safer nursing care.

PURPOSE: The antineoplastic agents infusion through peripheral lines may lead to several adverse events such as extravasation that is one of the most severe acute reactions of this sort of treatment. The extravasation prevention and management must be part of a safe and evidence-based nursing care. Due to this fact, two algorithms were developed with the purpose of guiding nursing care to children who undergo chemotherapy through peripheral line. The objectives of this study were to determine the content validity of both algorithms with pediatric oncology nurses in Brazil and United States of America, and to verify the agreement between the evaluations of both groups. METHODS AND SAMPLE: A descriptive validation study was carried out through the Delphi Technique that has the following steps: development of the data collection instrument, application to the specialists, data analysis, algorithms' review, re-evaluation by the specialists, final data analysis and content validity determination. RESULTS: The data analysis was descriptive and based on the specialists agreement consensus equal or higher than 80% in every step of the algorithms. The process showed that the agreement with both instruments ranged from 92.8% to 99.0%. CONCLUSION: The algorithms are valid for application in nursing care with the main purpose of preventing and managing the antineoplastic agents' extravasation.

Extravasamento de drogas antineoplásicas: avaliação do conhecimento da equipe de enfermagem / Extravasacion de drogas antineoplasicas: evaluacion del conocimiento del equipo de enfermeria / Extravasation of antineoplastic drugs: assessment of the nursing team knowledge

A toxicidade dermatológica local decorrente do extravasamento de drogas antineoplásicas consiste em um dosprincipais efeitos adversos da terapia antineoplásica, sendo considerada uma autêntica emergência oncológica.Dado o exposto, a prevenção dessa complicação é uma importante medida, uma vez que gera estresse na equipede enfermagem e pode causar danos irreparáveis ao paciente. O objetivo foi avaliar o conhecimento da equipe deenfermagem de um Ambulatório de Quimioterapia Adulto sobre o extravasamento de drogas antineoplásicas. Esta éuma pesquisa exploratório-descritiva, de natureza quantitativa, desenvolvida em um hospital filantrópico, referênciaem oncologia na cidade de Curitiba-PR. A amostra foi composta por nove funcionários da equipe de enfermagem(33% enfermeiros e 67% técnicos de enfermagem). Os sinais e sintomas do extravasamento mais citados foramedema(89%), hiperemia (78%), dor (67%) e queimação/ardor (33%). Comrelação aos fatores de risco para o extravasamento,os mais citados foram“local da punção”(44%),“condições do membro puncionado”(33%) e“veias esclerosadas”(33%).Não houve consenso quanto à correta ordem de punção das veias para a realização de quimioterapia. A prevenção doextravasamento é uma preocupação constante na prática clínica dos enfermeiros. Neste estudo, traz-se a importânciade um aperfeiçoamento em serviço e a elaboração de uma diretriz clínica, a fim de que os profissionais identifiquemos pacientes com maior risco de extravasamento, procurando evitá-lo, em vez de apenas tratá-lo após ocorrido.

Local dermatologic toxicitydue to extravasation of antineoplastic drugs is one of the main adverse effects ofantineoplastic therapy and it is considered an oncologic emergency. Itsprevention is vital since it isasource of stressto the nursing team and it may cause irreparable harmto the patient.This study aimed to evaluate the knowledge of thenursing staff at an Adult Outpatient Chemotherapy Unit about antineoplastic drugs extravasation. It is an exploratory,descriptive and quantitative research carried out in a philantropic referral hospital for oncology in Curitiba (PR). Thesample consisted of nine nursing staff employees (33% nurses and 67% practical nurses). Themost cited extravasationsigns and symptomswere“oedema”(89%),“hyperaemia”(78%),“pain”(67%), and“burnings/stinging”(33%). Regarding therisk factors for extravasation, the most cited were“puncture site”(44%),“punctured limb condition”(33%), and“sclerosedveins”(33%).There was no consensus on the correct order to veinipuncture previous to the chemotherapy performance.Extravasation prevention is a constant concern in the nurses clinical practice.This study shows the importance of nursingcare refresher training and the elaboration of clinical guidelines, so that professionals can identify patients at higher riskof extravasavion aiming at preventing its occurrence instead of treating it afterwards.

La toxicidad dermatológica local resultante de la extravasación de drogas antineoplásicas consiste en uno de losprincipales efectos adversos de la terapia antineoplásica y se la considera una auténtica emergencia oncológica. Laprevención de esta complicación es una medida importante puesto que esta grave intercurrencia genera estrés enel equipo de enfermería y puede causar daños irreparables al paciente. Se ha buscado evaluar el conocimiento delequipo de enfermería de un Dispensario de Quimioterapia Adulto sobre la extravasación de drogas antineoplásicas. Setrata de una investigación exploratoria descriptiva de naturaleza cuantitativa, desarrollada en un hospital filantrópicode referencia en oncología en la ciudad de Curitiba (PR). La muestra estuvo compuesta por 9 integrantes del equipode enfermería (33% enfermeros y 67% técnicos en enfermería). Las señales y los síntomas del extravasación másnombrados fueron: edema (89%), hiperemia (78%), dolor (67%)yardor (33%). En lo relativo a los factoresde riesgo parala extravasación, los más nombrados fueron“sitio de la punción” (44%),“condiciones del miembro puncionado” (33%)y“venas esclerosadas”(33%). No hubo consenso sobre la orden de punción correcta de las venas para la realización dequimioterapia. La prevención de la extravasación es una preocupación constante en la práctica clínica de los enfermeros.El presente estudio expone la importancia de un perfeccionamiento en el servicio y de la elaboración de una directivaclínica, con la finalidad de que los profesionales identifiquen a los pacientes con mayor riesgo de extravasación, paraque traten de evitarla, en lugar de apenas tratarla después de que ocurra.

Anthracycline extravasations: prevention and management.

This article highlights the importance of being knowledgeable about anthracycline extravasations, including their prevention, early detection, and prompt and effective management. It also emphasizes the need for chemotherapy nurses to document and report all extravasations when they occur, summarizes the current management options, and offers recommendations for clinical practice. Extravasation refers to the unintentional administration of an agent into the surrounding tissue instead of the venous system; in this case, vesicant chemotherapy. Anthracycline extravasations can lead to significant and lasting tissue damage, infection, pain, and functional impairment; they remain a feared consequence for both the patient receiving the chemotherapy and the nurse administering it. The management of anthracycline extravasations remains a constant challenge to the professionals caring for the patient. One of these challenges is the lack of evidence for many of the treatment options available. The systemic antidote Savene® is the only approved treatment for anthracycline extravasations. It has proved highly efficacious and well-tolerated in prospective clinical studies and in routine clinical practice. Despite national and international professional organizations recommending Savene in their extravasation guidelines, many cancer networks in England still exclude it from their local protocol. Funding decisions regarding the use of supportive treatments are often made on the basis of clinical need; it is, therefore, imperative that nurses promptly report all extravasations or they will remain unknown and management of extravasations will not improve.

[Introduction of a clinical protocol for extravasation at the National Institute of Oncology, Budapest, Hungary]. / Extravazációs protokoll bevezetése az Országos Onkológiai Intézetben.

Extravasation of cytostatics occurs when an infusion containing a cytotoxic drug leaks into the surrounding perivascular and subcutaneous tissues. Incidence of cytostatic extravasation is found to be 0.1-6% according to the literature. Depending on the severity of complications, pain, loss of function in the extremities, or in extreme cases tissue necrosis necessitating an amputation may develop, drawing consequences like delay or interruption of the chemotherapy. Extent of complications is greatly influenced by the type of medication administered, general condition of the patient, and professional preparedness of staff providing the oncological health service. The protocol recently implemented in the National Institute of Oncology is a short, compact guidance for physicians and nurses providing oncological care, so by quick and adequate management of extravasation cases, severe complications could be prevented. More complex practical guidelines including algorithms could be created as a result of a wider collaboration, with the help of which oncological health professionals could easily cope with this rare problem. The authors describe in their review the implementation of the use of dry warm and cold packs, dymethylsulfoxide and hyaluronidase and their function within the algorithm of extravasation treatment.

Extravasation management: clinical update.

OBJECTIVE: To present a clinical update on the prevention, detection, and evidence-based management of vesicant chemotherapy extravasations. DATA SOURCES: Journal articles, published and unpublished case reports, personal experience. CONCLUSION: In the 4 years that have elapsed since the publication of the original article, much more is known about vesicant chemotherapy extravasation, and effective evidence-based treatments now are available. The antidotes sodium thiosulfate for mechlorethamine extravasations and hyaluronidase for plant alkaloid extravasations are recommended by the manufacturers of these vesicants and cited in nursing guidelines. The anthracycline extravasation treatment dexrazoxane for injection, the first and only extravasation treatment with proven effectiveness, is now available as Totect (dexrazoxane; TopoTarget USA, Rockaway, NJ, USA) in the US and Savene (SpePharm, Amsterdam, The Netherlands) in Europe. IMPLICATIONS FOR NURSING PRACTICE: Nurses who administer vesicant chemotherapy agents need to be aware of the most current evidence (or lack of evidence) for various types of extravasation treatment. Well-informed nurses are patient advocates and instrumental in detecting, managing, and documenting extravasations. Most importantly, nurses play a key role in preventing vesicant chemotherapy extravasations.

Vesicant chemotherapy extravasation antidotes and treatments.

Oncology nurses and pharmacists often are given the responsibility of developing or updating institutional policies to manage vesicant chemotherapy extravasations. Antidote and treatment recommendations of vesicant chemotherapy manufacturers, antidotes and treatments approved by the U.S. Food and Drug Administration (FDA), and guidelines and recommendations made by professional oncology organizations are useful resources in this process. This article describes manufacturers' recommendations, lists antidotes and treatments approved by the FDA, and reviews published guidelines and recommendations. Available antidote and treatment formulations and their preparation and administration also are discussed.

Current recommendations for prevention and therapy of extravasation reactions in dermato-oncology.

Despite the introduction of many targeted therapies, a wide variety of cytostatic agents are still frequently used in dermato-oncology. In order to avoid further morbidity in tumor patients, prevention of extravasation reactions is of highest importance. The optimal management of extravasation requires an early diagnosis, the application of specific antidotes and a well-trained oncology team.

European Oncology Nursing Society extravasation guidelines.

An infrequent, but potential complication of chemotherapy is vesicant chemotherapy extravasation. Vesicants have the potential to cause blistering and ulceration when they extravasate from the vein or are inadvertently administered into the tissue. In 2007, the European Oncology Nursing Society published guidelines for extravasation prevention, detection, and management. Recommended management includes topical heating for plant alkaloid extravasations and topical cooling for anthracycline and other antitumor antibiotic vesicants. For treatment of antracycline extravasations topical dimethylsulfoxide (DMSO), sodium thiosulfate, and hyaluronidase have been described in the literature but due to lack of evidence to support their use as vesicant extravasation antidotes, it is recommended that these agents are studied further. Furthermore, Savene (dexrazoxane) is the only registered drug for the treatment of antracycline extravasation. Nurses need to be aware of current evidence-based guidelines for detecting and managing vesicant extravasations and need to be prepared to administer evidence-based treatment.

Vesicant extravasation part I: Mechanisms, pathogenesis, and nursing care to reduce risk.

PURPOSE/OBJECTIVES: To review the literature regarding the incidence, current practice, guideline recommendations, nursing management, and knowledge gaps relevant to vesicant extravasation. DATA SOURCES: Published research articles, books, case reports, and national guidelines. DATA SYNTHESIS: Vesicant extravasation is a relatively rare but significant complication of chemotherapy administration. Extravasation may have a range of consequences that can cause serious physical and quality-of-life effects. Knowledge of risk factors and preventive measures can reduce patient risk. Data-based and empirical management strategies such as immediate local measures (agent withdrawal, comfort measures, and medical interventions) may minimize risk for extravasation, as well as lead to timely recognition and management and decreased morbidity should extravasation occur. CONCLUSIONS: Vesicant extravasation and sequelae constitute a complex patient problem that clinicians should strive to prevent or to minimize injury should it occur. To this end, clinicians must demonstrate awareness of risks and use specialized knowledge while administering vesicant agents. IMPLICATIONS FOR NURSING: Only nurses knowledgeable about extravasation and skilled in associated techniques should assume responsibility for vesicant administration.

Vesicant extravasation part II: Evidence-based management and continuing controversies.

PURPOSE/OBJECTIVES: To review the literature, synthesize current recommendations, and discuss remaining controversies regarding vesicant extravasation management. DATA SOURCES: Published evidence-based reports, clinical articles, and anecdotal case reports about antineoplastic and nonantineoplastic vesicant agent management. DATA SYNTHESIS: Prevention of vesicant extravasation sequelae requires knowledge about vesicant extravasation manifestations and differentiation of vesicant extravasation from other local IV site reactions. When evidence is weak or missing, logical application of data-based or empirical management strategies is critical. Actions may include timely administration of subcutaneous or topical antidotes, comfort measures, and surgical interventions to minimize the extent of tissue damage and morbidity should extravasation occur. CONCLUSIONS: Vesicant extravasation and sequelae constitute a complex patient problem. Clinicians should strive to prevent extravasation or seek to minimize injury should it occur. To this end, clinicians must demonstrate awareness of its risks and use specialized knowledge when administering vesicant agents. IMPLICATIONS FOR NURSING: Nurses who administer vesicant agents should understand the nursing and collaborative actions that should be taken to minimize patient morbidity, pain, and disability.

Structural visualization of expert nursing: Expert nursing care for extravasation of anticancer agent.

Chemotherapy aims to cure cancer or inhibit the growth of cancer cells by administering the anticancer agent in blood vessels (BV) to the cancer body. So it is very important to inject the agent in BVs without fail because there is risk of extravasation which brings about the chemical necrosis of the tissue around. Thus, nurses involved in chemotherapy care should learn to take interventions for prevention from extravasation and immediate treatment for it, in case. In the interventions there are care practices with advanced thinking processes. Clarification of such thinking processes contributes to the visualization of nursing practice and the support for nurses to learn expert nursing practices. Also it is supposed to realize the nursing quality assurance for care receiver-patients.

Clinical nurse specialist and evidence-based practice: managing anthracycline extravasation.

The clinical nurse specialist (CNS) is a clinical expert and client advocate in a specialized area of nursing practice, who directs efforts toward the improvement of nursing care. The CNS role is essential in closing the therapeutic gap between the development of science knowledge and its implementation in daily patient care situations. An essential step in developing evidence-based interventions is rating the quality of the evidence. An example of the CNS's role in improving care can be found in a response to an anthracycline extravasation. The clinical standard for extravasation was amended to incorporate new evidence-based guidelines that included prevention of extravasation and a new assessment method and intervention. When an extravasation is suspected with an anthracycline agent, a Wood's lamp (ultraviolet lamp) is shined on the area of interest, in a dark room. The anthracycline extravasation area, if present, will illuminate in the lamp's light. In addition to the standard interventions of topical DMSO applications, current literature also suggests an intravenous infusion of dexrazoxane (Zinecard) as an effective antidote to prevent tissue damage.