Rates and reasons for safety incident reporting in the medical imaging department of a large academic health sciences centre.

BACKGROUND: Safety incident reporting is essential in medical imaging (MI) departments due to the fast-paced environment and high patient volume. However, there is an evident knowledge gap in the identification and investigation of contributing factors to incidents reports in MI departments. The objective of this study was to investigate the following rates of incident reporting in a MI department at a large academic health sciences centre: departmental incident rate, incident rates per imaging modality, and incident rates per incident type. Characteristics associated with the most frequently occurring incident types were examined to identify opportunities for quality improvement. METHODS: This observational, retrospective study collected approximately 665 MI incident reports submitted by staff between July 2018 and July 2019. Individual incident reports were categorized according to imaging modality and incident type. Subcategories of the top four incident types were also created to identify possible contributory factors based on the staff member's safety incident report submission. RESULTS: The safety incident rate for the entire medical imaging department was 0.263%. The safety incident reporting rate was calculated (# of incidents reported per modality total/ # of completed exams in that modality x 100%) for each modality and varied from 0.113 to 1.26%. The four highest safety incident rates were from adverse drug reaction (ADR) (21.5%), followed by delay in care/treatment (18.9%), identification/documentation/order (18.5%) and extravasation (11.4%). Possible contributory factors involved transfer of accountability (TOA)/communication barriers, and incorrect ordering information. Further analysis was also completed to assess whether patients that experienced an ADR or extravasation incident followed the correct protocols. DISCUSSION: This study demonstrated the importance of how analysis of incident report data can be used to uncover opportunities for quality improvement in the medical imaging department. However, more information must be collected at the time of safety incident report submission to allow for quality improvement. Investigators hope that by future standardization of safety incident reporting, with the increased use of drop-down menus to capture more open-ended responses, corrective strategies can be implemented to address safety concerns in MI departments. In comparison to incident reporting rates published in similar studies, there may be a significant underrepresentation of safety incident reports filed from underreporting. Reducing barriers to reporting is essential in improving the effectiveness of the current safety incident reporting system.

Topical Sensor for the Assessment of Injection Quality for 18F-FDG, 68Ga-PSMA and 68Ga-DOTATATE Positron Emission Tomography.

INTRODUCTION: Calculation of the standard uptake value (SUV) and image quality in positron emission tomography (PET) hinges on accurate dose delivery. Extravasation or partial extravasation of the radiopharmaceutical dose can undermine SUV and image quality, and contribute to unnecessary imaging (time and CT dose). Topical sensor characterisation of injections has been reported, with extravasation rates ranging from 9% to 23% for 18F-FDG after manual injection. METHOD: A single site, single PET/CT scanner was used to characterise injections using an autoinjector with standardised apparatus, flush volume and infusion rate using 18F-FDG, 68Ga-PSMA and 68Ga-DOTATATE; more reflective of Australian PET facilities. 296 patients with topical application of LARA sensors were retrospectively analysed. RESULTS: Only 1.1% of studies showed evidence of partial dose extravasation. In total, 9.1% were identified to have an injection anomaly (including venous retention). No statistically significant differences were noted across the radiopharmaceuticals for demographic data. Although not demonstrating a statistically significant correlation, there was more extravasated doses associated with female patients (P = .334), right side (P = .372), and hand injections (P = .539). Extravasation was independent of dose administered (P = .495), the radiopharmaceutical (P = .887), who injected the dose (P = .343), height (P = .438), weight (P = .607) or age (P = .716). Extravasation was associated with higher glucose levels (P < .001), higher t-half (P = .019) and higher aUCR10, tc50, aUCR1 and c1 (all P < .001). CONCLUSION: Topical monitoring and characterisation of PET dose administration is possible and practical with the LARA device. Extravasation and partial extravasation of PET doses are not only readily detected but they are also preventable. The LARA device can provide the insights into variables that could eliminate extravasation as a cause of image quality or SUV accuracy issues.

Comparing volumetric and biochemical assessment of intravasation caused by hysteroscopic surgery.

BACKGROUND: During hysteroscopic surgery intravasation of irrigation fluid occurs, leading to potentially dangerous intravascular fluid overload. Currently, intravasation is usually measured volumetrically as fluid deficit. Intravasation could also be calculated using the decrease in hemoglobin or increase in chloride ion concentration, both phenomena known to result from intravasation. We compared the values of intravasation measured volumetrically as fluid deficit versus calculated from the biochemical change in hemoglobin and chloride. We expected that these values would show strong correlation and agreement. METHODS: In a retrospective data analysis of 51 patients who underwent hysteroscopic resection of myomas or endometrium a pre and post procedure concentration of haemoglobin and chloride was available. The fluid deficit was plotted against the two versions of calculated intravasation. Furthermore, we put the data into Bland-Altman plots to scrutinize their relationship. RESULTS: The volumetric assessed fluid deficit and both versions of biochemically assessed intravasation, either using the change in hemoglobin or chloride ion concentration, turned out to be three totally different entities with weak correlation. Bland-Altman plots show too wide limits of agreement, and a striking difference between the two methods of calculated intravasation. CONCLUSION: Our study shows significant differences and poor agreement between volumetric and biochemically assessed intravasation. Based on this study, routinely assessing intravasation by biochemical methods does not have additional benefit compared to the volumetric fluid deficit. It remains unclear which method resembles true intravasation.

Construção e avaliação de bundle frente ao extravasamento de antineoplásicos: estudo metodológico / Construcción y evaluación de bundle ante la extravasación de antineoplásicos: estudio metodológico / Bundle construction and assessment before antineoplastic extravasation: a methodological study

Resumo Objetivo Construir e avaliar o conteúdo de um bundle de prevenção e condutas frente ao extravasamento de agentes antineoplásicos em pacientes oncológicos adultos. Métodos Estudo metodológico, em três etapas: realização de Scoping Review, construção do bundle e avaliação do material por especialistas. Foi desenvolvido segundo o referencial metodológico da psicometria de Pasquali. Ressalta-se que o bundle foi dividido em um módulo com medidas de prevenção do extravasamento de antineoplásicos e outro módulo com condutas frente ao extravasamento. Para avaliação de conteúdo, aplicou-se a técnica de Delphi em duas rodadas (Delphi I [13 juízes] e Delphi II [nove juízes]) e considerou-se válidos aqueles itens com Coeficiente de Validação de Conteúdo (CVC) maior que 0.78 e consenso de mais de 80,0%. Os dados foram analisados através de estatística descritiva e inferencial (Teste binominal). Resultados Todos os requisitos do bundle alcançaram concordância entre os juízes superior a 80,0%, bem como todos os itens alcançaram níveis de avaliação estatisticamente significativos. Ao final do Delphi II, os dois módulos do bundle se apresentaram expressivamente válidos (prevenção do extravasamento de antineoplásicos [CVC = 0,93] e condutas frente ao extravasamento [CVC = 0,96]). Conclusão O conteúdo do bundle demonstrou alta credibilidade e, sua adoção nas instituições de saúde, pode contribuir para a qualidade da assistência e das condutas dos profissionais frente ao extravasamento de agentes antineoplásicos em pacientes oncológicos adultos.

Resumen Objetivo Construir y evaluar el contenido de un bundle (conjunto de medidas) de prevención y conductas ante la extravasación de agentes antineoplásicos en pacientes oncológicos adultos. Métodos Estudio metodológico, en tres etapas: realización de Scoping Review, construcción del bundle y evaluación del material por especialistas. Fue desarrollado según la referencia metodológica de la psicometría de Pasquali. Se resalta que el bundle fue dividido en un módulo con medidas de prevención de la extravasación de antineoplásicos y otro módulo con conductas ante la extravasación. Para la evaluación del contenido se aplicó el método Delphi en dos rondas (Delphi I, 13 jueces, y Delphi II, 9 jueces) y se consideraron válidos aquellos ítems con Coeficiente de Validez de Contenido (CVC) mayor a 0,78 y consenso de más de 80,0%. Los datos fueron analizados a través de estadística descriptiva e inferencial (Prueba binominal). Resultados Todos los requisitos del bundle lograron una concordancia superior a 80,0% entre los jueces, así como todos los ítems alcanzaron niveles de evaluación estadísticamente significativos. Al final del Delphi II, los dos módulos del bundle demostraron ser significativamente válidos (prevención de la extravasación de antineoplásicos, CVC = 0,93, y conductas ante la extravasación, CVC = 0,96). Conclusión El contenido del bundle demostró una alta credibilidad y su implementación en instituciones de salud puede contribuir a la calidad de la atención y de las conductas de los profesionales ante la extravasación de agentes antineoplásicos en pacientes oncológicos adultos.

Abstract Objective To construct and assess the content of a prevention and management bundle regarding the extravasation of antineoplastic agents in adult cancer patients. Methods There were three-step methodological study: Scoping Review, bundle construction and expert material assessment. It was developed according to the methodological framework of Pasquali psychometry. It is noteworthy that the bundle was divided into a module with measures to prevent antineoplastic extravasation and another module with conduits before extravasation. For content assessment, the Delphi technique was applied in two rounds (Delphi I [13 judges] and Delphi II [nine judges]) and those items with Content Validation Coefficient (CVC) greater than 0.78 and more than 80.0% consensus. Data were analyzed using descriptive and inferential statistics (Binominal Test). Results All bundle requirements reached agreement among judges greater than 80.0%, and all items achieved statistically significant assessment levels. At the end of Delphi II, both bundle modules were expressively valid (prevention of antineoplastic extravasation [CVC=0.93] and ducts before extravasation [CVC=0.96]). Conclusion Bundle content has demonstrated high credibility and its adoption in health institutions can contribute to the quality of care and conduct of professionals facing the extravasation of antineoplastic agents in adult cancer patients.

Ultrasonographic assessment of an induration caused by extravasation of a nonvesicant anticancer drug: A case report.

RATIONALE: Induration may occur after an anticancer drug extravasation in patients who recurrently receive chemotherapy because of reduced choice of an appropriate vein for inserting a peripheral intravenous catheter, resulting in catheter placement difficulty. Although induration affects treatment, its size, shape, or hardness remains unclear in the conventional observation method using palpation and inspection. Here, we report our observation results in using ultrasonography to assess the induration that occurred after an anticancer drug extravasation as a new assessment method. PATIENT CONCERNS: A 58-year-old woman with cervical cancer who complained of pain during the administration of a nonvesicant anticancer drug via a peripheral intravenous catheter. The medical staff's examination showed a swollen site; therefore, the catheter was replaced. DIAGNOSIS: Induration occurred on the site after an extravasation. Over 6 months later, pigmentation and induration, which can easily be confirmed through palpation, persisted. INTERVENTIONS: The subcutaneous tissue in the induration site was observed using ultrasonography (B-mode and elastography). OUTCOMES: The subcutaneous tissue might have degenerated the tissues surrounding the vein, making it thinner. Moreover, the hardness of the subcutaneous tissue was approximately 7 times than that of the surrounding tissues. LESSONS: Induration that affects the vein form and its surrounding tissues should be prevented, and ultrasonography is an effective method to objectively observe the site where extravasation occurred.

Intracardiac cement embolism during percutaneous vertebroplasty: incidence, risk factors and clinical management.

OBJECTIVE: To evaluate the incidence and risk factors for ICE during a PV. MATERIALS AND METHODS: Single-center retrospective analysis of 1512 consecutive patients who underwent 1854 PV procedures for osteoporotic (34 %), malignant (39.9 %) or other cause (26.1 %) of vertebral compression fractures (VCFs)/spine tumor lesions. Only thoracic or lumbar PVs were included. PVs were performed with polymethylmethacrylate (PMMA) low-viscosity bone cement under fluoroscopic guidance. Chest imaging (X-ray or CT) was performed the same day after PV in patients with high clinical suspicion of ICE. All post-procedural chest-imaging examinations were reviewed, and all ICEs were agreed upon in consensus by two radiologists. RESULTS: ICEs were detected in 72 patients (92 cement embolisms). In 86.1 % of the cases, concomitant pulmonary artery cement leakage was detected. Symptomatic ICEs were observed in six cases (8.3% of all ICEs; 0.32% of all PV procedures). No ICE led to death or permanent sequelae. Multiple levels treated during the same PV session were associated with a higher ICE rate [OR: 3.59, 95% CI: (1.98-6.51); p < 0.001]; the use of flat panel technology with a lower ICE occurrence [OR: 0.51, 95% CI: (0.32-0.83); p = 0.007]. CONCLUSION: Intracardiac cement embolism after PV has a low incidence (3.9 % in our study). Symptomatic complications related to ICE are rare (0.3%); none was responsible for clinical sequelae in our series. KEY POINTS: • The incidence of intracardiac cement embolism (ICE) during PVP is low (3.9%). • Having a high number of treated vertebrae during the same session is a significant risk factor for ICE. • Symptomatic intracardiac cement embolisms have a low incidence (8.3% of patients with ICE).

Treatment of extravasation injuries in infants and young children: a scoping review and survey.

BACKGROUND: Extravasation injuries are caused by unintended leakages of fluids or medicines from intravenous lines, but there is no consensus on the best treatment approaches. OBJECTIVES: To identify which treatments may be best for treating extravasation injuries in infants and young children. DESIGN: Scoping review and survey of practice. POPULATION: Children aged < 18 years with extravasation injuries and NHS staff who treat children with extravasation injuries. INTERVENTIONS: Any treatment for extravasation injury. MAIN OUTCOME MEASURES: Wound healing time, infection, pain, scarring, functional impairment, requirement for surgery. DATA SOURCES: Twelve database searches were carried out in February 2017 without date restrictions, including MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature) Plus and EMBASE (Excerpta Medica dataBASE). METHODS: Scoping review - studies were screened in duplicate. Data were extracted by one researcher and checked by another. Studies were grouped by design, and then by intervention, with details summarised narratively and in tables. The survey questionnaire was distributed to NHS staff at neonatal units, paediatric intensive care units and principal oncology/haematology units. Summary results were presented narratively and in tables and figures. RESULTS: The evidence identified in the scoping review mostly comprised small, retrospective, uncontrolled group studies or case reports. The studies covered a wide range of interventions including conservative management approaches, saline flush-out techniques (with or without prior hyaluronidase), hyaluronidase (without flush-out), artificial skin treatments, debridement and plastic surgery. Few studies graded injury severity and the results sections and outcomes reported in most studies were limited. There was heterogeneity across study populations in age, types of infusate, injury severity, location of injury and the time gaps between injury identification and subsequent treatment. Some of the better evidence related to studies of flush-out techniques. The NHS survey yielded 63 responses from hospital units across the UK. Results indicated that, although most units had a written protocol or guideline for treating extravasation injuries, only one-third of documents included a staging system for grading injury severity. In neonatal units, parenteral nutrition caused most extravasation injuries. In principal oncology/haematology units, most injuries were due to vesicant chemotherapies. The most frequently used interventions were elevation of the affected area and analgesics. Warm or cold compresses were rarely used. Saline flush-out treatments, either with or without hyaluronidase, were regularly used in about half of all neonatal units. Most responders thought a randomised controlled trial might be a viable future research design, though opinions varied greatly by setting. LIMITATIONS: Paucity of good-quality studies. CONCLUSIONS: There is uncertainty about which treatments are most promising, particularly with respect to treating earlier-stage injuries. Saline flush-out techniques and conservative management approaches are commonly used and may be suitable for evaluation in trials. FUTURE WORK: Conventional randomised trials may be difficult to perform, although a randomised registry trial may be an appropriate alternative. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Limits of intravascular contrast extravasation on computed tomography scan to define the need for pelvic angioembolization in pelvic blunt trauma: a specific assessment on the risk of false positives.

BACKGROUND: The objective was to assess the predictive performance of different intravascular contrast extravasation (ICE) characteristics for need for pelvic transarterial embolization (TAE) to determine the risk factors of false positives. METHODS: A retrospective study was performed in our trauma center between 2010 and 2015. All severe trauma patients with pelvic fracture were included. Pelvic ICE characteristics on computed tomography (CT) scan were studied: arterial (aSICE), portal surface (pSICE), and extension (exSICE) anatomic relationships. The overall predictive performance of ICE surfaces for pelvic TAE was analyzed using receiver operating characteristic curves. The analysis focused on risk factors for false positives. RESULTS: Among 311 severe trauma patients with pelvic ring fracture (mean age, 42 ± 19 years; mean Injury Severity Score, 27 ± 19), 94 (30%) had at least one pelvic ICE on the initial CT scan. Patients requiring pelvic TAE had significantly larger aSICE and pSICE than others (p = 0.001 and p = 0.035, respectively). The overall ability of ICE surfaces to predict pelvic TAE was modest (aSICE area under the receiver operating characteristic curve, 0.76 [95% confidence interval, 0.64-0.90]; p = 0.011) or nonsignificant (pSICE and exSICE). The high-sensitivity threshold was defined as aSICE 20 mm or more. Using this threshold, 76% of patients were false positives. Risk factors for false positives were admission systolic blood pressure of 90 mm Hg or greater (63% vs 20%; p = 0.03) and low transfusion needs (63% vs 10%; p = 0.009), extravasation in contact with complex bone fracture (78% vs 30%; p = 0.008), or the absence of a direct relationship between extravasation and a large retroperitoneal hematoma (100% vs 38%; p < 0.001). CONCLUSION: A significant pelvic ICE during the arterial phase does not guarantee the need for pelvic TAE. Three quarters of patients with aSICE of 20 mm or more did not need pelvic TAE. Several complementary CT scan criteria will help to identify this risk of false positives to determine adequate hemostatic pelvic procedures. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Functional CT assessment of extravascular contrast distribution volume and myocardial perfusion in acute myocardial infarction.

PURPOSE: In a pig model of acute myocardial infarction (AMI), we validated a functional computed tomography (CT) technique for concomitant assessment of myocardial edema and ischemia through extravscualar contrast distribution volume (ECDV) and myocardial perfusion (MP) measurements from a single dynamic imaging session using a single contrast bolus injection. METHODS: In seven pigs, balloon catheter was used to occlude the distal left anterior descending artery for one hour followed by reperfusion. CT and cardiac magnetic resonance (CMR) imaging studies were acquired on 3 days and 12 ±â€¯3 day post ischemic insult. In each CT study, 0.7 ml/kg of iodinated contrast was intravenously injected at 3-4 ml/s before dynamic contrast-enhanced (DCE) cardiac images were acquired with breath-hold using a 64-row CT scanner. DCE cardiac images were analyzed with a model-based deconvolution to generate ECDV and MP maps. ECDV as an imaging marker of edema was validated against CMR T2 weighted imaging in normal and infarcted myocardium delineated from ex-vivo histological staining. RESULTS: ECDV in infarcted myocardium was significantly higher (p < 0.05) than that in normal myocardium on both days post AMI and was in agreement with the findings of CMR T2 weighted imaging. MP was significantly lower (p < 0.05) in the infarcted region compared to normal on both days post AMI. CONCLUSION: This imaging technique can rapidly and simultaneously assess myocardial edema and ischemia through ECDV and MP measurements, and may be useful for delineation of salvageable tissue within at-risk myocardium to guide reperfusion therapy.

Strategies to increase patient safety in Hemodialysis: Application of the modal analysis system of errors and effects (FEMA system). / Estrategias para aumentar la seguridad del paciente en hemodiálisis: Aplicación del sistema de análisis modal de fallos y efectos (sistema AMFE).

BACKGROUND: Haemodialysis (HD) patients are a high-risk population group. For these patients, an error could have catastrophic consequences. Therefore, systems that ensure the safety of these patients in an environment with high technology and great interaction of the human factor is a requirement. OBJECTIVES: To show a systematic working approach, reproducible in any HD unit, which consists of recording the complications and errors that occurred during the HD session; defining which of those complications could be considered adverse event (AE), and therefore preventable; and carrying out a systematic analysis of them, as well as of underlying real or potential errors, evaluating their severity, frequency and detection; as well as establishing priorities for action (Failure Mode and Effects Analysis system [FMEA systems]). METHODS: Retrospective analysis of the graphs of all HD sessions performed during one month (October 2015) on 97 patients, analysing all recorded complications. The consideration of these complications as AEs was based on a consensus among 13 health professionals and 2 patients. The severity, frequency and detection of each AE was evaluated by the FMEA system. RESULTS: We analysed 1303 HD treatments in 97 patients. A total of 383 complications (1 every 3.4 HD treatments) were recorded. Approximately 87.9% of them was deemed AEs and 23.7% complications related with patients' underlying pathology. There was one AE every 3.8 HD treatments. Hypertension and hypotension were the most frequent AEs (42.7 and 27.5% of all AEs recorded, respectively). Vascular-access related AEs were one every 68.5 HD treatments. A total of 21 errors (1 every 62 HD treatments), mainly related to the HD technique and to the administration of prescribed medication, were registered. The highest risk priority number, according to the FMEA, corresponded to errors related to patient body weight; dysfunction/rupture of the catheter; and needle extravasation. CONCLUSIONS: HD complications are frequent. Consideration of some of them as AEs could improve safety by facilitating the implementation of preventive measures. The application of the FMEA system allows stratifying real and potential errors in dialysis units and acting with the appropriate degree of urgency, developing and implementing the necessary preventive and improvement measures.

[Improve the extravasation assessment of peripheral venous catheter by nurses, with the establishment of a standardized instrument and suitable for children] / Amélioration de la mesure d'extravasation des cathéters veineux périphériques par les infirmières en pédiatrie, grâce à l'utilisation d'un instrument d'évaluation spécifique.

In pediatric and neonatal intensive care units, severity assessment of extravasation is difficult, considering the specificity of this population. The purpose of this study was to demonstrate the ability to improve the measurement of extravasation by nurses with the establishment of a standardized instrument and suitable for children. 66 nurses, randomly assigned to two groups, assessed the severity of extravasations using 15 clinical vignettes.The intervention group with the Pediatric Peripheral Intravenous Infiltration Scale (PIV Scale) (n=33) and the control group based on clinical judgment only (n=33). The reference were obtained from a group of experts. For both groups, concordance and sensitivity were calculated. Concordance and sensitivity were improved by the use of the PIV scale κ=0,62 (IC 95% ; 0,57-0,67) vs κ=0,51 (IC 95 % ; 0,45-0,57), and (69 %) vs (60 %) (p<0,001), respectively. Severity assessment of extravasation on peripheral venous accesses by nurses was improved with the use of the PIV scale, compared to clinical judgment. As this study was based on clinical vignettes, further studies are needed to confirm these results in clinical setting.

Introduction of vincristine mini-bags and an assessment of the subsequent risk of extravasation.

INTRODUCTION: Numerous international organisations have advocated the preparation of vincristine in small volume intravenous bags in order to eliminate inadvertent intrathecal administration. However, the risk of extravasation is a significant deterrent, and adoption of this practice has been variable and only hesitantly accepted in the clinical setting. PURPOSE: We carried out a study with the aims of establishing the incidence of reported extravasation of vincristine administration to paediatric and adult patients in mini-bags; here we describe motivating factors and barriers faced by clinical staff. The secondary aim was to support the need for change and implementation of the international recommendations. METHODS: Chemotherapy-certified nurses completed a survey spanning August 2009 to August 2011, to ascertain the incidence of extravasation associated with the administration of vincristine in mini-bags. RESULTS: This period captured 421 occasions of vincristine administration in 25-ml or 50-ml mini-bags (in 0.9% sodium chloride). The median age of patients was 13 years (range 2.5 months to 99 years). Vincristine was administered through peripheral lines (26.4%), portacath (52.0%), PICC line (15.9%) and Hickman line (5.7%). The majority of infusions were over at least 10 minutes (50.1%). There were no cases of extravasation reported. CONCLUSIONS: The administration of vincristine in small volume intravenous bags was safe, practical, and feasible in all patient groups. The successful implementation of the international recommendations for vincristine administration in mini-bags to eliminate potential inadvertent intrathecal administration was dependent on stakeholder buy-in.

Prise en charge de l'extravasation associée aux traitements antinéoplasiques: guide de pratique clinique / Management of extravasation associated with antineoplastic treatments: a clinical practice guide

CONTEXTE ET OBJECTIFS: L'extravasation est une complication potentiellement grave pouvant survenir au cours de l'administration de la chimiothérapie. Peu de données probantes sont disponibles pour permettre l'élaboration d'un schéma de prise en charge optimale. Le présent guide a été préparé par le Comité de l'évolution des pratiques en oncologie (CEPO) en collaboration avec le sous-comité dédié aux guides et aux conseils du Comité de l'évolution de la pratique des soins pharmaceutiques à la Direction québécoise de cancérologie du ministère de la Santé et des Services sociaux. L'objectif est de faire état de la documentation scientifique pertinente concernant la prise en charge et le traitement de l'extravasation survenue au cours de l'administration de chimiothérapie à des patients atteints de cancer. MÉTHODES: Une revue de la documentation scientifique a été effectuée dans l'outil de recherche Pubmed. La période couverte s'est étendue du début de l'existence de la banque jusqu'à avril 2014 inclusivement. La littérature concernant le traitement de l'extravasation est bien souvent empirique, anecdotique et controversée. Pour ces raisons, les recommandations pour la pratique clinique et les consensus d'experts publiés par certains organismes internationaux et agences de cancer ont également été répertoriés. Ils proviennent, notamment, de la British Columbia Cancer Agency (BCCA), de l'European Society of Medical Oncology (ESMO) en collaboration avec l'European Oncology Nursing Society (EONS), du Gippsland Oncology Nurses Group (GONG), du Humber and Yorkshire Coast Cancer Network (HYCCN), de l'Oncology Nursing Society (ONS) et du West of Scotland Cancer Advisory Network Clinical Leads Group (WOSCAN). RÉSULTATS: La détermination des facteurs de risque potentiels ainsi que l'application des méthodes de prévention peuvent diminuer les risques d'extravasation. La reconnaissance et la prise en charge des symptômes deviennent essentielles pour les patients touchés par cette complication. L'enseignement adéquat aux patients concernant les symptômes à surveiller de même qu'au personnel responsable de l'administration de la chimiothérapie, de la prévention et de la prise en charge de l'extravasation est essentiel. L'utilisation de compresses sèches tièdes ou froides ainsi que de divers antidotes déterminés en fonction de l'agent responsable permet de traiter l'extravasation. L'utilisation du diméthylsulfoxide (DMSO), de la dexrazoxane, de l'hyaluronidase ou du thiosulfate de sodium est recommandée selon l'agent en cause de l'extravasation. Une approche chirurgicale doit être considérée lorsque le traitement conservateur avec les antidotes est insuffisant ou en présence de morbidités sévères. Le suivi des patients permet d'évaluer la progression ou la régression des symptômes et ainsi de prendre les mesures appropriées. Le temps de suivi est variable selon les progrès cliniques observés. L'utilisation d'un gabarit validé permettra d'optimiser la collecte d'information. RECOMMANDATIONS: Considérant les données probantes disponibles à ce jour et les lignes directrices publiées par divers organismes (BCCA, ESMO-EONS, GONG, HYCCN, ONS et WOSCAN), le CEPO recommande (recommandation de grade D à moins d'avis contraire): Général: 1. Que toutes les chimiothérapies soient administrées dans des centres où le personnel est qualifié; 2. Que le personnel responsable de l'administration de la chimiothérapie reçoive une formation adéquate pour la prévention et la prise en charge de l'extravasation; 3. Qu'une procédure documentée et facilement accessible soit mise en place dans les centres administrant de la chimiothérapie. La présence d'une ou de plusieurs trousses destinées au traitement de l'extravasation est fortement conseillée; 4. Que les patients soient informés du risque possible d'extravasation, des mesures de prévention et qu'ils soient formés à reconnaître les premiers symptômes afin d'en aviser immédiatement le personnel; 5. Que le ou les agents vésicants soient administrés en premier lorsque plusieurs agents différents sont donnés, si le protocole le permet; Traitement: Extravasation par voie périphérique: 6. Qu'un type de compresse particulier soit utilisé en fonction de l'agent antinéoplasique ayant causé l'extravasation: a. Compresse sèche froide (0 oC, 20 à 30 minutes à la fois et répétée 4 fois par jour pour les 24 à 48 premières heures suivant l'extravasation); b. Compresse sèche tiède (44 à 50 oC, 20 à 30 minutes à la fois et répétée 4 fois par jour pour les 24 à 48 premières heures suivant l'extravasation) 7. Que le DMSO (99 %, 4 gouttes/10 cm2 aux 6 à 8 heures pour 7 à 14 jours à débuter dans les 10 premières minutes suivant l'extravasation) soit utilisé pour le traitement de l'extravasation aux agents suivants: a. Mitomycine C. b. Anthracyclines, à défaut d'une possibilité de traitement avec la dexrazoxane dans les 6 heures suivant l'extravasation; 8. Que la dexrazoxane (1 000 mg/m2 [maximum: 2 000 mg/dose] aux jours 1 et 2 puis 500 mg/m2 [maximum : 1 000 mg/dose] au jour 3) soit utilisée pour le traitement de l'extravasation aux anthracyclines (recommandation de grade A). Un réseau de distribution pourrait être mis en place pour faciliter la disponibilité du produit; 9. Que l'hyaluronidase (150 à 1 500 unités (U); 150 U/ml dans la voie ou 1 500 U/ml pour 5 injections de 0,2 ml) soit utilisée pour le traitement de l'extravasation aux alcaloïdes de la vinca. Un réseau de distribution pourrait être mis en place pour faciliter la disponibilité du produit; 10.Que les corticostéroïdes systémiques ne soient pas utilisés pour le traitement de l'extravasation; 11.Que les corticostéroïdes topiques soient utilisés si nécessaire pour le traitement de l'inflammation autour du site d'extravasation, sauf en présence d'alcaloïdes de la vinca et d'épipodophyllotoxines; 12.Qu'une consultation en chirurgie soit demandée si la condition médicale du patient le justifie; 13.Que soient appliquées les mesures de l'algorithme A-1 pour la prise en charge de l'extravasation par voie périphérique. Extravasation par voie centrale: 14.Que le diagnostic soit confirmé par veinographie ou par imagerie; 15.Que la dexrazoxane (1 000 mg/m2 [maximum: 2 000 mg/dose] aux jours 1 et 2 puis 500 mg/m2 [maximum : 1 000 mg/dose] au jour 3) soit utilisée pour le traitement de l'extravasation aux anthracyclines (recommandation de grade A); 16.Que soient appliquées les mesures de l'algorithme A-2 pour la prise en charge de l'extravasation par voie centrale (annexe A); Suivi et documentation: 17.Que chaque incident d'extravasation soit documenté dans le dossier médical et rapporté de manière exhaustive. L'utilisation d'un gabarit contenant toute l'information à recueillir est fortement conseillée; 18.Qu'un rapport d'incident soit complété (formulaire AH-223), suivant la politique locale de l'établissement; 19.Qu'un suivi soit fait aux 24 à 48 heures pendant la première semaine puis aux semaines si amélioration jusqu'à la résolution des symptômes.(AU)

BACKGROUND AND OBJECTIVES: Extravasation is a potentially serious complication that can occur during the administration of chemotherapy. There is little evidence for developing an optimal management scheme. This guideline was prepared by the Comité de l'évolution des pratiques en oncologie (CEPO) in cooperation with the guideline and advice subcommittee of the Comité de l'évolution de la pratique des soins pharmaceutiques of the Ministère de la Santé et des Services sociaux's Direction québécoise de cancérologie. The objective was to examine the relevant scientific literature on the management and treatment of extravasation that occurs when chemotherapy is administered to cancer patients. METHODS: A scientific literature review was conducted using the PubMed search tool. The period covered was from the inception of the database up to and including April 2014. The literature on the treatment of extravasation is very often empirical, anecdotal and much debated. For these reasons, the clinical practice recommendations and expert consensuses published by certain international organizations and cancer agencies were included as well. In particular, they are from the British Columbia Cancer Agency (BCCA), the European Society of Medical Oncology (ESMO) in conjunction with the European Oncology Nursing Society (EONS), the Gippsland Oncology Nurses Group (GONG), the Humber and Yorkshire Coast Cancer Network (HYCCN), the Oncology Nursing Society (ONS) and the West of Scotland Cancer Advisory Network Clinical Leads Group (WOSCAN). RESULTS: Determining the potential risk factors and taking preventive measures can reduce the risk of extravasation. Recognizing and managing the symptoms is essential in patients with this complication. Providing adequate instruction on the symptoms to watch for to patients and to personnel responsible for administering chemotherapy, preventing and managing extravasation is essential. Warm or cold, dry compresses and various antidotes, which are determined according to the agent involved, are used to treat extravasation. The use of dimethylsulfoxide (DMSO), dexrazoxane, hyaluronidase or sodium thiosulfate is recommended, depending on the agent that has extravasated. Consideration should be given to a surgical approach when conservative treatment with antidotes is inadequate or if the patient has severe morbidities. Patients are monitored to assess the progression or regression of symptoms and to thus take the appropriate measures. Monitoring time varies according to the observed clinical progress. A validated template can be used to optimize information gathering. RECOMMENDATIONS: Given the evidence available at this time and the guidelines published by various organizations (BCCA, ESMO-EONS, GONG, HYCCN, ONS and WOSCAN), the CEPO recommends (Grade D recommendation, unless indicated otherwise): General: 1. That all chemotherapies be administered at facilities whose personnel are qualified; 2. That personnel responsible for administering chemotherapy be adequately trained in extravasation prevention and management; 3. That a written and easily accessible procedure be established at facilities that administer chemotherapy. Having one or more extravasation treatment kits on hand is strongly advised; 4. That patients be informed of the potential risk of extravasation and of the preventive measures, and that they be trained to recognize the initial symptoms so that they can inform the personnel at once; 5. That the vesicant or vesicants be administered first when several different agents are to be given, if the protocol allows this; TREATMENT: Peripheral extravasation: 6. That a specific type of compress be used according to the extravasated antineoplastic agent: a) A cold, dry compress (0 °C, 20 to 30 minutes at a time and repeated 4 times a day for the first 24 to 48 hours after the extravasation. b. A warm, dry compress (44 to 50 °C, 20 to 30 minutes at a time and repeated 4 times a day for the first 24 to 48 hours after the extravasation). 7. That DMSO (99%, 4 drops/10 cm2 every 6 to 8 hours for 7 to 14 days, starting within the first 10 minutes after the extravasation) be used to treat extravasation of the following agents: a.) Mitomycin C; b) Anthracyclines, if treatment with dexrazoxane within the first 6 hours after the extravasation is not possible. 8. That dexrazoxane (1000 mg/m2 [maximum: 2000 mg/dose] on days 1 and 2, then 500 mg/m2 [maximum: 1000 mg/dose] on day 3) be used to treat the extravasation of anthracyclines (Grade A recommendation). A distribution network could be put in place to facilitate access to dexrazoxane; 9. That hyaluronidase (150 to 1500 units (U); 150 U/mL into the line or 1500 U/mL for five 0.2-mL injections) be used to treat the extravasation of vinca alkaloids. A distribution network could be put in place to facilitate access to hyaluronidase; 10.That systemic corticosteroids not be used to treat extravasation; 11. That topical corticosteroids be used if necessary to treat inflammation around the extravasation site, except if the patient is receiving vinca alkaloids or epipodophyllotoxins; 12.That a surgical consultation be requested if warranted by the patient's medical condition; 13.That the measures indicated in Algorithm A-1 be taken to manage peripheral extravasation; Central extravasation: 14.That the diagnosis be confirmed by venography or imaging; 15.That dexrazoxane (1000 mg/m2 [maximum: 2000 mg/dose] on days 1 and 2, then 500 mg/m2 [maximum: 1000 mg/dose] on day 3) be used to treat the extravasation of anthracyclines (Grade A recommendation); 16.That the measures indicated in Algorithm A-2 be taken to manage central extravasation; Follow-up and documentation: 17.That each extravasation incident be recorded in the patient's chart and exhaustively reported. The use of a template indicating all the information that needs to be gathered is strongly recommended; 18.That an incident report be completed (Form AH-223) in accordance with the facility's local policy; 19.That a follow-up be done every 24 to 48 hours during the first week, then every week, if there is improvement, until the symptoms resolve.(AU)

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.

Rate of contrast material extravasations and allergic-like reactions: effect of extrinsic warming of low-osmolality iodinated CT contrast material to 37 degrees C.

PURPOSE: To retrospectively determine whether extrinsic warming of the low-osmolality contrast material iopamidol to 37°C prior to intravenous administration at computed tomography (CT) affects extravasation and allergic-like reaction rates. MATERIALS AND METHODS: The need to obtain informed patient consent was waived for this HIPAA-compliant and institutional review board-approved analysis. All adverse events related to the intravenous administration of iopamidol during CT examinations occurring 200 days before (period 1) and 200 days after (period 2) the cessation of extrinsic contrast material warming (37°C) for intravenous injections of less than 6 mL/sec at Duke University Medical Center (Durham, NC) were retrospectively reviewed. Adverse event rates were compared by using χ2 statistics. RESULTS: There were 12,682 injections during period 1 (10,831 injections of iopamidol 300 and 1851 injections of iopamidol 370) and 12,138 injections (10, 064 injections of iopamidol 300 and 2074 injections of iopamidol 370) during period 2. Adverse event rates for iopamidol 300 were not affected by extrinsic warming (extravasation rates: 0.30% [32 of 10,831] in period 1 vs 0.23% [23 of 10,064] in period 2, P=.64; allergic-like reaction rates: 0.39% [42 of 10,831] in period 1 vs 0.46% [46 of 10,064] in period 2, P=.74; overall adverse events: 0.68% [74 of 10,831] in period 1 vs 0.69% [69 of 10,064] in period 2, P=.99). Discontinuation of extrinsic warming was associated with significantly increased extravasation and overall adverse event rates for iopamidol 370 (extravasation rates: 0.27% [five of 1851] vs 0.87% [18 of 2074], P=.05; allergic-like reaction rates: 0.16% [three of 1851] vs 0.39% [eight of 2074], P=.42; overall adverse events: 0.43% [eight of 1851] vs 1.25% [26 of 2074], P=.02). CONCLUSION: Extrinsic warming (to 37°C) does not appear to affect adverse event rates for intravenous injections of iopamidol 300 of less than 6 mL/sec but is associated with a significant reduction in extravasation and overall adverse event rates for the more viscous iopamidol 370.

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.

[Transrectal ultrasound assessment of anastomosis after videolaparoscopic radical prostatectomy: our experience]. / Il controllo ecografico transrettale dell'anastomosi dopo VLRP. La nostra esperienza.

BACKGROUND: Trans-Rectal UltraSound (TRUS) has proved to be an accurate procedure comparable to that of Fluoro-cystography (FC) to assess vesicourethral anastomosis after radical prostatectomy, with the advantages of lower costs, no radiation exposure and no dependence on the radiology department. METHODS: 60 Video Laparoscopic Radical Prostactomies (VLRP) were performed at our institution between September 2008 and January 2010. All patients underwent anatomosis assessment on postoperative day 6 with TRUS (Aloka A7 US machine with endorectal end-fire probe). 200 ml of sterile saline was manually instilled into the bladder by an assistant, while TRUS visualization of anastomosis was carried out by an urologist. The test was considered positive if any expanding anechoic shadow developed beside the anastomosis. In case of negative test the catheter was removed. In case of positive test the catheter was left in place and reassessment was performed every 5-7 days with both TRUS and FC, until negative result. RESULTS: At the initial TRUS assessment we had 4 positive and 56 negative tests. Three out of the four patients with a positive test had a second assessment on p.o. day 14, which gave a negative result. The 4th positive case had a positive second assessment on p.o. day 14 and a third negative one on p.o. day 21. In a total of 20 assessments both TRUS and FC were performed. The results of the two procedures were always in accordance. CONCLUSIONS: We have introduced TRUS assessment of vescicourethral anastomosis after laparoscopic radical prostatectomy as a routine procedure in our department. We are planning a comparative study, using FC as the gold standard, for validation purposes.

Extravasation of iodinated contrast medium during CT: self-assessment module.

The educational objectives for this self-assessment module on the extravasation of iodinated contrast medium are for the participant to exercise, self-assess, and improve his or her understanding of the frequency, appearance, recognition, and management of extravasation of iodinated contrast medium during contrast-enhanced CT.