Chemotherapy Infusion Reaction and Extravasation Case Lab

Case Lab: Chemotherapy Infusion Reaction and Extravasation

Case Snapshot

A 61-year-old is receiving cycle 1 of paclitaxel after standard premedication (dexamethasone, an H1 blocker such as diphenhydramine, and an H2 blocker such as famotidine). Ten minutes into the infusion the patient reports chest tightness, flushing, dyspnea, and back pain. At a neighboring chair, a peripheral IV that earlier delivered a vesicant push now shows redness, swelling, and no blood return. Two time-critical problems: a hypersensitivity reaction and a possible extravasation.

First Priorities for an Infusion Reaction

For a suspected reaction, stop the infusion immediately. Keep IV access open with normal saline per policy and assess airway, breathing, circulation, vital signs, SpO2, skin, pain, mental status, and symptom onset. Call for help and notify the provider. Give emergency medications only per standing protocol or order: oxygen, antihistamine, corticosteroid, bronchodilator, IV fluids, and epinephrine for anaphylaxis. Do not restart the drug unless the provider directs a rechallenge and the patient is stable.

Paclitaxel reactions are frequently nonimmune (related to the Cremophor EL vehicle) and occur within the first few minutes of cycles 1-2; platinum reactions are usually true IgE-mediated hypersensitivity emerging after several cycles. Both are managed the same in the moment: stop, assess, treat, escalate.

Extravasation Recognition and Management

Extravasation is leakage of a vesicant or irritant into surrounding tissue; it can cause blistering, necrosis, and functional limb loss days to weeks later. Watch for burning, stinging, swelling, tightness, blanching, erythema, coolness, a damp dressing, a slowed infusion, or absent blood return. Central lines extravasate too, via catheter migration, rupture, or port-needle dislodgement.

When suspected, stop the infusion and do not flush the line, which would push more drug into tissue. Disconnect tubing, attempt aspiration of residual drug per policy, leave the catheter until aspiration is done, then notify the provider. Identify the agent, estimate the volume, mark and measure the area, and photograph per policy. Apply the correct compress by drug class: cold for most vesicants (anthracyclines, mitomycin) to localize the drug; warm for vinca alkaloids (vincristine, vinblastine) to disperse it. Antidotes are drug-specific: dexrazoxane (Totect) for anthracyclines, hyaluronidase for vinca alkaloids.

Always follow the institutional extravasation algorithm rather than memory.

Safe Handling and Patient Teaching

Hazardous-drug safety follows USP General Chapter <800>. Use appropriate PPE (chemo-rated double gloves, impervious gown, eye protection) for preparation, administration, disposal, and spill response. Prime tubing safely, use closed-system transfer devices (CSTDs) when required, and place waste in yellow chemotherapy containers, not red sharps boxes. Staff who are pregnant, breastfeeding, or trying to conceive follow institutional exposure guidance, and a spill kit must be within reach.

Patient and caregiver teaching after hazardous-drug therapy:

• Use gloves to handle body fluids (urine, stool, vomit, blood) for about 48 hours after most regimens, per agency policy
• Flush the toilet twice with the lid down; wash soiled linens separately
• Store oral chemotherapy in original containers away from children and pets; never crush or split unless directed
• Call for fever >=38.0 C, uncontrolled vomiting, or a missed/double oral dose

Rechallenge, Escalation, and Documentation

After a reaction, reassess vital signs, SpO2, lung sounds, skin, and pain at frequent intervals. Rechallenge belongs to the provider and protocol; if restarted, the rate is slower with closer monitoring. Recurrent reaction, hypotension, airway symptoms, or chest pain means stop again and escalate. Document onset time, drug, dose, rate, symptom sequence, objective findings, vitals, IV-site assessment, actions, medications given, provider notification, response, and follow-up.

For extravasation add site measurements, photographs, estimated volume, catheter status, aspiration attempt, antidote, compress type, limb instructions, and reassessment plan.

Vesicants, Irritants, and Common Traps

The OCN exam expects you to classify agents. Vesicants can cause tissue necrosis on extravasation and split into two groups: DNA-binding (anthracyclines such as doxorubicin, plus mitomycin), which cause progressive, late-developing injury, and non-DNA-binding (vinca alkaloids such as vincristine, vinblastine), which are more readily neutralized. Irritants (carboplatin, etoposide) cause local burning and inflammation without true necrosis. Only vesicants carry the highest extravasation stakes, and central venous access is preferred for continuous vesicant infusions to lower peripheral extravasation risk.

Key hazardous-drug and reaction facts:

• Premedication for paclitaxel exists precisely because of the high early-reaction rate; the presence of premeds does not mean a reaction cannot happen.
• Anaphylaxis is treated with intramuscular or IV epinephrine per protocol, oxygen, fluids, and antihistamines/steroids; epinephrine is the first-line drug, antihistamines are adjuncts.
• USP <800> requires chemotherapy waste in yellow containers; placing it in red sharps boxes is a frequent wrong answer.
• Body-fluid precautions of about 48 hours protect caregivers from cytotoxic metabolites excreted in urine, stool, sweat, and vomit.

Classic distractors in infusion items: slowing the rate instead of stopping (wrong for a true reaction), flushing a suspected vesicant line (worsens injury), and applying the wrong compress temperature for the drug class. The defensible answer almost always stops the exposure first, then assesses, treats per protocol, escalates, and documents objective reassessment rather than relying on the patient's reassurance that symptoms will pass.