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INTRODUCTION

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Irritants

Irritant drugs may produce any of the following reactions: erythema along a vein or phlebitis, with sensations of tenderness, warmth, or burning, and pain, and, as a consequence of extravasation, inflammatory reactions, which may include local swelling, erythema, induration with sensations of itching, warmth, aching, tightness, or pain, but generally not tissue necrosis. Drugs categorized as irritants are more or less irritating to soft tissues owing to intrinsic differences in their physical and chemical properties and the properties of excipient products with which they are formulated. The manifestations and severity of reactions after extravasation with irritant drugs often correlate with the concentration of drug, the amount of drug and volume extravasated, and the duration of exposure; that is, some irritants exhibit properties characteristic of vesicants if the amount of drug extravasated is large or highly concentrated. However, except for local changes in pigmentation at an extravasation site (often hyperpigmentation), symptoms associated with irritant drug extravasations are typically of short duration (days to weeks), and there are no lasting sequelae

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Vesicants

Vesicant drugs may cause severe tissue injury, usually resulting in necrosis; consequently, vesicant extravasation is a medical emergency requiring prompt situationally appropriate action. Vesicant extravasation injuries may be subtle with a delayed onset of morbidity, or immediately apparent with a rapid onset of symptoms. The severity of lesions, the time over which they develop, and the likelihood of spontaneous healing without intervention, also vary among vesicant drugs. DNA-binding agents (eg, anthracyclines, anthracenediones, mitomycin, dactinomycin) tend to produce more severe and persistent lesions than drugs that do not bind to DNA (eg, Vinca alkaloids, taxanes). Over a period of days to weeks, erythema, swelling, induration, and pain may increase and progress to brawny discoloration, blistering, or dry desquamation. Lesions may ulcerate and form eschars. Ulcers are characteristically painful with erythematous borders and necrotic bases. Spontaneous reepithelialization typically does not occur. Lesions caused by DNA-binding agents may continue to expand laterally and deepen for weeks to months after an extravasation event, involving adjacent structures after cytolytic release of active drug from necrotic tissues

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What to Avoid in Placement of Vascular Access Devices (VADs)

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What to Avoid in Placement of Vascular Access Devices (VADs)
Peripheral VADs Central VADs and Implanted Ports
  • Fragile, small, or low-flow vessels such as the dorsal aspect of the wrist

  • Vessels overlying areas with little subcutaneous tissue such as the dorsum of the hand and wrist, and areas of flexion, such as the wrist and antecubital fossa, particularly for administering irritants or vesicants

  • Areas of hematoma, edema, impaired lymphatic drainage, frank lymphedema, or distal to lymphatic dissection, phlebitis, inflammation, induration or obvious infection, and sites previously irradiated or treated with irritating or sclerosing drugs

  • Veins in extremities with decreased sensation, paresthesia, or neurologic weakness. Impaired tactile sensation may prevent a patient from feeling and promptly reporting discomfort associated with extravasation

  • Sites distal to ...

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