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Chapter 11

Oncology: Nursing management in cancer care

extravasation but are of no benefit for taxane or oxaliplatin (Eloxatin) extravasation. Warm compresses are recommended for vinca alkaloid extravasation. Depending on the guidelines for specific agents, extravasation management may include aspiration of any infiltrated medication from the tissues and injection of a neutralising solution into the area to reduce tissue damage. Selection of the neutralising solution depends on the extravasated agent (Gullatte, 2007; Sauerland et al., 2006). Examples of neutralising solutions include sodium thiosulfate, hyaluronidase and sodium bicarbonate. Recommendations and guidelines for managing vesicant extravasation have been issued by individual pharmaceutical manufacturers, pharmacies and the Australian Oncology Nursing Society. Nurses should be aware of these guidelines prior to administering the agents. Prevention of extravasation is essential and relies on vigilant nursing care. Vesicant chemotherapy should never be administered in peripheral veins involving the hand, wrist or elbow. Peripheral administration is permitted for short duration infusions only, and placement of the venipuncture site should be on the forearm area using a soft, small gauge, plastic catheter. For any frequent, or prolonged administration of antineoplastic vesicants, tunnelled right atrial silastic cath- eters, implanted venous access devices, or peripherally inserted central catheters (PICC) should be inserted to promote safety during medication administration and reduce problems with access to the circulatory system (Figures 11-2 and 11-3). Indwelling or subcutaneous catheters require vigilant nursing care. Complications associated with their use include infection and thrombosis (Arch, 2007). Hypersensitivity reactions Most of the available chemotherapeutic agents have the poten- tial to cause hypersensitivity reactions; however, the overall incidence of hypersensitivity reactions to these agents is only about 5%. Understanding and managing hypersensitivity

Huber needle

Self-sealing septum

Skin line

Subcutaneous tissue

Suture

Catheter

Muscle

Fluid flow

Vein

A

B

reactions is critical when caring for patients receiving chemo- therapy because these reactions are potentially life-threatening. Prevention is the first line of defence, and nurses need to have a clear understanding of which agents have the potential for precipitating hypersensitivity reactions, determining the patient’s responses to certain agents via skin testing, and pro- viding appropriate premedication before administering agents with a high potential for causing hypersensitivity reactions. Education of patients should emphasise the importance of adhering to prescribed self-administered premedication before presenting for the infusion and recognising and reporting the signs and symptoms to the nurse once their infusion has started. Early intervention can prevent progression of a reaction to systemic anaphylaxis. Most reactions coincide with chemotherapy agent administration, but some reactions can be delayed or occur after several uneventful courses of therapy. Although patients may react to the first infusion of a chemo­ therapy agent, repeated exposure increases the likelihood of administering medication, fluids, blood products and nutrition. The self-sealing septum permits repeated puncture by Huber needles without damage or leakage. (B) Two Huber needles used to enter the implanted vascular port. The 90 8 needle is used for top-entry ports for continuous infusions. Figure 11-3  Implanted vascular access device. (A) A schematic diagram of an implanted vascular access device used for

Entrance site

Subclavian vein

Superior vena cava

Dacron cuff

Exit site

Figure 11-2  Tunnelled central catheter. The tunnelled central catheter is inserted into the subclavian vein and advanced until its tip lies in the superior vena cava just above the right atrium. The proximal end is then tunnelled from the entry site through the subcutaneous tissue of the chest wall and brought out through an exit site on the chest. The Dacron cuff anchors the catheter in place and serves as a barrier to infection.