Forum topic

 Have you checked the gallery of photos on this site? I wish you would publish. I looked at the references from my recently updated online CE course on infiltration/extravasation and did not find a reference for treatment of Vancomycin extravasation. Hyaluronidase has been reported for Nafcillin though. Lynn

I am going to add my request that you publish. We all need something in print to show our MDs and P&T committees.

I was in the process of creating a policy for infiltration/extravasation at our hospital.  Pulled up much literature, utilized INS standards as well as policy and procedure manual.  After all that was done and policy typed and sent for review several doctors shot it down due to the mention of antidotes.

The P&P commitee then just removed any mention of antidotes and included all other recommendations.  The 2 physicians who did not want it to be listed are our Critical Care Physicians.  They dont feel that the use of antidotes is proven effective .   They dont want it listed in our policies and then choose not to utilize it  and then get in problems for not following hospital policy.

We did fight it, we ( myself and pharmacy) pulled up all the literature published and brought that up for review as well.  they still did not want it listed in our policy. 

Unfortunately, they are not the only 2 physicians who have patients who might have extravasations.  These critical care  physicians may be able to make a decision to use or not use the antidote.  However, I do not feel that most of our primary care physicians are even familiar with what options are out there.  When we had a protocol that listed all options it was a resource to be utilized by nurses and physicians to guide them in teh appropriate treatment.  We also have the option to consult with pharmacy, who would definitley want a policy that includes antidotes.

We certainly have these drugs /antidotes available for use.  I am wanting to do an inservice on infiltration/extravasation for our staff members.  There is much confusion and lack of knowledge on how to handle this situation here at our facility, especially now with the policy being so vague.   I would like to educate the staff on all the treatments that are available and may come into play including antidotes.  that way when they call the physician they can discuss the issue and then when inquiring as to what his further orders are they are aware of the possiblity of an antidote and inquire if he wants that as well.

I am going to pull up the info and recommendations on each medicine from teh manufacturere that we typically encounter this with and read their recommendations. But.....I know research and evidenced based medicine is best ( they shot that down though as I mentioned earlier).  I will see what the inserts say and use that to guide the staff in the education process. 

Do you think it is ok to not include antidotes in the policy , do you think it is ok to not use antidotes at all???   I am thinking if I dont do any teaching or further education patients who have an extravasation will just get iv removed, elevated limb, cool or heat to site , monitoring and photos and nothing else ( or surgery if indicated) is that acceptable??

INS standards says;   Treatment of infiltration depends on the severity when it is recognized.  Treatment may include extremity elevation, thermal manipulaiton, use of antidodtes and surgical interventions.

Thanks so much for your input as always,  Gina Ward R.N.

 So sorry you are having this problem. I agree that antidotes should be addressed in your written documents. These are critical care physicians. Have you discussed this with oncologist? Just remember that the list of vesicant is far longer than oncology drugs. They would most likely be in favor of using antidotes as there are ONS guidelines in detail for use with those drugs. In fact, for adriamycin extravasation, the use of Totect infusion as an antidote is now considered to be the standard of care. This is a 3 day infusion not an intradermal injection. I don't understand their rationale for not using antidotes. When I review a legal case, use of antidotes is one thing I am looking for. I would agree that there is a lack of evidence for many drugs on which antidote is best. I doubt that you will find much information in the package inserts about which antidote is recommended. The drug manufacturers do not conduct the research necessary to get this information cleared by the FDA. So the only thing you have to rely upon is what is published. And for ethical reasons we do not conduct such comparative studies on humans. For instance there would never be a study comparing use of one antidote to another for treatment of an extravasation of calcium chloride (just one example). The only thing we have to rely upon is case reports and animal studies. I would do a couple of things. First, I would network with other physicians emphasizing that the risk of giving an antidote is far less than the potential benefits it can provide. Second, I would take this to your risk management dept. I would take these actions while I was also educating the staff. You are absolutely correct that at 10 pm at night when an extravasation has occurred, there is no time to conduct an extensive literature search to determine what is the best treatment approach. So you must have some form of guidance. I would think you could have written protocols that require a physician order. These protocols are not the same as policies yet they would serve to have this information readily available when an event occurs. The nurse can use these to contact and educate the physician about what can/should be used. Then the physician would just have to say "activate the XXX protocol". So while you may not change the minds of the physicians you have encountered, you do have ways to do an end run around them to get to the same outcome of better patient care. Good luck and let us know the outcome of your great efforts. Lynn

thank you Lynn!  Great idea, for a  pre printed order set.  I will look into creating those.   

We do not do Oncology here so......they 2 physicians that spoke up are our most powerful/knowledgable physicians here on these points.   I did not bring it up to risk management either, so I will do that.  Although I think she is a part of the Policy Writting committee.

Thanks  again,  Gina