Injection Site Reactions

Injection site reactions discussed here are local skin reactions that occur when the drug escapes from the veins or IV catheter into the skin (extravasation). 

Drugs That Cause Injection Site Reactions:

The drugs that can cause injection site reactions are divided into 2 types: irritants and vesicants.

Irritants cause a short-lived and limited irritation to the vein:

• Symptoms are; tenderness, warmth, or redness along the vein or at the injection site.
• A variation to this is a hypersensitivity "flare reaction" at the injection site. 
• Symptoms of this reaction are redness and itching at the injection site.
• Irritant chemotherapy agents include: bleomycin, carboplatin, carmustine, cisplatin, dacarbazine, denileukin difitox, doxorubicin, doxorubicin liposome, etoposide, ifosfamide, streptozocin, teniposide, thiotepa, vinorelbine.

Vesicants cause an injection site reaction often referred to as a chemical cellulitis:

• The reaction to vesicants initially looks like a irritation but may worsen, depending on the amount of vesicant that has leaked under the skin.
• Vesicants can cause redness and blistering. Larger amounts of vesicant leakage from the chemotherapy injection can lead to severe skin damage in a matter of days.
• Symptoms from leakage of vesicants may be delayed for up to 6-12 hours after chemotherapy injection.
• Complaints of itching are common in the absence of pain.  
• Severity of the injection site reaction depends on the vesicant potential of the drug, the amount and concentration of the drug exposure, and the immediate measures taken once the extravasation occurs.
• Vesicant chemotherapy agents include: Dactinomycin, daunorubicin, doxorubicin, epirubicin, idarubicin, mechlorethamine, mitomycin, mitoxantrone, paclitaxel, streptozocin, tenoposide, vinblastine, vincristine, vinorelbine.

Symptom Management:

Prevention of extravasation is the key to managing these types of injection site reactions:

• PICC  line:  Although still considered temporary, a PICC line can be inserted for chemotheraphy injection and used for six weeks to a few months before it is discontinued. This involves the placement of a long plastic catheter into one of the larger veins of the arm.  This procedure is a non-surgical outpatient procedure.  A special x-ray, called fluoroscopy will confirm that the catheter is in the right place, reducing risk of infection site reaction.  This option is ideal for multiple short infusions or continuous infusions given in a hospital or at home with a portable pump.
• Tunneled catheter: Tunneled catheters are placed through the skin in the middle of the chest.  They are tunneled through the subcutaneous tissue (the layer of tissue between the skin and muscle) and inserted into the superior vena cava vessel at entrance of the right atrium of the heart.  There is a dacron cuff about two inches from the part of the catheter that exits the skin in the chest.  Scar tissue forms around the cuff to hold the catheter in place.  These catheters are inserted in an outpatient surgical procedure and a special x-ray, called fluoroscopy, must be done to be sure the catheter is in the right place, reducing risk of leaking vesicants.  These catheters can be left in place for chemotheraphy injection for months or years with low incidence of infection.  Dressing changes and maintenance is required.  These catheters can have multiple lumens (entrances) for medications to be infused or for blood to be drawn.  A single lumen has one entrance for medications, a double lumen has two entrances and a triple lumen (the most available) has three entrances.  These catheters are most often used for extensive chemotherapy regimens such as bone marrow transplant procedures.  Tunneled catheters are usually called by their brand names:  Broviac^®, Groshong^®, and Hickman^®.  
• Port-a-cath: A more permanent injection site option involves the placement of a port-a-cath.  The port-o-cath is placed under the skin on the chest.  The cathether is then inserted into the superior vena cava vessel at entrance of the right atrium of the heart.  This catheter can be placed in radiology by an interventional radiologist or by a surgeon in the operating room. It is approximately a one-hour procedure. The useful lifetime of a port-a-cath can be as long as three to five years.  The port-o-cath can be felt under the skin and the nurse can find the injection site by locating the edges of the port-o-cath and inserting (cannulating) a special needle (called a Huber needle) into the soft middle section.   Medications can be given through the port-a-cath and blood can be drawn from it eliminating the need for a blood draw from the arm. The use of a portable pump and port-a-cath allows the medication to be given over several days in the home setting rather then as a patient in the hospital.  There are no dressing changes required but there is some maintenance involved.

Things You Can Do To Prevent Injection Site Reactions:

• Notify your health care professional immediately if you experience pain or discomfort at the injection site.
• If you have redness or discomfort at the site after leaving the chemotherapy treatment facility, apply ice to the injection site and notify your healthcare professional of potential irritant or vesicant leakage.  
• EXCEPT: If extravasation of a vinca alkaloid medication - vincristine, vinblastine or vinorelbine, then you would apply warm compresses and notify your health care professional of the possibility of injection site reaction.

Treatments or Drugs for Injection Site Reactions:

• Prevention of extravasation is the key to management of this problem.
• If one of the above medications has extravasated the health care professional will attempt to remove as much of the medication as possible from the injection site and discontinue the IV.
• Ice or heat (in the case of vinca alkaloid chemotherapies) will be applied to the injection site.
• There are various antidotes that may be given based on the chemotheraphy that extravasated, and the amount of drug infused.  The nurse or doctor will work with the chemotherapy pharmacist to decide if an antidote is available and appropriate to the situation.

When to Contact Your Doctor or Health Care Provider:

• If you have received an irritant or vesicant medication and notice redness, pain or blistering at the site of infusion.

Note: We strongly encourage you to talk with your health care professional about your specific medical condition and treatments. The information contained in this website about chemotheraphy, injection site reaction and other medical conditions is meant to be helpful and educational, but is not a substitute for medical advice.

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