Care During Chemotherapy and Beyond
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
- 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
- The reaction to vesicants initially looks like an 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
- 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.
Prevention of extravasation is the key to managing these types of injection
The nurse or doctor giving these types of chemotherapy injections must be carefully
A central venous access device might be recommended such as:
- PICC line: Although still considered temporary, a PICC
line can be inserted for chemotherapy 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
chemotherapy 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:
- 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 than 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
- There are various antidotes that may be given based on the chemotherapy 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 chemotherapy, 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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