St Lukes Cancer Alliance NHS

Guidelines for prevention and management of

CHEMOTHERAPY EXTRAVASATION
Please note that this policy refers to the management of extravasation of cytotoxic chemotherapy only.
Refer to local Trust policies for management of non-cytotoxic extravasation.

Definitions
Extravasation is the inadvertent leakage of intravenous drugs out of the vein into surrounding tissues.
Extravasation injury refers to the damage caused by the leakage of solutions from the vein into the surrounding tissue
spaces. Depending on the substance that is extravasated into the tissue, the degree of injury can range from a very
mild skin reaction to severe necrosis.
The term Infiltration is sometimes used instead of extravasation to refer to the inadvertent administration of non-vesicant
solution/medication into surrounding tissues. Whilst the medication itself cannot damage the tissues, if the volume of fluid is
large, the swelling can result of compression of the nerve. Therefore the site must be observed and the degree of swelling
documented. The patient should be questioned regarding any numbness or loss of sensation in the affected limb and this
should be reported accordingly.
Flare is a localised inflammatory reaction characterised by a localised erythema, venous streaking and pruritus along the
injected vein. This is distinguishable from extravasation by the absence of pain and swelling and may include the presence
of a blood return.

Classification of Chemotherapy Agents

Cytotoxic drugs may be classified according to their potential to cause serious necrosis when extravasated (see
Appendix A).
Extravasation of vesicants is a medical emergency; early detection and prompt appropriate action is required to
prevent necrosis and functional loss of the tissue or limb involved.

Prevention of Extravasation

Forethought, planning and improved prevention measures can minimise the risk of extravasation.
i)

Careful assessment of the most appropriate cannulation site should be undertaken before insertion. Siting the
cannula over joints should be avoided, as tissue damage in these areas has serious consequences. If venous
access proves difficult, the opinion of an experienced practitioner should be sought as placement of a central
venous access device (CVAD) may be necessary.

Reason for Update: discontinued nurse reconstitution of

Savene; removal of reference to Savene kit; no access to
Savene out of aseptic hours; pixantrone added to Appendix C
Version: 8
Supersedes: All previous versions

Approved by Chair of Alliance Chemotherapy Nurses: Claire Savage

Approved by Chair of Alliance Chemotherapy Group: Dr J De Vos

Date: 12/06/2014

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ii) Extravasation can occur in CVADs, often with delayed onset, and can be recognised by the patient complaining of

sudden pain, discomfort, inflammation or swelling around the extravasation site.

iii) Some patient groups are at increased risk of extravasation. These include obese, elderly, paediatric patients,

thrombocytopenic patients, diabetics with peripheral neuropathy and patients who have had previous
chemotherapy / radiotherapy. Non-English speaking patients and those with communication difficulties are also at
risk. Extra care should be taken with all these patient groups.
iv) Vesicant drugs in a chemotherapy regimen must be given before the other cytotoxic agents.
v) When given peripherally, bolus doses (in syringes) of vesicants must be given via a fast running infusion of a

compatible fluid. Continually assess the cannulation site throughout the administration for signs of swelling, pain or
inflammation, and monitor the fast running infusion for change in rate.
vi) Only the following vesicant cytotoxics may be given by peripheral infusion (in bags): paclitaxel, vinca alkaloids,

dacarbazine, streptozocin. However, the central venous route minimises the extravasation risk, and should be
considered on an individual patient basis. Any other cytotoxic vesicant infusions (in bags) should be administered
via a CVAD.
vii) Anthracycline administration must be carried out during normal working hours except in situations of life

threatening urgency, in which case direct Consultant authorisation is required and the reasons recorded in the
medical notes, as well as subsequent routine review of such episodes by the local chemotherapy group.
All out-patient and day case appointments for anthracycline administration should be scheduled for the
morning or early afternoon, so that all management options can be considered in the event of an anthracycline
extravasation.
All pre-planned out-of-hours anthracycline administration for AML should be delivered via a central venous
access device, again except for exceptional situations when direct Consultant authorisation is required and
reasons documented.

Management of Extravasation of Cytotoxic Drugs

Signs and Symptoms
An extravasation should be suspected if one or more of the following symptoms have occurred:

The patient complains of burning, stinging, or any discomfort / pain at the injection site. This should be
distinguished from a feeling of cold that may occur with some drugs.

Observation of swelling or induration at the device insertion site or along the tunnel/around port pocket or into
the shoulder and neck on the side of the port or catheter OR redness or blistering at the device insertion site.
This should be distinguished from the nettle rash effect seen with anthracyclines.

No blood return is obtained. This is not a sign of extravasation if found in isolation.

A resistance is felt on the plunger of the syringe of a bolus drug.

There is absence of free flow of the infusion.

If in any doubt, treat as extravasation.

If an extravasation is suspected, take immediate action as documented in the algorithm below:

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Stop the injection/infusion. Disconnect the intravenous tubing.

Withdraw as much of the drug as possible, via existing cannula or central venous access device (CVAD).

Mark area of skin with indelible pen. Take a photograph of the area as soon as possible. (Cameras are
often available from Accident & Emergency departments)

If appropriate, remove the peripheral cannula (do not remove the CVAD).

Open extravasation kit (see Appendix B for list of contents).

Refer to Appendix C to establish: whether a hot pack or cold pack should be used, or whether neither is
required; and what further treatment is recommended. Follow guidance in flow chart below accordingly.

Note that for Neutral drugs, neither a cold pack nor a hot pack is required. Aspirate as much fluid as
possible, and then remove the peripheral cannula. No further treatment should be required. Manage the
situation symptomatically. Document the incident in the patients notes.

CYTOTOXICS REQUIRING WARM

PACK

CYTOTOXICS REQUIRING COLD PACK

See Appendix C for specific onward management, EITHER:

 Inject 1500 iu hyaluronidase (in 1ml

WFI) via pincushion s/c injections in
0.1 0.2ml volumes around the site
 Apply a warm pack to aid absorption
of hyaluronidase

Cold pack + hydrocortisone cream

Apply cold pack for 15-20 minutes 3-4 times a day for up to 3 days.
Apply hydrocortisone 1% cream tds, as long as redness persists.
Once opened, cream must be labelled with patient details.
OR

 Warm pack to remain in situ for 2-4

hours

Cold pack + DMSO* (see NOTES below for details)

OR

ELEVATE THE LIMB

on a pillow

Consider Savene (dexrazoxane)

If extravasation of doxorubicin, epirubicin, idarubicin or daunorubicin
occurs (5ml or more peripherally or any volume via a CVAD) then
stop cold pack, do not apply DMSO and consider use of
dexrazoxane*** (see NOTES below)

INFORM THE MEDICAL STAFF

Consider urgent referral to plastic surgeon for saline flush-out**

Document the incident by completing trust incident form and extravasation record form.
File copies in patients health record.

GIVE PATIENT THE PATIENT INFORMATION SHEET and follow up

appointments as indicated (see Subsequent Action below)

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Subsequent action

Encourage gentle movement of the affected limb.

Patient follow up arrangements will be dependent upon the type of drug and volume that extravasated, and will
be decided by a practitioner who has experience of extravasation management.

Extravasation of vesicant and exfoliant drugs requires completion of the Follow up Flow Chart in Appendix D.

Consider prescription of analgesia as required.

Notes:
* Use of 98% dimethyl sulfoxide (DMSO)

DMSO should be applied within 10 25 minutes of the extravasation occurring.

Draw around area of extravasation with indelible pen. Then, a thin layer of 98% DMSO solution should be
applied topically to the extravasated area using the applicator provided. Contact with good skin should be
minimised, as there are some reports associating DMSO with blistering of the skin. Once DMSO dries, apply
1% hydrocortisone cream and 30 minutes of cold compression. This process (DMSO, hydrocortisone cream,
cold compression) should be repeated as above every 2 hours for the first 24 hours.

After 24 hours of the above, for the next 7 days, 98% DMSO should be applied every 6 hours alternating with 6
hourly applications of 1% hydrocortisone cream, so that a preparation is being applied every 3 hours overall.

** Plastic surgeon referral and Flush-out procedure

After peripheral or central extravasation of any vesicant or exfoliant, seek advice from the Lead Chemotherapy
Nurse or Day Services Manager regarding an urgent referral to a plastic surgeon for a saline flush-out.
In the case of a large volume extravasation of a vesicant or exfoliant, urgent saline flush-out of the
extravasation area, as soon as possible, ideally within 2 hours, and no later than 24 hours after extravasation1,
should always be considered. Unfortunately the literature does not define large, as it is often dependent on
the size and age of the patient, as well as the nature of the drug.
For anthracycline extravasation, the flush-out technique should not be used in combination with dexrazoxane
(Savene).
See below for plastic surgeon contact details for each Trust:

For patients receiving chemotherapy at RSCH, a Consultant plastic surgeon should be contactable via RSCH
switchboard. If unavailable via this route, contact the consultant plastic surgeon secretary at RSCH or St
Georges for further advice.

For patients receiving chemotherapy at SASH, contact the Plastics SpR on-call at Queen Victoria Hospital
(switchboard tel 01342 414000).

For FPH and ASPH patients, contact the Consultant plastic surgeon at Chelsea & Westminster hospital via the
C&W switchboard (tel 0208 7468000). At FPH, there is also a plastic surgeon secretary on site, who is
available in normal working hours on ext 4160.

For the saline flush-out, the patient will usually need to travel to the hospital where the plastic surgeons are
based. As the procedure is potentially limb-saving (mention this to the ambulance service), an
emergency ambulance should be requested for the transfer.
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*** Guidance for prescribing of dexrazoxane (Savene) - for use in Adults only
Dexrazoxane is a DNA topoisomerase II drug that protects against tissue damage with certain anthracyclines:
doxorubicin, epirubicin, daunorubicin and idarubicin.
Side effects include nausea (very common) and neutropenia/thrombocytopenia (common).
It MUST ONLY be prescribed in the following circumstances:
 If there is a suspected peripheral extravasation of 5ml or more of doxorubicin, epirubicin, daunorubicin or
idarubicin.
OR
 There is an extravasation of doxorubicin, epirubicin, daunorubicin or idarubicin via the central venous route.
The case must be discussed with the Trust Lead Chemotherapy Nurse, or the Senior Chemotherapy Sister, as
well as the patients Consultant, before Savene is prescribed.
See Appendix G for more details with regards to prescribing dexrazoxane.
Dexrazoxane (Savene) is a cytotoxic drug. It must therefore be reconstituted in a pharmacy aseptic unit.
The Savene pre-printed prescription, which is available in Appendix H, should be used for prescribing.

*** Arrangements for preparation and delivery of a dose of dexrazoxane (Savene)

10 vials of Savene are stored in the aseptic department at RSCH. This is sufficient to treat one anthracycline
extravasation.
See Appendix J and below for the supply and delivery arrangements:
a) Request for Day 1 Savene dose during normal aseptic working hours
RSCH

St Lukes Pharmacy to fax prescription to the Pharmacy Aseptic Unit for reconstitution
Prepared dose delivered to clinical area for administration

ASPH / FPH / SASH

Pharmacy Department at relevant Trust to fax an order to RSCH Pharmacy Aseptic Unit for Savene
reconstitution. Receipt of this fax should be confirmed by telephone.
Transport should be organised by RSCH pharmacy staff, according to Appendix J. The urgent nature of
the delivery should be highlighted in order that the 6 hour window of efficacy is not breached, and a
transport collection time agreed.
The pre-prepared Savene dose is transported to a pre-specified location at ASPH, FPH or SASH.
RSCH will invoice the Trust for the Savene, via the usual mechanism for invoicing chemotherapy.

b) Extravasation identified out of aseptic working hours

Savene cannot be considered as a treatment option. An urgent plastic surgeon referral for a saline flushout should be considered.

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Day 2 and Day 3 doses of Savene

Day 2 and Day 3 doses of Savene should be given at the same time of day (+/- 3 hours) as Day 1.
Once reconstituted, the shelf-life for Savene is only 4 hours at 2 - 8oC.
If either of the Day 2 and Day 3 doses falls on a weekend or Bank Holiday, RSCH aseptic unit cannot guarantee a
service. The situation would have to be discussed on a case by case basis at the time of the event. If staff are
available and willing to come in, then an exceptional out of hours service would be provided in order to aseptically
prepare the dose, plus ensure urgent transportation to the required location.
See Appendices G, H and J for further information on Savene prescribing, preparation, administration, and
transport arrangements.

See Appendices for:

Appendix A: Classification of cytotoxics according to extravasation risk
Appendix B: Contents of cytotoxic extravasation kit
Appendix C: Chart of cytotoxic drugs according to immediate treatment
Appendix D: Cytotoxic extravasation documentation form
Appendix E: Patient Information Leaflet
Appendix F: DMSO Unlicensed Medicine recording sheet
Appendix G: Preparation and administration of Savene (Dexrazoxane)
Appendix H: Pre-printed prescription template for Savene (Dexrazoxane)
Appendix J: Transport Arrangements for Savene

References:
Allwood M, Stanley A, Wright P; Cytotoxics Handbook 4th Ed. Radcliffe Medical Press: Oxford 2002
European Oncology Nursing Society (EONS) Extravasation Guidelines 2007
Dougherty, L and Lister, S. RMH Manual of Clinical Nursing Procedures 8th Edition (2011)
1Gault, DT; Br J Plast Surg 1993; 46: 91 96
Mouridsen, H et al; Annals of Oncology 2007; 18: 546 550

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APPENDIX A:

Classification of cytotoxic drugs according to their potential to cause serious necrosis

when administered outside of the vein, known as extravasation or infiltration
Vesicants*
Group 1
Amsacrine

Exfoliants*
Group 2
Cisplatin

Irritants
Group 3
Bendamustine

Inflammitants
Group 4
Fluorouracil

Neutrals
Group 5
Alemtuzumab

Cabazitaxel

Liposomal
Daunorubicin

Carboplatin

Methotrexate

Asparaginase

Carmustine

Docetaxel

Dexrazoxane

Raltitrexed

Bevacizumab

Dacarbazine

Liposomal
Doxorubicin

Etoposide

Bleomycin

Dactinomycin

Mitoxantrone

Irinotecan

Bortezomib

Daunorubicin

Oxaliplatin

Cetuximab

Doxorubicin

Topotecan

Cladribine

Epirubicin

Cyclophosphamide

Idarubicin

Cytarabine

Mitomycin

Eribulin

Paclitaxel

Fludarabine

Streptozocin

Gemcitabine

Treosulfan

Ifosfamide

Vinblastine

Ipilimumab

Vincristine

Melphalan

Vindesine

Pemetrexed

Vinflunine

Pentostatin

Vinorelbine

Rituximab
Trastuzumab

Definitions:
*Vesicants:

Drugs which are capable of causing pain, inflammation and blistering of the local skin,
underlying flesh and structures, leading to tissue death and necrosis

*Exfoliants:

Drugs which are capable of causing inflammation and shedding of the skin, but less likely to
cause tissue death

Irritants:

Drugs which are capable of causing inflammation, irritation or pain at site of extravasation, but
rarely cause tissue breakdown

Inflammitants:

Drugs which are capable of causing mild to moderate inflammation and flare in local tissues

Neutrals:

Inert or neutral compounds that do not cause inflammation or damage.

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APPENDIX B: CONTENTS OF CYTOTOXIC EXTRAVASATION KIT

Hyaluronidase 1,500 units injection ( 1 ampoule)

Hydrocortisone 1% cream labelled with directions for use

Sterile water for injection 1 x 10ml

Dimethyl sulfoxide (DMSO) 98% solution 1 x 10ml bottle with applicator

Hot Pack

Cold Pack

Cytotoxic Drug Extravasation documentation form (see Appendix D)

Patient information leaflet (see Appendix E)

DMSO Unlicensed medicine recording sheet (see Appendix F)

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APPENDIX C: Chart of cytotoxic drugs according to immediate treatment in the event of extravasation:
Drug
Amsacrine
Bendamustine
Bleomycin
Bortezomib
Cabazitaxel
Carboplatin
Carmustine
Cisplatin
Cladribine
Cyclophosphamide
Cytarabine
Dacarbazine
Dactinomycin
Daunorubicin
Docetaxel
Doxorubicin
Epirubicin
Eribulin
Etoposide
Fludarabine
Fluorouracil
Gemcitabine
Idarubicin
Ifosfamide
Irinotecan
Liposomal, Daunorubicin
Liposomal, Doxorubicin
Melphalan
Methotrexate
Mitomycin
Mitoxantrone
Oxaliplatin
Paclitaxel
Pemetrexed
Pentostatin
Pixantrone
Raltitrexed
Streptozocin
Topotecan
Treosulfan
Vinblastine
Vincristine
Vindesine
Vinflunine
Vinorelbine

Cold/Warm pack
Cold
Cold
None
None
Warm
Cold
Cold
Cold
None
None
None
Cold
Cold
Cold
Warm
Cold
Cold
None
Cold
None
Cold
None
Cold
None
Cold
Cold
Cold
None
Cold
Cold
Cold
Warm
Warm
None
None
None
Cold
Cold
Cold
Cold
Warm
Warm
Warm
Warm
Warm

Treatment
Hydrocortisone cream
Hydrocortisone cream
No antidote
No antidote
Hyaluronidase
Hydrocortisone cream
Hydrocortisone cream
Hydrocortisone cream
No antidote
No antidote
No antidote
Hydrocortisone cream
DMSO
DMSO (*but see below)
Hyaluronidase
DMSO (*but see below)
DMSO (*but see below)
No antidote
Hydrocortisone cream
No antidote
Hydrocortisone cream
No antidote
DMSO (*but see below)
No antidote
Hydrocortisone cream
DMSO (for 10 14 days)
DMSO (for 10 14 days)
No antidote
Hydrocortisone cream
DMSO
DMSO
Hyaluronidase
Hyaluronidase
No antidote
No antidote
No antidote
Hydrocortisone cream
Hydrocortisone cream
Hydrocortisone cream
Hydrocortisone cream
Hyaluronidase
Hyaluronidase
Hyaluronidase
Hyaluronidase
Hyaluronidase

*For 5ml volume peripheral extravasation, or any central extravasation, of an anthracycline, Savene may be a more
appropriate alternative. Discuss with the Lead Chemotherapy Nurse or Day Centre Manager
If an extravasation occurs and the drug is not listed above, please contact pharmacy for classification and advice.
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APPENDIX D: Cytotoxic Drug Extravasation Documentation Form (Part 1)

Patient Name:

Hospital number:

Please complete ALL sections in BLOCK capitals and in black ink

1) Name of drug (s):
2) Date and Time of Extravasation:
3) Signs and symptoms to alert you to a possible extravasation: please circle Yes or No
a) Did the patient complain of:

Burning
Stinging
Other acute changes

Yes / No
Yes / No
Yes / No - If answer is Yes, please specify:

b) Was the injection / infusion site:

Indurated
Swollen
Red
Blistered

Yes / No
Yes / No
Yes / No
Yes / No

c) Was there:

Blood return
Yes / No
Resistance on plunger of bolus syringe
Yes / No
Absence of free flow of infusion
Yes / No

Please now document the Emergency Nursing Management section before completing the rest of this form
4) Bolus or infusion? (Please circle one)
5) Type of device: Cannula / Other (Please specify, including gauge)
6) Was a pump being used?

Yes / No

7) a) How much of the drug had been given?

b) Estimate how much had extravasated
8) Extravasation site Please roughly draw area on body, e.g. arm, and illustrate position of device,
extravasation area, length and width of affected area (cm)

Staff Name and designation:

Clinical Area:

Signature:

Date:

Please photocopy this form and send one copy with the Trust incident form and place one copy in the
patients notes
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Emergency Nursing Management (Part 1 continued)

Patient Name:

Hospital number:

Name of Drug(s):

Date and Time:

** Please date and time and sign for ALL steps **

Nursing Management

Has this been

done?

If the answer is NO,

give reasons

1: Stop the infusion. Withdraw as much drug as

possible.
2. Mark area of skin with indelible pen.

Yes / No

3. Remove the device where appropriate. (do not

remove CVAD)
4. Consider flush-out technique

Yes / No

5. See Appendix C and Pages 3 4 of the Alliance

extravasation policy for specific management of
suspected cytotoxic
6a) For vinca alkaloids, paclitaxel, docetaxel,
cabazitaxel or oxaliplatin;
use hyaluronidase and a warm pack as directed on
page 3 of the Alliance extravasation policy.
6b) For extravasation of doxorubicin, idarubicin,
epirubicin or daunorubicin; 5ml or more peripherally
or any volume via a CVAD: contact your LCN to
advise on use of Savene.
6c) For anthracyclines (where Savene not
appropriate), mitomycin, mitoxantrone or
dactinomycin;
use a cold pack and apply DMSO and
hydrocortisone cream as directed on pages 3 & 4 of
the Alliance extravasation policy.
6d) For amsacrine, carboplatin, cisplatin,
dacarbazine, etoposide, 5FU, irinotecan,
methotrexate, raltitrexed, streptozocin, topotecan;
use a cold pack and hydrocortisone cream as
directed on page 3 of the Alliance extravasation
policy.
6e) For neutral cytotoxics, no specific antidote
required
7. Elevate the limb

Yes / No

8. Inform the patients oncology / haematology

Consultant or SpR for assessment and
consideration of referral to plastic surgeon
9. Implement any further medical treatment
prescribed
10. Has a photograph been taken?

Yes / No

Name of doctor
informed:

Yes / No

If yes, give details:

11. Give patient the Extravasation Patient

Information Sheet
12. Follow up arrangements made

Yes / No

Date and
Time

Nurse
Signature

Yes / No

Yes / No

Yes / No

Yes / No

Yes / No

Yes / No

Yes / No
Yes / No

Yes / No

Yes / No

Please photocopy this form and send one copy with the Trust incident form and place one copy in the
patients notes
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Cytotoxic Drug Extravasation Documentation Form (Part 2)

Follow Up Flow Chart for Suspected Extravasation of Vesicant / Exfoliant
Patient Name:

Hospital Number:

Date & Time of Extravasation:

Ward:

Name of Drug Extravasated:

Follow Up (To score, refer to grading scale below)

Day

14

21*

28*

35*

42*

Date
Call / Visit
Skin Colour
Skin Temperature
Skin Integrity
Oedema
Mobility
Pain
Fever
Nurse Initials
* May be omitted if signs and symptoms of extravasation resolved
Grading Scale
Skin Colour

0
Normal

1
Pink

2
Red

3
Blanched
area
surrounded
by red

4
Blackened

Skin Integrity

Unbroken

Blistered

Superficial
skin loss

Tissue loss &

exposed
subcut tissue

Tissue loss &

exposed
bone/muscle with
necrosis crater

Skin Temp.

Normal

Warm

Hot

Oedema

Absent

Non-pitting

Pitting

Mobility

Full

Slightly
limited

Very Limited

Pain
Fever

Immobile

Grade using a scale of 0-10; where 0 = no pain and 10 = worst pain

Normal

Elevated

Please photocopy and place one copy in patients notes and attach one copy to Trust Incident Form

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APPENDIX E:

Patient Information Sheet on Extravasation

What is extravasation?
Extravasation is the leakage (or accidental infiltration) of drugs outside of the vein and into the surrounding tissues.
This can lead to an immediate painful reaction, and may with some drugs result in local tissue damage. You may have
noticed pain, stinging, swelling or other changes to the skin at the site of drug administration, or the nurse may have
noticed that the drug was not flowing in easily.
Why did this happen?
Extravasation is a rare but known complication of intravenous chemotherapy. It is impossible to prevent this even
though we take all possible precautions. The important thing is that it has been detected and treated.
Why is extravasation a problem?
It can lead to pain, stiffness and tissue damage.
What treatment have I received to prevent tissue damage?
The nurse has given you the recommended treatment for the extravasation. Although this will help to minimise the
chance of developing further problems, you will need to keep checking the area every day.
Checking the area
Once a day, check the area for the following:

Has the area changed colour or increased in redness?

Is the area blistering, peeling or flaking?
Is the area more uncomfortable?
Is the pain making it difficult for you to exercise the arm or hand?

What else do I need to do?

Gently exercise the affected arm or hand.

Take mild painkillers if required.
Do not apply any other lotions, creams or ointments unless you have been instructed to do so by a doctor or
nurse.
Do not expose the area to strong sunlight.
Avoid wearing tight clothing around the affected area.
Protect the affected area when bathing (or having a shower) so that it does not get wet.

When should I contact you?

If you answered YES to any of the questions in the checklist above, or if you have any other concerns, then you must
contact someone at this hospital who is experienced in extravasation.

Contact Telephone Number ..

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PHARMACY DEPARTMENT

APPENDIX F: DMSO for Unlicensed Use in Treatment of Extravasation

Dimethyl Sulfoxide (DMSO) 98% Solution
To be used according to the St Lukes Cancer Alliance Guidelines for Prevention and Management of Chemotherapy
Extravasation, Version 8, 2014
This product is not licensed for the treatment of extravasation injuries. Therefore patient details must be recorded each
time it is used for this purpose.
Please complete the details below:

Patient Name:
Hospital Number:
Consultant:
Date:
DMSO must be prescribed on the drug chart.

Product Details: DMSO 98%

Batch Number:
Expiry date:

Please give this sheet to your pharmacist for replacement supply. The product may only be replaced if the above
details have been completed.

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APPENDIX G: Preparation and administration of dexrazoxane (Savene)

Dexrazoxane should be given once daily for 3 consecutive days following anthracycline extravasation.
Dexrazoxane dosing is as follows:
Day 1: 1000mg/m2
Day 2: 1000mg/m2
Day 3: 500mg/m2

(max 2000mg)
(max 2000mg)
(max 1000mg)

Dexrazoxane is a cytotoxic drug and therefore may only be reconstituted in a pharmacy aseptic unit.
It has a short shelf life once reconstituted (4 hours at 2 8oC).
The patient must be consented for dexrazoxane, as it is a cytotoxic.
The prescription should be written using the template in Appendix H.
Dexrazoxane may only be administered by a trained chemotherapy nurse.
Each dose should be infused, in 500ml of buffered diluent provided with the Savene, over 1 2 hours.
Day 2 and Day 3 doses should be given at the same time of day (+/- 3 hours) as Day 1.
Special precautions for the administration of Dexrazoxane (Savene):
 The first dose must be administered as soon as possible, and initiated within 6 hours of extravasation.
 Cooling and DMSO should not be used in combination with treatment with dexrazoxane (local cooling should be
removed at least 15 minutes prior to administration) as they may interfere with efficacy of dexrazoxane. Hydrocortisone
cream should also not be used.
 The patient should be cannulated in the opposite arm to the extravasation wherever possible or, if this is not possible,
higher than the site of extravasation.
 This current cycle of chemotherapy must be discontinued and not restarted until at least 48 hours following day 3
infusion. The consultant must be informed as soon as possible as they will need to consider re- prescribing the cycle
of chemotherapy.
 It is not recommended in children (age < 18 years) or in patients with hepatic or renal impairment (CrCl <
40ml/min).
 It is generally not recommended in combination with live attenuated vaccines or with phenytoin.
 Patients at risk of hyperkalaemia should be monitored for plasma potassium levels. It also contains sodium which may
be harmful to patients who have a raised sodium level.
 Patients on anticoagulants should be monitored more frequently i.e. daily whilst patient receiving dexrazoxane.
 Local examination (for phlebitis and local injection site pain) and haematological monitoring should be performed on a
regular basis (e.g. daily) after treatment until resolution.
 Patient referral to a plastic surgeon for assessment of the extravasation injury within 7 days after the extravasation is
mandatory.
This is an expensive drug; therefore you should seek guidance for prescribing from your Lead Chemotherapy Nurse or Day
Centre Manager, and consult the dexrazoxane algorithm below.
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St Lukes Cancer Alliance NHS

Dexrazoxane (Savene) Algorithm

An extravasation has occurred

YES

Was it doxorubicin; epirubicin; idarubicin or daunorubicin?

NO

Is it an adult or child?

ADULT

CHILD (< 18
years)

Was the extravasation from a

CVAD?

YES

YES

Dexrazoxane not required but

consider flush out technique
NO

Did 5ml or more extravasate from

the peripheral device?

NO

Discontinue all administration of chemotherapy

Apply cold pack to area
Do not apply DMSO
Refer patient for possible DEXRAZOXANE infusion

If less than 6 hours since

extravasation

Considerations for prescriber

1.

Savene not recommended in

patients with hepatic or renal
impairment (CrCl < 40ml/min) or in
combination with live attenuated
vaccines or with phenytoin

2.

Savene not accessible out of RSCH

aseptic hours; consider saline flush-out

2.

Discuss and explain to patient

a) Side effects of drug
b) Requirement for 3 days treatment
c) Need to re-treat with chemotherapy

3.

Obtain patients consent

3.

Prescribe as follows:Day 1: 1000mg/m2

Day 2: 1000mg/m2
Day 3: 500mg/m2

If BSA more than 2m2, Day 1 and 2 doses

should not exceed 2000mg;
Day 3 dose should not exceed 1000mg.

Considerations for person administering

a) Collect drug from pharmacy pre-prepared
b) Stop cold pack 15 minutes prior to administration
c) Attempt to cannulate patient in opposite arm (if peripheral
extravasation)
d) Initiate administration as soon as possible and within 6
hours of extravasation
e) If receiving scalp cooling will need to consider continuing
during dexrazoxane infusion.

Post Administration

Drug added to 500ml diluent provided with

Savene and infused over 1 2 hours.

Do not administer any of the remaining chemotherapy

Check dexrazoxane infusion site for phlebitis or site pain
Patients own medical team to be informed
Referral to plastic surgeon for assessment within one week of
the event
Monitor patients FBC and U&Es regularly (nadir expected
Day 11 12)

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St Lukes Cancer Alliance NHS

APPENDIX H: Dexrazoxane prescription chart

Patient Addressograph or details;

CONSULTANT:

CHEMOTHERAPY REGIMEN:

ALLERGIES:

Ht:

Wt:

kg

BSA:

m2

Patient Name:
Address:
DOB:
Hospital Number:

Dexrazoxane (Savene) 1000mg/m2 IV Days 1 & 2, then 500mg/m2 IV Day 3

Must ONLY be prescribed in the following circumstances:

5ml or more peripheral extravasation of doxorubicin, epirubicin, daunorubicin or idarubicin

All central venous extravasations of doxorubicin, epirubicin, daunorubicin or idarubicin
Adult patients only (age > 18 years)
Case discussed first with Trust Lead Chemotherapy Nurse or Senior Chemotherapy Sister
Infusion initiated less than six hours after extravasation event (administer as soon as possible)
Written patient consent obtained (dexrazoxane is cytotoxic)
Not recommended for patients with hepatic or renal impairment (CrCl <40ml/min), or those taking phenytoin, or
recently received a live attenuated vaccine

Refer to extravasation policy and treatment algorithm for full details.

Do not apply DMSO, stop cold pack at least 15 minutes prior to dexrazoxane administration.
Each daily dose should be given at the same time of day (+/- 3 hours)
DATE:

LOCATION:

Dose

Route

Administration
details

*Ondansetron

8 mg

PO

*Dexamethasone

8 mg

PO

* If not given prior to

extravasation
* If not given prior to
extravasation
In 500ml of buffered diluent
(provided with Savene)
Infuse over 1 2 hours

Drug

DAY
1

DAY
2

DAY
3

IV

Dexrazoxane
1000 mg/m2
(Max 2000 mg)

mg

Ondansetron

8 mg

PO

Dexamethasone

8 mg

PO

Dexrazoxane
1000 mg/m2
(Max 2000 mg)

mg

IV

Ondansetron

8 mg

PO

Dexamethasone

8 mg

PO

Dexrazoxane
500 mg/m2
(max 1000mg)

CONFIRMED BY:

mg

DATE:

IV

Prescriber
sig. & date

Date
given

Time
given

In 500ml of buffered diluent

(provided with Savene)
Infuse over 1 2 hours

In 500ml of buffered diluent

(provided with Savene)
Infuse over 1 2 hours
PHARMACIST:
Page 17 of 18

DATE:

FAXED:

Sig. of
nurse

St Lukes Cancer Alliance NHS

APPENDIX J: Guide to Transport Arrangements for Savene

This guide should be followed for delivery of Savene to St Peters Hospital, Ashford Hospital, East Surrey Hospital or
Frimley Park Hospital.
(If a patient is at Crawley Hospital, they will be transferred to East Surrey Hospital for Savene administration)
As Savene administration needs to be initiated as soon as possible following an anthracycline extravasation - and no
later than 6 hours after the extravasation - it is important to organise urgent transport of the Day 1 dose of Savene to
the requesting Trust.
Also note that, once reconstituted, the shelf-life for Savene is only 4 hours at 2 8oC.
To minimise the delivery time, transport will always be organised by RSCH pharmacy staff, rather than the requesting
Trust.
The requesting Trust must inform the RSCH pharmacist exactly where the Savene is to be delivered e.g. specify the
ward name, or pharmacy department.
The options for transport are:
a) RSCH Trust hospital transport
Hospital transport desk open 8am to 5pm Monday - Friday
Tel no: 01483 464895 or 01483 464111
The hospital transport service cannot guarantee a rapid response time, and is not designed to provide an emergency
service, but should be contacted first within working hours, as there may be a vehicle available. Hospital transport
should only be used if it is available to leave RSCH within 30 minutes maximum from the time that aseptics expect the
prepared dose to be ready.
b) City Cabs and Cars Ltd
Tel no: 01483 888666 or 01483 560063
If there is no hospital transport available to leave RSCH within a suitable timeframe, transport should be arranged with
this local taxi company, with whom RSCH have an account.
RSCH switchboard staff will book the taxi on our behalf (switchboard have the RSCH account number, which needs to
be quoted). Pharmacy need to give the switchboard staff our Pharmacy cost centre code.
RSCH pharmacy will bill the requesting Trust retrospectively for the taxi fare.
Whichever transport service is booked, ensure that a collection time and collection place are agreed, and that the
driver is aware of the urgent nature of the delivery.

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