Extravasation

Advocacy, General 3 Minutes

Ok, the first time I heard this word, I confess that I was confused. Extra, what? And then I learned more and I knew that I needed to share.

The formal definition of “Extravasation” from the National Institute of Cancer is: “The leakage of blood, lymph, or other fluid, such as an anticancer drug, from a blood vessel or tube into the tissue around it. It is also used to describe the movement of cells out of a blood vessel into tissue during inflammation or metastasis (the spread of cancer).”

Basically, in my words, extravasation can be caused when the nurse or other person inserting an IV needle misses the vein or target and whatever is in the IV goes into the surrounding area instead. This happened to me once when I was going into surgery — the nurse had inserted the IV in the pre-op area and when the “happy juice” was injected into the IV, the inside of my elbow suddenly ballooned. It wasn’t a small thing either and it was pretty freaky looking and freaked me out when I was already anxious. The anesthesiologist accessed a vein in my hand when I got into the operating room, I got my happy juice, and I haven’t had any issues with my vein or that area.

BUT

What if instead of happy juice, the injection was nuclear material? Or something else?

For those of us with Stage IV Metastatic Breast Cancer (MBC), we get scans regularly that include injections of isotopes of different kinds for contrast. Radioactive isotopes. And, for most of us, those injections are given in our veins (side note, another good reason to ask for a power port!!). I’ve not personally experienced extravasation with nuclear material, but here’s some information I received from Rx 4 Good about what could happen:

Text Box: Diagnostic Extravasation A 44-year-old male with end-stage cardiac failure was administered Technetium (Tc) through an IV in the arm as part of a “nuclear stress test” to evaluate how well his heart was pumping. Six days after the procedure, the patient developed discoloration at the injection site, and the skin later peeled off completely. Evaluation by vascular access experts confirmed extravasation of the radiopharmaceutical caused the severe tissue and skin damage.
Text Box: Therapeutic Extravasation A 29-year-old male with non-Hodgkin’s Lymphoma was treated with Yttrium-90, a high-energy radiopharmaceutical used as a therapy to kill cancer cells. The technologist administered the drug via an existing forearm catheter, which had not been checked to ensure correct functioning. The extravasated drug deposited its radioactive energy into healthy skin tissue, resulting in the severe necrosis shown above after 25 days.

Pretty scary looking, right?

Of course, I put my advocacy (and lawyer) hat on and started to ask questions about where this is reported to and what is done about it and to my surprise, a U.S. Nuclear Regulatory Commission (NRC) policy allows providers to keep extravasations hidden from patients, treating physicians, and NRC itself.

Um, what?

Any policy that allows anyone to keep something about my care or a potential issue from my attention hidden raises some serious red flags for me. Especially since it’s already happened once to me and no one said anything about it. In fact, after I learned about this issue, I accessed the surgical report from that surgery and it wasn’t mentioned at all. My complaint to the hospital about how I’d requested my port to be accessed rather than my hand and was ignored talked about it, but nothing made it to my file.

Nothing.

Again, from Rx 4 Good:

Current NRC policy specifically excerpts incidents like these (pictures above) from medical event reporting because the NRC was told in 1980 that extravasations are “virtually impossible to avoid.” As a result, information is not shared with patients, their treating physician, or any regulatory body. Centers are not required to actively monitor radiopharmaceutical administrations beyond a visual inspection of the injection site during delivery, despite the fact that radiation injury may not become evident until weeks or months later. Active monitoring of radiopharmaceutical administrations can alert clinicians to possible extravasations. Immediate awareness of high doses can help clinicians take mitigation steps to minimize the damage to the patient’s tissues.

NRC knows that extravasations can be avoided but has yet to change its outdated policy. Significant extravasations, like the cases above, should be reported to the patients are affected, their healthcare team, and the NRC.

This may seem like a small issue, but when I add up the amount of times I’ve been given an IV in the four (4) years I’ve been living with MBC, I start to hyperventilate a little. On the one hand, I’m pretty thankful that this has only happened once to me in all that time that I’m aware of and, on the other hand, how many times it could have happened is pretty scary. Add in a dollop of secrecy and I’m on my way to a full blown panic attack.

While I get the concerns about having to report something that happens without anyone being in the “wrong,” the fact that a patient might have nuclear or some other material eating up their skin in addition to whatever else is going on, is just all kinds of inappropriate. Why should patients have to wonder?

Here’s a great letter that has been sent to the NRC by the organizations listed in the header — maybe YOU know an organization that might want to add their name to the list!

extravasations-group-letterDownload

Bottom line? We as patients, especially those of us who will be in treatment forever, need to be armed with information. Nothing should be hidden from us, ever. Empower us with information, I say, to all that I am in contact with.

Published by Abigail Johnston

I'm a daughter, a wife, a mother, and I've been living with Stage IV Metastatic Breast Cancer since March, 2017. All of the words I publish are my own.

Published

23 thoughts on “Extravasation”

  1. Thank you once again for this interesting bit of info. The level of self -advocacy we are responsible for never ceases to amaze me! At my facility the nurses always flush any IV line with saline before other meds and also make sure they can get blood out easily (this must be standard practice). They make sure the saline is going in correctly and I make sure I notice that saline taste/sensation. I knew this was to prevent anything from escaping the veins but I never knew the word for it or the potential consequences (and lack of consequences for the medical facility/practitioners). Yikes!

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  2. Wow. One more thing to add to your Little Deaths sheet (I wrote a long, LONG response to that). I don’t like to think about how many times I have received radioactive meds for scans, etc. I do ALWAYS thank the person drawing blood who has done an excellent job (no pain, nor problems) and I have asked for another person if they can’t get me on the first jab. I have large, prominent veins so it should not and usually is not difficult. Thanks for this very helpful information.

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  3. Extravasation! Why not just say a leak? I became familiar with this term when my old port developed an extravasation. It wasn’t hidden from me. My surgeon and his NP discussed it in front of me during an office visit to plan for removal. I had to ask what the term meant but had it figured out from context.

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  5. I’ve had this happen three times!!! Once with the saline flush before they injected the CT contrast (fortunately it was just saline), once with a Zometa infusion and, most concerning, once with the radioactive bone scan tracer!!! With the Zometa and bone scan tracer, it was near the end of the infusion / injection so not sure if the needle had been improperly inserted or if my vein just gave out (same vein both times). All three eventually absorbed but the bone scan tracer was particularly painful, yet when I asked about possible complications, my concerns were waived off, which was super frustrating. Now, I bring it up every time I get one of these treatments and you can bet that the person inserting the needle takes extra care!

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  6. I’m freaking out a bit right now as I’m due to have a PET scan in a few hours and you’ve reminded me of when a friend’s chemo leaked into her arm. There was general panic in the chemo suite with doctors being called along with a medical photographer to record the damage. It was not pleasant.

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  8. WOW ! This makes me stand even higher on my platform to scrutinize the technique in which my new nurses start IV’s and access ports. Thank you for posting this. Sending nurses to this post.

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  9. Hey Abigail your scary picture is nowhere to be found. While this is indeed important the photo I’m sure would’ve given your point that extra oomph. Now that my ports gotta come out it’s worrisome to me too as it should be for anyone receiving nuclear injections causing enough concern as it is. Barbaric and incredulous come to mind in that we haven’t the right to know what’s going on in our own body let alone the audacity of keeping us glowing in the dark. Yuck.

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  10. Pingback: Weekly Round-Up | Journeying Beyond Breast Cancer

  11. It happened to me once with an IV during a hospital stay. I told the nurse it didn’t feel right. She pushed saline to check. She asked if it hurt. I said yes actually a little. And I have a very high pain tolerance.

    She then said maybe she hadn’t opened the line with that little plastic thing that slides to stop it, and she thought maybe she didn’t, so she put a SECOND syringe full of saline into my arm!

    She finally admitted it was not in my vein and moved to another arm. But not before it swelled up so much that it was bruised from 2014 until now I think. Unless it’s the lighting in this room, I have been able to see it ever since. I thought it was just never going away.

    I think I’ve also mentioned how I went into cardiac arrest in 2001 and nobody ever told me. They did say I gave them a scare, but they never told me my heart stopped. A few years later I was going through some paperwork and noticed a medical document that said cardiac arrest. I assumed it was something related to my late husband, but when I looked it had my name on it. I kept thinking of the Raymond episode where they didn’t tell him he hadn’t come out of the anesthesia, and he says, “When you die, somebody should TELL YOU!” 🤦🏽‍♀️

    I completely agree all those doctor notes that don’t show up in our records should be available to us. There are some shady doctors out there just like there are in every field. And this is a pretty important one to just let things like that slide.

    I feel so sorry for people who aren’t like us and just settle for substandard care. They don’t know how to make heads spin like we do. 😂

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    1. Girl, you know we make heads spin and roll and all sorts of poltergeisty things. Sometimes I wonder if it’s better to be more accepting and oblivious, but when you know a thing, it can’t be unknown. All we can each do is just keep putting one foot in front of the other. Love you, friend.

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