Forum topic

 Drug dilution will not alter the fact that a drug is a vesicant. If any vesicant escapes into the SC tissue, there will likely be tissue necrosis. 

You defintely need 2 important resources. First is the INS Standards of Practice and Second is the ONS Chemotherapy and Biotherapy Guidelines. You are held accountable to these documents in your practice. 

Any vesicant infusing for more than 30 minutes should be infused through a CVAD such as the PICC you mentioned. Confirmation of tip location immediately after it is inserted, all nurses infusing through the line must know where that tip is located anatomically. Radiology saying "in good position" is not sufficient. You must know that it is in the lower third of the SVC at or near the cavoatrial junction. There is still no guarantee that extravasation will not occur with a CVAD. So you must assess for all signs and symptoms of tip malposition which includes a blood return the color and consistency of whole blood. When infusing a vesciant through a PIV, the recommendation is to assess blood return every 2-3 mL or every 5-10 minutes. There are no time or volume recommendations for this assessment when infusing through a CVAD. You must educate the patient and family about all signs and symptoms and what to do if they occur at home. Then every day when the fluid container is changed, make those same assessments for tip migration and extravasation. And document everything with each visit. Doxorubicin is one of the most dangerous vesicants, regardless of the dilution. Lynn

We frequently infuse Adriamycin in the home infusion environment.  We have a regimin that we do that includes cytoxan, doxorubicin and dacarbizine in a contiunous infusion over 7 days.  We check for blood return at start of care-pt then goes home and returns in one week for disconnect.  They are given oral and written instruction regarding an extravasation and what to do.  Fortunately we have only had one issue in the 20 plus years we have been doing this and it was due to needle dislodgement at the port site.  The MD that does this is very progressive and doesn't like his pts to be hospitalized if it can be avoided.  These pts do quite well some even continuing to work while they are infusing.

Agree with Lynn and dpotts. NEVER this infusion via PIV over 30 min and nurse stays with patient during short infusion via PIV. Continuous infusion can be done safely in outpt setting, but I would NOT recommend a port. There is a much higher incidence of extravasations in ports because of accidental needle dislodgement (see dpotts comment). PICCS and tunneled Groshongs would be my CVCs of choice for the type of outpt infusion you describe. VERY SPECIFIC written instructions to the patient about turning pump off and returning to clinic if line was tugged on. Two questions: If you are doing this from an Infusion Center or onc office setting, who will answer the call with problems in the middle of the night? Secondly, what type of infusion pump are you using? There is still some risk in sending the patient into their home environment if they do not follow instructions to the letter or are cavalier about the infusion. I don't think I would have the pt check for blood return or do any flushing if he is returning each day to see the RN. And in spite of the 20 mg in 500 ml, all continuous infusion vesicant standards should be followed. ONS does not indicate how often a line should be checked for blood return when pt is receiving a continuous infusion vesicant. In the hospital (my setting), we have to balance infection control risks of entering the line with our need to assure we are still receiving blood return. If a central line is undisturbed, I think once/8-12 hour shift is enough to check for blood return--but each RN needs to assess this to assure that the CVC is functioning properly under her/his care. (I try to minimize the hazardous drug exposure that MAY occur during the blood return checks, so don't encourage Q 2 hr or Q 4 hr checks.) However, if patient gets line caught on something, or falls, I would immediately stop it and assess the line to see if there is more visible externally and if we still had blood return. I would get a CXR to assess tip location if there was more visible externally (more than a cm or two, depending on where the tip started out).