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If a chemotherapy drug leaks out of the vein into the skin around a drip or port, the nurse stops the drip at once, draws back what they can, marks the area and then treats it according to the drug, with an antidote or a cold or warm pack. Tell the team straight away if the site stings, burns, swells or changes colour, during treatment or in the days after.
Extravasation is leakage of an intravenous anticancer drug into the surrounding tissue. Management starts the same way for every drug: stop the infusion, leave the cannula or port needle in place, aspirate what can be withdrawn without flushing, mark and photograph the area, inform the senior nurse and doctor, then remove the device and elevate the limb.
The specific measures depend on the drug's class. Vesicants are split into DNA-binding agents (anthracyclines, mitomycin, dactinomycin, mechlorethamine), which are localised and neutralised with cold, and non-DNA-binding agents (vinca alkaloids, taxanes), which are dispersed with warmth and hyaluronidase. The ONS/ASCO 2025 guideline, the newest GRADE-based one, recommends antidotes where available: dexrazoxane for doxorubicin, daunorubicin, epirubicin and idarubicin; hyaluronidase for vinca alkaloids, and conditionally for paclitaxel and docetaxel; topical dimethyl sulfoxide for mitomycin and mitoxantrone, or for an anthracycline when dexrazoxane is unavailable or contraindicated; sodium thiosulfate for more than 20 ml of high-concentration cisplatin and for bendamustine. Thermal compresses are used three to four times daily for 48 to 72 hours: cold for most vesicants, warm for vinca alkaloids, etoposide and oxaliplatin, and for taxanes when hyaluronidase is given.
Dexrazoxane is given intravenously in the opposite limb, 1000 mg/m2 on days 1 and 2 and 500 mg/m2 on day 3, the first dose within six hours, with cooling removed 15 minutes beforehand and no dimethyl sulfoxide alongside. Extravasation from a central venous access device, and high-risk cases, are referred early for surgical review. The Japanese 2024 guideline differs on heat (it weakly recommends against warm compresses alone) and makes no recommendation on aspiration; it weakly recommends against local steroid injection and against debriding an ulcer without necrosis. Documentation, patient teaching and follow-up for weeks complete the protocol.
Why: Early signs are often subtle, and treatment works best when it starts as soon as extravasation is suspected.
Oncology Nursing Society and American Society of Clinical Oncology 2025
Why: Leaving the device in gives a route to draw back drug still sitting in the line or tissue.
“Stop the infusion immediately but leave the needle or catheter in place to allow for the possibility of aspirating any residual drug from the line or tissue.”
Why: Less drug left in the tissue means less damage; flushing or pressure would push more of it in.
“Attempt to withdraw as much of the drug as possible using a syringe, then disconnect the tubing.”
Why: Antidotes and referrals need a prescriber, and some have to start within hours.
“A doctor should be informed of the incident immediately; in the case of vesicants or an extravasation via a CVAD a consultant should be informed.”
West Midlands Expert Advisory Group for Systemic Anti-Cancer Therapy, NHS England 2017
Why: A marked outline and a photograph show later whether the injury is spreading or settling.
“Mark the extravasated area with a pen, take a digital image if possible.”
West Midlands Expert Advisory Group for Systemic Anti-Cancer Therapy, NHS England 2017
Why: Raising the limb helps the fluid be absorbed; firm pressure spreads the drug.
Oncology Nursing Society and American Society of Clinical Oncology 2025
Why: The class decides whether the area is cooled to keep the drug in one place or warmed to spread it, and which antidote applies.
“DNA – binding: these drugs are absorbed locally, enter cells and bind to their DNA, precipitating the death of the cell. Following this, the drug can then be re-released to further destroy healthy cells leading to deeper erosion of cells within the tissue”
West Midlands Expert Advisory Group for Systemic Anti-Cancer Therapy, NHS England 2017
Why: Cold narrows the vessels, which keeps the drug in a small area.
“Cold compresses vasoconstrict and reduce spread and are best for alkylating agents, anthracyclines, taxanes (without hyaluronidase use), and antimetabolites.”
Why: Warmth spreads the drug so that it is diluted and absorbed.
“Warm compresses disperse the agent and should be used for vinca alkaloids, etoposide, oxaliplatin, paclitaxel, and docetaxel (when coadministering hyaluronidase).”
Why: The guideline panel preferred this longer course to a single day.
“Using compresses use three to four times daily over 48–72 hours is recommended over shorter durations (e.g., 24 hours).”
Why: Dexrazoxane is the antidote licensed for anthracycline extravasation, and the window for the first dose is short.
“The first infusion should be initiated as soon as possible, within the first six hours after the accident.”
Why: This is the licensed three-day schedule used in the trials that supported it.
“Treatment should be given once daily for 3 consecutive days. The recommended dose is: Day 1: 1000 mg/m2 Day 2: 1000 mg/m2 Day 3: 500 mg/m2”
Why: The drug has to reach the injured tissue through the blood, which cold slows.
“Cooling procedures such as ice packs should have been removed from the area at least 15 minutes before the Savene administration in order to allow sufficient blood flow.”
Why: In animal studies the combination caused skin wounds that dexrazoxane alone prevented.
“Dimethylsulfoxide (DMSO) should not be used in patients who are administered dexrazoxane to treat anthracycline extravasation”
Why: Dimethyl sulfoxide is thought to protect tissue by scavenging free radicals.
“Dimethyl sulfoxide for extravasation occurring with mitomycin C and mitoxantrone as well as when dexrazoxane is not available or is contraindicated”
Why: It should treat the injured area without irritating healthy skin.
“Carefully apply a thin layer of DMSO topically to the marked area avoiding contact with unaffected areas”
West Midlands Expert Advisory Group for Systemic Anti-Cancer Therapy, NHS England 2017
Why: This is the schedule the ONS/ASCO algorithm gives; see the variants for a six-hourly one.
Oncology Nursing Society and American Society of Clinical Oncology 2025
Why: Hyaluronidase breaks down the tissue's binding substance so the drug spreads and is absorbed.
“Hyaluronidase for extravasation occurring with vinca alkaloids, paclitaxel, and docetaxel”
Why: Ringing the area spreads the enzyme evenly through it.
“Subcutaneously (or intradermally) inject 1 ml (150 IU) of hyaluronidase as 5 separate 0.2 ml injections around the periphery of extravasation site.”
West Midlands Expert Advisory Group for Systemic Anti-Cancer Therapy, NHS England 2017
Why: Taxane leaks may not cause severe injury, but the panel judged the possible benefit worth the low risk.
“Although paclitaxel or docetaxel extravasations may not result in severe tissue injury, the experts made a conditional recommendation that patients receive hyaluronidase as an antidote because of a potential benefit in minimizing injury and the low potential for harm.”
Oncology Nursing Society 2025 · conditional recommendation
Why: The ONS/ASCO panel names it as the antidote for these two drugs.
“Sodium thiosulfate for extravasation occurring with > 20 ml of cisplatin in high concentration (greater than 0.5 mg/ml) and bendamustine”
Why: The UK network guideline classes these as DNA-binding vesicants and puts them on the cold, localise pathway.
West Midlands Expert Advisory Group for Systemic Anti-Cancer Therapy, NHS England 2017
Why: Irritants rarely break the skin down, so comfort and the drug's action guide the choice.
“For extravasation of agents not listed, consider the mechanism of action, presence of pain or swelling, and patient comfort when selecting a compress.”
Why: In the evidence the Japanese panel reviewed, injected steroids were linked to worse injury and slower recovery.
“It is weakly recommended not to inject local steroids for EV of anticancer drugs.”
Japanese Society of Cancer Nursing, Japanese Society of Medical Oncology and Japanese Society of Pharmaceutical Oncology 2024 · Not recommend (weak), certainty D
Why: The panel judged these patients the likeliest to benefit from early specialist review.
“The panel suggested that patients with central line extravasation of vesicants or irritants with vesicant properties be referred for surgical evaluation or escalation of care in addition to conservative management when indicated.”
Why: Ulcers without necrosis can heal without surgery, and it is hard to judge early how deep the damage goes.
“It is weakly recommended not to debride EV-induced skin ulcer lesions without necrosis.”
Japanese Society of Cancer Nursing, Japanese Society of Medical Oncology and Japanese Society of Pharmaceutical Oncology 2024 · Not recommend (weak), certainty C
Why: A full record guides follow-up and lets the service learn from each event.
“Document the event carefully, including the drug, dose, timing, interventions taken, and the patient’s response.”
Why: Damage can appear days or weeks later, at home.
“Monitor the area for changes such as redness, pain, blistering, peeling, or streaks and report any delayed reactions such as fever higher than 100.4º F.”
Why: A planned review catches injury that is getting worse.
“All patients must have a review of their extravasation injury within 1 week, this appointment must be arranged prior to the patient leaving clinic”
West Midlands Expert Advisory Group for Systemic Anti-Cancer Therapy, NHS England 2017
Why: Injury from DNA-binding drugs has a history of appearing late.
Oncology Nursing Society and American Society of Clinical Oncology 2025
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
The strongest current recommendation is the ONS/ASCO guideline (2025, GRADE): stop, aspirate and mark; use the drug's antidote where one exists (dexrazoxane for anthracyclines, hyaluronidase for vinca alkaloids and conditionally for taxanes, dimethyl sulfoxide for mitomycin and mitoxantrone or when dexrazoxane cannot be used, sodium thiosulfate for concentrated cisplatin and bendamustine); thermal compresses for 48 to 72 hours, cold for most vesicants and warm for vinca alkaloids, etoposide and oxaliplatin; and early surgical referral after a central line extravasation. Dexrazoxane follows its licensed three-day schedule, started within six hours. Guidelines disagree on two points. ONS/ASCO recommends warm compresses for the dispersing drugs and its algorithm advises aspiration; the Japanese JSCN/JSMO/JASPO guideline (2024) weakly recommends against warm compresses used alone, partly because hyaluronidase is not approved for extravasation in Japan, and makes no recommendation on aspiration because the evidence could not be weighed.
Oncology Nursing Society 2025 · Oncology Nursing Society and American Society of Clinical Oncology 2025 · European Medicines Agency 2024 · Japanese Society of Cancer Nursing, Japanese Society of Medical Oncology and Japanese Society of Pharmaceutical Oncology 2024
Where it differs: Sorts vesicants by DNA binding: DNA-binding drugs get cold compresses and antidotes, non-DNA-binding drugs get warmth and hyaluronidase. Compresses for 20 minutes four times daily for 1 to 2 days. Chooses the anthracycline antidote by volume: topical dimethyl sulfoxide under 3 ml, dexrazoxane over 3 ml. Starts hyaluronidase within 1 hour (ONS/ASCO says within 2 to 4 hours). Refers vesicant and irritant extravasations to the local plastics or flush-out team for a saline flush-out as soon as possible. Its dimethyl sulfoxide appendix says every 6 hours for 7 days while its own antidote table says every 8 hours.
Evidence: Expert consensus with no grades; the guideline describes the antidote evidence as often inconclusive. It passed its own review date in July 2019.
West Midlands Expert Advisory Group for Systemic Anti-Cancer Therapy, NHS England 2017
Where it differs: Cold compresses weakly recommended; warm compresses alone weakly recommended against; topical steroids weakly recommended and injected steroids weakly recommended against; no recommendation on aspiration. Classifies oxaliplatin, docetaxel, paclitaxel and mitoxantrone as vesicants on its own systematic review, where the UK network list calls oxaliplatin and mitoxantrone irritants.
Evidence: GRADE with the Minds handbook; certainty very low (D) for most local measures and moderate (B) for dexrazoxane.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Give dexrazoxane for anthracycline extravasation “Administration of dexrazoxane for EV induced by an anthracycline cancer drug is weakly recommended.” | Recommend (weak), certainty B | Japanese Society of Cancer Nursing, Japanese Society of Medical Oncology and Japanese Society of Pharmaceutical Oncology 2024 |
| Use cold compresses as local therapy “Cold compression is weakly recommended as local therapy to prevent aggravation/progression of tissue injury and inflammation induced by EV.” | Recommend (weak), certainty D | Japanese Society of Cancer Nursing, Japanese Society of Medical Oncology and Japanese Society of Pharmaceutical Oncology 2024 |
| Avoid warm compresses used alone “Avoidance of warm compresses (heat) is weakly recommended to prevent EV-induced skin damage and aggravation/progression of inflammation.” | Not recommend (weak), certainty D | Japanese Society of Cancer Nursing, Japanese Society of Medical Oncology and Japanese Society of Pharmaceutical Oncology 2024 |
| Aspirating residual drug or blood “No recommendation (no vote).” | None, certainty D | Japanese Society of Cancer Nursing, Japanese Society of Medical Oncology and Japanese Society of Pharmaceutical Oncology 2024 |
| Do not inject steroids locally “It is weakly recommended not to inject local steroids for EV of anticancer drugs.” | Not recommend (weak), certainty D | Japanese Society of Cancer Nursing, Japanese Society of Medical Oncology and Japanese Society of Pharmaceutical Oncology 2024 |
| Apply topical steroids “Applying topical steroids for EV of anticancer drugs is weakly recommended.” | Recommend (weak), certainty D | Japanese Society of Cancer Nursing, Japanese Society of Medical Oncology and Japanese Society of Pharmaceutical Oncology 2024 |
| Do not debride an ulcer without necrosis “It is weakly recommended not to debride EV-induced skin ulcer lesions without necrosis.” | Not recommend (weak), certainty C | Japanese Society of Cancer Nursing, Japanese Society of Medical Oncology and Japanese Society of Pharmaceutical Oncology 2024 |
| Give hyaluronidase after paclitaxel or docetaxel extravasation “the experts made a conditional recommendation that patients receive hyaluronidase as an antidote” | conditional recommendation | Oncology Nursing Society 2025 |
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Shares Peripherally inserted central catheters (PICC lines), Implanted ports for chemotherapy (port-a-cath, power-injectable, apheresis and intraperitoneal ports), Central venous access (port, PICC line).
Shares Infusion reactions, hypersensitivity and extravasation, Oxaliplatin, Docetaxel, Paclitaxel / nab-paclitaxel.
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Shares Dexrazoxane, Mitoxantrone, Daunorubicin, Etoposide.