As we meander through our treatments, we all will be forced to face the needle. Injections, injections, we all will receive injections and infusions. Despite the commonality of this experience, we read very little about them, especially injection sites and the available technologies for these injections and infusions. We also do not learn about injection site negative reactions until we experience them.

My interest in sharing this information was prompted by Scott Goodman’s recent post ( 3rd Update which I posted on November 24, 2008) on this blog about his journey on chemotherapy. After Scott mentioned that, he had a port-a-cath inserted by a surgeon prior to starting his first chemotherapy infusion, I received a number of emails from people asking what was a port-a-cath?

I also wish to describe the Injection site reactions that occur when the drug escapes from the veins or IV catheter into the skin (extravasation). Drugs escaping into the skin cause two types of site reactions, irritants and vesicants.

Irritant reactions are characterized by short-lived and limited irritation to the vein. Symptoms include: tenderness, warmth, itching or redness that extends along the vein or at the injection site.

Vesicant reactions, which are sometimes called chemical cellulites, include symptoms that initially look like an irritation but then worsen, depending on the amount of chemical that has leaked under the skin.

Vesicants can cause redness and blistering. Larger amounts of vesicant leakage from the chemical being injected can lead to severe skin damage in a matter of days.

Sometimes symptoms from leakage of vesicants may be delayed for up to 6-12 hours after a chemotherapy injection. Itching is common in the absence of pain at the injection site.

The actual severity of the injection site reaction depends on the vesicant potential of the specific chemical as well as the amount and concentration of the drug exposure and the immediate measures taken by hospital personnel once the extravasation occurs.

Vesicant chemotherapy agents include mitoxantrone in prostate cancer as well as: Dactinomycin, daunorubicin, doxorubicin, epirubicin, idarubicin, mechlorethamine, mitomycin, paclitaxel, streptozocin, tenoposide, vinblastine, vincristine, vinorelbine.

Prevention is always the best treatment of extravasation. Make sure that the administering nurse or doctor giving these types of injections has been carefully trained and is experienced.

When you are faced with needing to receive many needle sticks, a central venous access device might be recommended, as in the case with Scott and his regular chemotherapy infusions. There are a number of different options for central devices, they include:

*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 should be terminated. A PICC line involves the insertion 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.

Tunneled catheters are inserted in an outpatient surgical procedure and a special x-ray, called fluoroscopy, to insure the catheter is in the right place, reducing risk of leaking vesicants.

These catheters can be left in place for months or years while experiencing a low incidence of infection, however, dressing changes and maintenance is required to avoid infections. These catheters can have multiple entrances (lumens) for medications to be infused or for blood to be drawn. Tunneled catheters are usually called by their brand names: Broviac®, Groshong®, and Hickman®.

*Port-a-cath: (what Scott had inserted) 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 catheter is then inserted into the superior vena cava vessel at entrance of the right atrium of the heart. The insertion procedure takes approximately one-hour using radiological guidance by an interventional radiologist or by a surgeon in the operating room.

A port-a-cath can be left in place and used for as long as three to five years. The port-o-cath can be felt under the skin and the nurse can finds the injection site by locating the edges of the port-o-cath and inserting 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 then as a patient in the hospital. There is no dressing changes required but there is some maintenance involved.

What is important is that you:

* Notify your health care professional immediately if you experience pain, redness or discomfort at the injection site and follow their directions.

Remember, prevention of extravasation is the key to management of this problem. If a medication has extravasated your health care professional will attempt to remove as much of the medication as possible from the injection site and discontinue the IV.
They will also apply cold or heat to the injection site depending upon what chemical was in the IV. In some cases there are 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.

Joel T Nowak MA, MSW