Vesicant Administration Safety: Classification, Central Access Requirements, and Protocols

Vesicant medications are intravenous agents capable of causing tissue destruction, blistering, necrosis, and permanent functional impairment when they escape the vascular system and contact surrounding tissue. Vesicant administration requires more than appropriate vascular access — it requires pre-infusion assessment, ongoing monitoring, antidote availability, and a clear emergency response plan. Getting any of these elements wrong can result in catastrophic patient injury.

Parent guide: Infusion Therapy Safety: Complete Reference

Vesicant vs. Irritant: The Clinical Distinction

Vesicant: An agent that causes tissue blistering, necrosis, or permanent injury upon extravasation. Even small volumes of most vesicants cause significant tissue damage.

Irritant: An agent that causes pain, phlebitis, or local inflammation upon extravasation or peripheral administration, but does not cause necrosis. Tissue injury from irritants is generally reversible.

The distinction matters for access decisions: True vesicants require central access when given as continuous infusions or in therapeutic doses. Irritants may be administered peripherally with close monitoring, appropriate dilution, and vein selection.

Clinically important caveat: Classification is not binary. Concentration and dose matter. Some agents are irritants at standard doses but behave as vesicants when highly concentrated or in large volumes. Always verify the specific formulation being administered.

Vesicant Classification by Category

Chemotherapy Vesicants

Anthracyclines (all are confirmed vesicants):

• Doxorubicin (Adriamycin)
• Epirubicin
• Daunorubicin
• Idarubicin
• Mitomycin C
• Dactinomycin (actinomycin D)

Vinca alkaloids (all are confirmed vesicants):

• Vincristine (Oncovin)
• Vinblastine
• Vinorelbine (Navelbine)
• Vindesine

Taxanes (vesicant at standard concentrations):

• Paclitaxel (Taxol) — vesicant; also contains Cremophor EL (polyethylene castor oil) as a solubilizer
• Docetaxel (Taxotere) — vesicant
• Cabazitaxel

Other chemotherapy vesicants:

• Cisplatin (concentrations >0.4 mg/mL)
• Carmustine (BCNU)
• Streptozocin
• Mechlorethamine (nitrogen mustard)
• Treosulfan

Non-Chemotherapy Vesicants

Vasoactive medications:

• Norepinephrine (Levophed)
• Dopamine
• Vasopressin
• Phenylephrine
• Epinephrine
• Dobutamine (vesicant potential, lower risk than catecholamines)

Electrolytes and solutions:

• Potassium chloride >40 mEq/L
• Calcium chloride 10% (not calcium gluconate)
• Sodium chloride >3% (hypertonic saline)
• Dextrose >10%
• Sodium bicarbonate 8.4%

Other:

• Acyclovir IV (high-osmolarity solution)
• Phenytoin (fosphenytoin is less vesicant)
• Promethazine IV (significant vesicant; black box warning; avoid IV administration when possible)
• Diazepam IV
• Vancomycin (at high concentrations or peripherally with slow infusion)

Irritants (Not True Vesicants but Require Monitoring)

• Most IV antibiotics at standard dilutions
• Standard-concentration potassium (10–40 mEq/L)
• Erythromycin IV
• Amiodarone IV
• Low-concentration vancomycin infusions
• Most benzodiazepines at therapeutic concentrations (except diazepam)

Access Requirements for Vesicants

Central Access: When Required

Per INS 2021 Standard 27 (Vesicant Therapy):

Central access is required for:

• All vesicant chemotherapy (anthracyclines, vinca alkaloids, taxanes, and others listed above)
• Continuous vesicant infusions of any duration
• Peripheral access failure or documented poor venous access with vesicant need

Central access is strongly preferred for:

• Vasopressors expected to run >6 hours (many institutions require central access for all vasopressor infusions)
• High-concentration potassium chloride (>60 mEq/100 mL)
• TPN and PN admixtures (osmolarity also drives central access requirement)

Peripheral Administration: When Acceptable and How

Some vesicants may be administered peripherally in specific circumstances:

Conditions for peripheral vesicant administration:

1. Single-dose bolus (not continuous infusion) with close monitoring
2. Adequate peripheral venous access confirmed before start
3. Blood return confirmed before and monitored during administration
4. Antidote available at the bedside before infusion starts
5. Patient is able to report pain or burning immediately
6. Nurse will remain at bedside or check every 15 minutes for duration

Absolute requirements per INS 2021:

• Pre-administration blood return confirmation from target vein
• Monitoring frequency: every 30–60 minutes for peripheral vesicant bolus
• Written plan in nursing notes for response to suspected extravasation
• Antidote available: appropriate antidote stocked and accessible before first dose

Pre-Infusion Assessment: Non-Negotiable Steps

Before every vesicant infusion — peripheral or central:

Step 1: Verify Access Appropriateness

• Confirm access type is appropriate for the vesicant (central for all chemo vesicants)
• For peripheral: verify site meets minimum criteria (fresh site, forearm or antecubital, large bore)
• Review medical record for contraindications (lymphedema, mastectomy in planned arm)

Step 2: Confirm Blood Return

• Aspirate blood return from catheter before vesicant administration
• For CVAD: brisk, dark venous blood return from each lumen to be used
• For PIV: blood return in catheter and absence of signs of occlusion
• Do not administer any vesicant without confirmed blood return

Step 3: Confirm Patency

• Flush with 10 mL normal saline (CVAD) or 3–5 mL (PIV) without resistance or swelling
• If resistance is felt or patient reports discomfort during flush: stop; investigate; do not administer vesicant

Step 4: Assess Site

• Inspect insertion site for redness, swelling, tenderness, blister, or drainage
• Palpate surrounding tissue for firmness or bogginess indicating prior infiltration

Step 5: Document Baseline

• Document pre-infusion blood return, patency, and site assessment
• This baseline documentation is critical for post-event reconstruction if extravasation occurs

Monitoring During Vesicant Infusion

Continuous Infusions (CVADs)

• Assess site at start of infusion and every 1–2 hours during infusion
• For prolonged continuous vesicant infusions (>4 hours): document site assessment in nursing notes at each assessment interval
• Monitor for: change in infusion rate, patient complaint of pain or pressure, site appearance change

Bolus Infusions (Peripheral or CVAD)

• For PICC/CVC: blood return and site assessment before infusion; reassess midpoint for infusions >30 minutes
• For peripheral: remain with patient during bolus infusion; check every 15 minutes minimum

Patient Instructions

• Instruct patient to immediately report: pain, burning, stinging, pressure sensation, or coldness at or near the infusion site
• Patients receiving vesicants should not be left alone without a monitoring plan

Emergency Response to Suspected Extravasation

Immediately upon suspicion of extravasation:

1. Stop infusion — do not remove IV; leave catheter in place
2. Do not apply pressure to site
3. Aspirate through catheter before removal: attempt to withdraw 3–5 mL
4. Remove catheter after aspiration attempt
5. Mark extravasation area on skin with skin marker
6. Photograph per institutional policy
7. Call provider — this is a medical emergency for vesicant extravasation
8. Apply antidote per agent-specific protocol (dexrazoxane for anthracyclines, hyaluronidase for vinca alkaloids/taxanes, phentolamine for vasopressors)
9. Apply thermal treatment: cold compress for anthracyclines/taxanes; warm for vinca alkaloids
10. Document in detail in patient record; complete incident report

See Infiltration and Extravasation Guide for complete antidote protocols and follow-up care.

Vasopressor-Specific Considerations

Vasopressors (norepinephrine, dopamine, vasopressin) are vesicants primarily through their vasoconstrictor mechanism — extravasation causes ischemic necrosis of surrounding tissue.

Central access for vasopressors: Most institutions require central access for vasopressors expected to run >6 hours; some institutions permit short-term peripheral vasopressor use in emergency settings or when central access is not immediately available.

Peripheral vasopressor administration criteria (if permitted at institution):

• Large antecubital or forearm vein only
• Fresh peripheral site (not >24 hours old)
• Low concentrations of norepinephrine (≤8 mcg/mL) or dopamine (≤3,200 mcg/mL dilute)
• Monitoring every 30 minutes; discontinue and transition to central as soon as possible
• Phentolamine at bedside

Phentolamine for vasopressor extravasation: 5–10 mg phentolamine diluted in 10 mL NS injected subcutaneously around the extravasation site. Must be given within 12 hours for maximum benefit. Monitor for hypotension after phentolamine injection.

Related Resources

Related guides:

• Infiltration and Extravasation Guide
• Evidence-Based Device Selection
• High-Alert Medications in IV Therapy

Related policies:

• Infiltration and Extravasation Management
• Hazardous Drug Management

References

1. Gorski LA, et al. (2021). INS Infusion Therapy Standards of Practice (Standard 27). J Infus Nurs, 44(Suppl 1).
2. Pérez Fidalgo JA, et al. (2012). Management of chemotherapy extravasation: ESMO-EONS Guidelines. Ann Oncol, 23(Suppl 7):vii167–vii173.
3. Schulmeister L. (2011). Management of cancer therapy-associated extravasation. Semin Oncol Nurs, 27(4):355–369.
4. Reynolds PM, et al. (2014). Norepinephrine extravasation: a review. Ann Pharmacother, 48(5):625–631.