Case Description
A 77-year-old man with esophagus
cancer was receiving chemotherapy, paclitaxel, weekly through a
peripheral intravenous catheter at a chemotherapy room in a university
hospital in Japan. Data of patient character and details of drugs
administration method were collected from his medical chart.
No abnormal subcutaneous tissue condition was observed at the target
site, which was confirmed through ultrasonography, prior to
catheterization for the administration anticancer drug; on the second
week of paclitaxel administration, diameter of the target vein was 2.4
mm. It was calculated by measuring the minor axis and major axis three
times, and measurements were averaged. Then the average of the minor
axis was added to the average of major axis and divided by two.
All ultrasound images were obtained by one researcher using a
Noblus® with linear array (5–18
MHz) 2D probe (Hitachi, Ltd, Medical, Tokyo, Japan). Pre-catheterization
images were obtained by a 5-cm swept probe (peripheral side 2.5 cm;
center side 2.5 cm) with short axis over the point that nurses selected
as catheterization site, along the vein. Ultrasonographic images were
assessed with reference to previous studies [4,5]; although unclear,
superficial fascia at surrounding vein was judged as subcutaneous edema
presence, and ununiform echoic area in the intravascular lumen was
judged as thrombus.
The nurse inserted a 24G catheter at the patient’s cephalic vein on the
right forearm. Location of the catheterization site was recorded by a
measure and digital camera. Drug administration protocol was as follows:
First, the nurse secured the catheterization site by administering
normal saline solution; a 6.6 mg of dexamethasone sodium phosphate + 20
mg of famotidine + 5 mg of d-Chlorpheniramine Maleate + 50 mL of normal
saline were administered at 300 mL/hr. for 10 min. Next, 50 mL normal
saline was administered at 300 mL/hr. for 10 min. Then, 156 mg
paclitaxel + 50 mL normal saline were administrated at 300 mL/hr. for
60 min. Lastly, normal saline 30 mL at 300 mL/hr. for 6 min was
administered. Thus, total drug administration time was about 90 min.
Anticancer drug administration was completed without local adverse event
or discomfort such as swelling, redness, and pain; however, subcutaneous
edema and thrombus were observed through ultrasonography just after
finishing anticancer drug administration (Figure 2; A, B).
One week later, no abnormal findings at the catheterization site were
noted upon inspection or palpation. However, subcutaneous edema and the
remaining thrombus at the site were observed, which were confirmed
through ultrasonography. Three weeks later, the site was positively
assessed for induration by palpation, and subcutaneous tissue and
thrombus were observed through ultrasound. Four weeks later, the
induration, thrombus, and subcutaneous edema were still present (Figure
2; C, D, E). No symptoms were observed upon inspection at any one time,
and no subjective symptoms such as pain or sensations of burning were
reported.
On the post treatment days, ultrasonographic images were taken same way
as pre-catheterization, using puncture site or induration site as a
center point. Evaluation of the presence of induration through palpation
was conducted by a clinical nurse and one researcher who had clinical
experience as a nurse.
This observation was conducted in accordance with the Declaration of
Helsinki, and study protocol was approved by the Research Ethics
Committee of the facility where researchers belong (No. 11650-1). Using
images and information for report was permitted by the
patient. Observation period was from February to March in 2019.