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.