Care of Patients Undergoing Chemotherapy MMC-ONCOLOGY CLINIC BONE MARROW TRANSPLANT UNIT CES PAJE, BSN, R.N. Introduction The handling, preparation, administration and disposal of cytotoxic agents may constitute an occupational hazard. While it has not been established that handling cytotoxic agents is consistently linked with adverse health risks, handlers must be aware of the possibility. The implementation of suitable safety precautions reduces the possibility of adverse health effects to hospital employees Chemotherapy Preparation Admixture – leave to the professionals Always follow instructions provided from the manufacturer mixing solutions and amount light and temperature requirements equipment requirements – glass syringes Protect self and environment – gloves, goggle, gown; always use a BSC to prepare/mix Pre-Administration Procedures Chemotherapy orders require a signature by an Attending Physician prior to administration. The patient's current height and weight must be recorded on the patient's chart. Body Surface Area (BSA) must be calculated on all patients. BSA = ht (cm) X wt (kg) 3600 Pre-Administration Procedures An Absolute Neutrophil Count (ANC) must be verified and documented on all patients by an RN. ANC = WBC X Neutrophil (or Segmenters) The patient's labs are reviewed, documented, and approved by the Attending Physicians. Verify the orders for any chemotherapy prerequisites (i.e. hydration, pre-medications, home medications, audiogram, etc.) Verify the patient's treatment plan as specific by the ordering physician or by protocol. Chemotherapy dose ordered must be within ten percent of the calculated dose unless otherwise noted by the physician. Cannulation Procedure: 1. 2. 3. 4. Careful choice of the vein into which cannula to be inserted is important and the first step in the avoidance of extravasation. The smallest size plastic cannula should be used, especially for irritant and vesicant drugs. All peripheral cannulas should be sited in a long straight vein. Avoid bony prominences and joints, such as the antecubital fossa and inner wrist. When the cannula is in situ a free flow of saline should be ensured. Cannulation Procedure: 5. 6. 7. Cytotoxic Drugs must be administered into an existing cannula ( with the exception of patients receiving daily chemotherapy where the cannula is placed specifically for this purpose- usually for non vesicant drugs such as 5 FU or fludarabine). Dilatation techniques including warm water and heat are to be encouraged prior to siting a cannula in a patient with poor venous venous access. When a patient has a poor venous access, assessment should be made and their consultant should be notified so that consideration can be given to the placement of a long term intraveneous catheter e.g. P.I.C.C. line or tunelled central lines. Cannulation Procedure: 8. 9. 10. When anti-emetics , such as metoclopromide are required intraveneously, they should be dministered last, can cause pain on injection, causing uncertainty of vein patency. Check vein patency. All vesicant drugs should be administerd first ( otherwise greater pressure is placed on vein walls, increasing the risk of extravasation. Vesicant drugs must be administered into a running infusion of sodium chloride 0.9% or glucose 5% to avoid high drug concentrations. Do’s and Don’t’s on Peripheral IV Insertion Use the most distal vein first If veins are small – dilate using warmth, gravity, gentle tap Avoid sites distal to recent venipunctures If vein has blown – do not re-stick it again Use the smallest gauge needle possible Advance the needle completely into the vein and anchor securely, leaving site visible Caution patient to watch Do’s and Don’t’s on Peripheral IV Insertion Avoid areas of impaired lymphatic drainage, phlebitis, invading neoplasm, hematomas, sclerosed areas, impaired circulation Do not use lower extremities if possible Avoid sites that have been irradiated Use a new site for chemotherapy, especially for vesicants (unless VAD) Avoid sites of flexion Alternate arms whenever possible Types of infusion for cytotoxic agents Piggyback, or short-term, infusion 1. Do not pinch the intravenous (IV) catheter to determine blood return and patency. Pinching causes a dramatic change in pressure that may rupture a vein. To check for blood return and IV patency: Use a suction check: Gently aspirate the line, using a syringe at the y-site closest to the patient while clamping or pinching off fluid from the bag. Use a gravity check: Remove the bag and tubing from the administration control device (the pump) and gently lower it to a point below the patient’s IV site. Types of infusion for cytotoxic agents 2. 3. Insert the connecting tubing into the appropriate primary tubing y-site; follow the drug manufacturer’s guidelines. Use a Luerlock connection or some other locking device to prevent disconnection. Initiate flow rate in accordance with the physician’s orders or adjust the rate to administer the cytotoxic agent over a specified time. Types of infusion for cytotoxic agents 4. 5. If administering a vesicant in a peripheral vein: Administer the agent in a method that will decrease pressure on veins. For this reason, avoid the use of IV pumps. Monitor the patient frequently for extravasation during the infusion--ideally, every 5 min. Avoid hanging vesicant agents for extended periods, if possible. Upon completion of the infusion, check for vein patency; use a sterile, noncytotoxic IV solution to flush the line. Types of infusion for cytotoxic agents Continuous, or long-term, infusion 1. Check for blood return and IV patency; see guidelines for piggyback infusion. 2. Connect the chemotherapeutic agent directly to the IV catheter or as a secondary infusion through a compatible maintenance solution. 3. Secure the connection site by using a Luer-lock connection or some other locking device. 4. Monitor the IV site throughout the infusion. Types of infusion for cytotoxic agents 5. Check for blood return periodically during the infusion. 6. If administering a vesicant: Do not use a peripheral IV for continuous vesicant administration. Use a central venous access catheter (CVC) or implanted access device to administer any vesicant infusion for longer than 30-60 min. Check for blood return and patency periodically during infusion. 7. Upon completion of the infusion, check for vein patency; use sterile, noncytotoxic IV solution to flush the line. Types of infusion for cytotoxic agents IV push Use the push-pull technique to administer a vesicant to children: Push a very small amount, pull back on the syringe to obtain a blood return, and then push a small amount again; continue until the total amount has been administered. Types of infusion for cytotoxic agents 1. Free-flow method. Check for IV patency by gently aspirating the line at the y-site closest to the patient. Allow IV solution to flow freely. Slowly administer the agent by means of an IV push, using a free-flowing flush solution. Unless otherwise indicated, administer the agent at 1-2 cubic centimeter (cc) per min. If administering a vesicant, gently aspirate the line every 2-3 cc to verify blood return. Upon completion of the infusion, check for vein patency; use sterile, noncytotoxic IV solution to flush the line. Types of infusion for cytotoxic agents 2. Direct-push method: Establish patent IV access; use a syringe filled with sterile IV solution to flush the newly accessed line. Verify blood return and venous patency by aspirating the line gently. Detach the flush syringe; while maintaining sterile technique, attach the syringe containing the cytotoxic agent. Minimize blood loss. Slowly administer the agent; every 1-2 cc, monitor venous patency by using the syringe of cytotoxic agent to aspirate the line gently. Administration of Cytotoxic Agents via CVCs CVCs include percutaneous subclavian catheters, tunneled subclavian catheters, and peripherally inserted central catheters. (A midline catheter is considered a peripheral line because it ends in the middle of the upper arm.) 1. Verify that the type of catheter and its placement are correct. 2. Inspect exit site for evidence of leakage. Inspect ipsilateral chest for signs of venous thrombosis. 3. Inspect exit site for evidence of erythema, swelling,drainage, etc. Administration of Cytotoxic Agents via CVCs 4. Aspirate the line to ensure blood return. If blood return is not evident: a. Flush the catheter with saline, gently using the pushpull method. Avoid use of syringes less than 3 cc in size. b. Reposition the patient as appropriate. Ask the patient to cough. c. Explain to the patient why delaying therapy is necessary. Though the patient may indicate that not obtaining a blood return from his or her catheter is common and tells you to proceed, do not administer cytotoxic therapy. Remember that extravasation of a cytotoxic agent may have serious consequences. d. Obtain a physician’s order for a declotting procedure e. Before administering a cytotoxic agent, use x-rays or dye studies to confirm proper CVC placement. Implanted ports Implanted ports are available that allow venous access, peritoneal access, arterial access, and epidural access. Ascertain which type is being used. Some patients have more than one type. 1. Assess initial line placement by using the results of x-ray or fluoroscopic dye studies. 2. Choose a noncoring, 90-degree needle whose length is appropriate to the: Depth of the port -Size of the patient (i.e., the amount of subcutaneous tissue or fat located above the port) 3. Prepare the patient’s skin according to institution policy. 4. Access the port, ensuring proper placement of the needle in the reservoir. Implanted ports 5. 6. 7. 8. Establish blood return and patency for venous or arterial ports. Blood return is not expected with epidural or peritoneal access devices. Inspect the needle insertion site for needle dislodgement, leakage of IV fluid, drainage, or edema. Examine the ipsilateral chest for venous thrombosis. Apply an occlusive dressing to stabilize the needle. The dressing should be transparent, to allow a clear view of the insertion site. Experts disagree about other characteristics that are desirable. Oral Cytotoxic Drug Administration Care should be taken so that tablets and capsules are tipped from their container directly into a disposable medication cup. After the patient has taken the tablet/capsule, also without handling it, the medication cup should be discarded as cytotoxic waste. Many tablets and capsules may be dispersed in water, and the pharmacy will advise accordingly. It is best to contact the pharmacy if it is necessary to use oral cytotoxic agents to produce a mixture. After administration, gloves should be discarded as cytotoxic waste, and hands washed. Topical Cytotoxic Drug Administration WASH HANDS and put on PROTECTIVE CLOTHING (gown, protective glasses, respirator mask and 2 pairs of gloves) Apply a film of medication (use a disposable spatula) Dispose of gloves and spatula as cytotoxic waste Clean and launder other protective clothing The patient should be advised not to wear clothing that may come in contact with the treated area, and to be careful not to accidentally touch the medication Side Effects of Chemotherapy a. Myelosuppression Neutropenia Anemia Thrombocytopenia b. GI and Mucosal Side Effects Nausea and Vomiting Diarrhea Mucositis Anorexia Constipation Perirectal cellulitis c. Alopecia d. Fatigue e. Cardiac toxicity f. Pulmonary toxicity g. Hemorrhagic cystitis h. Hepatotoxicity i. j. k. l. m. n. Nephrotoxicity Neurotoxicity Alterations in sexuality and reproductive function Cutaneous Reactions Acral erythema Hyperpigmentation Inflammation of keratoses Nail changes Neutrophilic eccrine hydradenitis Radiation enhancement Radiation recall Hand-and-foot syndrome Ocular Toxicity Secondary Malignancies Classification of Chemotherapy Drug VESICANT – CAPABLE OF PRODUCING BLISTERS Dactinomycin Doxorubicin Epirubicin Idarubicin Mitomycin Vinblastine Vincristine Vinorelbine Classification of Chemotherapy Drug NONVESICANT (Irritant)- CAPABLE OF PRODUCING PERI-VENOUS PAIN AT THE SITE OF INJECTION OR LONG THE VEIN INJECTION OR INFUSION Cisplatin Dacarbazine Docetaxel Etoposide Mesna (undiluted) Mitoxantrone Paclitaxel Teniposide Classification of Chemotherapy Drug NONVESICANT (None) Asparaginase BCG Bleomycin Carboplatin Clodronate Cyclophosphamide Cytarabine Fludarabine Fluorouracil Gemcitabine Goserelin Ifosfamide Interferon Irinotecan Leucovorin Leuprolide Mercaptopurine Mesna (diluted) Methotrexate Ocreotide Oxaliplatin Pamidronate Raltitrexed Rituximab Vasospasms Symptoms pain at infusion site slowing of infusion rate loss of blood return in the line Management slow or stop infusion apply heat or warmth elevate extremity on a pillow re-start again at a later time, very slowly IF NOT SURE – Start a new line Flare Reaction Painless Local reaction Along the Vein or Near the Intact Injection Symptoms blotches or streaks (histamine release phenomenon), symptoms usually subside with or without treatment 30 min after the infusion is stopped, although they may last for 1-2 hours and rarely more than 24 hours Management Stop chemotherapy and re-start later Run IV fluids IF NOT SURE – Start a new line Irritation no tissue necrosis or ulceration; classify a drug as irritant if it causes phlebitis and/or sclerosis of veins at intact injection site or along the vein Symptoms aching and tightness along the vein full length of the vein may be reddened or darkened blood return is usually present but may not be Management: Stop chemotherapy; slow down IV rate Apply heat and elevate extremity Slowly re-start chemotherapy IF NOT SURE – Start a new line Vesicants blistering, local or extensive tissue necrosis with or without ulceration Symptoms pain, burning, and tingling appearance of a bleb or erythema at IV site or along the vessel Loss of blood return Decreased IV flow rate or increased resistance during IV push Procedure for the extravasation of a VESICANT At the time of extravasation: 1. STOP the drug injection IMMEDIATELY. 2. STOP the IV Infusion. 3. Immediately aspirate and discard any residual drug and blood in the intravenous tubing, needle and suspected infiltration site. If applicable, instill the ordered antidote intravenously and then remove the IV catheter/needle. 4. If unable to aspirate the residual drug from the intravenous tubing, remove the IV catheter/needle. Avoid excess pressure at the site. Procedure for the extravasation of a VESICANT 5. 6. 7. 8. 9. Inject the antidote SC clockwise into the infiltrated area using G25 needle. Change and discard needle with each new injection. The number of injection needed depends upon the extent of the exravasated area. Avoid applying pressure to the suspected infiltration sites. Apply topical ointment as needed, if ordered. Elevate the arm. Apply warm or called compress as ordered. Procedure for the extravasation of a VESICANT 5. 6. Observe patient regularly for pain, erythema, induration, &/or necrosis, up to 14 days after the incident. Document interventions in the patient medical record. Include the following: Date, time Physician notified Drug administered, amount of drug extravasated Condition of patient Appearance of site Follow-up measures Follow-up: Patients should be closely followed after suspected extravasation so that appropriate further action can be taken. Some extravasations, although painful, may heal without surgical intervention. This is particularly true of vinca alkaloids. Others, particularly those due to doxorubicin, other DNA binders and mechlorethamine, may recycle locally and produce progressive necrosis and slough requiring surgical intervention. Areas of extensive blistering or ulceration, progressive induration and erythema, or persistent severe pain, are indications for surgical assessment and possible excision of the injured tissue. Surgical intervention should not be delayed for long in the presence of progressive local injury. Analgesics should be given, as required, for pain. Assessment of Extravasation Versus Other Reactions Assessment Parameter Extravasation Immediate Manifestations of Extravasation Pain Spasm/Irritation of the Vein Flare Reaction Delayed Manifestations of Extravasation Severe pain or Hours - 48 burning that lasts minutes or hours and eventually subsides; usually occurs while the drug is being given and around the needle site Aching and No pain tightness along the vein Assessment of Extravasation Versus Other Reactions Assessment Parameter Extravasation Immediate Manifestations of Extravasation Spasm/Irritation of the Vein Flare Reaction Delayed Manifestations of Extravasation Redness Blotchy redness around the needle site; it is not always present at time of extravasation Hours - months The full length of the vein may be reddened or darkened Immediate blotches or streaks along the vein, which usually subside within 30 minutes with or without treatment Ulceration Develops insidiously; usually occurs 48-96 hours later Hours – months Not usually Not usually Assessment of Extravasation Versus Other Reactions Assessment Parameter Extravasation Immediate Manifestations of Extravasation Spasm/Irritation of the Vein Flare Reaction Delayed Manifestations of Extravasation Swelling Severe swelling; usually occurs immediately Hours – 48 Not likely Not likely; wheals may appear along the vein line Blood return Inability to obtain blood return Good blood return during drug administration Usually Usually Other Change in the quality of infusion Local tingling and sensory deficits Possibly resistance felt on injection Urticaria Doxorubicin and epirubicin Are particularly likely to cause a local wheal or red streaking (a histamine release phenomenon) which will subside but may take thirty minutes or more after the injection is stopped. Hydrocortisone injected into the IV line may hasten clearing of the reaction, and requires a physician's order. The injection may then be cautiously resumed. Thrombosis or Sclerosis Of veins may occur due to the local effect of chemotherapeutic agents on the endothelium. These can be managed conservatively with warm or cold compresses to the area plus an analgesic for pain, if required. Guidelines for the use of an antidote It is difficult to be certain that injection of antidotes into the area of extravasation is of benefit and reports are conflicting. Most small extravasations do not result in serious problems without injection of antidotes, so that injection of specific antidotes should likely be restricted to larger extravasations (>1-2 mL). Recommended Extravasation Antidotes Class / Specific Agents Local Antidote Recommended Alkylating Agents Cisplatin Mechlorehtamine HCL 1/6 or 1/3 M sodium thiosulfate Mitomycin-C Dimethylsulfoxide 50% - 99% (w/v) solution DNA intercalators Doxorubicin HCL Daunorubicin HCL Amsacrine Cold Compress Dimethylsulfoxide 50%-99% (w/v) solution Vinca alkaloids Vinblastine Vincristine Vinorelbine Warm compress, Hyaluronidase Epipodophyllotoxins Warm compress, Hyaluronidase Target Therapy Never give as a bolus Slowly infuse over at least 30 minutes Have crash cart available (especially at the first time) Monitor vital signs (BP, P, RR and T) before, at 15 – 30 minutes into the infusion) and after the infusion; PRN before patient leaves the clinic Antineoplastic Agents: Who might be exposed to antineoplastic agents in hospitals? Hospital staff who work in areas where solutions of these agents (including agents prepared from crushing or breaking tablets) are prepared, administered, and disposed of Pharmacy personnel who prepare the solutions Hospital staff in oncology departments and infusion units who administer these solutions Hospital staff who dispose of feces, urine, etc. of patients treated with these agents Hospital staff who handle bed clothing of patients treated with these agents Antineoplastic:When are workers most likely to be exposed to antineoplastic agents in hospitals? by breathing them ingesting them unintentionally, or having skin contact with them during the following procedures: Counting tablets poured from multidose bottles Crushing or breaking tablets to be made into liquid preparations Preparing solutions Handling solutions Administering solutions Disposing of solutions Disposing of used intravenous (IV) sets or other drug administration equipment Cleaning spills Disposing of feces, urine, bed clothing, etc. of patients treated with these agents Handling soiled bed clothing of patients treated with these agents Antineoplastic: How can I protect myself from exposure to antineoplastic agents? Prepare agents in a centralized area restricted to authorized personnel only. Prepare agents in a biological safety cabinet (BSC)— Class II Type B, or Class III. (A BSC with an outside exhaust must be vented away from outside fresh-air intake units.) Use syringes and IV sets with Luer-Lock-type fittings for preparing and administering these agents. Place these syringes and needles in chemotherapy waste containers designed to protect workers from injuries. Consider using closed-system drug transfer devices and needle less systems. Antineoplastic: How can I protect myself from exposure to antineoplastic agents? Avoid skin contact. Use a disposable gown made of a lint-free, low-permeability fabric. The gown should have a closed front, long sleeves, and elastic or knit closed cuffs. Use good quality, powder-free, disposable gloves that cover the gown Use two pairs of gloves. Change gloves periodically. Wear a plastic face shield or splash goggles to avoid contact of eyes, nose, or mouth with these agents whenever splashes, sprays, or aerosols are generated. Remove protective clothing carefully to avoid spreading contamination. Waste Disposal All waste from the administration of cytotoxic drugs (IV tubing, bags, vials, etc.) will be placed in trash cans with cytotoxic waste liners or cytotoxic waste receptacles. Needles and syringes will be disposed of in the needle receptacles or in hard plastic cytotoxic waste receptacles. Patient care staff will place a cytotoxic waste receptacle in the room when a patient begins a course of chemotherapy administration. Housekeeping personnel will then change the trash can liners and keep the appropriate liners in place until the door tag has been removed. Each unit will determine its needs for special waste containers to be maintained at strategic areas. Any cytotoxic drug not administered to patients due to excess or contamination will be returned to Pharmacy for disposal. Only empty bags can be placed in the disposal containers.