Care of Patients Undergoing Chemotherapy

1. Care of Patients Undergoing Chemotherapy MMC-ONCOLOGY CLINIC BONE MARROW TRANSPLANT UNIT CES PAJE, BSN, R.N.

2. 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

3. 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

4. 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

5. 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.

6. Cannulation Procedure: • 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.

7. Cannulation Procedure: • 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.

8. Cannulation Procedure: • 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.

9. 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

10. 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

11. 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.

12. Types of infusion for cytotoxic agents • Insert the connecting tubing into the appropriate primary tubing y-site; follow the drug manufacturer’s guidelines. Use a Luer-lock 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.

13. Types of infusion for cytotoxic agents • 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.

14. Types of infusion for cytotoxic agents • Continuous, or long-term, infusion • Check for blood return and IV patency; see guidelines for piggyback infusion. • Connect the chemotherapeutic agent directly to the IV catheter or as a secondary infusion through a compatible maintenance solution. • Secure the connection site by using a Luer-lock connection or some other locking device. • Monitor the IV site throughout the infusion.

15. Types of infusion for cytotoxic agents • Check for blood return periodically during the infusion. • 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. • Upon completion of the infusion, check for vein patency; use sterile, noncytotoxic IV solution to flush the line.

16. 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.

17. Types of infusion for cytotoxic agents • 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.

18. Types of infusion for cytotoxic agents • 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.

19. 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.) • Verify that the type of catheter and its placement are correct. • Inspect exit site for evidence of leakage. Inspect ipsilateral chest for signs of venous thrombosis. • Inspect exit site for evidence of erythema, swelling,drainage, etc.

20. Administration of Cytotoxic Agents via CVCs • Aspirate the line to ensure blood return. If blood return is not evident: • Flush the catheter with saline, gently using the push-pull method. Avoid use of syringes less than 3 cc in size. • Reposition the patient as appropriate. Ask the patient to cough. • 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. • Obtain a physician’s order for a declotting procedure • Before administering a cytotoxic agent, use x-rays or dye studies to confirm proper CVC placement.

21. 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. • Assess initial line placement by using the results of x-ray or fluoroscopic dye studies. • 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) • Prepare the patient’s skin according to institution policy. • Access the port, ensuring proper placement of the needle in the reservoir.

22. Implanted ports • 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.

23. 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.

24. 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

26. a. Myelosuppression Neutropenia Anemia Thrombocytopenia b. GI and Mucosal Side Effects Nausea and Vomiting Diarrhea Mucositis Anorexia Constipation Perirectal cellulitis Alopecia Fatigue Cardiac toxicity Pulmonary toxicity Hemorrhagic cystitis Hepatotoxicity Side Effects of Chemotherapy • 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

27. Classification of Chemotherapy Drug • VESICANT – CAPABLE OF PRODUCING BLISTERS • Dactinomycin • Doxorubicin • Epirubicin • Idarubicin • Mitomycin • Vinblastine • Vincristine • Vinorelbine

28. 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

29. Classification of Chemotherapy DrugNONVESICANT (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

30. 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

31. 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

32. 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

34. 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

36. Procedure for the extravasation of a VESICANT • At the time of extravasation: • STOP the drug injection IMMEDIATELY. • STOP the IV Infusion. • 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. • If unable to aspirate the residual drug from the intravenous tubing, remove the IV catheter/needle. Avoid excess pressure at the site.

37. Procedure for the extravasation of a VESICANT • 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.

38. Procedure for the extravasation of a VESICANT • 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

39. 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.

40. Assessment of ExtravasationVersus Other Reactions

41. Assessment of Extravasation Versus Other Reactions

42. Assessment of ExtravasationVersus Other Reactions

43. 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.

44. 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.

45. 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).

46. Recommended Extravasation Antidotes

47. 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

48. 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

49. 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 preparationsPreparing 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

50. 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.