Chemotherapy: Safety Protocols. Janet Modrakovic, BAS, CVT

Transcription

1 Chemotherapy: Safety Protocols Janet Modrakovic, BAS, CVT The word chemotherapy strikes fear in the heart of every pet owner whose beloved pet has been diagnosed with cancer. The incidence of cancer in cats and dogs has increased and is the leading natural cause of death (nearly 50% annually) in geriatric dogs and cats (Crump, n.d.). This has lead to an in increase in the administration of antineoplastic drugs. However, training for veterinary personnel in the administration, preparation, handling, and disposal of these drugs is sadly inadequate. Chemotherapeutic drugs have the potential to be mutagenic, teratogenic, carcinogenic and cytotoxic. This means that chemotherapy drugs may cause damage to chromosomes, a developing fetus, harm new cell growth, and be a source of secondary cancer. All hospital staff working with chemotherapy drugs should be taking measures to protect themselves from possible exposure. The exposure risk greatly increases during the preparation and administration of chemotherapy, therefore rational and safe handling is required at all times (Bergman, 2003). The best way to avoid exposure is to follow proper storage and handling techniques. Chemotherapy drugs must be stored separately from other medications and food items. They should be labeled clearly and stored on shelves or bins with front barriers that prevent bottles from rolling off the shelves. Chemotherapeutic drugs that require refrigeration should be in separate plastic bags that are individually labeled and stored separately from other medications. Ideally, chemotherapy drugs should be prepared and reconstituted in a class-ii or class-iii Biological Safety Cabinet (BSC). This is not practical in most veterinary hospitals; therefore, chemotherapy drugs should be prepared in a low traffic area, away from windows, doors and drafts. During preparation all surface areas should be covered with an absorbent pad (McCurnin, 2006). Only trained and experienced staff members should prepare and administer chemotherapeutic drugs.

2 The use of personal protective equipment such as a non-absorbent gown with long sleeves, non-powdered heavy duty latex gloves or other chemotherapy approved gloves worn over the sleeves, a face mask and a face shield can minimize the risk of exposure. Surgical masks are not appropriate for chemotherapy administration. Other commercially available devices should be used to minimize exposure to personnel including Luer-lok syringes to prevent accidental separation from the syringe or chemo-pin, and venting vial devices. Most ideal are closed systems such as PhaSeal, which use a double membrane setup to ensure leak-free transfer of drugs (Jorgenson, 2008). Chemotherapy drugs that have been reconstituted and have to be transported to the treatment area should be sealed and labeled in plastic bags (Crump, n.d.). Strict protocols should be in place in order to prevent any potential problems that may arise during the administration of chemotherapeutic drugs. Each patient should have some form of identification on them and on their cages (Smith, 2005). Name collars and cage cards are excellent forms of identification. Each patient should have a current weight which is then calculated to surface area (square meters). Identify the drug to be administered. The dose should be calculated and then rechecked by a second person. The appropriate route and administration material should be selected, which includes the use of a butterfly catheter or an indwelling peripheral catheter (Smith, 2005). Personnel administering the drugs should wash their hands thoroughly before dressing in their PPE and after removing their gloves (OSHA, Sec. IV, Ch. 2). This helps to keep any drug that may have accidently spilled from absorbing into the skin. Once the appropriate injection site has been chosen, the area should be prepared aseptically by shaving and scrubbing gently with an antimicrobial agent. Care should be taken to avoid irritation. All personnel assisting should be dressed in the appropriate safety attire. It is extremely important to maintain proper restraint during administration to prevent extravasation of the drug as severe tissue damage may occur requiring the limb amputation. Technicians administering chemotherapy drugs should always make certain that their venipuncture is a clean

3 stick. If one has to use the same vein it should be done proximal to the first stick. If at all possible a new vein should be used. When flushing IV and butterfly catheters, heparinized saline should not be used. Many chemotherapy drugs such as doxorubicin will precipitate in the presence of heparin. Normal saline flushes should be used instead. Before administering the chemotherapy drug, place an absorbent pad under the area of the injection site and hold a 4x4 alcohol gauze pad over the injection port which will help to eliminate any aerosolization. Administer the drug at the appropriate rate for the drug given. Some drugs can be given quickly while other must be given as a slow infusion. Personnel must be familiar with the drug and how it is given. Once the administration is over, flush again with normal saline to make certain all the drug is out of the catheter port. This will prevent extravasation of the drug while removing the catheter. After catheter removal, the site should be bandaged snuggly to prevent any hematoma formation (Smith, 2005). The material, supplies and chemotherapy drugs used are just as dangerous after administration as they are during the preparation and administration phases. All used supplies should be disposed of in the proper receptacles. Syringes, catheters, gloves, gowns, bandages, and absorbent liners should all be bagged and labeled for biohazard disposal according to local regulation. Chemotherapy waste should be clearly labeled and handled separately from regular medical waste. Large plastic yellow bags are usually used to help identify chemotherapy waste from that of regular biohazard waste. Sharps, such as needles should never be recapped, crushed, or bent in any way. They should be disposed of in a properly designed sharps container that has been designated for hazardous drug waste. Once the sharps container is full it should be placed into a yellow chemotherapy biohazard bag (Bergman, 2003). Inappropriate handling of chemotherapy drugs can lead to a number of potential health risks. According to Michael D. Lucroy, DVM, MS, ACVIM (Oncology) of Oklahoma State

4 University, urine mutagenicity, presence of chemotherapy drugs in urine, lymphocyte chromosome abnormalities, and increased incidence of fetal loss have been observed in human healthcare professionals with routine exposure to cytotoxic drugs. Researchers have also noted that urine mutagenicity is highest at the end of the work week and lowest after the weekend (Lucroy, 2001). Personnel handling chemotherapeutic agents must understand the routes of possible contamination; inhalation of aerosolized drug particles, ingestion, and absorption through skin. Ocular toxicity consisting of epiphora, conjunctivitis, and keratopathies have been reported in people from aerosolization (Royer, 2005). Asthma like symptoms, headaches, nausea, and dizziness have also been reported due to inhalation (Royer, 2005). Aerosolization is most likely to occur during mixing and administration of the drugs (Smith, 2005). Studies measuring air levels of cyclophosphamide (a common chemotherapy agent) when biological safety cabinets (BSC) were not used showed increased levels of the drug in the room s HEPA filter (Smith, 2005). This poses a risk for personnel changing the filter. Ingestion is most likely to occur during eating, drinking, application of cosmetics and smoking after hands have become contaminated. Increased levels of mutagens in the urine of human oncology nurses who smoke have been observed (Royer, 2005). Absorption through skin and mucous membranes can occur during any time during preparation, administration, clean up, and later contact with areas that have been contaminated. Exposure to urine, feces and litter box waste of patients should be limited and only handled wearing latex gloves during the first forty-eight hours following treatment. Skin rashes have been reported in people with cutaneous exposure (Royer, 2005). Self inoculation can result in cellulitis and localized skin sloughs (Royer, 2005).

5 Chemotherapy spill kits should also be readily available where chemotherapy drugs are mixed or administered. Each kit should contain 2 pairs of latex gloves (non-powdered), 2 absorbent pads with plastic back, protective eye goggles, low permeability gowns, 2 spill control pillows (250 and 1000ml), sharps container, small scoop for glass fragments, and 2 large hazardous drug disposal bags (Lucroy, 2001). The appropriate respirator mask should also be worn during clean up of spills. The spill should be absorbed by the absorbent pads and the area cleaned with detergent and water. The use of spray bottles should be avoided to prevent further aerosolization (Lucroy, 2001). All material should be discarded in the appropriate hazardous drug receptacle and the area isolated (for spills larger than 5ml) (Smith, 2005). Immediate and thorough cleaning after chemotherapy administration is imperative as studies have indicated that doxorubicin (a common antineoplastic drug) can remain stable on various surfaces for up to seven weeks (Smith, 2005). Contamination of personal protective equipment (PPE) should also be addressed immediately. Chemotherapy safety protocols are important in preparation, administration, and as well as patient care after treatment. There are many nursing care considerations that should be addressed when taking care of a post chemotherapeutic patient. Patients should be observed for a few hours after administration for any immediate side effects such as anaphylaxis. Any and all abnormal signs must be well documented and the supervising oncologist or doctor alerted immediately. Many chemotherapy drugs are excreted from the body through urine, feces and vomit. Depending on the drug, it can be excreted for a few hours up to several days. While it is not a goal to scare clients from touching their animals, safety should be stressed in discharge instruction, especially when handling their pet s excrement. They should be supplied with latex or appropriate gloves and instructions on how to properly handle their pet s waste. They should also be encouraged to play and touch their pet in all the normal ways such as petting and hugging as all normal and safe activities and very good for their pet. Clients should also be given

6 handouts describing the drug and possible side effects their pet may exhibit. If all the proper measures are taken during the preparation, administration and post care/education phases of a chemotherapy treatment, toxicity should be minimized and the animal should maintain an excellent quality of life during therapy (McCurnin, 2006). The use of chemotherapy is becoming more common and requires a great understanding of these drugs. Although many steps are being taken to ensure the safety of the patient during treatment with chemotherapy, more training of staff is needed to avoid potential health risks. Exposure to chemotherapy agents poses a serious health hazard that should not be ignored. More specialization by veterinary personnel in this area is very necessary. References Bergman, P. J. (2003). Chemotherapy Preparation, Administration and Disposal. Armonk; NY. Bright Heart Veterinary Centers. Crump, K. T. (n.d.). Cancer and Chemotherapy. Retrieved September 17, 2009, Jorgenson, J., Spivey, S., Au, C., Canann, D., Ritter, H., & Smith, B. (2008, September). Contamination Comparison of Transfer Devices Intended for Handling Hazardous Drugs. Hospital Pharmacy, 43(9), Retrieved September 17, 2009, from Academic Search Complete database.

7 Lucroy, M. (2001). Chemotherapy Safety in Veterinary Practice: Hazardous Drug. Compendium, 23(10), Retrieved September 16, 2009, from McCurnin, D. M. (2006). Clinical Textbook for Veterinary Technicians (6 th ed.). St. Louis; MI. Elsevier Saunders. Royer, N. (2005, October 27). Chemotherapy safety. Retrieved from Smith, K. L. (2005). Chemotherapy Safety and Administration. Proceedings from The North American Veterinary Conference, Orlando, FL. Retrieved September 16, 2009 from United States Department of Labor, OSHA (n.d.). Controlling Occupational Exposure to Hazardous Drugs. Retrieved September 15, 2009, from