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Important precautions recommended when using chemotherapeutic drugs
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Chemotherapeutic agents are routinely used in many small animal practices. Many if not all of them come from human medicine which implicates that they potentially have effect on humans coming in contact with them. Do you know what precautions you and your staff should take? Susan Ford, Dip ACVIm, gives an excellent overview!

All hospital personnel should be aware of the following procedures for handling chemotheraputic drugs.

Potential exposure to themselves and the environment.
Exposure is most often through inhalation of aerosolized particles, direct absorption through skin contact, indirect contact from unprotected hand-to-face contact or accidental ingestion from eating/drinking or smoking via hand-to-mouth contact.
The safety concerns and proper methods of cleaning up after patients and spills.
Proper disposal methods of used vials and expired drugs as well as equipment used.
Hospital staff members who are trying to conceive, are pregnant, breastfeeding or are immunosuppressed should refrain from administering chemotherapy.

Chemo patients should be clearly identified while in the hospital. A different colored name tag/ID band and cage label will help hospital staff know to use extra precautions when dealing with these patients. A brightly colored waterproof chemotherapy laundry bag is recommended.

Store in a separate, secure area to other medications like you would controlled drugs.
Keep away from areas of food/drink preparation and storage.
Each open bottle should be separately stored in a zip-lock bag and kept within the container.
Certain drugs need to be dated and the strength marked on the bottle, as once reconstituted they are only good for a certain period of time. Read drug inserts and manufacturers` instructions regarding storage temperature and time.
All boxes should be labeled with chemotherapy or hazard labels.

It is useful to have three Tupperware containers; one for unopened drugs, one for open drugs and one in a secure cupboard for drugs not requiring refrigeration.

Safety equipment required
Nitrile gloves (or double up on unpowdered latex exam gloves).
Respirator mask – surgical masks are not advised.
Impermeable gown
Safety goggles
Nurse`s cap

Drug preparation
Drug calculations should always be double checked.
Safety gear includes nitrile gloves, respirator mask, impermeable gown, safety goggles and nurses cap.
All safety gear is to be worn and extreme care used when reconstituting chemotherapy drugs. Respirator mask should be fitted snugly onto the face to ensure one is breathing through the mask rather than around the edges. For most of us an appropriate fume hood is not readily available, so it is imperative that mixing should be done in a well-ventilated area, away from drafts caused by vents/fans and away from where others are working. A plastic backed, absorbent pad should be used to protect work surfaces from contamination. Luer-lock syringes and chemo safety pins are recommended to reduce the chance of disconnection and aerosolization.
A chemo pin is a safety device that is pushed into the top of a vial and provides additional security against overpressurization and aerosolization. If a chemo pin is not available, use extreme care in maintaining slight negative to neutral pressure within the vial. Select syringes based on estimated volume, to ensure accuracy and to reduce exposure due to overfilling and spillage. To maintain negative pressure within the drug vial, inject a small amount of diluent followed by removal of a small amount of air. Wrap an alcohol-dampened gauze around the top of the vial and needle exit site. Mix gently by swirling the vial to ensure that all powder is in solution. Invert vial and withdraw drug slowly. Make sure not to push the `air` out of the syringe. It will still contain small particles of the cytotoxic drug.

Materials used per patient for administration:
IV catheter
1-in. PRN adapter
Luer lock extensions set
10 ml NaCl flush for catheter placement
Saline flush for chemo admin - MIN 12 ml, will need more for certain drugs (i.e. doxorubicin).
Flush should not be heparinized because this may cause precipitation of the drug (i.e. doxorubicin).
Vet wrap (choose a color specifically for chemotherapy patients for personnel safety.)

Excellent venipuncture technique is essential when administering chemotheraputic drugs. As a general rule if you do not hit the vein on the first stick or you are not certain of the catheter placement, go to another vein. Flush at least 6 to 10 mls of saline into the extension set, evaluating the catheter insertion site and the distal end of the catheter, checking for a flashback to ensure good placement. Always use a catheter gauge smaller than what you would normally use to ensure blood flow around the catheter. We use 22g for cats and small dogs, and 20g for large dogs. Perivascular injection may result in severe tissue necrosis and in some cases, loss of the limb (e.g. with doxorubicin).

Source: Susan Ford (2003): Take precautions when using chemotherapeutic drugs. In: DVM Newsmagazine November 1, 2003. www.newscientist.com/dvm/

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