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


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
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

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



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

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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

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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

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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)

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Asparaginase
BCG
Bleomycin
Carboplatin
Clodronate
Cyclophosphamide
Cytarabine
Fludarabine
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Fluorouracil
Gemcitabine
Goserelin
Ifosfamide
Interferon
Irinotecan
Leucovorin
Leuprolide






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
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.