ST. TAMMANY PARISH HOSPITAL
COVINGTON, LOUISIANA
DEPARTMENT OF NURSING
ADOPTED DATE:
4/06
REVIEW/REVISED DATE:
7/08
_______________________________________
DIRECTOR OF NURSING
TITLE:
INTRAPERITONEAL (IP) CHEMOTHERAPY ADMINISTRATION
USING AN IMPLANTED PORT
_____________________________________________________________________________________________
OBJECTIVE:
A.
To provide higher concentration of drug directly to the tumor location.
B.
To minimize systemic toxicity of chemotherapeutic agents.
C.
To attempt to control malignant ascites.
IP chemotherapy is contraindicated in the following situations:
A.
Disease outside the peritoneal cavity (unless IP therapy is combined with IV therapy).
B.
Residual disease greater than 1cm in peritoneal cavity post debulking surgery to allow adequate drug penetration.
C.
Dense adhesions or fluid loculations within the peritoneal cavity.
EQUIPMENT & SUPPLIES
(VAD ACCESS KIT AVAILABLE):
1000cc/NS (warmed to room temperature using fluid warmer, or in a warm bath or on heating pad/warming blanket for 15
minutes).
VAD Access Kit x 2 (one for central PAC, other IP).
IV tubing with Y port
Right Angle needle (1 ½ inch 19-20 gauge)
Procedure for Administration of IP Chemotherapy
1.
NURSING ACTION
Explain procedure to patient. Obtain vital signs
prior to administration and every 15 minutes (or as
ordered by physician).
Administer antiemetics via central port per MD
Orders.
2. Have patient void prior to initiation of chemotherapy.
POINTS OF EMPHASIS
2. A foley catheter may be ordered by physician. If no foley
is ordered, patient may use fracture bedpan for comfort and
minimal movement during infusion. Always assure proper
needle position is maintained after movement.
3. Warm NS to room temperature. Infuse per IP port.
3. Warmed NS is used to decrease chance of abdominal
spasms. Use fluid warmer, a warm bath or heating pad for 15
minutes
4.
4. Pre meds do not go through (IP) site. Chemotherapy will
only be given per (IP) port as ordered.
Assess patient for subclavian port-a-cath and
intraperitoneal (IP) site. Palpate both sites for
placement confirmation. If no subclavian PAC
resent, a peripheral IV site is needed to administer
pre-medications. Access subclavian PAC using sterile
technique with appropriate needle.
No Other meds except chemotherapy or normal saline
are to be infused per IP port.
5.
Access IP port-a-cath using sterile technique with
1.5” right angled needle.
6.
Place patient on complete bed rest in semi-fowler’s
position throughout (IP) administration.
7.
Prime IV tubing with attached Y port with warmed
NS (according to specific patient orders) as rapidly as
possible via gravity.
8.
Observe site of IP port for swelling, leakage, or
redness
9.
If no untoward effects noted after completion of NS
infusion, attach primed chemotherapeutic agent to
free IP Y connector at closest port to patient. Clamp
NS infusion line and infuse IP chemotherapy as
rapidly as possible, (as per specific patient orders)
After infusion of IP chemotherapy complete, clamp
IP chemotherapy tubing and open NS tubing.
Infuse additional NS (according to specific orders)
as rapidly as possible. Flush IP port with
heparinized saline or as directed by physician.
Remove IP needle from IP port and dispose in
sharps container. Apply sterile dressing.
After removal of IP needle, reposition patient every
15 minutes from side to side for a total of 1 hour.
Document chemotherapy administration.
5. A 19-20 gauge right angled needle is preferred for optimal
flow. A 1.5” needle will allow room for abdominal distention.
No blood return is available in IP ports; aspiration not
recommended.
6. Head of bed must be no higher than 30 degrees to prevent
dislocation of right angled needle during infusion. A flat
position during infusion may increase pressure on diaphragm
causing respiratory compromise/GI upset in patients
receiving IP infusions
7. Warmed fluid is more comfortable for patient during
infusion and decreases the incidence of cramping associated
with IP infusions. (Infusion pumps are not used during IP infusions
due to the incidence of needle dislocation from the high pressure of pump.)
8. Migration of catheters or dislodging of right angled needle
may occur. See Table 1 for troubleshooting catheter
complications.
9. IP chemotherapy may take as little as 30 minutes or as long
as 2-3 hours to infuse. If infusion takes longer than 3 hours,
RN should notify physician. If flow is slow, verify tip of
needle touching back of port or slightly change patient
position.
10. This will enable appropriate dispersement of chemotherapy.
10.
11.
12.
13.
11. Patient may remove in 48 hours.
12. Repositioning disperses fluid throughout the peritoneal
cavity.
13. Use appropriate in-patient or out-patient documentation
tool to record administration.
References:
2006 GOG (Gynecologic Oncology Group) website regarding IP chemotherapy.
STPH Chemotherapy Administration Procedure
STPH Vascular Access Device Procedure
Implementation of Intraperitoneal Chemotherapy for the Treatment of Ovarian Cancer. Hydzik, C., Clinical Journal
Oncology Nursing, 2007, Vol 11 #2, pp221-225
Intraperitoneal Chemotherapy: Implications Beyond Ovarian Cancer. Marin, K., Oleszewski, K., Muehlbauer, P. Clinical
Journal of Oncology Nursing. 2007, Vol 11 #6, pp881-889
K:\Oncology\CHEMO Protocols\procedures\Intraperitoneal (IP) Chemo Admin-Using Implanted Port.doc
Table 1. Managing Intraperitoneal Catheter Complications
COMPLICATIONS
Slow infusion rate of
solution
Inflow failure
ETIOLOGY
Kinks in catheter or
tubing
Fibrin sheath formation
Obstruction of catheter
by adhesions, omentum,
or tumor
Catheter kinks
Blood or fibrin clots in
catheter
Obstruction of catheter
by abdominal adhesions
or omental blockage
Catheter migration
Tumor progression.
PREVENTIVE
MEASURES
Check administration of
tubing for kinks
Irrigate catheter well
before and after
administering chemotherapy and NS. Ensure
that administration and
drainage tubing is free of
kinks.
Outflow failure
Fibrin sheath formation
creating a one-valve effect
Omental adhesion or
tumor causing outflow
blockage of catheter.
When draining, ensure
drainage bag is below
insertion site.
Exit site infection
Break in aseptic technique
when performing
treatments, dressing
changes, and catheter care
Contamination of open
area at exit site (usually
from skin flora)
Immunosuppressed
patient
Separation of port from
catheter
Dislodgement of port
needle from septum
Migration of catheter out
of the peritoneum
Incomplete healing of
tunneled tract
Maintain aseptic
technique when assessing
catheter.
Leakage of
chemotherapy
Layer absorbent material
around tubing connections.
MANAGEMENT
Increase height of bag. Irrigate catheter with
20 ml normal saline (NS). Change patient’s
position. If using a port, check needle
placement and gauge. Flush with 10 ml
heparin, 100 units/ml after completion of
treatment, and let dwell until next treatment.
Reposition patient. Flush vigorously with
NS, repeat with 20 ml heparinized saline, 100
units/ml if necessary. Prepare for dye study
to check catheter position. If catheter is in
place but unable to irrigate, instill tissue
plasminogen activator (tPA). Let dwell for
two to four hours. If still unsuccessful,
catheter may need to be removed and
therapy reevaluated.
Reposition patient, attempt to flush with 20
ml NS. If still unsuccessful, flush with 10 ml
heparin, 100 units/ml. Attempt to withdraw
a fluid sample after 30 minutes. Notify
physician if no improvement occurs. Assure
patient that fluid will absorb at a rate of 1 L
per 24 hours. Prepare patient for dye study
to diagnose the problem. If catheter still
infuses, future treatments may continue as
ordered without the drainage of contents.
tPA may be ordered.
Culture exudates. Administer oral or IV
antibiotics as ordered. Increase local
measures; clean exit site once or twice a day,
and apply new sterile dressing. Teach
patients and families how to care for the
dressing at home. Allow patients to perform
a return demonstration.
Stop intraperitoneal infusion. Refer to
institution policy or standard of practice for
management of hazardous drug spill.
Provide skin care around site of leakage if
necessary.
Note: Based on information from Camp-Sorrell, 2004; Coles & Williams, 2000; Z00k-Enck, 1990.