Chemo Administration Policies
Chemo Administration Policies
Chemo Administration Policies
Policy/ Procedure
TITLE: NUMBER:
Administration of Cancer Chemotherapy STP-003
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use.
Administration of Cancer Chemotherapy Page 2 of 64
TABLE OF CONTENTS
3
Preamble…………………………………………………………………………………
4
Section 1. Safe Handling Of Cancer Chemotherapy Drugs and Waste
• Guiding Principles
• Policy
• Equipment
• Best Practice Procedure
Cleaning Chemotherapy Administration Area And Equipment 9
• Policy
• Best Practice Procedure
Cytotoxic Spills
11
• Policy
• Best Practice Procedure
Section 2. Cancer Chemotherapy Drug Administration 14
General Administration Practice
• Policy 16
Intravenous Cancer Chemotherapy Drug Administration
• Policy
• Best Practice Procedure
Intramuscular or Subcutaneous Cancer Chemotherapy Drug Administration 26
• Policy
• Best Practice Procedure
Administration Of Intravesical Chemotherapy 30
• Policy
• Best Practice Procedure
Administration Of Oral Or Topical Cancer Chemotherapy Agents (Including Nasogastric
Administration) 35
• Policy
• Best Practice Procedure
Administration Of Cancer Chemotherapy On Non-Oncology Units 39
• Policy
40
Definitions
43
Appendices
• Appendix 1: Medical Surveillance
• Appendix 2: Cytotoxic Precautions: Home Teaching
• Appendix 3: Cytotoxic Precautions in the Hospital
• Appendix 4: Patient Education for Oral Chemotherapy Drugs
• Appendix 5: Management of Extravasation
• Appendix 6: Management of Hypersensitivity Reaction
64
References
65
Related Documents
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 3 of 64
PREAMBLE
1. Cancer Care Nova Scotia (CCNS) is the provincial cancer program, with a mandate
to develop standards of cancer care across Nova Scotia. CCNS has developed a
“Systemic Therapy Manual for Cancer Treatments”, cataloging the drugs and
regimens used for the systemic therapy of cancer.
2. Cancer chemotherapy is systemic therapy to cure, control or palliate people with
cancer. The most common routes to administer chemotherapy drugs are oral (PO)
and intravenous (IV), but some drugs may be given by intrathecal injection (IT- into
the cerebrospinal fluid via the spinal cord), intraperitoneal injection (IP),
subcutaneous injection (subcut), intramuscular injection (IM), or intravesicular
instillation (into the bladder).
3. Cytotoxic chemotherapy for cancer patients is a high-risk area of pharmacotherapy.
These drugs are also used for non-cancer treatment and should be handled and
administered with the same criteria as used for cancer treatment.
4. Handling cytotoxic chemotherapy agents is an area of occupational risk for hospital
employees. Chemotherapy agents include cytotoxic (cell-killing) agents, which are
known to be occupationally hazardous. Non-cytotoxic agents are not proven to have
occupational hazards, but should be handled with the same degree of precaution.
5. Portions of this policy may only be performed by a Registered Nurse with
Chemotherapy Certification (RNCC) who has achieved the Post-Entry Level
Competency certification.
6. Specific policies and procedures are needed to ensure quality patient care and
optimal occupational safety during the administration of chemotherapy drugs. Oral
chemotherapy agents are usually self-administered but reasonable occupational
safety precautions should be taken to protect health care staff.
7. Policies and procedures, common to all health districts in Nova Scotia, will enhance
clarity and relationships between health care professionals providing chemotherapy
care, and thus further improve patient safety and quality care.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 4 of 64
SECTION 1.
SAFE HANDLING OF CANCER CHEMOTHERAPY DRUGS/WASTE
GUIDING PRINCIPLES
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 5 of 64
16. Health Care Providers follow best practice procedures, to ensure safety in the
administration of cytotoxic agents and with handling cytotoxic waste.
• All employees involved in any aspect of the handling of cytotoxic drugs and/or
waste are informed about the risks of occupational exposure.
• All employees who routinely handle cytotoxic drugs or waste will receive training
on safe handling practices.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 6 of 64
• All equipment for safe handling must be available to employees for administration
of chemotherapy and disposal of cytotoxic waste. Safe handling equipment and
Personal Protective Equipment (PPE) should be stored in one designated area of
the unit.
• Protective equipment must be used by all employees to reduce the risk of
exposure to cyotoxic agents and waste.
• In an effort to minimize cytotoxic exposure, protective equipment is not be worn
outside of the administration area except when managing a cytotoxic spill.
• Employees who are pregnant, attempting to conceive or father a child, or who are
breast feeding, may request to be transferred to other duties that do not involve
handling cytotoxic drugs. Each department will develop a policy to provide direction
with this issue.
• An eye wash station is accessible to the chemotherapy administration area.
• A safety shower or equivalent (e.g. hand held spray device) is readily accessible.
17. Strict hygiene procedures are developed and followed in the chemotherapy
administration area. Employees will not eat, drink, chew gum, apply cosmetics
or store food in or near the chemotherapy administration area.
18. Patient excreta (i.e. urine, feces) that are contaminated with cytotoxic drugs or
their metabolic byproducts must be handled as cytotoxic waste materials for at
least 48 hours following the last dose of chemotherapy administered.
EQUIPMENT
1. Personal Protective Equipment (PPE) is required when administering cytotoxic
drugs and handling cytotoxic waste. Best practice recommends thorough hand
washing with soap and water before donning PPE and immediately after
removing. Personal Protective Equipment includes:
a. GOWNS
• A long sleeve, back closure, water/drug repellent, disposable protective
gown with solid front and tight fitting cuffs (elastic or knit)
• The gown is discarded at least once daily or if soiled or torn during
administration/handling.
• The gown is not worn outside the chemotherapy administration area except
when managing a chemotherapy spill or disposing of cytotoxic waste.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 7 of 64
b. GLOVES
• Disposable powder-free non-latex gloves designed and validated for
chemotherapy administration (e.g. Nitrile glove)
• Wash hands thoroughly with soap and water before donning gloves and
immediately after removing gloves.
• Gloves are changed regularly, at least every 30 minutes , or immediately if
they are torn, punctured or contaminated. Gloves must be changed
between each patient.
c. MASKS
• Properly fitted masks must be used when there is a risk of exposure to an
uncontained amount of cytotoxic agent or when there is risk of
aerosolization of cytotoxic drugs (N95 masks meeting NIOSH respiratory
protection standards).
d. GOGGLES
• Protective eyewear (i.e. safety glasses with side shields) must be used
during cleaning procedures or when there is a risk of aerosolization of
cytotoxic drugs and during the clean up of any spill.
• If there is any risk of splashing, masks with face shields should be worn.
e. DISPOSAL CONTAINERS
• All cytotoxic drug waste is separated from general waste. Clearly labeled
cytotoxic waste receptacles are kept in all areas where cytotoxic drugs are
administered.
• Leak-proof, puncture proof sharps containers that clearly and visibly display
the cytotoxic hazard symbol are required for disposal of contaminated
administration equipment such as needles, syringes, glass bottles and
intravenous catheters, bags and tubing.
• Non-sharp closed-lid waste containers lined with double plastic bags that
clearly and visibly display the cytotoxic hazard symbol are required for
disposal of contaminated non-breakable materials such as disposable PPE,
dressings, gauzes or ostomy equipment.
• When full, the sharps and non-sharp containers are disposed by
housekeeping as cytotoxic waste, according to DHA policies.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 8 of 64
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 9 of 64
POLICY
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 10 of 64
monthly.
2. Waste generated throughout the cleaning or decontamination procedures is
collected in suitable plastic bags (labeled as cytotoxic waste), and removed
according to district procedures.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 11 of 64
CYTOTOXIC SPILLS
POLICY
1. All employees who routinely handle cytotoxic drugs or waste are trained in proper
spill management and cleanup procedures.
2. Employees will follow established policies and procedures for cytotoxic spill
management and clean up procedures.
3. The circumstances and handling of spills are documented and reported according to
district policies and procedures.
4. Spill kits, containing all materials and equipment necessary to clean a spill, are
available and readily accessible at each area where hazardous drugs are handled.
A written procedure for spill management is included in each spill kit. Spill kits are
either assembled or purchased. Components of a spill kit include (but may not be
limited to):
a. 2 pairs disposable non-latex gloves- large size
b. Low permeability gown and shoe covers
c. Safety glasses, splash goggles or face shield
d. Respirator mask (unless included in face shield)
e. plastic backed absorbent sheets or spill pads (sufficient to absorb a spill of up
to 1000mL)
f. Disposable towels or swabs for absorbing and cleaning liquid spills
g. At least 2 sealable plastic waste bags “Cytotoxic Waste”
h. Disposable scoop for collecting glass fragments
i. Puncture-resistant container for glass fragments, clearly labeled as cytotoxic
waste container
j. Cleaning solution for cleaning and decontamination of area
k. Instructions on the management of a cytotoxic chemotherapy spill.
l. Warning signs to alert other staff to the hazard and isolate the area of the
spill.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 12 of 64
2. In the event of a cytotoxic spill, these steps are to be followed for clean up
procedure:
a. Alert other staff in the area of the potential hazard; limit access to the area
while a spill kit is obtained and then place the warning sign (from the kit) in a
prominent position.
b. Remove the contents from the spill kit. Don personal protective equipment in
this order: the mask/face shield, the safety glasses, one pair of non-latex
gloves, gown, shoe covers, and the second pair of non-latex gloves.
c. For a liquid spill, carefully place an absorbent pad over the spilled liquid.
Absorb as much liquid as possible into the pad.
d. If the spill involves a powder, carefully place a damp disposable pad over the
powder and then carefully pat the spill area to adsorb as much powder as
possible.
e. If there is broken glass in the spill, carefully pick up the glass pieces using the
disposable scoop and place all glass in the puncture-proof container.
f. Gather up the contaminated pads. Discard all of this waste into the cytotoxic
waste container or bag.
g. Repeat steps until the entire spill has been cleared.
h. Use the cleaning solution to wash the area of the spill thoroughly, discarding
all waste generated into the waste container.
i. Rinse the area well with clean water.
j. Dry the area completely to prevent accidental slippage on wet floor.
k. Discard all used items including personal protective equipment into the
cytotoxic waste container or bag. Remove protective apparel in the following
sequence: top pair of gloves, safety glasses, mask, shoe covers and gowns.
l. Wearing second pair of gloves, double bag with the aide of a second person
and dispose of these gloves.
m. Arrange for collection of waste according to institution policy.
n. Wash hands thoroughly with soap and water.
o. Arrange for hospital cleaning staff to re-clean the area.
p. Arrange for a replacement spill kit to be obtained.
q. Notify the Health Services Manager or Charge Nurse and complete an
‘Occurrence/Safety Report’ as per District policy
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 13 of 64
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 14 of 64
SECTION 2.
CANCER CHEMOTHERAPY DRUG ADMINISTRATION
POLICY
1. Best practice procedures to ensure safety standards are followed for the
administration, handling and disposal of cancer chemotherapy drugs.
2. Chemotherapy administration facilities maintain documentation of all quality
monitoring processes and records, which may include:
a. Maintenance logs for all equipment
b. Certification status of all Registered Nursed involved in chemotherapy
administration.
3. To administer cancer chemotherapy, the Registered Nurse (RN) must successfully
complete an approved Post-Entry Level Certification (PELC) program. This RN will
be designated as a Registered Nurse with Chemotherapy Certification (RNCC).
a. Chemotherapy given by routes other than intravenous may be given by a RN,
as described in the policies for each section below.
4. The RNCC administers only chemotherapy drugs that have been approved for the
Level of Care designation assigned to the local hospital.
5. Intrapertioneal and intravesical cancer chemotherapy will be administered according
to the Levels of Care designation for the facility.
6. The RNCC is knowledgeable of the procedures for managing anaphylaxis and a
suspected extravasation.
7. A regimen specific Physician Pre-printed Order (PPO) form must be used for
chemotherapy prescriptions (when available provincially). If a PPO does not exist for
a specific protocol, the physician / nurse practitioner (NP) will use the generic
chemotherapy template PPO to prescribe the chemotherapy. When the PPO’s are
available provincially, the RNCC will not accept chemotherapy orders written any
other way. A physician / NP may order other fluids, volumes, rates or methods of
delivery as warranted by specific patient situations. Rationale for modifications will
be documented on the PPO. (See Policies and Procedures on Ordering Cancer
Chemotherapy).
8. Specialized chemotherapy procedures (e.g. intrathecal, intraperitoneal, pleuredesis,
intraoperative, intra-hepatic or intra-arterial infusions) may be administered by other
specialists, such as surgeons, internists, gastroenterologists or radiologists, only
according to specific policies & procedures approved by the district health authority
consistent with the Levels of Care model.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 15 of 64
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 16 of 64
POLICY
1. To administer cancer chemotherapy the RN must be deemed competent in:
completing a pre-treatment nursing assessment; safe handling of chemotherapy
drugs; administering infusional cancer chemotherapy and administering IV direct
cancer chemotherapy; and management of adverse effects. The RN must be
certified as a Registered Nurse with Chemotherapy Certification (RNCC).
2. The RNCC must be competent in IV therapy initiation, and care and maintenance of
central venous access devices (CVAD).
3. The RNCC is competent in IV direct administration of drugs, when it is required for
specific protocols and/or procedures (i.e. hypersensitivity reactions).
4. Prior to administration of chemotherapy, the RNCC will assess the patient, provide
necessary education and verify the chemotherapy order.
5. The main IV line, which is attached to the indwelling IV catheter, will be a non-
chemotherapy containing solution. All IV bags and IV injections will be made into
the secondary line connection(s) to the main line.
6. Prior to administration, the RNCC is responsible to know if a chemotherapy drug is
classified as a vesicant, irritant or non-irritant. Medications are labelled “Vesicant” or
“Irritant” as appropriate for each drug.
7. Vesicant drugs administered peripherally may be given via two routes: intermittent
infusion or IV direct. Exception: Vincristine must be given via minibag and not IV
direct (to avoid any possibility of this drug being given accidentally as an intrathecal
dose).
8. Vesicant drugs administered by intermittent peripheral infusion (mini bag) must be
administered by gravity and never administered via an infusional pump.
9. When administering vesicant drugs peripherally, the RN will start a new venous
access for any IV site older than 2 hours. The antecubital fossa must not be used
for vesicant drugs (It is also recommended to avoid the vessels of the hand or wrist,
if possible.)
10. If a vesicant requires administration by continuous infusion, a central venous access
device (CVAD) and an infusion pump is required.
11. When administering a series of chemotherapy drugs, the sequence should be
vesicants first, irritants and then non-irritants. Small volume infusions are commonly
administered prior to large volume infusions. An exception to this is an established
protocol that has a specific sequence, which requires a specific agent to be
administered first due to pharmacokinetic reasons (i.e., clearance, synergism).
12. For the inpatient units, it is recommended that initiation or discontinuation of a
cancer chemotherapy infusion not occur around the change of shift.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 17 of 64
Chemotherapy Verification
3. Prior to the administration of cancer chemotherapy in any District Health Authority
facility, the RNCC who is administering the chemotherapy will:
a. Verify that the consent has been obtained.
b. Confirm the initial BSA (if used to calculate the dose) or recalculate the BSA
(Standard BSA formula) if weight has changed by greater than10% from baseline
c. Recalculate the creatinine clearance (for AUC dosing) with each cycle of
chemotherapy (e.g. each dose of Carboplatin)
d. Recalculate or verify all doses, to confirm accuracy of calculations
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 18 of 64
e. Verify that the correct drug(s) have been ordered consistent with the cycle and
week(s) as defined by the regimen. Compare with last treatment order.
f. Verify that the dose or dosage range is appropriate for the patient and treatment
plan using an approved reference.
g. Review lab results and other diagnostic test/procedures required by the regimen,
and ensure these have also been reviewed by the physician.
h. Verify pre-hydration if ordered
i. Verify pre-medication as ordered
j. Determine the sequence of the drugs to be infused; vesicants, then irritants, then
non-irritants, unless otherwise specified
k. Review procedure for extravasation and hypersensitivity reactions (if appropriate)
l. Verify with another RNCC (or registered nurse, nurse practitioner, pharmacist or
physician, if another RNCC is not available) that the information on the
chemotherapy drug label matches the information on the physician order and/or
medication administration record (MAR).
m. Check patient’s name, patient identification number, drug name and dose, route,
time, infusion rate, and diluent solution.
n. Both RNs must sign the MAR and Chemotherapy Administration Checklist and
Calculation Form (as per DHA procedures) when the checking is completed.
o. Inspect all chemotherapy admixtures for expiry date, particulate matter, signs of
incompatibility, degradation or contamination prior to administration.
p. Verify that the full name and patient identification number on the chemotherapy
drug label matches the full name and patient identification number on the
patient’s identification armband or equivalent personal identification on the
patient, as per DHA procedures.
4. Correct drug(s), dose(s), BSA calculations, creatinine clearance (as appropriate),
infusion rate calculations (as appropriate), correct cycle/date(s), and lab tests must
be verified by two oncology health professionals (e.g. oncology nurse(s), oncology
pharmacist), performing the verification independent from one another, and the
calculations will be documented as per DHA procedures.
a. If any calculation (dose, BSA or AUC) differs by 10% or more from the order,
these must be clarified with the prescriber before drug administration
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 19 of 64
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 20 of 64
7. Vesicant Drugs:
a. Vesicant drugs may be administered peripherally or via a CVAD.
b. Vesicant drugs may be administered as an intermittent infusion or as a
continuous infusion
c. Vesicant drugs administered by intermittent peripheral infusion will be
delivered via the direct IV method of administration or by piggyback infusion
in a minibag.
d. Vesicants are never administered continuously via peripheral infusion. If a
vesicant requires administration by continuous infusion, a CVAD and an
infusion pump is required.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 21 of 64
b. When administering vesicant peripherally, the RN will start a new venous access
for any IV site older than 2 hours.
c. Choose an appropriate IV site. The antecubital fossa must not be used for
vesicant drugs (It is also recommended to avoid the vessels of the hand or wrist,
if possible.).
d. RNCC must stay with the patient for the duration of the peripheral vesicant
infusion.
e. The RNCC must constantly monitor peripheral venous patency while
administering the drug, regardless of which method is used (IV direct or mini-
bag).
9. Peripheral - Direct IV :
a. Cleanse the lowest Y-port with an alcohol swab. Place a 2x2 guaze under the
injection port to absorb any droplets. Insert the syringe containing the vesicant
drug into the injection port. Open IV clamp on the mainline and ensure the IV is
free flowing.
b. Verify blood return and patency immediately prior to initiating the vesicant
injection
c. Administer the vesicant drug at the prescribed rate of infusion
d. The RNCC will ensure the IV continues to flow freely and IV patency is verified
every 3mLs by aspiration of blood return and assessment of the signs and
symptoms of extravasation. (Follow algorithm for Cancer Chemotherapy
Extravasation, as indicated).
e. Following chemotherapy administration and/or between drugs, the line is flushed
through the injection port with 10 mL of compatible IV solution. In addition to this,
50 mL of IV solution is flushed through the mainline. Once the procedure is
completed saline lock, discontinue or continue IV, depending on orders.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 22 of 64
Irritant Drugs:
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 23 of 64
13. Irritant chemotherapy drugs are administered using the same equipment and
procedures as outlined above.
a. Irritant drugs may be administered peripherally or via a CVAD.
b. Irritant drugs may be administered as an intermittent infusion or as a
continuous infusion
c. Irritant drugs that are administered by intermittent peripheral infusion will be
delivered via the direct IV method of administration or by piggyback infusion
in a minibag.
d. If an Irritant requires administration by continuous infusion, a CVAD and an
infusion pump is required (with the exception of designated regimens)
e. Blood return and patency is verified immediately prior to initiating the irritant
infusion
f. For all peripheral infusions of irritants, monitor IV site and patient sensation every
30 minutes. Check for blood return at least once every hour. Check for blood
return more often if there is any discomfort.
g. For continuous infusions of irritants via a CVAD, monitor CVAD site and
patient sensation at least once every hour, and check blood return at least
once per shift (inpatient area)
Non-Irritant Drugs:
14. Non-irritant chemotherapy drugs are administered as a direct IV injection or
intermittent IV infusion or as a continuous infusion through a peripheral IV or
CVAD.
a. The preferred method to administer non-irritant drugs is to follow the same
procedures and precautions as irritant chemotherapy agents, outlined above.
b. In some circumstances, non-irritant drugs may be administered as a direct
injection into the IV catheter followed by a flush injection (without the use of a
free-flowing IV line). This would be specified in the drug monograph, the
Systemic Therapy Manual or district policy.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 24 of 64
e. When the balloon reservoir and the flow restrictor / luer lock connection are at the
same height
17. Prepare the following equipment for this procedure:
a. PPE
b. Plastic backed absorbent pad
c. Alcohol swabs
d. 2 x 10 mL pre-filled normal saline syringes
e. Waterproof tape
f. Pre-filled elastomeric ambulatory infusion pump
g. Carrying device / pouch
h. Transparent dressing
18. An extension tubing will be added to the infusor tubing by pharmacy to allow for
additional length as well as providing a clamp.
19. All elastomeric infusion pumps will arrive at the nursing unit with the line primed with
the chemotherapy agent.
20. To connect the elastomeric infusion device:
a. Verify the elastomeric infusion pump delivers correct hourly rate.
b. Prior to removing the infusion pump from the sealed bag, inspect for leakage.
c. Working over a plastic backed absorbent pad, remove the infusion pump from
the sealed bag. Ensure the protector cap on top of the infusion pump is secure
and the clamp is closed.
d. Verify patency of IV / CVAD by checking for blood return. Flush with 20mL 0.9%
sodium chloride.
e. Working over a plastic backed absorbent pad, remove the cap from the end of
the extension tubing. Ensure the liquid has moved to the end of the tubing.
f. Attach the tubing of the ambulatory infusion pump to the adaptor on the central
venous access device. Secure luer lock connections tightly.
g. Tape all connections with waterproof tape (as per district policies).
h. Open clamps.
i. Secure the flow restrictor to the patient’s skin.
j. Leaving the elastomeric infusion pump in a plastic bag, place the elastomeric
infusion pump in a carrying device. Should be carried at waist level
k. Review patient teaching.
l. Ensure patient has been notified of return date/time for pump disconnect
/change.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 25 of 64
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 26 of 64
POLICY
1. Subcutaneous and intramuscular cytotoxic cancer chemotherapy may only be
administered by a Registered Nurse with Chemotherapy Certification (RNCC) or a
Registered Nurse (RN) with additional knowledge and skills about cytotoxic
precautions, management of expected toxicities and other care required by oncology
patients. See Appendix 2.
2. Subcutaneous cytotoxic cancer chemotherapy doses may be self-administered in
the home setting by the patient and/or family member with self-administration
teaching,.
3. Safety precautions, as outlined in Section 1, should be followed during the
administration of all cytotoxic drugs to prevent undue exposure of the health care
provider and the patient.
4. To administer cancer chemotherapy the RNCC must be deemed competent in:
completing a pre-treatment nursing assessment; administering subcutaneous and/or
intramuscular cancer chemotherapy.
5. Prior to administration of chemotherapy, the RNCC will assess the patient, provide
necessary education and verify the chemotherapy order.
6. For subcutaneous or intramuscular injection a syringe will be prepared in the
chemotherapy preparation area of the pharmacy. A protective cap is placed on the
end of the syringe.
7. Vesicants or irritant chemotherapy agents are not to be administered by
subcutaneous or intramuscular route.
8. Ensure adequate platelet count (greater than > 50 x 109 cells/L) for intramuscular
(IM) injection.
9. Air should not be expelled from syringes prior to administration.
Equipment:
• Appropriate personal protective equipment (nitrile gloves, chemo gown).
• Non-permeable plastic backed absorbent pad
• Appropriate gauge and length of needle(s)
i. For subcutaneous injections, it is recommended to use 26 gauge needles (or
higher gauge, unless specified by manufacturer)
ii. For intramuscular injections, it is suggested to use 22-27 gauge needles of
appropriate length (unless a lower gauge is required for the patient or as
specified by manufacturer).
• Skin antiseptic swab
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 27 of 64
Chemotherapy Verification
3. Prior to the administration of cancer chemotherapy in any District Health Authority
facility, the RNCC, who is administering the chemotherapy, will:
a. Verify that the consent has been obtained.
b. Ensure that a physician is accessible in case of an emergency
c. Confirm the initial BSA (if used to calculate the dose) or recalculate the BSA
(Standard BSA formula) if weight has changed by greater than10% from baseline
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 28 of 64
a. If it is anticipated that a work surface will be needed at the bedside, prepare one
by placing a non-permeable plastic-backed absorbent drape on a hard, flat
surface.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 29 of 64
9. Inspect sealed bag (containing the chemotherapy syringe) before opening to ensure
there is no spillage within the bag.
10. Select a suitable site for the injection, and prep skin with approved antiseptic swab;
allow to dry.
a. Ensure the site is rotated each time if repeated administration is required.
11. Remove the chemotherapy syringe from the protective plastic bag onto non-
permeable plastic backed pad.
12. Carefully remove the connector top from the Luer-lock syringe and attach an
appropriate needle (e.g. 26-gauge needle with a needle length of 8mm). Ensure
needles for administration are secure, taking care to minimize risk of spillage on the
skin.
13. For subcutaneous injections, use a pinch technique, administer the injection at a 45
or 90 angle. Aspiration is not required prior to the injection of the drug.
14. For intramuscular injections, administer the injection using z track technique via
ventrogluteal injection site (or as specified in manufacturers’ recommendations).
15. Following injection, leave the needle in place for a few seconds then remove slowly
to minimize drug leakage from injection site.
16. Remove the syringe and needle. Do NOT recap the needle; ensure safety devise is
engaged before disposal.
17. Dispose in the cytotoxic sharps container.
18. Following administration, if needed, place gauze over site until bleeding or weeping
of the agent has ceased.
19. Cover with occlusive dressing or bandage if necessary.
20. If further injections are required, rotate the site of administration and maintain record
of administration sites.
21. Ensure all potentially contaminated materials are placed on the protective work
surface. Roll the plastic backed pad with contents, place in the appropriate cytotoxic
waste container.
22. Remove PPE (including gloves) and discard into appropriate cytotoxic waste
container.
23. Wash hands.
24. Document medication administration and injection site.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 30 of 64
POLICY
1. Intravesicular administration agents will be performed by a urologist or a registered
nurse with PELC certification for this procedure. For administration of cytotoxic
drugs, the nurse must also be an RNCC.
2. Intravesicular chemotherapy agents will only be administered if there is a physician
available while the instillation is being administered.
3. BCG is a live attenuated virus and should not be handled by employees with
known immunological deficiency.
4. BCG is contraindicated within 14 days of TUR of bladder tumour, after a traumatic
catheterization, in the presence of hematuria or urinary tract infection, and in acute
febrile illness.
5. BCG is reconstituted by a pharmacist or RN with PELC certification through the
use of a closed system. Contaminated materials used to administer BCG (e.g.
catheter, syringe) must be disposed of in Biohazard containers. All work surfaces
must be disinfected with a disinfectant with a tuberculocidal claim.
6. Other drugs used for bladder instillation are Mitomycin, Epirubicin and Interferon.
They will be prepared by the pharmacy and handled using all cancer
chemotherapy safe handling procedures.
BEST PRACTICE PROCEDURE
Pre-treatment Assessment and Teaching
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 31 of 64
i. Document assessment
2. The Oncology Nurse will educate the patient/family in collaboration with other
oncology health professionals (see Patient Education Standards for Adults).
Teaching is documented on a chemotherapy teaching tool as per DHA. Parameters
of teaching plan must include (but not limited to):
a. Explain procedure to patient and provide written teaching instruction for post
procedure care at home.
b. Description of treatment, including drugs, specific protocol, scheduling and
administration
c. Review of potential side effects (immediate, early and delayed), management
and self care practices to prevent/manage side effects, coping, psychosocial
support
d. Review of cytotoxic/tuberculocidal precautions
Chemotherapy Verification
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 32 of 64
4. Correct drug(s), dose(s), correct cycle/date(s), and lab tests must be verified by two
oncology health professionals (e.g. oncology nurse(s), oncology pharmacist),
performing the verification independent from one another, and the calculations will
be documented as per DHA procedures.
a. If any calculation differs by 10% or more from the order, these must be clarified
with the prescriber before drug administration
5. Procedure: BCG Administration When administering BCG through intravesicular
catheter into the bladder:
a. Ensure there is a written physician’s order and signed consent
b. Ensure that a physician is accessible in case of an emergency
c. Prepare the following equipment for this procedure:
a. Catheter tray including cleansing solution, lubricant, labelled specimen
container
b. #12 straight catheter or #14 straight catheter
c. 60 mL syringe (luer-lock)
d. 50 mL normal saline
e. Closed system i.e. BCG reconstitution kit
f. Vial of BCG
g. Plastic backed absorbent pad
h. Cytotoxic waste container
i. Mask
j. Rubbing alcohol
k. Long sleeved chemotherapy gown
l. Sterile gloves
m. Goggles
d. Prepare work area by placing a plastic backed absorbant pad on the work
surface; ensure cytotoxic sharps container is within easy reach for disposal of
equipment.
e. Pour 50 mL sterile normal saline into a sterile urine bottle and lay bottle of BCG
beside it. Place a plastic backed absorbent pad under the patient to protect the
examination bed from contamination.
f. Assemble equipment. Open and arrange catheter tray dropping BCG
reconstitution kit onto sterile field as well as 60 mL luer lock syringe. Draw up 50
mL of sterile normal saline.
g. Don PPE: gown, mask, goggles (including a face shield if danger of splashes or
sprays), and sterile gloves.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 33 of 64
h. Catheterize using a #12 straight catheter or #14 (Coudé tip catheter may be
necessary if having difficulty inserting straight catheter. NOTE: Contact a
physician if you have not been taught how to insert a Coudé tip catheter)
i. Obtain urine for culture and sensitivity and assess for hematuria. Ensure the
bladder is completely empty.
j. Leave catheter in place.
k. Reconstitute BCG in the following manner.
a. Take the 50 mL of sterile normal saline holding the syringe in a downward
position.
b. Lock it into the BCG reconstitution kit.
c. Insert bottle of BCG onto other end; 1 mL of normal saline will automatically
enter BCG bottle.
d. Mix this solution then draw it back into syringe.
e. Instill 1 mL of the solution from the syringe back into the bottle, mix and draw
back into syringe.
l. Lay BCG reconstitution kit on sterile field with BCG bottle far from the catheter
tray.
m. Insert catheter tip of BCG reconstitution kit into catheter and slowly over three
minutes instill the BCG into the bladder.
n. Remove catheter, unless otherwise ordered.
o. Place catheter, tray, supplies, gown, gloves, goggles and mask in a cytotoxic
waste container for disposal.
p. Instruct patient to hold solution for two hours. Note: Some patients cannot hold
for 2 hours so instruct to hold as long as they can up to 2 hours. Rotate patient
position as per protocol orders.
q. Ensure the patient can verbalize the instructions regarding safe self-care post
BCG administration and how to access assistance if needed.
r. Document procedure and patient tolerance and send urine culture to the lab.
s. After each patient, clean and disinfect the mixing area and treatment table/area
with 70% isopropyl alcohol wearing protective equipment (including mask). All
work surfaces must be disinfected with a product that has a tuberculocidal claim.
t. In the event of a spill or incontinence, pour copious amounts of the tuberculocidal
disinfectant on area and let sit for 10-15 mins. Clean spill and area with
detergent. Dispose of all materials in a cytoxoxic waste container.
6. When administering other cytotoxic chemotherapy agents (e.g. Mitomycin)
through a catheter into the bladder, follow the procedures used for BCG
intravesicular administration, except as follows:
a. Cytotoxic chemotherapy agents are prepared by pharmacy in syringes ready
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 34 of 64
for instillation.
b. Administration should be done in a chemotherapy administration unit, if
possible.
c. In the event of a spill or incontinence, handle the same as any other cytotoxic
spill.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 35 of 64
POLICY
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 36 of 64
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 37 of 64
h. Both RNs must sign the MAR and Chemotherapy Administration Checklist and
Calculation Form (as per DHA procedures) when the checking is completed.
i. Verify the full name and patient identification number on the chemotherapy drug
label matches the full name and patient identification number on the patient’s
identification armband or equivalent personal identification on the patient, as per
DHA procedures.
2. At the beginning of each cycle, correct drug(s), dose(s), correct cycle/date(s), and
lab tests must be verified by two oncology health professionals (e.g. oncology
nurse(s), oncology pharmacist), performing the verification independent from one
another, and the calculations will be documented as per DHA procedures.
a. If any calculation differs by 10% or more from the order, these must be clarified
with the prescriber before drug administration
Oral Cancer Chemotherapy Administration
3. Administer pre-medication, if ordered.
4. When administering oral cancer chemotherapy (including liquid formulations), the
Registered Nurse will:
a. Ensure oral chemotherapy drugs are stored separately from other medications
b. If it is anticipated that a work surface will be needed at the bedside, prepare one
by placing a non-permeable plastic-backed absorbent drape on a hard, flat
surface.
c. Avoid touching the tablets/capsules directly
d. Wear gloves when handling oral cancer chemotherapy drugs. If there is a risk of
being sprayed or splashed with a liquid chemotherapy agent, additional personal
protective equipment is worn.
e. Inspect all chemotherapy doses for expiry date, particulate matter, signs of
incompatibility, degradation or contamination before administration.
f. Drop dose into a medication cup.
g. If possible have patient swallow medication whole with a drink of water or
preferred liquid.
h. Remove gloves and wash hands after handling chemotherapy drugs and
equipment
i. Dispose of all equipment used in the administration of medication (e.g.
medication cups, syringes, gloves, etc) in appropriate cytotoxic waste containers.
j. Follow cytotoxic precautions (inpatient unit) or teach cytotoxic precautions for
ambulatory patients
k. Document chemotherapy administration on the patient’s chart/MAR.
Nasogastric Administration
5. When administering cancer chemotherapy via feeding tube the Registered Nurse
will:
a. Ensure oral syringe containing chemotherapy drug is stored separately from
other medications
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 38 of 64
Topical Administration
6. When administering topical cancer chemotherapy the Registered Nurse will:
a. Ensure container(s) with topical chemotherapy drug is(are) stored separately
from other medications, enclosed in a sealed plastic bag.
a. Wear gloves when handling topical cancer chemotherapy drugs. If there is a risk
of occupational exposure, additional PPE is worn.
b. Protect the work area with a plastic backed absorbent pad.
c. Apply the topical drug in a thin layer to the area to be treated with a sterile tongue
blade or cotton tipped applicator at the frequency ordered; avoid contact with
unaffected skin and mucous membranes of the eyes, nose and mouth.
d. Unless contraindicated, and if the drug is being applied to exposed skin, cover
the treated area with an appropriate dressing to prevent exposure to other areas
of the body, clothing or people.
e. If applicable, remove the drug completely at the end of the required contact time.
f. Remove gloves and wash hands after handling chemotherapy drugs and
equipment
g. Dispose of all equipment used in the administration of medication (medication
cups, syringes, gloves, etc) in appropriate cytotoxic waste containers.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 39 of 64
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 40 of 64
POLICY
If an oncology patient is to receive cancer chemotherapy on a nursing unit where
nursing staff do not have certification for chemotherapy administration:
1. Before administration of cancer chemotherapy in a non-oncology unit, a discussion
on a case by case basis needs to occur about options to ensure that priority is
considered for the patient who most needs expert oncology nursing care to receive
this in the most appropriate location.
2. Administration of intravenous doses, and other doses as included in defined
chemotherapy regimens, must be given by a Registered Nurse with Chemotherapy
Certification (RNCC).
a. All reasonable effort should be made to transfer the patient to an oncology unit
for parenteral chemotherapy administration and monitoring.
b. Exceptions to moving or switching patient care location would include patients
with needs for other nursing expertise and support greater than the need for
expert oncology nursing care (e.g. ICU monitoring).
c. If the patient cannot be transferred, then an RNCC must go to the unit and
administer parenteral cancer chemotherapy to the patient at that location.
d. Patients in long term care or continuing care facilities will be treated at the most
accessible ambulatory chemotherapy administration area.
3. Administration of oral, nasogastric, topical, intravesicular, subcutaneous, or
intramuscular doses may be given on the non-oncology unit by a RN other than
RNCCs if the RN is knowledgeable about cytotoxic precautions, management of
expected toxicities and other care required by oncology patients. Order verification
for cytotoxic cancer chemotherapy doses must involve two independent oncology
health professionals. See policy sections on “Administration of Oral or Topical
Cancer Chemotherapy Agents (Including Nasogastric Administration)”,
“Administration of Intravesical Chemotherapy” and “Administration of Subcutaneous
or Intramuscular Chemotherapy”
4. Employees on the non-oncology units should be educated regarding cytotoxic
precautions, management of expected toxicities, cleaning of equipment and patient
care area(s), cytotoxic waste management, other occupational safety issues, and
other care required by oncology patients after the chemotherapy administration.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 41 of 64
DEFINITIONS
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 42 of 64
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 43 of 64
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 44 of 64
APPENDIX 1
Medical Surveillance of Health Care Worker Handling Cytotoxic
Drugs and Waste
According to Occupational Safety and Health Administration (OSHA, USA), safe
levels of occupational exposure to cytotoxic agents can not be determined. No
reliable method of monitoring exposure exists. It is imperative that those who work
with cytotoxic agents adhere to practices, as outlined above, to eliminate or reduce
occupational exposure.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 45 of 64
APPENDIX 2
Cytotoxic Precautions - Home Teaching
When a patient returns home following treatment with a cytotoxic agent(s) or has
chemotherapy infusing at home via an infusion device, the nurse will explain cytotoxic
precaution/safe handling practices.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 46 of 64
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 47 of 64
APPENDIX 3
Cytotoxic Precautions in the Hospital
While a patient is in the hospital receiving treatment with a cytotoxic agent(s), the nurse
will explain cytotoxic precaution/safe handling practices used by staff and those that
should be practiced by the patient.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 48 of 64
APPENDIX 4
Patient Education for Oral Chemotherapy Drugs
• Before starting oral chemotherapy, tell your doctor or nurse about other
medication and over the counter drugs you are taking.
• Let your doctor, nurse or pharmacist know if your have a problem paying for or
getting your cancer medications. There may be services available to help with
the prescription costs.
• Tell other doctors, dentists or heath care workers that you are taking oral
chemotherapy for your cancer. Carry with you, in your wallet or purse, a list of
medication you are taking, including your cancer medication.
• Keep the oral chemotherapy in a safe place where children and pets cannot
reach them.
• Do not mix your oral chemotherapy pills/tablets with other medication. Keep
these pills separate from other medication.
• You should handle your own medications, if possible. If someone else is giving
you your oral chemotherapy medications, they should not touch them with their
bare hands; they should be wearing gloves or should put the pills in a medication
cup.
• Do not crush, chew, split, break or cut your pills/tablets or open capsules unless
you have been told to do so and shown how to do so in a correct and safe
manner by your nurse, doctor or pharmacist.
• Keep your oral chemotherapy medications away from heat, sunlight, or moisture
as these may damage the medication and make it less effective.
• Take your oral chemotherapy medications on the correct day and at the correct
time of day you have been told by your doctor, nurse or pharmacist. Follow a
clock, timer or calendar to keep yourself on track for the correct day and time. If
you are uncertain about the time(s) to take your medications, ask your doctor,
nurse or pharmacist again, until you clearly understand.
• Be sure you know what to do if you miss a dose. It is important that you do not
take two doses at the same time.
• Be sure you know what to do if you vomit after taking your oral chemotherapy.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 49 of 64
• If you take too many pills/capsules by accident or if someone else takes your
pills/capsules, contact your cancer doctor immediately; if you are unable to reach
your cancer doctor go immediately to the nearest emergency department.
• Plan ahead to make sure you have enough medication for travel, holidays and
weekends.
• You should not become pregnant or make a woman pregnant while on oral
chemotherapy. If you have questions about birth control, please ask your doctor
or nurse for help and advice.
• Read the information you have been given on the side effects of the medication.
• Let your cancer doctor or nurse know right away if you have any side effects of
the oral chemotherapy medications.
• Ask if you should avoid certain foods while on your oral chemotherapy
medications.
• Follow up appointments for blood work and clinic appointments or phone calls by
clinic nurses are important. These help to decide if another cycle of treatment
can be started or if treatment should be continued. Remember to keep these
appointments.
• Your nurse will tell you about cytotoxic precautions to use in the home. It is
important to know that the risks to your family and others in the home are just as
serious with oral chemotherapy as they are with chemotherapy given by IV in the
hospital. If you do not have the information about home precautions, be sure to
ask your nurse as soon as possible.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 50 of 64
APPENDIX 5
Guidelines for the Management of Extravasation of Cancer
Chemotherapy Agents
Adapted From QEII Pharmacy Department in Conjunction with
Oncology/Medical Surgical Specialities/Transplant Nursing
Date Approved By Oncology Therapy Subcommittee: May 23,1997
I. DEFINITIONS
Infiltration: Refers to the (IV) intravenous cannula which has slipped from a vein
into the tissue.
Vesicant: An agent capable of causing tissue necrosis when infiltrated from the
vein into the subcutaneous tissue causing progressive severe tissue damage.
Irritant: An agent capable of causing pain and local inflammation but not tissue
necrosis.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 51 of 64
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 52 of 64
CANCER
CLINICAL COMMENT ON EFFECTS OF
CHEMOTHERAPY VESICANTS
EXTRAVASATION
Generic Name
Amsacrine • Immediate pain, erythema and swelling
• Severe skin ulcers
Dactinomycin • Immediate pain, erythema, swelling
• Known to produce severe skin ulcers
Daunorubicin • Immediate pain, erythema and swelling
• Severe skin ulcers
Doxorubicin • Immediate pain, erythema and swelling
• Severe progressive tissue necrosis
• Blisters may appear in 1-2 days and ulceration
days to weeks after extravasation
Epirubicin • Same as doxorubicin
Idarubicin • Same as doxorubicin
Liposomal Daunorubicin • Same as doxorubicin
Mechlorethamine • Immediate pain and swelling
(Nitrogen Mustard) • Severe and prolonged skin ulcers; lesions heal
poorly
Melphalan • Mild pain and/or irritation; resolves within few
hours
• Skin ulceration at injection site
Mitomycin-C • Initial local erythema, edema, and pain
• Progress slowly to non-healing skin ulcerations
• Symptoms are sometimes delayed months;
lesions can expand over weeks
Streptozocin • Tissue necrosis
• Burning sensation at injection site and up the
arm
Vinblastine • Produces pain, erythema and localized swelling
within minutes
• Skin blisters form after several days and
resolve slowly over several weeks
Vincristine • Same as vinblastine
Vinorelbine • Produces pain, erythema, localized swelling
• Local tissue necrosis and/or thrombophlebitis
• Venous discoloration
• Possible ulceration
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 53 of 64
CANCER
CHEMOTHERAPY
CLINICAL COMMENT ON EFFECTS OF EXTRAVASATION
IRRITANTS
Generic Name
Aldesleukin • Injection site reactions
• Nodules or indurations at injection site
Carmustine • Possible phlebitis due to ethanol content (drug
reconstituted with ethanol)
Cisplatin • Rarely produces necrosis (vesicant properties) and only
when large amount of highly concentrated solution is
extravasated
Dacarbazine • Phlebitis is rare
• Light induced activation pathway of drug suggests
protection of exposed tissues from light during
administration
Docetaxel • Localized pain and discoloration of skin
• Erythema, desquamation
• At higher doses, docetaxel may perform as a vesicant
Etoposide • Phlebitis, urticaria and erythema (due to drug formulation)
• Possible skin ulceration
Ifosfamide • Local pain, inflammation, induration, phlebitis
Gemcitabine •
Liposomal • Should be considered as an irritant
Doxorubicin • Use same procedures as doxorubicin
Liposomal • Should be considered as an irritant
Doxorubicin • Use same procedures as doxorubicin
Pegylated
Mitoxantrone • Does not appear to consistently produce necrosis if
extravasated
• Relatively painless upon immediate extravasation
• Blue discoloration of skin
• Possible ulceration
Oxaliplatin • Injection site reactions
• At higher doses, oxaliplatin may perform as a vesicant
Paclitaxel • Inflammation
• Pain, erythema, cellulites
• Possible sclerosis, hyperpigmentation, skin ulceration
and peeling and blistering of skin
• At higher concentrations, paclitaxel may perform as a
vesicant
Paclitaxel NAB • Same as paclitaxel
Teniposide • Similar to etoposide
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 54 of 64
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 55 of 64
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 56 of 64
Suspect extravasation
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 58 of 64
APPENDIX 6
Guidelines for the Management of Hypersensitivity Reactions /
Anaphylaxis With Cancer Chemotherapy Agents
Adapted From QEII Health Science Centre
Approved By Oncology Therapy Subcommittee
Anaphylaxis
• Syndrome elicited in a hypersensitive individual on subsequent exposure to a
sensitizing antigen
• Ranges from localized response to systemic response which may lead to
anaphylactic shock and death
Discussion
• May have no correlation with the known pharmacologic properties of the drug
• May occur on first exposure or develop after subsequent administration (i.e. a number
of previous cycles)
• Only occurs in a small percentage of patients
• May present with early or late onset of symptoms
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 59 of 64
Chemotherapeutic agents for which pre-medications are not routinely used but which
may require treatment for allergic reactions that can occur during infusion
• alemtuzumab • bleomycin
• asparqaginase • carboplatin
• bevacizumab • etoposide
• The patient should be closely monitored when receiving drugs with documented
potential for hypersensitivity response. The Registered Nurse (RN) must remain with
the patient for the first 15 minutes when administering these drugs. Most reactions
become evident early on within seconds or minutes after exposure to an antigen.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 60 of 64
Algorithm
Hypersensitivity Reaction
(may occur on first or subsequent
exposure)
Action:
No Yes Nurse Administering Chemotherapy
• Assess vitals immediately then q10 minutes
until symptoms resolve
Continue cancer Stop infusion • Maintain IV access
chemotherapy • Ensure mainline IV running - wide open
treatment as ordered. (vascular space expander - 0.9% NaCl
Notify physician preferred)
STAT • Assess respiratory status, loosen clothing,
consider paging Respiratory Department for O2
Subsequent cycles
• Position patient supine with feet elevated if
as planned
Physician respiration not compromised.
assessment to • Administer Diphenhydramine 50 mg over 2
determine minutes IV push then Hydrocortisone 100 mg
severity of IV push slowly over 1 minute
reaction plus • Have emergency equipment available (eg.
treatment plan Crash Cart, Epinephrine 1:10,000,
bronchodilators such as Salbutamol Nebules)
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 61 of 64
Retreatment Discussion
• Careful consideration of the risk versus benefit
• Discussion between patient and physician
• May be successful in certain circumstances: interventions with pre-medications such
as H1 and H2 antagonists and/or a variety of options including increasing fluid
volumes or slowing infusion rates may allow for re-treatment
• Most frequent agents encountered are listed below
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 62 of 64
REFERENCES:
1. Ordering Cancer Chemotherapy Policy, Cancer Care Nova Scotia, 2011
2. Preparation of Cancer Chemotherapy Policy, Cancer Care Nova Scotia, 2011
3. Interdisciplinary Clinical Policy & Procedure “Administration of Cancer
Chemotherapy”, Capital District Health Authority
4. Interdisciplinary Clinical Policy & Procedure “Intravesical Administration of
Bacillus Calmette – Guerin (BCG)”, Capital District Health Authority
5. Standards of Practice, Canadian Association of Nursing in Oncology?
6. Standards of Practice, Canadian Association of Pharmacy in Oncology, 2008
7. Policy for the Management of Extravasation of Cancer Chemotherapy Agents.
QE II Health Sciences Centre, 1997
8. Policy for the Management of Hypersensitivity Reactions / Anaphylaxis With
Cancer Chemotherapy Agents. QE II Health Sciences Centre, 2002
9. Systemic Therapy Manual for Cancer Treatment. Cancer Care Nova Scotia,
2008
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 63 of 64
REFERENCES
Cancer Chemotherapy Guidelines, Oncology Nursing Society
National Institute for Occupational Safety and Health (NIOSH). Preventing occupational
exposures to antineoplastic and other hazardous drugs in healthcare settings.
Cincinnati, Ohio: NIOSH - Publications Dissemination; 25 March 2004.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011
Administration of Cancer Chemotherapy Page 64 of 64
RELATED DOCUMENTS:
Patient Teaching Materials- Chemo Precautions at Home, Chemo Precautions in the
Hospital
Ordering Cancer Chemotherapy Policies
Systemic Therapy Manual for Cancer Treatment
Preparation of Cancer Chemotherapy Policies
Patient Education Standards for Adults, CCNS, 2011
Provincial Cancer Drug Formulary
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the server file version prior to use. Approved 1 November 2011