How should chemotherapy be safely administered via different routes?

From Cancer Guidelines Wiki

Introduction

Cancer therapy and associated treatment can be administered by several routes including oral, intravenous infusion, intravenous bolus, intraventricular, subcutaneous and intradermal. Many of these routes require administration by an appropriately credentialed cancer nurse or an appropriately informed patient, where the medication is being self-administered. Administration via more specialised routes such as intrathecal and intraperitoneal may require a medical practitioner with specialist or surgical experience. There are a number of safety checks required to ensure safe administration of cancer therapy.


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Evidence Summary

Policies, procedures and equipment for safe administration and handling of cancer therapy must be easily accessible, understood and adhered to by all nurses involved in the administration of cancer therapy.[1][2][3][4]

Administering cancer treatment in an area that is suitable for the process and equipped to manage any reasonably foreseeable adverse events associated with the medication or route of administration is an essential part of medication safety. The environment should be free from unnecessary noise and activity. The patient conditions (e.g. seating, lighting) should enable the patient to comfortably receive therapy and encourage easy communication with nursing staff.

The availability of local procedures, medical assistance and medications to manage any complications that may arise during administration ensure adverse events are managed appropriately and in a timely manner.

Administration of cancer therapy by the wrong route can result in serious or fatal consequences.[5][6][7][8]


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Recommendations

Consensus-based recommendationQuestion mark transparent.png

The chemotherapy, targeted therapy and related medications must be checked at the point of administration by two registered nurses with the appropriate training and skills.

  • All dosage and administration rate-related calculations should be independently verified (White et al, 2010a; White et al, 2010b).

At least one staff member with current, age appropriate training in basic life support should be present during chemotherapy administration (Neuss et al, 2017; Belderson and Billett, 2017).


Only healthcare professionals who have obtained competence in the administration of cancer therapy by the specific administration route should administer cancer therapy via that route.


Cancer therapy should be administered in an area that is equipped to manage any reasonably foreseeable adverse events that may be associated with the medication or route of administration.


Local occupational health and safety workplace guidelines must be followed when handling hazardous medications (NIOSH, 2014; Clinical Oncology Society of Australia and Cancer Pharmacists Group of Australia, 2013).


Policies and procedures for safe medication administration, management of extravasation and emergency procedure protocols must be followed when administering cancer therapy (Polovich et al, 2014; Goldspiel et al, 2015a).


All administrations, observations and actions related to the patient during administration must be documented in the patient’s healthcare records including vital signs, adverse events and patient reported concerns (Polovich et al, 2014). The entry must be made at the time and point of delivery of patient care and be signed and dated.


Nursing staff involved in the administration of therapy in the home should ensure that appropriate procedures are in place to manage any complications and be able to access medical assistance and medications for the management of an adverse event (Evans et al, 2016). Procedures must maximise patient safety and minimise the risk of errors.

(White et al, 2010a)[9] ;(White et al, 2010b)[10] ;(Neuss et al, 2017)[2] ;(Belderson and Billett, 2017)[11] ;(NIOSH, 2014)[12] ;(Clinical Oncology Society of Australia and Cancer Pharmacists Group of Australia, 2013)[13] ;(Polovich et al, 2014)[1] ;(Goldspiel et al, 2015a)[14] ;(Evans et al, 2016)[15]


Practice pointQuestion mark transparent.png

Administration of cancer treatments closer to home for people with cancer from rural and remote locations is currently being implemented in some Australian states (Sabesan et al, 2012; Clinical Oncology Society of Australia, 2015; SA Cancer Clinical Network Steering Committee, 2010). Under these service models nursing staff should ensure that procedures for administration are followed that maximise patient safety and minimise the risk of errors.


Preparations for parenteral administration must be checked for leaks, precipitation or any other visual signs of problems with the solution. Seek advice from the providing Pharmacist if any concerns or if advice is required.

(Sabesan et al, 2012)[16] ;(Clinical Oncology Society of Australia, 2015)[17] ;(SA Cancer Clinical Network Steering Committee, 2010)[18]


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Tables

Table 16: Administration of cancer therapy by specified routes

ADMINISTRATION VIA THE INTRAVENOUS ROUTE

[1][4][14][19][20]

  • For all prolonged infusions and vesicant medications a Central Venous Access Device (CVAD) is the preferred route of administration.
  • Intravenous chemotherapy and targeted therapy should be administered during operational hours where possible to ensure appropriately trained medical staff are available to assist in an emergency. For protocols with complex scheduling times (e.g. cytarabine given every 12 hours) this may not always be possible and consideration must be given to the timing and minimising risk.
  • Intravenous lines must not be primed with cytotoxic chemotherapy or monoclonal therapy unless specific instructions are given or a risk assessment has been conducted.
  • The nurse should be aware of the risk of extravasation and be able to identify which medications are vesicants or irritants. Staff must be able to manage an extravasation according to local procedure.
  • The nurse should be aware of the risk of hypersensitivity reactions, be able to identify which medications have potential for these reactions and be able to manage them according to local procedure.
  • All therapy must be given according to the sequencing of the protocol where stated or according to local administration policy.
  • Programming for infusion pumps should be independently checked by a second competent nurse to include calculation of infusion rates. Care must be taken to ensure the rate is correctly set according to the time span (i.e. mLs/h or mLs/24 h). The use of error reduction software or smart pumps should be considered.[21][22]
  • The rate of infusions should be checked at the initiation of the infusion, periodically throughout the infusion and when a new nurse takes over the care of the patient. Due attention should be given to the Clinical Handover process.[23]
  • After administration the intravenous line must be flushed with a sufficient volume of compatible fluid to ensure the medication is cleared from the line.
ADMINISTRATION VIA THE INTRAMUSCULAR AND SUBCUTANEOUS ROUTE

[1][4][19][14][20][24]

  • Where appropriate, checks and cautions that apply to intravenous administration also apply to the intramuscular and subcutaneous route.
  • Intramuscular injections are administered deep into the muscle.
  • Subcutaneous injections are administered through the epidermal and dermal layers into the subcutaneous tissue.
  • Injections sites may need to be rotated if multiple injections are needed.
ADMINISTRATION VIA THE INTRATHECAL ROUTE

[8][25][26]

  • Where appropriate, checks and cautions that apply to intravenous administration also apply to the intrathecal route.
  • All staff responsible for administering intrathecal chemotherapy (including checking of intrathecal chemotherapy) should be aware of the catastrophic outcomes associated with errors in administering incorrect chemotherapy medications via the intrathecal route.
  • All staff involved in administering intrathecal therapy should undergo appropriate training and be assessed as competent to perform their roles and responsibilities regarding intrathecal therapy.
  • A register of staff designated as competent to administer intrathecal therapy for cancer should be maintained and accessible across the institution. Only staff listed on the register should undertake the task.
  • Staff administering intrathecal medication must use checking procedures that include a “Time Out” involving at least two health professionals. “Time Out” is a final patient safety check undertaken immediately before commencing the treatment. This should be carried out without interruption.[19]
ADMINISTRATION VIA THE ORAL ROUTE

[3][19][27][28][29][30]

  • Where appropriate, checks and cautions that apply to intravenous administration also apply to the oral route.
  • Oral cancer medications carry the same risks in terms of toxicity and risk of medication errors as therapy administered by other routes.
  • Ensure that the patient can swallow the medication and there are no risk factors for aspiration.
  • Oral cytotoxic and targeted therapy tablets and capsules should not be crushed. Crushing tablets and opening capsules carries both exposure risks and changes to bioavailability. If a patient is unable to swallow or medication is being administering via a PEG tube or nasogastric tube, contact the pharmacist for advice on alternative dose formulations. The Society of Hospital Pharmacists also provide a resource with advice on crushing medications.[31]
  • Oral cancer therapy should be administered using the “non touch technique”. Uncoated tablets and liquid formulations should be administered using full personal protective equipment.
  • If an antiemetic is required then this should be administered not less than 30 minutes prior to, and not more than 90 minutes before the administration of oral therapy unless instructed otherwise in the protocol.
  • If the patient experiences emesis immediately after ingestion of an oral cancer therapy agent a further dose must not be administered. Inform the treating medical officer of the episode for further guidance.
  • Where oral cancer therapy is administered outside the hospital setting by the patient or their carer, ensure that appropriate education has been provided (verbal and written) and follow up appointments have been scheduled.
  • Targeted therapies are not considered cytotoxic but should be handled with caution. Immunomodulatory medicines (IMiDs) e.g. thalidomide, lenalidomide, pomalidomide are teratogenic and must be handled with caution by pregnant staff.


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References

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