Chemotherapy Products and Procedures

Chapter 14

1. Chapter 14 Chemotherapy Products and Procedures  2012 Paradigm Publishing

2. Learning Objectives Gain an awareness of the historical roots of using chemotherapy to treat cancer. Identify the special situations and actions that must be considered when preparing chemotherapy . Identify the USP Chapter <797> procedures that must be performed when compounding chemotherapy . Demonstrate correct technique in preparing chemotherapy CSPs.  2012 Paradigm Publishing

3. Topics Learning Objectives Introduction Common Chemotherapy Drug Categories Properties of Chemotherapy CSPs Compounding of Chemotherapy CSPs Handling Risks for Chemotherapy Training for Chemotherapy Preparers Administration of Chemotherapy CSPs Administration Risks of Chemotherapy USP Chapter <797> Guidelines for Chemotherapy Preparation Understand the Resources and Supplies Preview the Lab Procedure Chapter Summary  2012 Paradigm Publishing In Slide Show view, click the desired topic to the left to link directly to the related slide. To return to this slide at any point in the presentation, click the Topics button below.

4. Introduction Chemotherapy is primarily used to treat cancer primary chemotherapy is prescribed with the intention of curing the patient adjuvant chemotherapy is prescribed as a follow-up treatment to the removal or reduction of a tumor by surgery and is commonly prescribed after surgical procedures , such as a mastectomy in breast cancer , or an oopharectomy in ovarian cancer palliative chemotherapy is sometimes prescribed as a treatment for incurable cancers  2012 Paradigm Publishing

5. Introduction…/2 There are a limited number of other conditions for which chemotherapy may be prescribed, including autoimmune disorders  2012 Paradigm Publishing

6. Common Chemotherapy Drug Categories The prescriber orders the chemotherapy treatment proven to be most effective against the patient’s specific type, location, and stage of cancer o ther factors such as the patient’s age, kidney function, liver function , and ability to tolerate the side effects of the specific chemotherapy treatment are considered when choosing the most appropriate chemotherapy  2012 Paradigm Publishing

7. Common Chemotherapy Drug Categories…/2 Alkylating agents are drugs that bind to specific DNA cells and stop their replication Antimetabolite medications are drugs that block the use of nutrients essential to the growth of cancer cells Antimicrotubule agents are drugs that interfere with cell formation and growth Chemotherapeutic antibiotics , also known as antitumor antibiotics , are special types of antibiotics formulated to inhibit RNA synthesis as well as slow down or prevent cell mitosis  2012 Paradigm Publishing

8. Common Chemotherapy Drug Categories …/3 Hormone therapy employs drugs that interfere with the growth of certain proteins within cancer cells, thereby inhibiting their growth or replication the use of hormones or their antagonists slows the growth of hormone-dependent tumors Mitotic inhibitors are drugs that inhibit the process of cell mitosis Targeted therapy is a sophisticated type of chemotherapy that targets the specific molecular features of certain cancer cells to inhibit their growth  2012 Paradigm Publishing

9. Common Chemotherapy Drug Categories …/4 Topoisomerase inhibitors disrupt DNA repair functions within the cell, thereby inhibiting the growth and replication of cancer cells Many cancer treatment regimens incorporate treatment with a combination of chemical agents, hormone therapies, surgery, and radiation  2012 Paradigm Publishing

10. Properties of Chemotherapy CSPs Chemotherapy CSPs are typically LVP solutions made from a standard, premade IV base solution into which a chemotherapeutic medication is injected during sterile compounding procedures cytotoxic medications are drugs that poison or otherwise destroy cancer cells so that they are not able to grow or reproduce antineoplastic medications are drugs that reduce or prevent the growth of cancer cells  2012 Paradigm Publishing

11. Properties of Chemotherapy CSPs…/2 In addition to killing cancer cells, many chemotherapeutic agents are also toxic to healthy cells may have properties that make them carcinogenic , teratogenic , mutagenic , or immunosuppressive may also have numerous side effects bone marrow suppression is a potentially dangerous type of toxicity that may lead to an increased risk of bleeding or infections, such as septicemia some chemotherapy drugs are vesicants , which may cause blisters or tissue necrosis  2012 Paradigm Publishing

12. Compounding of Chemotherapy CSPs Due to the dangerous nature of these hazardous drugs , many facilities take special precautions prior to the compounding process to avoid chemotherapy-related medication errors  2012 Paradigm Publishing

13. Compounding of Chemotherapy CSPs…/2 Chemotherapy Medication Orders Many facilities use preprinted chemotherapy medication order forms  2012 Paradigm Publishing

14. Compounding of Chemotherapy CSPs…/3 Chemotherapy Medication Orders…continued In addition to the chemotherapy CSP, chemotherapy medication orders generally prescribe a number of other CSPs that are not hazardous drugs t he orders for these CSPs are often called chemotherapy support orders , or chemotherapy comfort orders t his often includes orders for LVP hydration preparations, IVPB antiemetics , and medications for pain and anxiety  2012 Paradigm Publishing

15. Compounding of Chemotherapy CSPs …/4 Dosage Calculations Methods Body surface area (BSA) is an estimated measurement of the human body based on the patient’s height and weight and is expressed in meters squared ( m 2 ) t he prescriber determines a patient’s BSA using a nomogram once the desired dose has been determined , additional dosage calculations—using dimensional analysis and either the basic formula calculation or the ratio and proportion calculation —are required to determine the amount of medication to draw up for the CSP  2012 Paradigm Publishing

16. Compounding of Chemotherapy CSPs …/5 Chemotherapy Compounding Environment Hazardous drug chemotherapy should be prepared in a vertical laminar airflow hood a type of hood that offers added protection to the worker and the environment when working with these toxic chemicals  2012 Paradigm Publishing

17. Compounding of Chemotherapy CSPs …/6 Chemotherapy Compounding Environment…continued A biological safety cabinet (BSC) is a special hood that has several features specifically designed to protect sterile compounding personnel should be located in a negative-pressure clean room  2012 Paradigm Publishing

18. Compounding of Chemotherapy CSPs …/7 Chemotherapy Compounding Environment…continued Another type of hood used to prepare chemotherapy is the compounding aseptic containment isolator (CACI ) is a completely enclosed system accessed through the use of a fixed pair of gloves at the front of the hood  2012 Paradigm Publishing

19. Compounding of Chemotherapy CSPs …/8 Surface Sampling of BSC or CACI No matter which type of primary engineering control (PEC) is used during the compounding of chemotherapy CSPs , quality control measures must be implemented to ensure that the hood offers adequate containment for the toxic chemicals the work area surrounding the BSC or CACI must undergo surface sampling at least every six months  2012 Paradigm Publishing

20. Handling Risks for Chemotherapy Safety Regulations OSHA regulations require maintenance and easy access to material safety data sheets (MSDSs) for all chemotherapy drugs  2012 Paradigm Publishing

21. Handling Risks for Chemotherapy…/2 Safety Regulations…continued OSHA recommends facilities have a chemotherapy spill kit readily available in areas where chemotherapy is compounded or administered  2012 Paradigm Publishing

22. Handling Risks for Chemotherapy …/3 Storage and Labeling of Chemotherapeutic Agents With regard to pharmacies, chemotherapy drugs must be stored separately from other pharmacy inventory Some chemotherapy drug manufacturers utilize tall-man lettering , also known as mixed-case lettering , to draw attention to chemotherapy drug names that look or sound similar  2012 Paradigm Publishing

23. Handling Risks for Chemotherapy …/4 Transport and Disposal of Chemotherapeutic Agents Transport companies must follow procedures designed to properly package and transport chemotherapy drugs to protect handlers from breakage or spillage of the containers in addition, those personnel who stock pharmacy shelves must wear special, extra-thick chemotherapy gloves when handling drug vials  2012 Paradigm Publishing

24. Handling Risks for Chemotherapy …/5 Transport and Disposal of Chemotherapeutic Agents…continued Chemotherapy waste containers must be affixed with hazardous drug warning labels Chemotherapy waste must be incinerated at a high temperature to avoid human and environmental contamination  2012 Paradigm Publishing

25. Your Turn  2012 Paradigm Publishing This type of chemotherapy is prescribed with the intention of curing the patient. immunosuppressive palliative adjuvant primary Some chemotherapy drug manufacturers utilize this type of lettering to draw attention to chemotherapy drug names that look or sound similar. italics capitals tall-man coloration In Slide Show view, click here to see the answer to Question 1. Then click again to advance to Question 2. In Slide Show view, click here to see the answer to Question 2.

26. Training for Chemotherapy Preparers USP Chapter <797> mandates that, at a minimum, sterile compounding personnel preparing chemotherapy CSPs must be expertly trained and must undergo two types of evaluation: a written exam and a laboratory procedure exam Compounding personnel with reproductive capabilities should sign a statement of understanding regarding the potential teratogenic risks of handling hazardous drugs  2012 Paradigm Publishing

27. Administration of Chemotherapy CSPs Most chemotherapy is administered in a hospital or clinic setting by a nurse who is specially trained in the parenteral administration of hazardous drugs administered intravenously via an IV pump programmed to administer the medication at a controlled IV flow rate  2012 Paradigm Publishing

28. Administration of Chemotherapy CSPs…/2 Administration time for one session typically requires a minimum of several hours , and chemotherapy treatment may last for a year or more, with monthly cycles lasting approximately one week CSPs are generally administered into a large vein in the chest, most often the subclavian vein accomplished by placing a central venous catheter (CVC) into the vein during a minor surgical procedure  2012 Paradigm Publishing

29. Administration Risks of Chemotherapy Complications may include: nosocomial infection allergic reaction (including anaphylaxis) phlebitis tissuing embolism extravasation cellulitis Stevens-Johnson syndrome nephrotoxicity  2012 Paradigm Publishing

30. Administration Risks of Chemotherapy…/2 Chemotherapy medications may also produce a number of adverse reactions and side effects Patients on chemotherapy must be closely monitored to ensure that the medication is not creating unexpected damage to the patient’s vital organs  2012 Paradigm Publishing

31. USP Chapter <797> Guidelines for Chemotherapy Preparation As well as defining the appropriate environment in which chemotherapy CSPs should be prepared, USP Chapter <797> also details the type of equipment that must be used by sterile compounders and the special training requirements for healthcare personnel who compound chemotherapy CSPs these procedures are reinforced in each facility’s P&P manual  2012 Paradigm Publishing

32. Understand the Resources and Supplies Essential Supplies Most chemotherapy sterile compounding procedures require the same essential supply items to be available for use in both the anteroom and the clean room  2012 Paradigm Publishing

33. Understand the Resources and Supplies…/2 Procedure-Specific Supplies Chemotherapy Equipment, Supplies, and Special Procedures a chemotherapy gown is a sterile , single-use gown made of a thick, woven material that repels fluid  2012 Paradigm Publishing

34. Understand the Resources and Supplies…/3 Procedure-Specific Supplies…continued Chemotherapy Equipment, Supplies, and Special Procedures…continued chemotherapy gloves are sterile nitrile gloves that are thicker than regular sterile gloves  2012 Paradigm Publishing

35. Understand the Resources and Supplies…/4 Procedure-Specific Supplies…continued Chemotherapy Equipment, Supplies, and Special Procedures…continued chemotherapy preparation requires the use of special eye protection a chemotherapy compounding mat is a thin mat, approximately 12” × 18”  2012 Paradigm Publishing

36. Understand the Resources and Supplies…/5 Procedure-Specific Supplies…continued Chemotherapy Equipment, Supplies, and Special Procedures…continued a chemotherapy dispensing pin is a small plastic device with a spike at one end and a Luer-lock syringe adaptor at the other end air may be safely vented from the chemotherapy drug vial without fear of aerosolization  2012 Paradigm Publishing

37. Understand the Resources and Supplies…/6 Procedure-Specific Supplies…continued Chemotherapy Equipment, Supplies, and Special Procedures…continued a closed-system transfer device (CSTD) is a small, disposable device that may be used to safely draw fluid from a vial into a syringe, or to inject fluid from a syringe into an IV or IVPB  2012 Paradigm Publishing

38. Understand the Resources and Supplies…/7 Procedure-Specific Supplies…continued Chemotherapy Equipment, Supplies, and Special Procedures…continued the IV base solution bag is the same type of bag used for other LVPs: a bag with a tail injection port sterile , nonvented IV tubing is attached to the LVP bag to administer the chemotherapy CSP to the patient CSPs require auxiliary warning labels  2012 Paradigm Publishing

39. Understand the Resources and Supplies…/8 Procedure-Specific Supplies…continued Chemotherapy Equipment, Supplies, and Special Procedures…continued chemotherapy sharps containers are similar to regular sharps containers in shape and function, and generally bright yellow in color.  2012 Paradigm Publishing

40. Understand the Resources and Supplies…/9 Procedure-Specific Supplies…continued BSC a Class I BSC provides protection for the worker but does not provide a suitable HEPA-filtered, ISO Class 5 environment to prepare CSPs a Class II BSC provides protection for the worker and an ISO Class 5 environment suitable for chemotherapy sterile compounding a Class III BSC is designed for the manufacture of microbiological agents and provides maximum worker protection  2012 Paradigm Publishing

41. Understand the Resources and Supplies…/10 Procedure-Specific Supplies…continued Components of the BSC air intake grills blower glass shield exhaust HEPA filter hood HEPA filter prefilter work surface  2012 Paradigm Publishing

42. Understand the Resources and Supplies…/11 Procedure-Specific Supplies…continued Cleaning the BSC cleaning procedures for the BSC are significantly different from those procedures used for cleaning a standard horizontal laminar airflow hood Special Considerations for Supplies compounding of chemotherapy CSPs has unique requirements for the placement , selection, and handling of supply items  2012 Paradigm Publishing

43. Critical Sites of Essential Supplies and Chemotherapy Supplies Before beginning preparatory procedures in the anteroom or clean room, the IV technician must recall the critical sites of the supplies i dentifying the critical site of each supply item helps you to determine the proper procedure for handling the supply item once you have entered the clean room and begin to work in the hood  2012 Paradigm Publishing

44. Preview the Lab Procedure Anteroom Preparatory Procedures Clean Room Preparatory Procedures Chemotherapy CSP Compounding Procedure  2012 Paradigm Publishing

45. Your Turn  2012 Paradigm Publishing Chemotherapy CSPs are generally administered into a large vein in this body part. abdomen leg chest arm Chemotherapy CSPs require this type of warning label. auxiliary best-before throw-away refrigerate-for In Slide Show view, click here to see the answer to Question 3. Then click again to advance to Question 4. In Slide Show view, click here to see the answer to Question 4.