Safe Use of Chemo - In Practice
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In Practice q MARCH 2005118
TO TREAT OR REFER?
Many of the issues and techniques discussed in this
article should be considered with respect to individual
practice facilities, expertise, staffing levels and time con-
straints. What may be safe or appropriate practice for one
clinic may be unsuitable for another and the onus is on the
individual practice to establish protocols that can be safe-
ly applied within its own setting. Poor preparation or ad
hoc decisions to treat, driven by client pressure or clinical
curiosity, are likely to lead to unacceptable risks to the
patient and veterinary personnel who are in direct or indi-
rect contact with the patient and drug preparation area.
Establishing a practice policy on chemotherapy usage
and administration will lead to appropriate and safe
working practices, as decisions about treatment with
anticancer drugs often have to be made quickly. Onward
referral to one of the numerous centres offering special-
ist, multidisciplinary cancer patient care should be con-
sidered at an early stage. A shared care arrangement can
work very well and has advantages for the practice and
the patient/owner, enabling wider treatment options to be
considered and empowering the owner to make appropri-
ate and timely decisions based on the most up-to-date
advice available. As with many chronic medical condi-
tions, owners appreciate consistency of care and the
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ONCE very much taboo subjects, cancer and chemotherapy are being demystified. Clients are increasingly
well informed about the options available for treating cancer in humans and pets alike. Indeed, cancer
is now often considered to be a curable disease in humans and there is growing pressure on veterinary
practitioners to ensure the appropriate and safe use of cancer therapies in animals. Many cases of cancer
can be cured or very effectively managed without causing unnecessary suffering. Chemotherapy plays
a central role in managing some common diseases, and many appropriate chemotherapy protocols are
cited in the literature. Often these protocols have been adapted or developed within universities or
training/research establishments, where clinicians have wide-ranging expertise in cancer-related issues
and the dilemmas associated with clinical and ethical patient management. Chemotherapy drugs (also
known as cytotoxic, anticancer and antineoplastic drugs) have a narrow therapeutic index, and should
not be administered unless the practitioner is familiar with individual drug toxicities and possible drug
interactions. This article addresses the safety aspects of administering cytotoxic drugs within the smallanimal veterinary practice environment, focusing in particular on safety issues relating to the patient,
veterinary professionals and carers.
Safe use of anticancer chemotherapy
in small animal practice ALISON HAYES
Veterinary practices shouldestablish a clear policy onchemotherapeutic usage andadministration to ensure thesafe handling of cytotoxicdrugs
opportunity to discuss any concerns they may have.
Once a diagnosis of cancer has been made, events can
often move very rapidly and every detail of the animals
behaviour and wellbeing comes under scrutiny, with
owners needing information, reassurance or action with-
out delay. Managing oncology patients and helping their
owners can be rewarding, but is also time consuming
and difficult in many busy small animal practices.
RISKS OF EXPOSURE
Cytotoxic drugs are mutagenic (cause permanent, cumu-
lative DNA damage), carcinogenic, teratogenic, and some
are direct tissue irritants. Much of the information avail-
Alison Hayesgraduated fromGlasgow in 1991and spent five years
in mixed and smallanimal practice innorth-west England.She subsequentlyundertook a three-year Blue Crossresidency in oncologyat the Animal HealthTrust in Newmarket,where she is now aclinical oncologist.She holds theRCVS certificate inveterinary radiologyand is currentlystudying for an MScin clinical oncologyat the University ofBirmingham medical
school.
In Practice (2005)27, 118-127
This is a review article and should not be considered
a definitive guide to the Control of Substances
Hazardous to Health (COSHH) Regulations relating
to cytotoxic drugs. It is intended that practices
might use this article to assist in establishing a spe-
cific health and safety document on chemotherapy
usage and administration in discussion with the
practice COSHH adviser.
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In Practice q MARCH 2005 119
able on their use is based on animal experiments and
human patients who have been given therapeutic doses.
It is well recognised that second malignancies occur in
previously treated human cancer patients, but these cases
are deemed to be high risk, which outweighs any future,
adverse biological effects of a drug. This is obviously not
the case where occupational exposure is concerned. The
risks associated with occupational exposure to cytotoxic
drugs are small when compared with patients treated
therapeutically, but are less well understood. The biologi-
cal effects remain impossible to quantify even when
biological monitoring of staff is undertaken. Studies con-
ducted on human hospital workers have revealed the
presence of drugs and their metabolites in body fluids,
while other reports have demonstrated an association
between drug exposure, reproductive outcomes and
leukaemia, despite improvements in hospital procedures
over the past 20 years. Clearly, procedures should be
designed to keep occupational exposure to chemotherapy
drugs and their metabolites to an absolute minimum.
PROCEDURES/RECORD KEEPING
Where a practice decides to offer chemotherapy, certain
procedures need to be documented and records held.
Risk assessments should be performed and local rules
and standard operating procedures, similar to those used
for radiation protection purposes, should be drawn up.
These should cover:
s Drug preparation;
s Storage and dispensing;
s Drug administration and patient restraint;
s Handling of in-patients after they have received
chemotherapy.
Staff should be given this written guidance as part
of their induction and ongoing in-house training, and
expected to follow the guidelines at all times when
handling chemotherapy patients and cytotoxic drugs. Sep-
arate consideration should be given to those members
of staff, both male and female, who may be planning
a family, and expectant or breast-feeding mothers, all of
who should not be exposed to any cytotoxic drugs.
As well as patient-based case notes, a separate record
of all chemotherapy procedures should be kept. This
should note the date(s) on which treatment was adminis-
tered, the animal which received therapy, the weight and
dose of the drug used, details about any intravenous site
employed and the staff involved. This enables the prac-
tice to monitor drug usage and rotate staff where possi-
ble; it also serves as a back-up record of what treatment
was given to which individual animal should patient
records be lost.
Where a safety cabinet is used for drug preparation,
details of commissioning and annual safety checks
should be kept. All incidents of unexpected exposure,
such as spillage or needle stick injuries, should be
recorded separately and stored with other health and
safety documentation held by the practice. Where a
designated room is available, details of cleaning, and
removal of sharps containers and waste facilities should
be kept and monitored to ensure regular thorough clean-
ing and to prevent waste from accumulating in the area.
Although much data is available to support the use of
cytotoxic drugs in veterinary medicine, all such agents
are unlicensed for use in animals. Owners should be
informed about this, and appropriate, written consent
obtained. Owners should be made fully aware of the pos-
sible side effects and the likely timing of these reactions,
and be encouraged to seek advice and assistance, where
necessary, at the earliest opportunity. Written instruc-
tions on drug usage should be provided so that these may
be passed on to others who may be asked to care for the
animal in the absence of the primary carer.
Material safety data sheets (MSDSs), available from
drug manufacturers, should be kept for all cytotoxic
drugs used by the practice. MSDSs provide information
on the physical, chemical and toxicological properties
of the drugs, as well as handling and storage instructions.
MSDSs are required in order to carry out a risk assess-
ment in a practice setting, and are distinct from the data
sheets inserted into product boxes.
METHODS OF EXPOSURE
When handling chemotherapy drugs, patients, cytotoxic
waste, or body fluids/faeces from treated animals, occu-
pational exposure may occur in the following ways:
s Accidental self-injection;
s Inhalation;
s Ingestion;
s Skin/mucosal absorption.
Depending on the task being performed and the type of
equipment available in the practice, the risk of exposure
by any particular route will vary. However, these risks can
be minimised by good preparation and techniques.
PERSONAL PROTECTIVE EQUIPMENT
Suitable personal protective equipment (PPE) should be
provided for staff. This should be used and worn appro-
priately depending on how the drug is prepared and
administered. PPE should be comfortable and should
not interfere with ease of movement or patient restraint,
both of which could promote accidental contamination.
However, no amount of PPE is likely to provide total
protection and it must not be regarded as a substitute for
safe practice.
Disposable gloves should be worn at all times when
handling cytotoxic drugs, waste and body fluids/faeces
from treated patients. While no glove provides complete
protection, broadly speaking, thicker gloves give better
protection than thinner ones; however, gloves should be
Double gloving, with removal of the outer pair of glovesafter direct drug handling, can reduce contamination
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tional eye and, possibly, face protection, together with
respiratory protective equipment (RPE), should be worn
if drugs have to be prepared outside this environment.
Advice on suitable RPE and, importantly, its correct fit-
ting is available from the Health & Safety Executive.
Cytotoxic spillage kits contain a filtering facepiece or
disposable mask (conforming to FFP3 BS EN 149 1992),
which can also be purchased separately. Paper surgical
face masks offer no respiratory protection, but may help
Procedure Minimum personal protective equipment required
Spillage, heavily soiled kennels Gown, gloves, eye/face protection, respiratoryprotective equipment, overshoes, additionalheavy-duty gloves
Preparation of drugs outside a safety cabinet* Gown, gloves, eye/face protection, respiratoryprotective equipment
Administration of injectable drugs Gown, gloves, eye/face protection
Preparation of drugs inside a safety cabinet Gown, gloves
Unpacking deliveries. Dispensing/administering Gloves
tablets
*The preparation of cytotoxic drugs without access to suitable methods of operator protection,such as those offered by an appropriately installed safety cabinet, is a compromise and cannot berecommended. This may be deemed acceptable if only occasional treatments are given, but regularpreparation of drugs in this way should be avoided
SUGGESTED PERSONAL PROTECTIVE EQUIPMENT ACCORDING TO PROCEDURE
A long-sleeved, water-resistant gown, together withgloves and eye protection, should be worn by all staffinvolved with chemotherapy administration.Picture, Mr G. N. Hayes
Respiratory protective equipment (RPE) should be worn inaddition to a gown, gloves, eye protection and overshoeswhen dealing with spillages and heavily soiled kennels.RPE should also be worn when a decision is taken toprepare drugs outside a safety cabinet. Picture, Mr G. N. Hayes
Spillage kits
Spillage kits are commercially available and should bekept where chemotherapy drugs are stored, preparedand administered. Picture, Dr S. Shaw
Spillages and heavy kennel soiling should be
regarded as serious incidents. Commercially avail-
able spillage kits should be placed where drugs are
stored, prepared and administered. Staff should be
familiar with the contents of such kits and manu-
facturers instructions for their appropriate use.
well fitting and should not limit manual dexterity. Powder-
free gloves should be worn, as powder can adsorb cyto-
toxic drugs. Gloves developed specifically for cytotoxic
preparation in isolators are available, but users may find
these limit dexterity for other procedures. Frequent glove
changing and double gloving are recommended. Hands
should be washed before gloves are worn, to remove
residues that may promote absorption through the glove,
and again after the gloves are removed. Double gloving,
whereby the outer pair of gloves is removed after direct
drug handling, reduces contamination during the rest of
the procedure. An additional, heavy-duty glove, as sup-
plied with commercial spillage kits (see box on the right),
should be used together with standard chemotherapy
gloves for dealing with spillages and very soiled kennels.
In addition to gloves, a long-sleeved, disposable, poly-
mer-coated gown with tight fitting cuffs should be worn
when working with cytotoxic drugs. There should be no
risk of exposure from inhalation or skin mucosal splash
when working within a safety cabinet. However, addi-
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to avoid mucosal contamination. When administering
injectable drugs, apart from accidental self-injection, the
risk of exposure is from mucosal absorption due to splash
or spillage, so adequate protection should be achieved
with gown, gloves and eye/face protection. When dealing
with a spillage or a heavily soiled kennel, the maximum
level of PPE is required.
Eye protection must be worn at all times when
working outside a safety cabinet. Goggles offer suitable
protection and are also very easy to use, as the entire
periphery is in contact with the face. Spectacle-type eye
protection and visors do not give full protection and
can easily slip, thereby needing adjustment by bringing
potentially contaminated gloves up to the face.
STORAGE, DISPENSING AND
STOCK CONTROL
Depending on the workload of a practice, chemotherapy
may be an infrequent treatment, which may lead to expen-
sive or difficult to obtain drugs exceeding their shelf-life.
Adequate stock control is therefore required. Many of the
common injectable and oral preparations require refriger-
ation; these agents should be kept away from any animal
or human food sources. Although cytotoxic products are
not controlled drugs, they can be abused with disastrous
consequences and storage in a separate, locked refrigera-
tor is recommended. For drugs stored in the practice phar-
macy, a separate locked area should be designated, and
drugs should only be dispensed by trained personnel,
wearing suitable PPE. Drug residues have been found on
the outside of manufacturers packaging and on surfaces
adjacent to stored, unused cytotoxic products. Thus, from
the time the drug arrives in the practice, suitable PPE
should be worn when handling the product packaging or
the drug itself. Transparent, plastic, zip-lock type bags
are very useful for storing pharmacy items, with the bag
only being opened by trained personnel wearing suitable
PPE. The use of cytotoxic warning tape provides a clear
reminder not to open the bag unless suitably protected.
Tablets should never be split or crushed and capsules
should never be opened and divided. This applies even
when the tablets are coated. Apart from the unacceptable
risks of exposure to the operator, there is no guarantee
that the active component of a drug is equally distributed
throughout the drug carrier and inadvertent overdosing
may result. Safe dosing schedules can be devised for
most drugs, particularly in cats, by increasing the inter-
dosing interval, sourcing an alternative formulation or
reverting to the injectable form of the drug. If unsure,
an experienced veterinary oncologist should be contact-
ed for advice. Tablets and capsules should be dispensed
without altering the manufacturers packaging, where
possible (eg, manufacturers childproof bottles should
not be replaced by conventional tablet bottles). Tablets
and capsules should not be removed from blister packs
to be dispensed into a practice container. Childproof dis-
pensing is preferable and large bottles can be used to
contain single, blister-packed tablets.
In addition to the usual labelling requirements, an
explicit warning not to crush or split tablets and cap-
sules, together with instructions to the owner to wear
gloves, should appear on the label. The cytotoxic symbol
is clearly recognisable and can be used to alert the owner
to the content of the bottle or package, which is especial-
ly useful when multiple items are being dispensed.
Suitable gloves should be provided for the owner to use.
To avoid surplus, unusable stock, some practices may
charge the client for the entire amount of the drug
ordered if the pack size is large or the drug is expensive.
However, small units of medication may be sourced
from cooperative, local hospital pharmacies and many
oral preparations are available on prescription from high-
street chemists. Large quantities of oral medications
should never be dispensed to an owner. Patients should
be seen regularly for haematological monitoring at the
very least and only sufficient medication should be dis-
pensed to last until the next visit.
DRUG AND PATIENT SELECTION
Drug availability should not be the criterion on which
therapy is based. The drug regimen employed should be
specifically indicated for the disease and species in ques-
tion, and the patients health status should be taken into
account when deciding on treatment. The biochemical
and physiological effects of a drug on the body (pharma-
codynamics) can be influenced by intercurrent disease
and other medications (eg, any previous myocardial com-
promise should be considered before administering
anthracycline). The absorption, distribution, metabolism
and excretion (pharmacokinetics) of a drug determines its
pharmacological action and toxicity. Hydration status and
recent general anaesthesia may affect the rate of elimina-
tion of drugs such as carboplatin, which is excreted large-
ly unchanged in urine. Drugs metabolised or excreted by
Many oral and injectable cytotoxic drugs requirerefrigeration; these should be kept away fromany animal and human foods. Picture, Mr G. N. Hayes
Gloves should always be worn when dispensing cytotoxicdrugs. Bottles must be clearly labelled, and should instructthe carer not to crush or split tablets/capsules, and to weargloves. Picture, Dr S. Shaw
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the liver (eg, cyclophosphamide, doxorubicin, vincristine
and vinblastine) require dose reductions in patients with
hepatic impairment. Dehydration or reduced blood pres-
sure may lead to increased plasma concentration over
time and, hence, to increased toxicity. The interaction
between cytotoxic drugs and most homeopathic remedies
is not known. Cisplatin and fluorouracil are toxic to cats
and are contraindicated in this species.
TREATMENT PLANNING
Owners and carers should be aware of the need to clean
up and dispose of contaminated waste from their pet.
This responsibility should be discussed before any drugs
are administered, as some owners may be unable to safe-
ly achieve this. Often, little more than normal hygiene
precautions are required, but specific instructions should
still be given. Solid waste and small amounts of
absorbent material can be flushed down the toilet. Small
amounts of other waste should be double bagged and
placed with domestic refuse. Owners should be encour-
aged to contain and absorb rather than dilute and distrib-
ute any soiling, and final cleaning with household bleach
is recommended. Dogs should be encouraged to urinate
on grass to avoid owners having to clean or hose down
solid surfaces, which can cause splashing.
Owners are very often concerned about exposure to
their other pets, rather than themselves, and may find the
thought of putting other animals at risk unacceptable.
Families with young children who have regular and
close contact with pets require special consideration as
constant segregation or insisting on regular hand wash-
ing may not be achievable. As with veterinary personnel,
pregnant women, and men or women who are planning
a family, should not have contact with cytotoxic drugs
or waste products. Animals which are incontinent may
be deemed unsuitable for treatment, depending on the
individual domestic circumstances.
DRUG PREPARATION
The hazard of aerosolisation during drug preparation is
well recognised. This can be minimised with good tech-
niques, which should always be practised, even when
using a safety cabinet. The use of ready-to-administer
formulations in rubber stoppered, multidose bottles
avoids the need for reconstitution. Drugs should be
drawn up, avoiding excessive positive and negative pres-
sure in bottles and syringes. Air must never be injected
back into a bottle, nor should syringes containing air be
vented directly into the atmosphere. Commercial recon-
stitution and venting devices, with a liquid repellent
filter, are available and help to equalise pressure during
reconstitution and as drugs are being drawn up. Non-
filtered air vents, such as a regular hypodermic needle
placed into the bottle stopper, should not be used to
reduce negative or positive pressure build-up.
The workspace used for drug preparation should be
free of clutter and able to be easily decontaminated after
use. Disposable absorbent mats should be used on hori-
zontal surfaces and spirit-soaked swabs should be applied
to shroud needle insertion points to reduce aerosolisation.
Double gloving, with removal of the outer pair of gloves
immediately after drug preparation, reduces contamina-
tion of ancillary objects. Work surfaces and the outside of
prepared drug syringes and fluid bags should be cleaned
with disposable spirit-soaked wipes. All prepared fluid
bags and syringes should be clearly labelled.
Ideally, drug preparation and administration should
take place in a designated room. Where this is not possi-
ble, a quiet, low traffic, well ventilated, draught-free
room should be used. It should be possible to isolate the
room from other areas of the practice in case spillage
Owners should be informedof hygiene requirements inthe domestic setting beforechemotherapy is administered
The use of rubber stopperedbottles, containing ready-to-use formulations, avoids theneed for reconstitution
A filtered venting device can be used to draw up agentsfor administration; this avoids pressure build-up duringthe preparation of an injectable drug. Picture, Dr S. Shaw
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occurs. A lock on the door will prevent any untimely
interruptions during drug administration. Drugs should
be prepared inside a suitable safety cabinet, of which
there are many on the market. There is currently no
easily applicable, worldwide standard relating to equip-
ment specifically for use with chemotherapeutics, but the
standard for microbiological safety cabinets (MSCs), BS
EN 12469 2000, provides useful information. Very sim-
ply, equipment can offer protection to the operator (class
I), the operator plus the drug (class II) based on airflow,
or can be designed as a sealed isolator (class III) to offer
both operator and drug protection. In all of these systems,
air is filtered through high efficiency particulate absorp-
tion (HEPA) filters before being discharged to the atmos-
phere, either after double HEPA filtration back into the
room or by a dedicated extraction system to the outside
air. These devices are not the same as fume hoods, which
simply alter local airflow and are counter-productive.
Conventional laminar airflow cabinets are similarly
unsuitable as the product is protected at the expense of
the operator, with airflow directing droplets towards the
operator. Readers are encouraged to seek the advice of a
reputable company to survey their own particular needs.
Equipment should be commissioned after installation to
determine the level of protection likely to be achieved as
efficiency can be influenced by room traffic. The safety
of internally vented equipment is currently uncertain, and
the Health & Safety Executive should be contacted for
specialist advice prior to installing such systems.
Few practices are currently likely to have access to
a safety cabinet. However, it should be noted that pre-
paration of cytotoxic drugs without access to suitable
methods of operator protection, such as those offered
by an appropriately installed MSC, is a compromise and
cannot be recommended. This may be deemed accept-
able if only occasional treatments are given, but regular
preparation of drugs in this way should be avoided. The
maximum level of PPE is required if drugs are prepared
outside an MSC.
DRUG ADMINISTRATION
Intravenous injection is the most likely route of adminis-
tration in a practice setting. Some drugs may be given by
oral, subcutaneous or intramuscular routes, and the route
of administration should always be verified. A secure,
preplaced, over-the-needle catheter should always be used
for intravenous administration. Many drugs in regular use
are group 1 vesicants and accidental perivascular injec-
tions into the subcutaneous or subdermal compartments
(extravasation) may result in severe and extensive tissue
necrosis requiring aggressive surgical reconstruction or,
more commonly, limb amputation. There is no place for
direct venous access and off-the-needle techniques for
any cytotoxic drug, even when only small volumes are
to be given. In human wards, drugs are routinely deliv-
ered via peripherally or centrally placed central venous
catheters, and procedures are designed to reduce the risk
and consequences of extravasation (eg, infusions during
the night are avoided); in addition, rapid access to plastic
surgeons is ensured should an extravasation be suspected.
In the veterinary setting, peripheral catheters and
short duration or bolus infusions are standard practice.
Peripheral catheters must be accurately and securely
placed; repeated attempts to place a catheter should be
avoided. A vein should not be used within 24 hours of a
previous attempted catheterisation or venepuncture. Poor
(left) The workspace for drug preparation should be clutter-free and able to be easily decontaminated. Disposable absorbentmats should be used to protect horizontal surfaces. (right) A suitable safety cabinet for preparing cytotoxic drugs; makingup drugs without such equipment increases the hazard to the operator. Picture, Mr G. N. Hayes
Food and drink mustnot be consumed in thepreparation area. Applyingmake-up and lipsalve, andsmoking are also prohibited
Type Examples
Group 1 Vesicant DoxorubicinEpirubicinMustineVinblastineVincristine
Group 2 Exfoliant CisplatinMitoxantrone
Group 3 Irritant Carboplatin
Group 4 Inflammatory Methotrexate
Group 5 Neutral AsparaginaseCyclophosphamideCytarabine
COMMONLY USED CYTOTOXIC DRUGS GROUPED ACCORDINGTO THE EFFECT OF EXTRAVASATION
Extensive tissue necrosis,which resulted in limbamputation, followingperivascular doxorubicininjection in a dog.Picture, E. R. Simonson
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circulation in the chosen limb results in slow drug egress
and increases the likelihood of local leakage. Regularly
used veins can become difficult to catheterise and should
be used in rotation and not for routine phlebotomy.
Chemical restraint should be considered for nervous or
fractious patients, or when larger or prolonged infusions
are being given. An animal should never be left unat-
tended while an infusion is taking place. Frequent draw-ing back during the injection and continued observation
of the injection site is recommended so that the infusion
can be terminated if extravasation is suspected. The
methods of dealing with an extravasation are specific to
each individual drug, and the advice of an experienced
oncologist should be sought immediately. An attempt to
dilute the extravasated drug by injecting saline under the
skin should not automatically be performed.
The manufacturers advice on administration and
dilution should always be checked and followed.
Depending on the drug chosen, 09 per cent saline, waterfor injection or 5 per cent glucose solution can be used
Used needles should not berecapped. The needle andsyringe should be disposedof as a single unit, directinto a cytotoxic sharpscontainer. Picture, Dr S. Shaw
Leur lok syringes, saline minibags, flexible extension sets,T-ports, over-the-needle catheters, clear bungs and tapeare useful, disposable items. Picture, Dr S. Shaw
(left) Drugs for intravenous injection should be administered via a securely placed over-the-needle catheter. The site of drug administration should berecorded and peripheral sites used in rotation, where possible. (middle) Accurate catheter placement is important; repeated attempts at placement inthe same limb compromise vascular integrity and predispose to perivascular leakage. (right) The catheter securely inserted
(left and right) Once in place,the catheter should be carefullytaped to the limb to avoidunscrewing of the T-port
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for small volume infusions. Needleless administration is
preferred, to reduce the risk of accidental self-injection,
and drugs can often be prepared into 50 ml minibags
away from the patient and any associated distractions. If
the giving set is attached and charged before the drug is
added to the bag, no contact with the drug should occur
prior to and during the infusion. Once the infusion is
complete, a further 10 to 30 ml of saline can be added to
the minibag to remove the final, residual drug volume.
Bags should be lowered to a comfortable operator height
and the injection performed with a spirit-soaked swab
to shroud the injection point and help absorb any leak-
age. The giving set should then be flushed via its side
port and, again, at the catheter, before the catheter and
infusion set are removed as a single unit, to minimise
operator exposure. The greatest risk of accidental self-
injection is when recapping a needle. All needles should
be disposed of directly into a suitable sharps container
without recapping or removal of the needle from the
syringe, irrespective of whether they have been used to
inject drugs or simply for saline flushing.
Small volume injectables, such as vincristine, can be
given via a short extension set, such as a T-port (Veni-
systems, Abbott Ireland), an extension set or into a free-
running drip line. Injections should never be made when
there is resistance; the use of the same gauge needle for
saline flushes and drug administration enables any pres-
sure changes to be noted more easily. Syringes used for
drugs and saline flushes should be of a leur lok design and
should never be filled to the maximum volume. Catheters
should be flushed with non-heparinised saline immediately
prior to drug administration to ensure patency and to
remove any traces of heparin, which can cause precipita-
tion of certain drugs. After administration, a saline flush is
repeated to remove traces of drugs that may cause tissue
irritation and operator exposure; the catheter can then be
removed. The advantage of administering drugs into
extension sets and drip lines is that patients are likely to be
easier to restrain and, consequently, catheters are less like-
ly to be pulled out. However, constant examination of the
injection site is still recommended and patients should not
be left unattended while an infusion is taking place.
CONSIDERATIONS FOLLOWING DRUG
ADMINISTRATION
Patients excrete potentially harmful drugs and their
metabolites in urine, faeces, vomit, saliva and sweat for
variable periods of time following the administration
of injectable or oral preparations. Such excretions can
potentially contribute to the exposure of veterinary per-
sonnel and carers, and steps should be taken to minimise
this exposure. Much of the information discussed below
All personnel should wear protective clothing during drug administration.Good restraint of the animal is essential
The catheter is flushed with normal saline before cytotoxic drugs areinjected. Some of these drugs will precipitate in heparin
Spirit-soaked swabs are used to absorb traces of cytotoxicdrugs during administration
Catheter removal immediately after drug administrationavoids inadvertent exposure of other staff members tocytotoxic agents
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In Practice q MARCH 2005 127
applies equally to veterinary staff and animal carers out-
side the practice setting.
All patients should be clearly identified as receiving
or having recently received chemotherapy. This is espe-
cially important for in-patients, which may be cared for
by staff not present at the time of drug administration.
Identifying the patient with a colour-coded collar and
marking the kennel are easy ways of communicating this
to all relevant personnel. Catheters should be removed
immediately after drug administration unless they are
clearly marked as contaminated. Gloves should be worn
when taking blood samples from patients that have
recently received cytotoxic drugs.
Feed bowls and bedding should be washed separately.
Repeating the washing cycle with an empty machine
reduces contamination of the next load. Dogs should be
encouraged to urinate frequently on grass after receiving
cytotoxic drugs and patients should be treated and dis-
charged as soon as possible into the care of the owner to
avoid inappropriate elimination in the kennel environment.
Where concrete runs must be hosed, appropriate PPE
should be worn and splashing avoided. Gloves should be
worn when cleaning up faeces. Faeces should be double
bagged and placed into clinical waste for incineration. As
in the domestic setting, when cleaning up soiling, the aim
should be to contain and absorb rather than dilute and dis-
tribute. Areas should then be disinfected with household
bleach. Cat litter trays should be cleaned regularly.
DISPOSAL
All soft disposables should be double bagged before dis-
posal. Cytotoxic bins for DOOP (destruction of old phar-
maceuticals) waste are available for drug disposal. As
even small DOOP bins can take a long time to fill, indi-
vidual items may be placed into sealed bags to reduce
leaching. However, excessive storage times must be
avoided. Sharps are disposed of in the usual way into
cytotoxic sharps disposal units to avoid waste build-up.
All cytotoxic waste should be treated as special waste
and sent for incineration. Practices should consult their
waste disposal provider for more specific details.
SUMMARY
Veterinary practitioners are treating an ever-ageing pop-
ulation of domestic pets that enjoy a central role in fami-
ly life. When cancer is diagnosed in veterinary practice,euthanasia is no longer an automatic decision. However,
safe use of anticancer chemotherapy demands best prac-
tice, and constant and close attention to the issues dis-
cussed in this article.
AcknowledgementThe author would like to thank Audrey Scott for her general adviceand encouragement during the preparation of this article.
Further readingALLWOOD, M., STANLEY, A. & WRIGHT, P. (Eds) (2002) TheCytotoxics Handbook, 4th edn. Abingdon, Ratcliffe Medical PressNYGREN, O., GUSTAVSSON, B., STROM, L. & FRIBERG, A. (2002)Cisplatin contamination observed on the outside of drug vials.
Annals of Occupational Hygiene 46, 555-557SELEVAN, S. G., LINDBOHM, M. L., HORNUNG, R. W. & HEMMINKI,K. (1985) A study of occupational exposure to antineoplastic drugsand fetal loss in nurses. New England Journal of Medicine 313,1173-1178SKOV, T., MAARUP, B., OLSEN, J., RORTH, M., WINTHEREIK, H.& LYNGE, E. (1992) Leukaemia and reproductive outcome amongnurses handling antineoplastic drugs. British Journal of Industrial
Medicine 49, 855-861VALANIS, B., VOLLMER, W. M. & STEELE, P. (1999) Occupationalexposure to antineoplastic agents: self-reported miscarriages andstillbirths among nurses and pharmacists.Journal of Occupationaland Environmental Medicine 41, 632-638
Drug Route Urine Faeces
Doxorubicin Intravenous 6 days 7 days
Vinca alkaloids Intravenous 4 days 7 days
Cyclophosphamide Any 3 days 5 days
Cisplatin Intravenous 7 days ?
*Based on human studies
SUGGESTED PRECAUTIONARY PERIODS FOR HANDLINGURINE/FAECES FOLLOWING CESSATION OF TREATMENTWITH COMMONLY USED CYTOTOXIC DRUGS*
All members of staff should be aware ofin-patients receiving chemotherapy, as staffabsent during chemotherapy administrationmay provide ongoing care
Cytotoxic DOOP bins are available.Prolonged storage should be avoided.Bagging individual bottles will reduceleaching. Picture, Mr G. N. Hayes
Further informations HEALTH & SAFETY EXECUTIVE.SAFE HANDLING OF CYTOTOXIC DRUGS.HSE information sheet MISC615.www.hse.gov.uks
FILTER DEVICES AND MEDICALCLEANROOM DISPOSABLES.www.helapet.co.uks SAFETY CABINETS.www.kojair.co.uk
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