Administration of chemotherapy

Cytotoxic chemotherapeutic drugs may cause serious harm if not prescribed, dispensed and administered with great care. Drugs should be prescribed, dispensed and administered by an experienced multidisciplinary team with shared clear information on:

• The fitness of the patient to receive chemotherapy (e.g. recent FBC for myelosuppressive agents, renal function studies for cisplatinum).

• Appropriate protocol and chemotherapeutic regimen for the patient.

• Prescribed drugs and individualised dosage for the patient's surface area (seep682), taking note of cumulative maximum doses (e.g. anthra-cyclines).

• Appropriate supportive treatment required e.g. allopurinol, antiemetic prophylaxis, anti-infective prophylaxis, and hydration.

Chemotherapy for IV administration should be reformulated carefully in accordance with the manufacturer's instructions by an experienced pharmacist using a class B laminar airflow hood. Care should be taken to ensure that the drug is administered within the expiry time after it has been reformulated in the form chosen.

Many cytotoxic drugs are best administered as a slow IVI in dextrose or 0.9% saline over 30 minutes to 2h. Vesicants e.g. vincristine, daunorubicin, adriamycin and mitozantrone should be administered as a slow IV 'push'. However this should only be administered through the side access port of a freely flowing infusion of 0.9% saline or dextrose and should never be injected directly into a peripheral vein.

If the patient does not have an indwelling intravenous catheter (Hickman line), a Teflon or silicone intravenous cannula of adequate bore (<21G) should be inserted into a vein of sufficient diameter to permit a freely flowing 0.9% saline infusion to be commenced. Site chosen should be one where cannula can be easily inserted and observed, can be fastened 572 securely and will not be subject to movement during drug administration. The veins of the forearm are the most suitable for this purpose followed by those on the dorsum of the hand. Antecubital fossae and other sites close to joints are best avoided. The risk of extravasation (see p578) is increased by the use of a cannula which has not been inserted recently and by the use of steel (butterfly) cannulae.

A slow 'push' injection should be administered carefully into the side access port on the IV line with continuous observation of the drip chamber ensure that the infusion is continuing to run during injection of the cytotoxic drug. The patient should be asked whether any untoward sensations are being experienced at the site of the infusion and the site should be carefully observed to ensure that no extravasation is occurring. Patency of the IV site should be verified regularly throughout the procedure. The saline or dextrose infusion should be continued for 30 minutes after the chemotherapy administration has been completed before the cannula is removed.

The administration of potentially extravasable chemotherapy, site of can-nulation, condition of the site and any symptoms associated with administration should be clearly documented in the patient's notes.

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