SARASOTA MEMORIAL HOSPITAL NURSING PROCEDURE TITLE: ISSUED FOR: CHEMOTHERAPEUTIC AGENTS BY INTRAVENOUS (IV) Nursing DATE: REVIEWED: PAGES: RESPONSIBILITY: * Oncology RN 3/86 11/18 1 of 6 PURPOSE: OBJECTIVE: DEFINITION: KNOWLEDGE BASE: To provide guidelines for the administration of non-vesicant chemotherapeutic agents via intravenous (IV) push peripherally or through a central line. The nurse will administer non-vesicant peripheral chemotherapy via IV push through a peripheral or central line as per procedure, safely, with no or minimal complications. In this procedure IV push refers to the administration of non-vesicant chemotherapeutic agents into a peripheral vein or central line either directly or indirectly through the sidearm of a free-flowing IV. All other chemotherapy guidelines should be followed. 1. Administration of chemotherapeutic agents requires skilled nursing techniques and a firm knowledge base of administration hazards and side effects of chemotherapy. Chemotherapy will only be given by registered nurses who have completed chemotherapy administration training or who have documented experience in the safe handling and administration of cytotoxic agents. 2. SMH Nursing Procedures and Oncology Nursing Society (ONS) guidelines for chemotherapy administration will be maintained. Refer to nursing procedure Administration of Chemotherapeutic Agents and Biotherapies-Adults (onc01) for routes of administration and responsibilities. 3. Non-vesicant chemotherapeutic agents may be administered IV push directly into the IV site connector, indirectly through the sidearm of a free-flowing diluent infusion, or directly into the IV site connector using a programmable mini-infuser. Dilution may be contraindicated with certain chemotherapy (for example: Abraxane). When dilution is contraindicated and administration time exceeds 10 minutes, the nurse may place the syringe on a programmable mini-infuser to infuse directly into a peripheral or central line over a specified time. 4. Chemotherapeutic agents are administered utilizing a closed system transfer device (CSTD) system. a. For administration, the CSTD system consists of a syringe adaptor attached to the chemotherapy syringe or IV tubing that connects with a Luer-lock adaptor attached to the IV
PAGE: 2 of 6 site access. b. In order to maintain the safety of the CSTD system, do NOT disconnect the CSTD equipment from the tubing, syringe, or IV site access once connected. If it is necessary to remove the CSTD Luer-lock adaptor, only remove the CSTD Luerlock adaptor after flushing with a flush solution. (Flushing of the IV site access should be done by either a) applying a CSTD syringe adapter to a flush syringe, or b) by attaching a non-cstd equipped flush syringe, to the sidearm of the IV tubing using the port closest to the patient and that syringe will remain attached to the tubing at all times.) c. If the CSTD syringe adaptor must be disconnected and then reconnected (as with stopping and starting the same infusion), scrub vigorously the internal section of the CSTD syringe adaptor with a chlorhexidine swabstick for at least 15 seconds and allow to dry fully before attaching to IV access. d. If the CSTD syringe adaptor must be disconnected from the CSTD Luer-lock adaptor for additional medication (as with infusion reaction management), a CSTD syringe adaptor must be utilized for access through the CSTD Luer-lock adaptor. e. If an infusion port on the chemotherapy IV tubing must also be accessed during the chemotherapy infusion, an additional CSTD Luer-lock adaptor must be attached to the infusion port. A CSTD syringe adaptor must be used for access through the CSTD Luer-lock adaptor on the infusion port. 5. Hand hygiene per policy (01.IFC.67) Hand Hygiene. INDICATIONS: PATIENT EDUCATION: Specific drugs that may be delivered via IV push include (but are not limited to): cytarabine (Ara-C), fluorouracil (5FU), methotrexate, Abraxane, and bleomycin. All other agents should be administered as specified by the physician. 1. Inform the patient to notify the nurse of any discomfort during the administration of the chemotherapy. 2. Inform the patient that counter measures will be instituted in the event of an extravasation. EQUIPMENT: 1. 10 ml pre-filled syringes with 10 ml sterile normal saline (NS) or other appropriate flush solution 2. Alcohol wipes 3. ASTM tested chemotherapy-approved gloves (2 pairs) 4. Chemotherapy-approved gown 5. CSTD Luer-lock adaptor(s) 6. CSTD syringe adaptor(s) (as needed) 7. Goggles and face shield if splashing might occur or 8. Goggles alone if only eye protection is needed.
PAGE: 3 of 6 9. Ordered dose of chemotherapy in prefilled syringe with CSTD syringe adaptor attached 10. If indirect sidearm administration through free-flowing diluent infusion: a. Appropriate diluent for free-flowing infusion b. Appropriate IV infusion tubing 11. If direct administration using a programmable mini-infuser: a. Mini-infuser/ IV tubing extension set b. Programmable mini-infuser NOTE: Follow nursing procedure Administration of Chemotherapeutic Agents and Biotherapies - Adult (onc01). NOTE: Double gloving is required for all hazardous drug handling activities, not just preparation and administration. PROCEDURE: 1. Assess any IV site prior to use for pain, phlebitis, infiltration. Avoid using an established peripheral IV site that is more than 24 hours old whenever possible. 2 Perform hand hygiene. 2. Before accessing any IV connector, infusion port or CSTD Luerlock adaptor, scrub the connector, infusion port or adaptor with an alcohol wipe for 15 seconds and allow to air dry thoroughly. 3. Clean IV site needleless connector, air dry and attach prefilled flush syringe. Verify IV site patency by infusing, checking for resistance, and drawing back for blood return. Remove syringe. NOTE: If no blood is visible with a peripheral line and troubleshooting does not produce a blood return, then discontinue administration and restart peripheral IV access in another site per nursing procedure Peripheral IV Therapy: Initiation and Care for the Adult Patient (inv02). If no blood return is visible with a central line and troubleshooting does not produce a blood return, then, discontinue administration and manage per nursing procedure Management of Vascular Access Complications (cen05). 4. Clean IV site connector, air dry and attach CSTD Luer-lock adaptor. 5. Prime tubing, if needed. a. If indirect sidearm administration through free-flowing diluent infusion, attach IV infusion tubing to diluent infusion bag and prime tubing. Clamp tubing. Attach CSTD syringe adaptor to IV tubing. b. If direct administration using a programmable mini-infuser, attached pre-filled flush syringe to mini-infuser tubing and prime tubing. Remove syringe and attach CSTD Luer-lock
PAGE: 4 of 6 adaptor. Attach CSTD syringe adaptor to distal end of tubing. 6. Attach tubing, if needed. a. If indirect sidearm administration through free-flowing diluent infusion: 1) Clean IV access CSTD Luer-lock adaptor, air dry and connect diluent CSTD syringe adaptor. 2) Clean sidearm injection port on diluent tubing closest to the patient, air dry and attach CSTD Luer-lock adaptor. b. If direct administration using a programmable mini-infuser, clean IV access CSTD Luer-lock adaptor, air dry, and connect mini-infuser tubing CSTD syringe adaptor. 7. Don 2 pairs of ASTM tested chemotherapy gloves and gown before handling chemotherapy. The second pair of gloves must cover the cuffs of the gown. Don goggles and face shield if splashing might occur or goggles alone if only eye protection is needed. 8. Connect the chemotherapy CSTD syringe adaptor and verify blood return. a. If indirect sidearm infusion: 1) Clean the sidearm CSTD Luer-lock adaptor, air dry and connect chemotherapy CSTD syringe adaptor. 2) Verify blood return by pinching the IV tubing above the infusion port and aspirating for blood. 3) If blood return present, unclamp tubing and set drip rate. b. If direct administration using a programmable mini-infuser: 1) Clean mini-infuser tubing CSTD Luer-lock adaptor, air dry, and connect chemotherapy CSTD syringe adaptor. 2) Draw back on syringe to check for blood return. c. If direct administration using a syringe: 1) Clean IV access CSTD Luer-lock adaptor, air dry and connect chemotherapy CSTD syringe adaptor. 2) Draw back on syringe to check for blood return. NOTE: If no blood return is visible with peripheral site, discontinue administration and restart peripheral IV access in another site. If no blood return is visible with a central line, discontinue administration and manage per nursing procedure Management of Vascular Access Complications (cen05). 9. If blood return visible, proceed to inject chemotherapy at ordered infusion rate or per nursing procedure Administration of Chemotherapeutic Agents and Biotherapies - Adult (onc01). 10. Check for blood return every 2-5 ml of chemotherapy administered. Blood return does not need to be assessed every 2-5 ml for drugs administered with the mini-infuser.
PAGE: 5 of 6 11. Monitor the site for any reactions, such as swelling, erythema, or pain. NOTE: If an extravasation is suspected, stop the infusion and follow nursing procedure Chemotherapy Extravasation Management Guidelines (onc10). 12. Infuse chemotherapy. When administration is completed check for blood return. 13. Flush IV site. a. If indirect sidearm administration through free-flowing diluent infusion, flush with at least 10 ml of IV diluent solution. b. If direct administration using a programmable mini-infuser or syringe: 1) Attach CSTD syringe adaptor to prefilled flush syringe. 2) Disconnect chemotherapy CSTD syringe adaptor. 3) Clean IV site CSTD Luer-lock adaptor, air dry and connect flush CSTD syringe adaptor. 4) Flush IV site. 5) Disconnect flush CSTD syringe adaptor from IV site CSTD Luer-lock adaptor. 14. If IV site is not removed, remove CSTD Luer-lock adaptor from IV access. 15. Dispose of PPE and administration equipment per nursing procedure Disposing of Chemotherapy Tubings, Solution Bags and Syringes (onc08). 16. Wash hands with soap and water. NOTE: If more than one drug is to be administered, be sure to flush with normal saline or other appropriate diluent between and after administration to prevent incompatibility reactions. Use at least 4 to 5 ml of diluent between each drug to clear the peripheral line. For central lines, use 10 ml of diluent to flush the line. Repeat all other steps for subsequent administration. DOCUMENTATION: 1. Medication Administration Record: Document time of administration and initials of nurse per established procedure. 2. Oncology Flowsheet: Document administration of chemotherapy/biotherapy agent(s), information on free-flowing diluent solution, IV access and blood return. 3. Nursing Reassessment: Document the patient response, side effects, and nursing management. Discharge instructions must be provided and documented.
PAGE: 6 of 6 REFERENCES: 1. Polovich, M., Olsen, M., & LeFebvre, K. B. (2014). Chemotherapy and Biotherapy Guidelines and Recommendations for Practice (4 th ed.). Pittsburgh, PA: Oncology Nursing Society. 2. Sarasota Memorial Hospital Nursing Procedures. Administration of Chemotherapeutic Agents and Biotherapies - Adult (onc01). Sarasota, FL: Author. 3. Sarasota Memorial Hospital Nursing Procedures. Chemotherapy Extravasation Management Guidelines (onc10). Sarasota, FL: Author. 4. Sarasota Memorial Hospital Nursing Procedure. Disposing of Chemotherapy Tubings, Solution Bags, and Syringes (onc08). Sarasota, FL: Author. 5. Sarasota Memorial Hospital Nursing Procedures. Management of Vascular Access Complications (cen05). Sarasota, FL: Author. 6. Sarasota Memorial Hospital Nursing Procedures. Peripheral IV Therapy: Initiation and Care for the Adult Patient (inv02). Sarasota, FL: Author. REVIEWING AUTHOR: Deena Damsky Dell MSN, CNS RN-BC, AOCN, LNC Barbara Poropat BSN, RN, OCN, NPD Rachael Pierce BSN, RN, OCN, Clinical Coordinator, SMI