Transcript Delivery of Intrathecal Chemotherapy

Delivery of Intrathecal
Chemotherapy
Kowloon Central Cluster
10Jan08
Background
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Inadvertent intrathecal
administration of vincristine
intended for intravenous
administration have occurred in
Hong Kong resulting in death
Tolerance
HA Guideline on Safe Handling of
Intrathecal Chemotherapy (18Sep07)
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Policy
Training and Competence
Prescribing
Dispensing and Preparation
Labelling, Packaging and Delivery of
intrathecal chemotherapy
Administration
Extra Precautions to avoid
inadvertent administration of vinca
alkaloids by intrathecal route
Policy
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Written Instruction
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Designated Officer
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Cross-check
Designated Officer
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Assigned by COS
Cross Check
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At least 2 persons
All specialty
3 Checks 5 Rights
Documentation
Working Instruction
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Staff
Training
Procedure
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Must not contravene HA guideline
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Working Instruction
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Not to disturb the routine
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To reinforce the routine
Staff on list
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Medical and Nursing staff of
Department
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Trainee from other unit or hospital
are not allowed unless approved by
designated officer after proper
training and assessment
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List of trained staff should be
available and update regularly
Training and Competence
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Organized by designated officer of
department on intrathecal
chemotherapy
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Lecture & working instruction and
assessment at bedside
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At least yearly or after revision of
instruction or new staff joining the
department
Procedure
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Prescribing
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Dispensing and Preparation
Labelling, Packaging and Delivery of
intrathecal chemotherapy
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Administration
Procedure
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Prescribing
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Dispensing and Preparation
Labelling, Packaging and Delivery of
intrathecal chemotherapy
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Administration
Procedure
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Prescribing
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Dispensing and Preparation
Labelling, Packaging and Delivery of
intrathecal chemotherapy
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Administration
Intrathecal Chemotherapy
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Agent
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Indication
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Route
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Protocol
Agent
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Methotrexate
50mg preparation
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Cytarabine ( Ara-C )
100mg preparation
without benzyl alcohol solvent
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Hydrocortisone
100mg preparation
Indication
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CNS prophylaxis
Burkitt lymphoma
Testicular lymphoma
Parameningeal extension
Acute Leukaemia
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Leptomeningeal disease
e.g breast or lung cancer
Route
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Lumbar puncture
Route
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Lumbar puncture
Intrathecal port
Route
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Lumbar puncture
Intrathecal port
Ommaya reservoir
Protocol
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SUMC ( Burkitt lymphoma )
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q3wk
MTX 12mg Day 1 & Day 10
Total 10 doses
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Protocol
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HyperCVAD ( Burkitt lymphoma )
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q3wk
MTX 12mg Day2 + Ara-C 100mg Day7
Total 16 doses
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Protocol
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Acute
Leukaemia
Protocol
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Leptomeningeal disease
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MTX 12mg + Ara-C 100mg
2 times per wk till CSF negative then weekly
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Vincristine
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Fatal if given intrathecally
Pre-printed MAR-ITC
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MAR-IT-MTX
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MAR-IT-ARAC
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MAR-IT-LM
Prescription
Label with patient
particular
5/11
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6/11
S1
6/11
S2
One of the medical staff involved
( prescription / verification ) must be
specialist
Dispensing , Preparation,
Packaging and Delivery of Drug
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All intrathecal chemotherapy must
be prepared by Aseptic Dispensing
Unit QEH
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MAR-ITC should be sent to ADU
one day before the injection
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QEH pharmacy policies in safe
administration of intrathecal
chemotherapy for further details
Administration
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Within normal working hour and day ( Monday to
Saturday 12pm )
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Should not be initiated at the same time with other
intravenous drug
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Trained staff or trainee under direct supervision of
trained staff
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Staff & patient should not be distracted during the
procedure
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In protected area with “sign of intrathecal
chemotherapy in progress” hanged on after check
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Check patient record & chemotherapy protocol
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Follow the step on MAR-ITC
Administration
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Last check should be the most
important check
Documentation
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6/11
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6/11
6/11
S3
S4
S5
Last check should be the most
important check
Documentation
Label with patient
particular
5/11
6/11
S1
6/11
S2
S4
Call for help
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Lumbar puncture
Access to intrathecal port
Must follow the checking step
before injecting drug
Caution
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Injecting substance without
labeling
Additional measures for vinca alkaloids
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All intravenous doses of vinca alkaloids must be
diluted in at least 50ml infusion minibags for
adults and 10-20ml syringe for paediatrics to
distinguish them from intrathecal drugs.
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All dispensed vinca alkaloids must be clearly
labelled on the bag and on the outer container
with a warning “For Intravenous Use only. Fatal if
given by other routes”. Negative labels, such as
“Not for Intrathecal Use” must not be used.
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Procedures should be in place for monitoring,
preventing and treating extravasation of vinca
alkaloids diluted in minibags.
Extravasation Kit
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Dimethylsulphoxide solution 99% 100ml
(DMSO – US pharmaceutical grade) x 1
Hyaluronidase (1500units injection) x 1
Hydrocortisone (100mg injection) x 2
Hydrocortisone 1% cream x 1
Sodium bicarbonate 8.4% injection x 1
Sodium thiosulphate 25% injection x 1
Water for injections 20ml x 2
Treatment protocol (basic treatment and
individual drug management)
Extravasation report form x 1