IV Drug Delivery Systems used in Cancer Care

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1 IV Drug Delivery Systems used in Cancer Care Cheri Constantino-Shor, RN, MSN, CRNI Seattle Cancer Care Alliance Nursing Staff Development Coordinator

2 Presentation Objective Describe drug delivery devices used in cancer care, including: O CVC O Peritoneal catheters O Ommaya reservoir

3 Multiple IV Delivery Devices in Oncology Peripheral Vascular Access Central Venous Therapy Midline Access Can be immediately stopped if an adverse reaction occurs!!

4 Incompatibility O To successfully mix medications in a solution for infusion, two things must be compatible: O The drug O The diluent O If you are not sure of the compatibility of a mixture, ASK THE PHARMACIST OR CHECK AN UP TO DATE COMPATIBILITY SOURCE!!

5 Peripheral Venous Therapy O Can be used for general vascular access and some chemotherapy administration O Insert a new IV for peripheral vesicants O Do not go below a recent venipuncture site (<24 hours) O Avoid lateral surface of the wrist for approx. 4-5 inches because of the risk for nerve damage O Begin distally and move proximally O Avoid hands, joints for any vesicant therapy O MUST have blood return for vesicant therapy In general, smallest gauge IV in largest possible vein for intended use!

6 INS guidelines for peripheral IV access Per Infusion Nurse s Society (INS) guidelines, peripheral IV not appropriate for: O Continuous vesicant therapy O Parenteral nutrition O Infusates with a ph outside of 5-9 O Infusates with an osmolarity >600 mosm/l (Osmolarity: the number of milliosmols per liter (mixed osmolarity of a drug with diluent) A midline is not a central line! O Used for 1-4 weeks of therapy O Same guidelines as above

7 Vesicant Chemotherapy Vesicants: Agents capable of causing pain, sloughing of skin, and/or tissue necrosis when they leak outside of a vein or are inadvertently administered into the tissue Extravasation: the process of leakage Non-DNA binding vesicant DNAbinding vesicant

8 Non-DNA binding vesicants Vinca alkaloids (vincristine, vinblastine) Do not bind to DNA in healthy cells when they extravasate into tissue Are metabolized in the tissue With heat, elevation, and hyaluronidase local injection (spreads vesicant throughout tissue for faster metabolism of the vesicant), these extravasations improve over a short period of time (days to weeks) DNA-binding vesicants Anthracyclines (doxorubicin, epirubicin, daunorubicin, idarubicin) Bind to DNA in healthy cells when they extravasate into tissue When not immediately treated with Totect (dexrazoxane), remain in the tissue and invade adjacent healthy tissue Left untreated, these extravasations become larger and deeper, and worsen over time (weeks to months)

9 Weighing the risks/benefits of a central venous access Risk of Sepsis Reduce frequent need for venipuncture

10 Types of Central line catheters/care O O Tunneled catheters (for long term use) (Only power-injectable if identified as such directly on line) O Broviac O Hickman O Groshong O Leonard (11.5 Fr) O Hemodialysis: order required for alternative use Nontunneled Catheters (Only power-injectable if identified as such directly on the line) O Subclavian, jugular or femoral O Mahurkar: for apheresis or hemodialysis O O Peripherally Inserted Central Catheters O Groshong/Open Ended/Power injectable (Only power-injectable if identified as such directly on line) Implanted Vascular Access Ports O Accessed with a Huber needle O Open-ended and Groshong O If port is power-injectable, must be identified by ID card or x-ray O If used for power injection, must also use a power-injectable Huber needle

11 Tip of Central Venous Catheter

12 Bard and PowerPort are trademarks and/or registered trademarks of C. R. Bard, Inc.

13 Groshong Catheter Tip

14 1. Place the patient in a supine position and attempt to aspirate blood. 2. If unsuccessful, use a 10 ml syringe containing 10 ml of normal saline and gently push-pull. 3. If unsuccessful, use a 20 ml syringe containing 5-10 ml of normal saline and gently push-pull (the larger syringe diameter exerts less pressure on the walls of the catheter). 4. If unsuccessful, follow institutional policy and procedures (e.g. dye study, instillation of a thrombolytic agent). A good blood return is generally defined as the ability to draw back 3 ml of blood in 3 seconds.

15 Central venous catheter facts O A central venous catheter is inserted with the tip in the Superior or Inferior Vena Cava O Cleansing with 2% aqueous chlorhexidine offers the best protection against central venous catheter colonization O Use a 10ml or larger syringe to flush central lines!! O Dressing changes are generally done using sterile technique O May be non-sterile, clean technique for tunneled catheter O Follow your institution s policy on flushing (Policy should specify use of Heparin. Valved catheters do not require Heparin!)

16 More central line facts! O New central lines should be xray confirmed before use and anytime line has moved from original position O Always confirm blood return before use O Turbulent flushing technique prevents fibrin build up O If a central line is occluded or does not have blood return, you must contact provider and NOT use line that day. O A thrombotic occlusion is caused by a clot in the line. O A mechanical occlusion is caused by a kink or malposition O Only use properly maintained central lines! O Know your line BEFORE you use it!

17 Intrathecal Chemotherapy Injected into the subarachnoid space Reaches the CNS Used to treat leukemia and lymphoma that has spread to the CNS (an area that chemotherapy cannot reach because of the blood-brain barrier jpg

18 Drugs Administered Intrathecally Only methotrexate and cytarabine may be administered via the intrathecal route Intrathecal hydrocortisone is often given at the same time (reduces inflammation) Must be preservative free to avoid CNS irritation

19 Administration Considerations Confirm patient identity using at least 2 identifiers. Review the patient s treatment plan and orders. Verify intrathecal drug, dose, volume, route, date/time of administration, and preparation (preservative-free) upon preparation and immediately prior to administration. Consider implementing a time out or use of a checklist. Administer intrathecal chemotherapy in an area in which IV chemotherapy is not administered. Place do not disturb or do not enter signs on the door ISMP recommends minibags for vinca alkaloids For Intrathecal Administration Only DO NOT ENTER INTRATHECAL CHEMOTHERAPY IN PROGRESS

20 Inadvertent administration of IV chemotherapy into the CNS (wrong route) is usually FATAL

21 Peritoneal Catheter