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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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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