Optimizing chemotherapy dilution: A clinical pharmacist’s perspective on safe and effective preparation

Anuradha. S

Clinical Pharmacist, Kauvery Hospital, Hosur, Tamil Nadu

Abstract

Chemotherapy dilution is a critical process in clinical settings, requiring precision and attention to detail to ensure safe and effective treatment. Accurate calculations, compatibility, stability, and sterility are essential considerations to prevent adverse reactions and optimize treatment outcomes. Clinical pharmacists play a vital role in chemotherapy dilution, working closely with the healthcare team to ensure seamless care. This review highlights best practices, challenges, and emerging trends in chemotherapy dilution, emphasizing the importance of precision, quality control, and collaboration to improve patient outcomes.

Introduction

Chemotherapy Dilution

Chemotherapy dilution refers to the process of preparing chemotherapy medications by mixing the prescribed dose with a suitable diluent, such as saline or dextrose solution, to achieve the desired concentration. This process requires precise calculations and attention to detail to ensure the correct dose is administered to the patient.

Purpose

To ensure safe and accurate preparation of chemotherapy medications through proper dilution, minimizing errors and adverse reactions.

Scope

This protocol applies to all healthcare professionals involved in chemotherapy preparation and administration.

General Instructions for Optimizing Chemotherapy

Proper Hand Hygiene

Perform proper hand hygiene before and after preparation.

  • Wash hands: Wash hands before starting preparation.
  • Use hand sanitizer: Use hand sanitizer after washing hands and between tasks.
  • Glove usage: Wear gloves during preparation and change them regularly.
  • Avoid touching: Avoid touching face, hair, or non-sterile surfaces.

Use of Personal Protective Equipment Gloves

  • Use double, latex gloves with minimal
  • Change the glove every hourly or when it is torn, punctured or contaminated with spills.
  • Use thicker, longer latex gloves that cover the gown cuff. Gown
  • A protective disposable gown made of lint free, low permeability fabric with a closed front, long sleeve; elastic and knit closed cuff should be worn.
  • Tuck the cuffs under the gloves
  • When double gloving, position the outer glove over the gown cuff and tuck the inner glove under the cuff to maintain a secure and sterile barrier.
  • Do not use the glove or gown outside the preparation area.

Sterile Equipment

Use sterile equipment, including syringes, needles, and containers.

Minimize Touch

  • Minimize touch contamination by avoiding contact with non-sterile surfaces.
  • Respiratory Protection: wear eye mask and face protection splashes, sprays or aerosols of chemotherapeutic drugs results in eye, nose or mouth contamination.
  • Eye wash facilities should be available in the cabinet.

Initial Assessment

Verify Patient Identity: Confirm patient’s name, date of birth, IP NO, UHID and medical record number.

Check Allergy Information: Review patient’s allergy history and sensitivities.

Confirm Medication Orders: Verify chemotherapy medication, dose and administration schedule.

Review Medical History: Consider patient’s medical history, including previous treatments and reactions.

Validate Lab Results: Check relevant lab results, such as blood counts and liver function tests.

Pre-preparation Procedure

  1. Check the height and weight of the patient and record it in the chart.
  2. Verify and document the absolute CBC
  3. Review and document the laboratory reports of the patient. • Verify the duration between each cycle.
  4. Chemotherapy orders must be written clearly (name of the drug, dosage, diluents, route, duration of administration and premedication) with the doctor’s signature and date.
  5. Protocol should be available and signed by the consultant.
  6. Oral or unclear orders should not be followed.

Follow Established Protocols

Adhere to established protocols and guidelines for chemotherapy dilution.

Use Aseptic Technique

Prepare chemotherapy dilutions using aseptic technique to prevent contamination.

Label Accurately

Label prepared chemotherapy dilutions accurately, including medication name, dose, and expiration date/time.

Store and Handle Properly

Store and handle prepared chemotherapy dilutions according to manufacturer’s instructions.

Monitor and Report

Monitor patients for adverse reactions and report any concerns.

Maintain Sterility

Maintain sterility during preparation and handling to prevent contamination.

Document Accurately

Document preparation, administration, and patient response accurately.

Stay Current

Stay current with emerging trends, research, and guidelines to continuously improve chemotherapy dilution practices.

Equipment Needed

  • Injection trolley with spirit, cotton ball jar, clamp bottle/cheatle forceps bottle, sharp container, sterlium, adhesive and scissors. Disposable syringes as needed.
  • Protective devices (gloves – 2, mask, apron, shoe cover and goggles).
  • Vertical laminal airflow/biological safety cabinet.
  • Diluents for mixing chemotherapy drugs and IV fluid for dilution. Drug label.

Preparation of Chemotherapy

  • While preparing chemotherapy drug responsible persons must be present there such as,
  • Clinical pharmacist who was specialized in Oncology
  • In charge nurses who are trained specially in preparation and administration of chemotherapy.
  • The assigned nurse for the particular patient also should be present throughout the preparation of cytotoxic drugs.
  • Clinical pharmacist must be counter check the drug dilution, dosage and route of administration

Clinical Pharmacist Responsibility

Dilution

  • Aseptic technique is crucial in chemotherapy dilution to prevent contamination and ensure patient safety.
  • Drug preparation and loading should be done in a restricted, preferably centralized area.
  • Class II biological safety cabinets should be used.
  • Unauthorized personnel should not be allowed to enter into the area.
  • Cabinet should be cleaned according to manufacturer’s instruction.

Verify Calculations

Double-check calculations for accuracy to ensure correct dilution ratios and doses.

Use Compatible Diluents

Select diluents compatible with chemotherapy agents to prevent incompatibility reactions.

Preparing Dilutions in a Bio Safety Cabinet

  • Assemble the needed equipment in the chemotherapy loading area.
  • Put on the UV light inside laminar hood 15minutes before procedure.
  • Put on the airflow.
  • Clean the internal surface of the cabinet with 70% alcohol and a disposable towel.
  • Cover the work surface with a clean plastic absorbent pad to minimize contamination by droplets or spills. Change the pad at the end of the shift or whenever a spill occurs.
  • Verify the drug, dosage and route of administration by checking the medication record against the doctor’s order.
  • Keep the prepared labels beside the IV bottles and the specific chemotherapy drugs.
  • Wash hands with sterilium.
  • Open the glove paper and drop the spirit swab, syringes as required for dilution
  • Check the IV fluids expiry date, contamination and any precipitation.
  • Remove the plastic cork of the IV fluid and wipe it with sprit swab.
  • Open the drug away from the face and body. Use a suitable pad or cotton for breaking the ampule. In case of vials, clean the top of the vial with spirit swab in a circular motion. Discard the cotton swab.
  • Introduce the diluents slowly into the vial to prevent high pressure being generated inside the sealed vial.
  • Withdraw the chemotherapy drug using the syringe and expel the air without spillage of medications. When excess air is expelled from a filled syringe, it should be exhausted in to the vial and not straight into the atmosphere. Mix the drug with IV fluid kept ready for infusion.
  • Keep sterile cotton on the loaded bottle and seal it with adhesive.
  • Label the drug correctly and get the counter sign from the Clinical pharmacist
  • Discard all the materials which have come into contact with the cytotoxic drugs (syringes, cotton, mask, apron, ampoules and vials) in a sealed black cover with adhesive.
  • Discard the needle in the sharp container.
  • Goggles, face shields, respiration are cleaned with mild detergents and are reused.

Administration

  • Before administration cross check the doctor’s order.
  • Drug should be carefully while transporting from bio safety cabinet to the patient’s bedside
  • Check the IV fluids occurs any discoloration and any precipitation.
  • Initially Pre-medicate the patient as per the doctor’s order.
  • Connect the drug to the right patient using all rights of medication administration.
  • Monitor drops or ml per minute and over hours
  • Assess the vital signs while chemotherapy is on flow.
  • Watch for any untoward reactions like nausea, vomiting, dyspnea, tachycardia, tachypnea, chest pain and allergic reaction.
  • Monitor for proper flow and complete the infusion on time and Clinical pharmacist should educate the staff.
  • If any ADR occurs to the Patient initially inform to the Oncologist and Clinical Pharmacist.

Roles and Responsibility of Clinical Pharmacist During ADR

  • Initially ask the patient what are the adverse reactions occurred in their body
  • Ask the nurse what the drug has administered to the patient on the time
  • Make a Report of suspected adverse drug reaction by using Adverse Drug Reaction Probability Scale (Naranjo)
  • ADR Probability Scale consists of 10 questions that are answered as either Yes, No, or “Do not know”. Different point values (-1, 0, +1 or +2) are assigned to each answer.
  • By using the scale clinical pharmacist should report the causality assessment.
  • Suspected adverse drug reaction consist of information such as,
    • Patient information
    • Event or Date of reaction started
    • Event or Date of reaction stopped
    • Suspected drug Brand / Generic name, Route, frequency and dose either (full dose or test dose)
    • If known Manufactured, Batch No./ Lot No and expiry date
    • Seriousness of reaction
    • Outcomes
    • Indications
    • Action taken after reaction
    • Finally Reporter details
  • Submit it to the nearest Adverse drug reaction monitoring centre (AMC) or directly to the National Coordination centre (NCC) for Pharmacovigilance Programme of India (PVPI) or Medicine and Health Care Products Regulatory Agency (MHRA) in UK

Roles and responsibility of clinical pharmacist if drug precipitant occurs

  • Immediately stop the medicine
  • Inform the consultant
  • Inform to the Pharmacy Purchase manager and Team
  • Ask the staff to write Drug Replacement Form
  • Fill the details of the drug and what reactions does the drug occurs
  • Make a Picture of the Drug
  • Immediately Pharmacy Purchase manager will contact the drug manufacture such as rep or sales manager of the drug
  • Replacement form must contain the seal and sign of the Oncologist, Verification sign by Clinical Pharmacist and administer of drug ie, Incharge nurse employee ID

Spills

Clean up of Small Spills

  • Spill less than 5 ml is considered as small spill.
  • The 5ml volume of material should be used to categorize spills as large or small.
  • Liquids should be wiped with absorbent gauze pads; solids should be wiped with wet absorbent gauze.
  • The spill areas should be cleaned three times using a detergent solution followed by clean water.
  • Any broken glass fragments should be picked up using a small scoop and placed in a sharp container.
  • Glassware and scoops are treated as reusable items.
  • For Minor spill (< 30 ml) Handle yourself if possible or notify Housekeeping

Clean Up of Large Spills

  • When a large spill occurs, immediately announce CODE ORANGE for Hazardous material spill
  • Responsible person such as
    • Floor Incharge/Supervisor
    • Patient safety nurse
    • Hospital safety officer
    • Quality manager
    • Security officer
    • Biomedical incharge
    • Laboratory incharge
    • Pharmacy Incharge
  • Should assemble after code is announced

Equipements

  • Gumboots and Goggles
  • Gloves pair
  • Hazardous bag
  • Respiratory mask
  • Face shield
  • Apron and Mercury Kit.

Procedure for major spill: (more than 30ml)

  1. The HAZMAT team is to be alerted immediately after chemical spill over 30 ml.
  2. Dial and Call CODE ORANGE.
  3. Mention the location/ward/ unit of the spill.
  4. Ensure the respective procedure is carried out
  5. Document the occurrence and Action take
  6. Chemical inactivation should be avoided in this setting.
  7. All contaminated surface should be thoroughly clean
  8. Keep the caution board near the spill.
  9. Place the tissue paper over the spill and collect the waste in the red colour dustbin
  10. Wait for the area to completely dry before removing the wet floor signboard
  11. Monitor Material Safety Data Sheet, document, record and notify the Safety Officer and Fill in the occurrence report.

Conclusion

Optimizing chemotherapy dilution requires adherence to protocols, and a commitment to patient safety by using accurate calculations, clinical pharmacists can ensure safe and effective preparation of chemotherapy agents. This expertise enhances patient care, minimizes risks, and promotes positive treatment outcomes. By prioritizing safety, accuracy, and quality, clinical pharmacists play a vital role in optimizing chemotherapy dilution and contributing to the success of cancer treatment.

Kauverian Bookshelf

Applied Medical Statistics

Journals

Kauvery Hospital
Find Doctor
Book Appointment