Delivery of Intrathecal Chemotherapy Kowloon Central Cluster 10Jan08

Delivery of Intrathecal Delivery of Intrathecal Chemotherapy Chemotherapy

Kowloon Central ClusterKowloon Central Cluster

10Jan0810Jan08

BackgroundBackground

Inadvertent intrathecal Inadvertent intrathecal administration of vincristine administration of vincristine intended for intravenous intended for intravenous administration have occurred in administration have occurred in Hong Kong resulting in deathHong Kong resulting in death

ToleranceTolerance

HA Guideline on Safe Handling of HA Guideline on Safe Handling of Intrathecal Chemotherapy Intrathecal Chemotherapy (18Sep07)(18Sep07)

PolicyPolicy Training and CompetenceTraining and Competence PrescribingPrescribing Dispensing and PreparationDispensing and Preparation Labelling, Packaging and Delivery of Labelling, Packaging and Delivery of

intrathecal chemotherapyintrathecal chemotherapy AdministrationAdministration Extra Precautions to avoid inadverteExtra Precautions to avoid inadverte

nt administration of vinca alkaloids bnt administration of vinca alkaloids by intrathecal routey intrathecal route

PolicyPolicy

Written InstructionWritten Instruction

Designated OfficerDesignated Officer

Cross-checkCross-check

Designated OfficerDesignated Officer

Assigned by COSAssigned by COS

Cross CheckCross Check

At least 2 personsAt least 2 persons All specialtyAll specialty 3 Checks 5 Rights3 Checks 5 Rights DocumentationDocumentation

Working InstructionWorking Instruction

StaffStaff Training Training ProcedureProcedure

Must not contravene HA guidelineMust not contravene HA guideline

Working InstructionWorking Instruction

Not to disturb the routineNot to disturb the routine

To reinforce the routineTo reinforce the routine

StaffStaff on liston list Medical and Nursing staff of Medical and Nursing staff of

DepartmentDepartment

Trainee from other unit or hospital Trainee from other unit or hospital are not allowed unless approved by are not allowed unless approved by designated officer after proper designated officer after proper training and assessmenttraining and assessment

List of trained staff should be List of trained staff should be available and update regularlyavailable and update regularly

Training and CompetenceTraining and Competence

Organized by designated officer of Organized by designated officer of department on intrathecal department on intrathecal chemotherapychemotherapy

Lecture & working instruction and Lecture & working instruction and assessment at bedsideassessment at bedside

At least yearly or after revision of At least yearly or after revision of instruction or new staff joining the instruction or new staff joining the departmentdepartment

Procedure PrescribingPrescribing

Dispensing and PreparationDispensing and Preparation Labelling, Packaging and Delivery of iLabelling, Packaging and Delivery of i

ntrathecal chemotherapyntrathecal chemotherapy

AdministrationAdministration









Intrathecal ChemotherapyIntrathecal Chemotherapy

AgentAgent

IndicationIndication

RouteRoute

Protocol Protocol

AgentAgent

MethotrexateMethotrexate 50mg preparation50mg preparation

Cytarabine ( Ara-C )Cytarabine ( Ara-C ) 100mg preparation100mg preparation without benzyl alcohol solventwithout benzyl alcohol solvent

HydrocortisoneHydrocortisone 100mg preparation100mg preparation

IndicationIndication

CNS prophylaxis CNS prophylaxis Burkitt lymphomaBurkitt lymphoma Testicular lymphomaTesticular lymphoma Parameningeal extensionParameningeal extension Acute LeukaemiaAcute Leukaemia

Leptomeningeal diseaseLeptomeningeal disease e.g breast or lung cancere.g breast or lung cancer

RouteRoute Lumbar punctureLumbar puncture

RouteRoute Lumbar punctureLumbar puncture Intrathecal portIntrathecal port

RouteRoute Lumbar punctureLumbar puncture Intrathecal portIntrathecal port Ommaya reservoirOmmaya reservoir

ProtocolProtocol

SUMC ( Burkitt lymphoma )SUMC ( Burkitt lymphoma ) q3wkq3wk MTX 12mg Day 1 & Day 10MTX 12mg Day 1 & Day 10 Total 10 dosesTotal 10 doses

ProtocolProtocol HyperCVAD ( Burkitt lymphoma )HyperCVAD ( Burkitt lymphoma ) q3wkq3wk MTX 12mg Day2 + Ara-C 100mg Day7MTX 12mg Day2 + Ara-C 100mg Day7 Total 16 dosesTotal 16 doses

ProtocolProtocol

Acute Acute LeukaemiaLeukaemia

ProtocolProtocol Leptomeningeal diseaseLeptomeningeal disease MTX 12mg + Ara-C 100mg MTX 12mg + Ara-C 100mg 2 times per wk till CSF negative then weekly2 times per wk till CSF negative then weekly

VincristineVincristine

Fatal if given intrathecallyFatal if given intrathecally

Pre-printed MAR-ITCPre-printed MAR-ITC MAR-IT-MTXMAR-IT-MTX

MAR-IT-ARACMAR-IT-ARAC

MAR-IT-LMMAR-IT-LM

PrescriptionPrescription

One of the medical staff involved One of the medical staff involved ( prescription / verification ) must be ( prescription / verification ) must be specialistspecialist

Label with patient particular

5/11 6/11

6/11

S1

S2

Dispensing , Preparation, Dispensing , Preparation, Packaging and Delivery of DrugPackaging and Delivery of Drug

All intrathecal chemotherapy must All intrathecal chemotherapy must be prepared by Aseptic Dispensing be prepared by Aseptic Dispensing Unit QEHUnit QEH

MAR-ITC should be sent to ADU MAR-ITC should be sent to ADU one day before the injectionone day before the injection

QEH pharmacy policies in safe QEH pharmacy policies in safe administration of intrathecal administration of intrathecal chemotherapy for further detailschemotherapy for further details


Within normal working hour and day ( Monday to Within normal working hour and day ( Monday to Saturday 12pm )Saturday 12pm )

Should not be initiated at the same time with other Should not be initiated at the same time with other intravenous drugintravenous drug

Trained staff or trainee under direct supervision of Trained staff or trainee under direct supervision of trained stafftrained staff

Staff & patient should not be distracted during the Staff & patient should not be distracted during the procedureprocedure

In protected area with “sign of intrathecal In protected area with “sign of intrathecal chemotherapy in progress” hanged on after checkchemotherapy in progress” hanged on after check

Check patient record & chemotherapy protocolCheck patient record & chemotherapy protocol

Follow the step on MAR-ITCFollow the step on MAR-ITC


Last check should be the most Last check should be the most important checkimportant check

DocumentationDocumentation

Last check should be the most Last check should be the most important checkimportant check

6/11

6/11

6/11

S3

S4

S5

DocumentationDocumentation

Label with patient particular

5/11 6/11

6/11

S1

S2

S4

Call for helpCall for help

Lumbar punctureLumbar puncture Access to intrathecal portAccess to intrathecal port

Must follow the checking step Must follow the checking step before injecting drugbefore injecting drug

CautionCaution

Injecting substance without Injecting substance without labelinglabeling

Additional measures for vinca alkaloidsAdditional measures for vinca alkaloids

All intravenous doses of vinca alkaloids must be dAll intravenous doses of vinca alkaloids must be diluted in at least 50ml infusion minibags for adults iluted in at least 50ml infusion minibags for adults and 10-20ml syringe for paediatrics to distinguish and 10-20ml syringe for paediatrics to distinguish them from intrathecal drugs.them from intrathecal drugs.

All dispensed vinca alkaloids must be clearly labelAll dispensed vinca alkaloids must be clearly labelled on the bag and on the outer container with a wled on the bag and on the outer container with a warning “For Intravenous Use only. Fatal if given by arning “For Intravenous Use only. Fatal if given by other routes”. Negative labels, such as “Not for Inother routes”. Negative labels, such as “Not for Intrathecal Use” must not be used.trathecal Use” must not be used.

Procedures should be in place for monitoring, preProcedures should be in place for monitoring, preventing and treating extravasation of vinca alkaloiventing and treating extravasation of vinca alkaloids diluted in minibags.ds diluted in minibags.

Extravasation KitExtravasation Kit

Dimethylsulphoxide solution 99% 100ml Dimethylsulphoxide solution 99% 100ml (DMSO – US pharmaceutical grade) x 1 (DMSO – US pharmaceutical grade) x 1

Hyaluronidase (1500units injection) x 1 Hyaluronidase (1500units injection) x 1 Hydrocortisone (100mg injection) x 2 Hydrocortisone (100mg injection) x 2 Hydrocortisone 1% cream x 1 Hydrocortisone 1% cream x 1 Sodium bicarbonate 8.4% injection x 1 Sodium bicarbonate 8.4% injection x 1 Sodium thiosulphate 25% injection x 1 Sodium thiosulphate 25% injection x 1 Water for injections 20ml x 2 Water for injections 20ml x 2 Treatment protocol (basic treatment and Treatment protocol (basic treatment and

individual drug management) individual drug management) Extravasation report form x 1 Extravasation report form x 1

Documents

Delivery of Intrathecal Chemotherapy Kowloon Central Cluster 10Jan08