Chemotherapy Administration: Mitomycin use in the ASC

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Chemotherapy Administration Mitomycin use in the
ASC

• KPOH Nursing Competency

Nsg.admin., 2013
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Learning Objectives

• After completing this competency presentation,
  the nurse should be able to
• Understand precautions with chemotherapy
  administration
• Discuss the safe handling of chemotherapy agents

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Definitions of Common Oncology Terms

• Cytotoxic A substance with the ability to kill
  cells.
• Mutagenic A substance with the potential to
  change DNA and the potential to cause cancer.
• Carcinogenic A substance or physical agent with
  the potential to cause cancer in certain
  circumstances or to make cancer more likely to
  occur.
• Teratogenic A substance capable of causing harm
  to an embryo or fetus to produce birth defects.

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Definitions of Common Oncology Terms

• Biologic/Targeted Agents Drugs used
  systemically to target a single receptor, which
  may modify the immune system.
• Adjuvant Therapy that follows the primary
  therapy.
• Personal protective equipment (PPE) Items worn
  by persons that provide a barrier between the
  person and the hazard (Follow EHS regulations
  with PPE and waste disposal of chemotherapy).

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Hazardous Drugs

• Chemotherapy is a hazardous drug because it is
  designed to affect cell division or growth and
  exposure can cause adverse health effects. Drugs
  are considered hazardous if they have one or more
  of the following characteristics
• Carcinogenicity
• Developmental toxicity
• Organ toxicity
• Genotoxicity

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Health Risks to Nurses if Hazardous Drugs are not
Handled Properly

• Increased risk of cancer
• Structural defect in a fetus
• Adverse reproductive outcomes
• Chromosomal damage
• Acute symptoms of exposure such as nausea, hair
  loss, bleeding and sores.

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Protection Against Hazardous Drugs

• Nurses must protect themselves, their coworkers,
  and patients when hazardous drugs are being
  administered. A recent study indicated that 17
  of nurses in multiple outpatient settings
  reported skin or ocular exposure to chemotherapy
  agents (Friese, et al., 2011).

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Protection Against Hazardous Drugs

• ONS Recommendations Double chemotherapy-tested
  gloves, protective gowns and protective eyewear
  (if there is potential for splashing) should be
  worn whenever handling hazardous drugs or
  contaminated items (e.g., administration
  materials, body fluids).

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Protection Against Hazardous Drugs

• These recommendations are based on increasingly
  strong research that indicates that surface and
  air contamination occur throughout chemotherapy
  preparation, administration, and disposal areas
  and that those who work in those areas can be
  exposed repeatedly to these agents at low,
  chronic levels.

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Oral Chemotherapy Exposure Precautions

• Exposure can occur through contact with
  contaminated body fluids, and the role of PPE and
  spill kits in preventing exposure is clear. Spill
  kits and spill management procedures need to be
  used to clean up large spills wherever patients
  reside and for the entire time patients
  potentially are excreting the chemotherapy drugs.

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What is a Vesicant?
A vesicant is a chemical, that if it escapes from
the vein will cause extensive tissue damage and a
blister or vesicle to form. Mitomycin is a
vesicant. See KPOH Policy Extravasation of a
Chemotherapy Agent HP.NUR.AIC.03
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What is Extravasation?

• Infiltration of a vesicant
• An irritant is similar, but much less severe. An
  irritant causes a short lived and limited
  irritation to the vein.
• Symptoms include redness
• along the vein or at the
• infusion site. Itching may
• also be present. Blisters may
• form later, followed by
• major tissue damage, such
• as seen in the picture.

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Symptoms of Extravasation

• Swelling (most common)
• Stinging, burning, or pain at the injection site
  (not always present).
• Redness (not often seen initially)
• Lack of blood return (if this is the only
  symptom, the IV should be reevaluated. If still
  not blood return, consider other options). Lack
  of blood return alone is not always indicative of
  an extravasation extravasation can occur even if
  a blood return is present.
• It is also important to note that an
  extravasation can occur without any symptoms.

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Vesicant Extravasation Issues

• Several of the most commonly administered
  chemotherapy drugs are vesicants, meaning that
  they cause tissue necrosis if they infiltrate or
  extravasate out of the blood vessel and into the
  soft tissue.
• When infiltration of a vesicant occurs,
  underlying tissue is damaged. The damage can be
  severe enough to result in physical deformity or
  a functional deficit, such as loss of joint
  mobility, loss of vascularity, or loss of tendon
  function.
• If a sufficient amount of an irritant
  infiltrates, it too can cause significant damage
  beyond discoloration and pain.

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What do I do if I suspect extravasation?

• See Extravasation of a Chemotherapy Agent Policy
• Stop the IV flow, aspirate the remaining drug in
  the catheter, and remove the IV line, unless you
  need the needle to infiltrate an antidote.
• Instill appropriate antidote according to policy.
• Record the extravasation site, patients
  symptoms, estimate the amount of infiltrated
  solutions and treatment. Include documentation of
  the time you notified the physician and the
  physicians name. Continue to document the
  appearance of the site and associated symptoms.

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Chemotherapy

• Chemotherapy is treating cancer with drugs that
  kill cancer cells with the use of cytotoxic
  drugs. These drugs interfere with the steps of
  the cell cycle.
• Chemotherapy began in the mid 1940s
• Chemotherapy can be curative
• Chemotherapy often is part of a combined modality
  therapy.

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Chemotherapy

• Mytomycin is classified as an antitumor
  antibiotic.
• Antitumor antibiotics are made from natural
  products by a species of soil fungus called
  Streptomyces.
• The drugs act during different phases of the cell
  cycle and are cell-cycle specific.
• Mitomycin is considered a miscellaneous antitumor
  antibiotic.

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Mytomycin

• Metabolized primarily hepatic and has saturable
  metabolic pathways.
• Elimination approximately 10 is excreted in the
  urine and increases with the dose.
• Drug interactions use of vinca alkaloids in
  patients who have previously or simultaneously
  received mitomycin has resulted in acute
  shortness of breath and sever bronchospasms.

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Mytomycin Adverse Reactions

• Dermatologic Alopecia desquamition pruritus
• GI Moderate to low potential for
  nausea/vomiting anorexia mucositis hepatic
  artery thrombosis (intra-arterial administration
  only).
• Genitourinary Amenorrhea
• Hematologic Bone marrow suppression
  thrombocyopenia nadir at 4 to 6 weeks leukopenia
  nadir at 6 weeks.

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Mytomycin Adverse Reactions

• Renal Increased serum creatinine and BUN
  glomerular sclerosis hemolytic uremic syndrome
  may result in irreversible renal failure.
• Respiratory Interstitial pneumonitis pulmonary
  fibrosis.
• Miscellaneous Hemolytic uremic syndrome, usually
  occurs after 6 months of therapy.

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Mytomycin Side Effects

• Side effects Important things to remember about
  the side effects of mitomycin
• Most people do not experience all of the side
  effects listed.
• Side effects are often predictable in terms of
  their onset and duration. 
• Side effects are almost always reversible and
  will go away after treatment is complete.
• There are many options to help minimize or
  prevent side effects.
• There is no relationship between the presence or
  severity of side effects and the effectiveness of
  the medication.

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Mytomycin Side Effects

• The side effects of mitomycin and their severity
  depend on how much of the drug is given, and how
  it is given. In other words, high doses may
  produce more severe side effects, or if it is
  given directly into the bladder the side effects
  will be localized to the bladder.
• The following side effects are common (occurring
  in greater than 30) for patients taking
  mitomycin
• Low blood counts.  White and red blood cells and
  platelets may temporarily decrease.  This can put
  patients at increased risk for infection, anemia
  and/or bleeding.  The nadir counts are delayed
  with this drug.
• Nadir Meaning low point, nadir is the point in
  time between chemotherapy cycles in which you
  experience low blood counts.
• Onset 3 weeksNadir 4-6 weeksRecovery 6-8
  weeks
• Mouth sores
• Poor appetite
• Fatigue

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Mitomycin Side Effects

• These side effects are less common side effects
  (occurring in about 10-29) of patients receiving
  mitomycin
• Nausea and vomiting, usually mild.
• Diarrhea
• Hair loss
• Bladder inflammation (urinary frequency, burning,
  cramping, pain) - seen with intravesical (into
  the bladder) therapy.

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Mytomycin Side Effects

• These are rare but serious complications of
  mitomycin therapy
• Lung problems pneumonitis, rarely pulmonary
  fibrosis.  The incidence of lung problems
  increases with age and pre-existing lung
  conditions.  There is a maximum lifetime dose of
  mitomycin.  The physician will monitor the amount
  of mitomycin the patient receives as well as lung
  function during treatment.
• Hemolytic-uremic syndrome. This syndrome is
  characterized by destruction of red blood cells,
  damage to the lining of blood vessel walls, and,
  in severe cases, kidney failure.  This is a rare
  event seen in less than 2 of patients treated
  with mitomycin, it can occur at any time but
  usually seen after several cycles of therapy. 
  The health care provider will monitor blood tests
  for early signs of this condition.

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Nursing Responsibility with Chemotherapy
Administration

• Nurses have the responsibility and accountability
  for the drugs and care of the patient receiving
  them. Serious problems can result if the nurse
  does not have sufficient knowledge of the
  medication, adverse effects or nursing
  interventions required for chemotherapeutic or
  biological agents.
• Side effects can and do occur with chemotherapy
  administration. Nursing interventions need to be
  evidence-based and implemented when caring for
  the individual needs of patients.

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Aims with Chemotherapy Administration

• The intended patient receives the correct
  medication, at the correct dose, via the correct
  route, at the correct time, for the correct
  period.
• Safety for the nurse, the other healthcare team
  members, the patient, the patients family or
  significant others is ensured.

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Medication Safety

• All employees should read and understand the
  policies of KPOH related to their individual
  practices, organizational practices, and scope of
  practice.
• High Alert Medication Program (HAMP)
• Administration of Chemotherapy
• Verbal Orders
• Chemotherapy Clean up/exposure

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Medication Errors

• Research on chemotherapy related medication
  errors has shown that over and under dosing of
  chemotherapy comprise a significant portion of
  chemotherapy errors.
• Factors found to contribute to chemo medication
  errors include
• Fatigue
• Understaffing
• Lack of experience with medications being
  administered.
• Unclear chemotherapy orders
• Complicated medication regimes

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Medication Errors

• Awareness of these factors in yourself and others
  will help promote a safer environment for
  chemotherapy administration.
• You should communicate safety
• issues or concerns to your
• Lead and Regional
• Safety Officer.

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Nursing Assessment Prior to Administering
Chemotherapy

• Physicians documented plan
• Physicians order sets
• Drug properties (irritant or vesicant)
• Patients response to past chemotherapy
  administration.

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Nursing Questions to Ask Before Administering
Chemotherapy

• Is the patients height and weight documented?
• Is the protocol documented?
• Do the orders correspond with the protocol?
• Is the dosage ordered within the safe therapeutic
  range?
• Is the time schedule to be followed for drug
  administration clear?
• Is the patient free of drug allergies to the
  medication being ordered?
• Has the consent been signed?

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Nursing Questions to Ask Before Administering
Chemotherapy

• If the drug ordered is known for the possibility
  of causing an allergic reaction, are
  counteracting emergency drugs available at the
  patients bedside?
• Is the patient informed that he or she is to
  receive chemotherapy?
• Has the patient been informed of possible drug
  adverse effects?
• Has the patient been instructed on what to do for
  an adverse reaction at home?

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Nursing Questions to Ask Before Administering
Chemotherapy (continued)

• Has the patient been informed of the possible
  drug adverse effects?
• Have you checked and double checked the orders
  with the protocol and another nurse following
  HAMP protocol?
• Refer to Policy JR.PC.10
• High Alert Medications

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Documentation of Chemotherapy Administration of
Mytomycin

• Drug and dosage administered.
• The specifics of the instillation of the
  chemotherapy and location.
• The amount and type of fluid used.
• The amount of fluid retained and then removed
  from the patient.

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Documentation of Chemotherapy Administration

• The condition of the site throughout treatment
• Any adverse reactions.
• The patients response to and tolerance of the
  treatment.
• Any topics discussed with the family/patient and
  their response to the discussion.
• Discharge teaching and education specific to the
  Mytomycin.

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Patient Education

• Patient education is an important part of nursing
  care. Both verbal and written instructions.
• Patient education should not only include
  education of patients, families, and caregivers,
  but should also assess the patients and family
  members abilities to apply and use what is
  taught.
• For example, to help assess family members
  understanding of neutropenia and fever
  management, you could ask, Your husband (the
  patient) has a temperature of 102 F. Tell me
  what you are going to do? Or, you could ask the
  family member to demonstrate how he/she would use
  safe handling precautions of any hazardous body
  fluids.

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KPOH Ambulatory Surgery Center Workflow
Mitomycin Utilization
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Related Policies

• Administration of Chemotherapy
• Chemotherapy Administration HP.NUR.AIC.05
• Discharge Teaching
• Discharge Teaching HP.NUR.GEN.11
• Chemotherapy Spills
• Chemotherapy Spills HP.NUR.AIC.06
• Extravasation Management
• Extravasation of a Chemotherapy Agent
  HP.NUR.AIC.03
• Order verification-Written and Verbal orders
• Managing Written Orders HP.NUR.GEN.13
• High Alert Medication Program
• High Alert Medications JR.PC.10

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Next Steps

• Upon review and completion of the learning
  module, the staff member is to print off the
  certificate of completion, sign, date, and turn
  in the original to the team Lead.

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References

• Crane, R. (2008). Cancer and chemotherapy.
  Nurse.com Retrieved on November 19, 2008 from
  www.nurse.com/ce/6075/Course
• Frieses, C., Himes-Ferris, L., Frasier, M.,
  McCullagh, M., Griggs, J. (2011). Structured
  and processes of care in ambulatory oncology
  settings and nurse-reported exposure to
  chemotherapy. British Medical Journal Quality and
  Safety. Published online August 16.
• Gates, R.A. Fink, R.M. (Eds). (2008). Oncology
  nursing secrets, 3rd Edition. St Louis Mosby
  Elsevier, Inc.

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References

• Griffin, E. (2003). Safety considerations and
  safe handling of oral chemotherapy agents.
  Journal of Oncology Nursing, 7(6), p. 25-29.
• Healty, C. (2007). Nursing care, education, and
  support for patients with neutropenia. Nursing
  Standard, 22(46), p 35-41
• Hendershot, E.M., Van-Clief, J., Honeyford, L.
  (2005). Outpatient chemotherapy administration
  decreasing wait times for patient and families.
  Pediatric Oncology Nurse, 22(1), 31-37.

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References

• Hume, R. (2007). Administration of chemotherapy.
  Hume Cancer Nurses Action Group. HRICS Clinical
  Practice Guideline.
• Polovich, M., Whitford,J., Olsen, M. (Eds).
  (2009). Chemotherapy and Biotherapy Guidelines
  and Recommendations for Practice, 3rd Edition.
  Pittsburgh Oncology Nursing Society

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Certificate of Completion

• By signing this document I attest to have read
• Chemotherapy Administration Mitomycin use in the
  ASC
• I understand the clinical practice, safety
  measures, and policies required for mitomycin use
  in the perioperative area.
• __________________________________________________
  ______
• Printed Name Date
• __________________________________________________
  ______
• Signature