Guidelines - Cytotoxic Drug Safety

Guidelines - Cytotoxic Drug Safety - Minimising the risk to veterinary staff and clients

Minimise exposure:

Exposure to cytotoxic chemotherapy agents and clinical waste can occur if control measures fail. Exposure can occur with direct skin contact and absorption, inhalation of aerosols, exposure to mucous membranes, accidental ingestion, or sharps injury.  It most commonly occurs with:

• preparation of drugs (including the from surfaces and equipment used)
• administration of drugs
• handling of the patient’s waste
• cleaning the patient’s environment (including cages, bedding, bowls)
• cleaning spills

Exposure to cytotoxic chemotherapy agents can lead to varying clinical outcomes ^1-7 including:

• low cell counts
• infertility, miscarriage, stillbirth, congenital malformations
• liver damage
• contact dermatitis

Risk Control:

This may be implemented by:

• having fully trained veterinary staff overseeing and implementing treatments
• careful planning and design of the designated chemotherapy administration area
• use of specialised equipment (cytotoxic agent/ biological safety cabinets, closed system transfer devices)
• wearing protective equipment
  • impermeable gown (changed every 3 hours, sooner if contaminated)
  • head covering (hairnet)
  • closed footwear and overshoes
  • protective gloves (powder free, changed after every patient)
  • protective eyewear
  • protective respiratory mask (class P2)
• providing written policies and standard operating procedures for handling cytotoxic drugs and waste
• training for all clients involved with administration, handling and cleaning
• workers who are pregnant, breastfeeding or planning pregnancy should be notified of potential health risks and given alternative duties
• use a non-touch technique, to avoid direct handling, when transferring capsules or tablets from the container into the pharmacy bottle
• wash hands after every procedure and patient
• during drug administration, do not:
  • recap needles
  • expel air or fluid from syringe
  • crush or break capsules or tablets

Waste management:

Exposure to chemotherapy cytotoxic waste can occur through:

• removing or inserting catheters (intravenous and urinary)
• handling vomitus, faeces, saliva, blood, fluid drained from body cavities
• handling bed linen, pads and cleaning cages
  • patients that have received chemotherapy drugs should be in a separate cage, away from heavy foot traffic, clearly labelled with cytotoxic signs
• cleaning drug preparation facilities
  • use a dedicated mop and bucket
  • treat all surfaces and equipment as potentially contaminated
  • first use water and then a detergent to clean all surfaces
• washing linen
  • If bedding is heavily contaminated, disposal is recommended
  • avoid direct handling
  • wash twice (first wash cold cycle, then second normal)
  • linen is no longer contaminated following second cycle and can be handled normally

Spills:

Spills of chemotherapy drugs and waste must be dealt with immediately due to a high risk of exposure to cytotoxic residue.³⁰ Spills can occur when drugs are being handled, during their administration or disposal, they also involve cytotoxic contaminated body fluids and waste. When a spill occurs, the people in the immediate vicinity need to be alerted. Procedures for handling spills should be available and part of training for any staff members involved in the handling, administration or disposal of cytotoxic chemotherapy agents in addition to any personnel cleaning a contaminated environment (bedding, cages).

A spill kit should be routinely evaluated to ensure supplies are adequate and functioning. A spill kit should include:

• instructions on use
• signs to identify and isolate the contaminated region
• personal protective equipment
  • gloves (powder free)
  • impermeable gown
  • respirator (class P2)
  • head covering
  • shoe covering
• waste bags
• absorbent pads or material (for liquid spills)
• incident report forms
• water (for dampening powder spill – place on mat not directly to powder)
• detergent to clean area
• absorbent towels (to dry affected area)

After cleaning a spill, place all contaminated material (waste, PPE) into cytotoxic bag and place in cytotoxic bin. Wash hands with soap and water.

Exposure of personnel:

If cytotoxic chemotherapy drugs come into contact with a mucosal membrane do the following:

• immediately flush the affected area with isotonic saline for at least 15 minutes
• report to supervisor or practice manager
• seek immediate medical advice
• document incident

Good practice controls – in the veterinary practice:

The following notes are recommended for best practice in the clinic:

• refer animals for cytotoxic chemotherapy administration to a veterinary centre that is equipped to provide the safest service, if possible
• review health and safety information about cytotoxic drugs if being used in your practice
• have an MSDS available for all chemotherapy agents
• purchase cytotoxic chemotherapy agents in the safest form available
• use a dedicated and isolated place for cytotoxic drug treatment
• all personnel using the cytotoxic chemotherapy agents must have appropriate training
• have appropriate warning signs on the doors of the treatment areas
• avoid hosing urine (creates aerosol)
• prevent environmental contamination (animal waste)
• care for personnel involved in cleaning
  • pregnant and breast feeding women should not be involved in cleaning

Good practice controls – in the animal’s home:

• care with owners administering cytotoxic chemotherapy agents at home
  • administration should not be carried out in the kitchen or bathroom
  • breaking or splitting capsules or tablets should not occur
  • latex gloves should always be worn
• care when handling excreta at home and during walks
• careful explanation and written notes provided on safe practice
  • pregnant and breast feeding women should be warned of risks of administering chemotherapy drugs as well as cleaning and managing waste
  • parents of young children need to be warned of the risk of exposure to chemotherapy drugs and waste
  • emergency procedures for accidental exposure or accidental ingestion of cytotoxic drugs by children (e.g. telephone state/territory poisons information centre immediately – include the telephone number)
  • care is required when laundering linen
  • how to store the cytotoxic chemotherapy agents
  • the duration (if known) that cytotoxic residues may be extracted after administration
  • how to clean up if a spill were to occur
  • how to dispose of cytotoxic medication that is no longer required