Body fluids and blood from patients undergoing chemotherapy treatment are said to be contaminated for up to 48 hours, starting from the time of administering the dosage. Precautionary measures as described below highlight the safety considerations that are applicable to intraoperative chemotherapy procedure. However, these guidelines should also be adhered to by all patients who may have received chemotherapy within 48 hours.
Health care providers administering chemotherapy treatment risk exposure through direct contact, ingestion, inhalation and injection. It is necessary to reduce risks associated with exposure to cytotoxic agents through the proper use of certain specialized medical supplies and equipment. Some essentials include impervious sterile gowns, unpowdered latex gloves, respirator mask (in case of a spill), a spill kit, protective eye wear, an impenetrable hazardous waste container, appropriate cytotoxic agent labels and specially marked linen bags.
The three major healthcare regulatory organizations that provide guidelines for safe handling of cytotoxic agents are the National Cancer Institute (NCI), the Joint Commission on Accreditation of Health Care Organizations (JCAHO), and the Occupational Safety and Health Administration (OSHA). Every healthcare institute or group that uses cytotoxic agents needs to develop individual operational procedures and policies. Below is a summary of safety guidelines provided by each of these regulatory organizations. However, for healthcare providers dealing with cytotoxic agents, a thorough reading of the complete references is recommended.
Following basic safety guidelines is a prerequisite for administering hyperthermic intraoperative intraperitoneal chemotherapy treatment in a safe manner. The primary requirement is to strictly follow Universal Precautions. Body fluids, blood, or tissue from patients receiving chemotherapy is potentially contaminated and should be handled in a safe manner. It is necessary that sterilized gowns, eye protection, masks, and gloves be used for preventing direct contact with contaminated objects. Items not part of the Universal Precautions include the following:
- Unpowdered latex gloves
- Smoke evacuators for removing vapors and aerosols
- Making changes in scheduled clean up of operating room
- Prescribed guidelines for cleaning up chemotherapy spills
Healthcare professionals should use unpowdered latex gloves every time they are required to deal with cytotoxic drugs. Powderless gloves are more effective than powdered gloves because they are less permeable and the latex in them acts as a better barrier in comparison to most other materials used. Safety measures such as OSHA’s recommendation to wear double gloves (unpublished data) and NCI’s guideline to change gloves every 30 minutes have been verified in laboratory studies that involved testing the permeability of gloves in relation to chemotherapy drugs. As per medical standards, it is recommended that surgeons wear a powderless latex under glove and an elbow-length over glove. To prevent the over glove from rolling down, wrapping a Coban around the cuff is also recommended.
To check for the presence of chemotherapy vapors and aerosols in the Coliseum Technique, air samples were taken during ten HIIC procedure involving mitomycin C. Hospital wall suction at -200 mm Hg was used to collect air samples at a distance of 5 cm above the plastic sheet. Sampled air was aspirated using a methanol trap during the entire HIIC procedure that lasted 90 minutes. The resulting methanol solution was then condensed and examined to check for mitomycin C traces using HPLC. Mitomycin C traces or its byproducts were detected in 6 out of the 10 experiments. The amount of mitomycin C that was detected per HIIC procedure was 0.12 - 3.0 µg. Results tested positive in cases when the smoke evacuator was not being used prior to the administration of chemotherapy in the abdominal region. Through policy changes, practitioners now ensure that the smoke evacuator is kept running at a high setting during all HIIC procedures. More tests are being carried on mitomycin vapors and the mutagenicity potential (through the Ame’s Test).
To ensure safety and effectiveness during routine cleanup of operating room, it is necessary to strictly adhere to Universal Precautions. Any material that is potentially contaminated should be segregated by staff members and kept inside appropriate receptacles, away from normal bio-medical waste and linen. Prior to disposing off the chemotherapy waste by authorized personnel at a licensed hazardous waste facility, it should be kept onsite for 48 hours to reduce contamination risks. The nursing staff should label all instrument trays with “Cytotoxic Agent” before they leave the operating room. The same labeling is required for all blood and pathology samples collected after the initiation of chemotherapy profusion. For cleaning contaminated items, bactericidal formulations should be avoided because they do not neutralize the chemotherapy and can react with the chemotherapy agent. For effective cleanup, OSHA recommends use of 70% isopropyl alcohol.
Clean up and safe disposal of chemotherapy spills should be governed by individual hospital policies and procedures, built around the safety guidelines provided by OSHA, JCAHO and NCI. It is the responsibility of the circulating nurse to contain and clean up chemotherapy spills. The exact procedure implemented will depend on the size of the spill. In case of direct contact, the personnel affected should immediately discard the contaminated clothing and dispose it off in an appropriately labeled container. Pure soap should be used for washing the affected skin and if eyes have come in direct contact, they should be treated with water or isotonic saline for around 5 minutes. The personnel then needs to report to the emergency room or to occupational health. However, if contamination is limited to the clothing, it should be discarded immediately and kept inside a cytotoxin linen bag.
As defined by OSHA, a small chemotherapy spill is one that is less than 5 grams or 5 ML of concentrated drug. When cleaning chemotherapy spills, medical staff members should always wear eye protection, impervious gowns, and double powderless surgical latex gloves. Liquid spills should be dried off using absorbent pads and solid spills should be removed using wet absorbent pads. The affected area should then be cleansed three times using pure soap or 70% isopropyl alcohol, and finally with clean water. Standard cleaning procedures can be carried out after the decontamination of the affected area.
For handling large spills, a spill kit is typically required. The same should be readily made available wherever chemotherapy is administered. Towels and absorbent pads can be used to contain large spills. Wearing a respirator mask is also necessary along with standard protective clothing. The spill area should have restricted access and safety guidelines should be properly implemented to avoid formation of vapors and aerosols.
Available commercially, spill kits should be labeled appropriately. A spill kit should ideally contain:
- Goggles
- Powderless latex surgical gloves
- A respirator mask
- Impervious shoe covers
- An impervious gown
- A minimum of two sheets of absorbent material
- Solusorb
- Cytotoxic agent labels
- 70% isopropyl alcohol and/or pure soap
- A small scoop and brush
- Large waste disposal bags and
- A “Caution” sign
Since toxicities of cumulative, low-level exposure effected during chemotherapy
sessions have not been properly defined, personnel with specific medical
conditions should avoid being in a chemotherapy environment. These conditions
include (but are not limited to) individuals planning to have a family,
pregnant or breastfeeding women, personnel diagnosed with dyscrasias or
those who are immunocompromised, and personnel who are taking hematologically
toxic medications. Keeping with the institutional policy, a periodic health
assessment has been recommended by the NCI for all personnel actively
involved with the handling of cytotoxic agents.
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