So thank you everyone for joining me this evening while I discuss chemotherapy safety in practise. So this evening, what I am planning to talk to you guys about is the the safety around working with all the cytotoxic medications. So, everything from storage to preparation, administration, and, disposal.
And then I'm gonna talk about some of the complications and side effects. Of chemotherapy as well. So we're gonna, discuss the, the possible routes of exposure, how we are going to store, prepare, administer, and, all the medications and how to deal with any spillages as well.
Pet handling. So once these once these guys have had the chemotherapy and they're still in your hospital, and then some of the complications, including extrovisation. Neutropenia and GI toxicity.
So we need to make sure that everyone who is involved with dealing with chemotherapy knows what the potential consequences are, for it not being handled properly and for people being exposed to it. Any pregnant women or immunocompromised people should not be involved with chemotherapy at all, not in any fashion at at all. I can't highlight that enough really.
Chemotherapy agents do pose a massive risk to patient welfare if it's not used, or administered correctly. There are a whole lot of side effects that can be, and complications if it is administered incorrectly. And we should only be using chemotherapy when it's absolutely indicated.
These, some of these drugs are absolutely, absolutely rotten, and we actually need to know that we're given the proper treatment for the for the cancer that it's indicated for. So according to the CVIN guidelines, I think this was from 2007, and I've included them in the note for you guys this evening. Any woman who is pregnant, breastfeeding, or anyone who was trying to conceive should not be involved at all with chemotherapy.
And there's been various studies to demonstrate that there's all sorts of links between exposure to drugs, and menstrual dysfunction. A lot of these studies were carried out in the 80s when PPE use was actually low, so hopefully that any any complications or problems are now absolutely minimal because we are so health and safety conscious. The highest risk is during the first trimester or during the 1st 3 months of pregnancy, as this is the time that there's most rapid cell division and differentiation of of the growing foetus.
So anyone that is involved with chemotherapy should be informed properly and then proof available that they have been informed for the methods of pre preventing any aerosol formation and the the spread of any contamination. The proper workings of a a fume cabinet, if you have a fume cabinet in practise, how to deal with the contamination or spillage. The principles of good personal protection and hygiene in practise and how to safely and correctly prepare and administer all forms of chemotherapy.
And everyone who was administering chemotherapy must, must, must be aware of the potential for extrovisation. And this is where the, the, the, chemo is administered outside of the blood vessels. So when the vein blows, what actually can happen there, and the disastrous consequences of that with some drugs.
So the roots of potential exposure for any of these drugs is inhalation, ingestion, absorption, and injection. Hopefully we can make we're minimising the injection now by using needle-free systems. So in the event, in the event of a contamination, so if anything has spilled on your gloves or, something's happened with a syringe, any contaminated clothing, the gowns, the gloves should be immediately removed and discarded.
The area, if you've managed, if you've got some on your hands or on your eyes, should be flushed with copious amounts of water or saline, and then medical advice should be sought. I should be flushed for 10 minutes, and then again, seek some medical advice. So any areas where these medications are stored or prepared or administered, or even where the patients are actually hospitalised should be identified clearly with a warning sign, on the door that leads into our chemotherapy suite.
I, we have a sign so that people know that if that sign is up, don't come in, because we're actually dealing with some chemotherapy. So please don't disturb us. And the access should be restricted.
We don't want everyone traipsing in and out as well. I And I, separate kennels, for patients that have had chemotherapy. So you can keep them separate to other patients is ideal.
And we do make sure that these are patients are identified. So we use a set coloured name tag, so these paper name colours that we use in in-house. We use all of the yellow ones.
We take, we, we hijack all of them and we use them for our patients. So anyone who notices, oh, this patient's got a yellow tag on, he must be potentially had chemotherapy. We have a different colour vet bed for our chemo patients, so everyone knows then this is a a blue vet bed as opposed to a white vet bed.
This bed needs washing twice. Any excreta, so any, urine or vomit or faeces are all potentially hazardous after this patient has had some chemotherapy, so they should be handled and disposed of accordingly. And during the during the period of risk, if this patient is staying hospitalised for a couple of days, we put the sign on the kennel anyway, but we will also highlight how long we need to wear the PPE for, and we'll leave that all available for, our inpatient care team.
So the PPE that we use for chemotherapy, we use make sure we use gloves, and we, we use a nitrile glove as this offers a better level of protection compared to latex. Ideally these should be a chemotherapy specific glove. The ones we use have also got quite a long cuff, so that when you've got your gown on, they actually come up a decent way up your arm so you're not, there's no gap then between your glove and the gown.
And they must provide barrier protection against chemotherapy drugs. The gowns Specific, and they will usually be they, they will be fluid and permeable on the front and arms, so should anything happen, you should be protected. Material and surgical gowns are not suitable as they will just absorb everything straight into the material, they won't protect you at all.
And for face and eye protection, we'll either use goggles and or a full face mask like a visor, plus a face mask as well. And we use a an FFP2 face mask over our nose and mouth, just, just for any, any inhalation potential. For cleaning, any materials that come into contact with these animals while they're in the hospital should be considered as potentially contaminated.
So the kennels, the litter tray, food bowls, everything, we should wash everything first with a detergent, and we just use a wash, just a washing up liquid. So everything should be washed first with the detergent, and then disinfected afterwards. The detergent cleans away any potential contamination, and then we disinfect after.
All bedding is labelled as potentially cytotoxic and it is double washed. And the fume cabinet, or if you have just a a set surface that you guys use to actually prepare the medication, we would then use, we have these HD cleaning wipes. It's a two-step process that removes any hazardous drug, surface contamination.
Or you can use a detergent and then disinfect afterwards, but these HD wipes are actually, they're pretty cool. Cat litter trays, I, I can either we can either use some cardboard disposable ones. And you can get some of them that they've got like a plastic lining in them, so they shouldn't actually leak or they shouldn't absorb anything.
But you need to make sure that they're definitely not going to leak and they're not going to start, falling apart if the kitty starts to take it, take any frustrations out on them. Or you can use the litter tray liners in a normal litter tray as well. A spill kit should be available and ready to go as well, just in case anything does happen.
We have full PPE in our kit, a gown with some gloves and a face mask, and we use this FFP3 mask, and this just offers a better level of protection, while you are dealing with a spill. We'll use some cotton wool or a puppy pad or something to soak up any liquids if they're on the floor or anywhere. And then use a brush or a pair of dressing forceps to pick up any broken glass should there be a vial or a needle or anything on the floor that you need to pick up.
And we need to put a sign up to keep people to keep people out of that room while that spill is dealt with, the last thing you want is people walking in and out. And make sure you record any spills as well. There should, any, any spills or any, any potential, incidents should all be clearly recorded.
So we're very, very lucky at North West actually have this beautiful fume cabinet. I'm dealing with chemotherapy agents, their raw drug every single day, and we're administering it multiple times a day. So we need a, a, a high level of protection.
They're completely, they're not essential if you're doing the occasional one in practise, as long as you are, super careful when you're actually drawing up, and preparing your medications. But if you do have one of these, you need to make sure that it is properly serviced and checked regularly. Ours has a yearly service.
And make sure that you know how to set it up and use it properly. There's no point in kind of just half using it and not actually knowing how to turn the philtres and the airflow on. And make sure you have set cleaning protocols.
So we clean ours down using them HD wipes, at the end of every day. And if we've had, if we've had quite a high turnover, we'll do that a couple of times through the day as well. As I said, these are not essential.
Lots of practises will do this in, in-house, or if you've got like just a quiet little corner that you can set out as your area to draw up chemotherapy. Or chemo pet is actually a fantastic, fantastic service who, if you, you can order the medications directly from them and they will then supply it to you in a lovely, in a little pre pre-drawn up syringe with everything already. .
And then they will supply you with your PPN as well. So if some, if you're not wanting to store or draw the medications yourself, this is an, an absolutely excellent option. And we, we, use these guys for, some of our medications as well.
So at the moment now, so now, there should be no, no needles used in the administrative chemotherapy, especially, definitely for intravenous. There may be a few where we have to use it if it's going to cut or if it's going into a, a cavity or into a mass. But they, this, the gold standard now is a closed or semi-closed system, and this is to prevent the, aerosol formation and to reduce any potential, complications from using needles.
So the, the, the needle-free system that we use is called a chemo clave, and we need to use a lure lock syringe with them, so we can actually attach them to the next part of the kit. I'm gonna show you. It can't be the lure slit ones.
It must be the lurelock for it to be safe. And when you've got your syringe, remember that you don't overfill the syringe. How many of you have pulled the end of a syringe while you've tried to, when you've been drawing up something and having a syringe full of chemotherapy leak out everywhere is the last thing that you need.
So, maximum 3/4 full. And even if that means you need to use a couple of syringes, well, that's absolutely fine. We need to, we have given sets and te connectors.
So whichever, however, whichever method that we're going to use. They've all got a port on the side, so we can attach the lu lock of the spinning of the, of the syringe or the spinnerspiro from the, from the chemo lave kit to it, so it locks on properly, so there's no, there's no hazards for the need for the syringe to potentially pop off as well. We don't tend to use fluid pumps for most of the chemo treatments.
We like to be in complete control about what's actually going on and what rate they're actually going in. But there's a few treatments that they'll be used for, either cytarabine CRI because we use this for neurology, or for some cancers as well. And that might go in over the course of about 8 hours at the carbazo, which is about 6 hours, and the tannovia is about 30 minute infusion, but we are actually sat.
These patients, especially for the decarbazin and the tanovvia. So back to the chemo lave. So when you've got your Lelock syringe, we have the spin and this will then attach to the spin and spiros, which is at the top of the screen.
And this will, once you attach it, it will lock on and it absolutely won't come off. Then it will just spin and spin and spin. And the idea of this spinner virus is once you've drawn your medication up, if you, even if you take the cap off, it won't inject.
You could drop it, you could squeeze it. I've put so much pressure on the ends of these syringes just to test it. And you won't get them to that, you won't get that seal to break unless you put on a heck of a lot of force, which I hope you wouldn't be doing routinely anyway with a, a chemo syringe.
They will only work when you then attach it to a vile adapter, when it actually screws on and locks on to a vile adapter or to a T connector or port on a given set. And then they have different vile adapters for different size vials. They have small and large, depending on which size, vial you're actually using.
The second system is called the seal. I, I, we, I've, I've never actually used this system, but it is another needle-free system, and they come with their own kit. So they have the vile adapters at the top, and then a syringe safety device, which then locks.
Into the vile adapter, and it also then locks into the, IV bag line and to actually administer the chemotherapy as well. So this was just a little trial that was done a little while ago, just to show, the potential contamination. So, up at the top is using the standard technique of using a needle and syringe, straight into the bag of fluid.
And you can see the, the needle or syringe cap, and then the end of the fluid bag is actually contaminated, with this fluorosome. But Used, and there's actually no contamination either around the end of the, infusion adapter or on the end of the, the vile adapter too, so needle free is definitely better and safer. So we use a bag spike or an infusion, this, we use the the Mer version, there are plenty of other ones available.
This is just what we use. And this is a device that will then, Attach into a, into the fluid bag, and then you can add the chemotherapy into the side and still add a given set into the into the bottom. You have to be very careful if you do use a normal, bag spike because some of the connectors can actually be loose, and we just don't make to make sure that there's absolutely no spills potentially going to happen.
Lots of places will use bureaurettes, and we did use these before we found these, them previous bag spikes. And we can add the chemotherapy into the top of the bureautte alongside some saline, and I'll let that run in, just through gravity. The only trick is to make sure that that little safety valve that is floated bobbing around in the burette, that that does not hit the bottom of the burette before you've run everything through, because once they hit that bottom, It locks, and then you can end up with a whole load of chemotherapy drugs just still sitting in the giving set line and not actually be able to administer the rest of the treatment.
So, be very careful when you use these. These syringe to syringe transfer devices can be used to dilute chemotherapy, and it means you can just attach the lower lock syringes with the spiros attached to either end to either add saline or to add saline into a drug. So yeah, having to dilute medications as you can see, and this this is potentially when if you're, if you, you need to dilute chemotherapy if we're going to do it as an intracavity or an intralesional use.
We use the Corhex, alcohol wipes, before, when we've opened the vial, we've taken the little top off. We'll clean the top of the vial, the little rubber vial at the bung at the top before we attach the vile adapter, and then we'll clean the top of the vile adapter before and after every medication is drawn is withdrawn, just to hopefully reduce any contamination. Implications for chemotherapy are based on milligramme per metre squared, not milligramme per kilogramme.
And this is, that means by actually dosing to their metabolic weight rather than, their actual, their actual body weight. So, hopefully a little bit more accurate, and hopefully reducing then the, the, the risk for potential side effects as well. And we always dose to lean body weight as well, and always make a note of it.
If you've got a 45 kg Labrador that's coming in and it should be 35 dose for 35 kg, and make sure you make a note of that. We have proper little charts, so we know that even if that dog starts to lose a little bit, a bit of weight, we will still always dose for 35 kg. So there's a couple of calculations that are a rat kicking around 4 metres squared and, there's the one that's on the screen and in the notes, or you can actually use a chart.
We, I still this on the chemo pet, and this is what we've got up in our wall, on, on our wall in the oncology room. So we can use this. The results kind of vary a little bit, but either should be absolutely fine.
So as I said, by dosing on the metres squared rather than the 1 kilogramme weight, we're hopefully reducing the risk of toxicity. But this does mean that sometimes smaller dogs will actually get a larger dose compared to larger dogs in proportion to their body weight. So sometimes we, we do have to chop and change the doses a little bit and.
So example, epiruicin for large dogs, we would use 130 milligrammes per metre squared. But if it was a cat or a small dog, we would use 1 milligramme per kilogramme, and that would usually work out as a, as a little bit of a lower dose. So it kind of gets just kind of means you just need to know the drugs a little bit.
Always double check the metres square, value that you've managed to work out, and then the calculation that you've worked out for the drug volume. And it, it's just kind of with experience as well, and knowing what the drug is and what volume, you should expect for that drug and for that patient size. Like if someone came to me and said, I've just worked out 3 mg 3 mL of rising for a cat, I'd say, actually, that is very, very wrong, go and do it again.
Whereas, 0.3 mLs for a cat is much more suitable. So when these guys come on in, you've got the patient, consider that this patient is potentially gonna be coming back to you for weekly treatment, especially if it's a lymphoma patient.
Consider yourself? Are you gonna be able to deal with this patient every single week, if they're getting a little bit narky, we do, we don't want narky, scratchy, bitey cats or dogs. And consider the medication that the patient is receiving as well, some of these medications, if they are administered incorrectly and the the vein blows can cause some horrible side effects, so.
We need to be very careful. So we like to have a nice bit of a nice chilled out environment. So as you can see from the picture on the right, this little border collie comes into us.
She's not a, not a huge fan of the kennel. So sometimes she just kind of hangs out under the desk while we get all of our little bits ready for her, and then she goes straight home, just to kind of make it a little bit of a nicer, experience for her. So all necessary measures should be taken to make sure that this animal is nice and calm and cooperative.
I am not, we, we, we use a lot of food bribery, I will admit. We kind of, I like it when they kind of just sit there, they ignore me. They just focused on my, kennel assistant and eating their snacks while I'm giving their chemo, and it makes it a whole much nicer experience.
If they want to sit on someone's knee during the chemo, well that happens too, as long as everything is done safely and that they're not wriggling around, that's absolutely fine. A lot of patients we may need to sedate, especially the, the wriggly ones, or anything that's potentially bay. If they're gonna be fidgeting around, go ahead and sedate them, the risk of the said these extra extrovisations of some of these medications, it is not worth the risk.
A little bit of sedation to chill them out, even just for that half an hour is perfect. There's been a study recently over the last couple of years about the use of gabapentin in cats, and I will admit that we use this a lot in our cat cat patients and it does work very, very well. And remember the benefits of having either fellyway or pet remedy, a nice big towel for some kitty cats sometimes when you just kind of wrap them a little bit nice and gently, they kind of just go, oh, go on then, OK, carry on as you were.
And make sure you've got no disturbances either to lock the door, turn off the ring on telephones, and take the phone off the hook, you don't want the phone ringing and making that patient jump while you're partway through a chemo. Any fitters or administering any drugs as part of a CRI or just alongside, it should always be saline and not Harman's. And we shouldn't be using heparin, he flush, to flush catheters, as it's incompatible when mixed with some drugs and it can actually, form a precipitate, so saline for everything.
I don't even keep heparin or Hartman's in our oncology room just so we don't, have any accidental administration there. So preparing for when you are preparing these. PPA at all times, nitro gloves, so I always double glove when I'm drawing up the medication, the gowns, and then full facial protection as well.
So I like to have everything all laid out and labelled and everything open, unwrapped and attached before I start getting the drugs out, because once you've got two sets of thick nitrile gloves on, trying to undo some small wrappers is actually quite difficult. So I'll have everything all ready, have a puppy pad laid out as well just in case there is a spill, it can absorb all of that. And if you're adding any medication into a into a fluid bag, if you need to prime that giving set, that should be done inside the chemotherapy, .
Cabinets as well. And we have a plastic Tupperware box that will click, will lock on all four sides. But when we do move the chemotherapy round, we've just got two rooms next to each other, but we will still always use that box, just in case anything, if you trip or fall or you drop it, at least then it is completely contained.
So as I said about these medications, some of these are an irritant and must be administered by a first stick or a clean stick IV catheter. So that is a case of you, you go through the skin, you go straight into that vein, and it is, and it advances. There can't be any jabbing and stabbing and, oh, I've hit the vein there, but now it won't advance.
I'll just back out and now I'll reposition. You, it must go in clean stick. You don't want all of these little holes in the veins.
We use the Emla cream, a lot, well, for every single chemo patient. It takes about 45 minutes to work, but by the time you've got the blood test run, that them running the chemo medication all worked out and it all set up, you've normally given yourself half an half an hour anyway, so, and it works very, very well. And it also does aid, actually, that first stick, catheter placement because the patient is less likely to jump with that needle going in if you've actually numbed that area as well.
So, yeah, we clip and aseptically prepare, once the, after the, well, once the he's been on, and then make sure that we secure that in, good and proper. Double check the catheter by flushing it with some saline, and we draw back to make sure that we have a good flash of blood, and then flush again. Make sure that you can feel, the fluid going on up that vein.
We always get someone else to double check, and they will flush and draw back as well. Double check, triple check, if in doubt, get someone else to check or even don't use that vein at all. And again, make sure you don't use hep saline, because it can cause some problems.
So if you're administering the bolus of medications such as Vchristen or viblasting, again, once you've, if you've got someone else to double check that catheter, before I always give the chemo, I will always check it again because them fidgeting around a little bit and then a couple of seconds, a couple of minutes while you're getting your gloves and getting everything all ready, something can dislodge sometimes. So again, yeah, make sure you are getting a good flashback. So then I'll attach the syringe to the T connector and then administer drawback, administer drawback to make sure I'm still getting a good flashback.
And at the end, disconnect the syringe and give it a good flush with some saline, normally about 5 to 10 mLs depending on the size of the patient, and then remove that catheter straight away. If we're administering a short infusion, so over say 15 to 30 minutes. Again, we, I'll double check before I attach the saline and the given set.
And then at the side, alongside that given set, there'll be a port where I can attach the chemo syringe, and I will still draw back along there, just to make sure I'm getting a good flashback. And do monitor for signs of that vein blowing. And so, I, I do draw back every, and I administer a bit and draw back, and just make sure that it is, it is flowing nicely.
And once the chemotherapy's finished, allow the saline to run for the chemo has been administered. So there's only, I think there's only one chemotherapy, well, there's two treatments that we would administer subcut, and I would actually use needles, but we've kind of moved away from, doing the cytarabine as a subcut injection. We give it as an IV infusion now.
The Llopirogenase is not chemotherapy, but it is very, very, very expensive, so we still need extreme care to be, when we're actually administering this medication. So for these, we would always make sure we've got PPE on and have an assistant to restrain the patient as well. The drug should be transported to the patient using that plastic box.
Needle cap should be removed and then the drug should be administered. The needle should not be at all be recapped due to the risk of accidental injury. How many times have you been stabbed when you've put the needle, the cap back on and it's come through the side.
It's happened to me a few times, not with chemotherapy. So we don't recap at all. And then the needle and syringe should go straight into the heart, into a hard-sided plastic cytotoxic waste bin.
And these are usually the yellow ones with the purple lid. Some chemo can go intralesional, and this means we're actually going to administer the chemotherapy directly into a mass. And hopefully, we can treat it that way.
And these are kind of an option, maybe sometimes for older patients that are not, poor GA candidates or not wanting to go ahead with massive surgery. It's not something we've done very commonly. I don't think in the 3 years I've actually, I've actually seen this done.
There's a massive risk of the chemotherapy actually then leaking back out of the, injection site. So that needs to be dealt with and cleaned up. So, yeah, we need to keep an eye on that.
And we need to consider pain in any possible tissue reaction from the chemotherapy going into that, mass. It's just I'll still do that a little paper that I saw just to show that it actually work the intralesional medication will actually work really well for this patient. So we can also administer this medication, into, into a cavity, so into a peritoneal or into a thoracic.
You might use a thoracic tube or just basically an hour needle and an extension set carefully, to administer that into the thoracic cavity. It could be administered into the spinal canal so that it reaches the CSF. And it can be in administered intraluminal as well.
And most of these medications need to be diluted before we actually put them into a cavity. So that's when them little syringe to syringe adapters will come in useful. Tablets most When you're administering them, sometimes you might need to adjust the dosing to make sure that, medica or I even have medication reformulated and there's a, a couple of reformulating labs and chemoet are very good, they have a good old selection of different sizes.
We make sure that we're wearing nitrile gloves and that I want double glove for medications. And then some face protection as well so we don't want any the patient to potentially cough and then cough a whole load of chemotherapy just all over you. We'll administer it on in food sometimes, we'll always give the patient a little bit of a test dose of some food and see how well they will eat, or we'll have to hand tablet them as well.
And these little gelatin capsules are actually really good because I found that some of the chemotherapy capsules, once they've been reformulated, they're actually quite soft and it doesn't take much for them to actually then fall apart. So we will send sometimes put the medication in one of these gelatin capsules as well. And then make sure you wash your hands in soap and water, after they've had you've administered the chemotherapy.
All waste should go straight into a chemotherapy waste box, . I've heard some people ask, are you ordering these, these small plastic tubs and not putting the lid on, and then you can actually put all of the kit that you've used in there, and the gowns and the gloves, and then you can put the lid back on right at the very end and seal it, which is a really good idea. Everything should go in these, so the syringes, the needles, vials, gloves, everything that is considered cytotoxic should go into one of these, or I'd definitely be labelled.
And make sure that you you strict hand hygiene as well, make sure that you do wash your hands once you've taken your gloves and gown and stuff off as well. We do have this fancy looking bin, and it's called a pactoa, and it can be used for either chemotherapy or like the infection like in, in an isolation ward. And these actually have like a plastic bag that goes all the way down, down, and you can make these and it heat seals, so you can put a gown in or something.
Press a pedal and it makes a little pocket and heat seals it. And we put our all some of our hard waste in there, so like vials, syringes, give this apart from needles goes in these, and these are actually these are actually really, really good. So as long as, well, the PPE should be worn when handling this patient, and making sure that there's a sign on the kennel to make sure so people know if you're not gonna be there overnight or for the next couple of days, making sure that people know that this patient's had chemo and needs to, you need to wear PPE for so many days afterwards.
We try and keep dogs walked in a separate run just to prevent them, prevent exposing them to anything else. Any urine should be rinsed away with water, from off the run, and any faeces should be double bagged as well. If they, if anyone, if any of the patients do urinate on themselves, and they get it on their feet or any on their legs, make sure you rinse that off as well with some water.
We don't need them, having that sitting on their skin either. And we could use the cat, the little trays for the cats and all that should be discarded inside a toxic bin as well. When the patients have gone home, we should clean up the kennel with a detergent and then disinfect afterwards with with disinfectant.
Any incontinence pads or puppy pads that you use in the kennel as well, should be discarded in the cytotoxic waste. So I'm gonna move on to complications and some side effects of the chemotherapy now. So we're gonna start with extrovisation.
This is the accident. Blood vessel. And with some of these medications, it can create severe and irreversible tissue damage.
And, this is, we, we, we class this as an emergency. And it will, it'll happen at some point. It's happened to me once, and it's happened to my other, my teammates a couple of, once or twice as well.
And the main thing is not to panic. You'll kind of feel like you're internally panicking and like, OK, what, what do we do? What do we do?
But you need to kind of stay calm and actually just follow your protocol. The extraversation can be caused by if the catheter hasn't gone in, clean stick. Or there's sometimes it can actually will actually then just leak out through the insertion site as well.
This is why we always say clean stick and try to, place a catheter as low down the limb, as possible. So if you, If you can't hit the vein low down, you can still go much higher up, but you can't, if you blow the vein high up, you can't go lower down because you've put little holes in that vein already. So we have a kit already, so we've got all of the drugs and all of the creams and a protocol for the main drugs already in a box should anything ever happen, so we're not fumbling around looking for what we need to do.
So if you notice anything's happened with the, with the treatment, you've noticed the veins blowing or something's not quite right. Start the treatment immediately, disconnect all of your chemotherapy administration, kit, and with and get that to one side. And we needed to withdraw any drug, as much drug through that catheter as possible.
So when it happened to me, I had a, I had someone pretty much throw in 5 mil syringes at me so I could attach it, draw back and I was literally getting a drop of . Medication back, put that in your tub to go into chemo waste, and then attach in another one, and I think I went through maybe about 8, 10 syringes just getting little drops back, but was trying to get as much as I could back. We don't try and dilute the drug, so we don't inject saline down the catheter or anything because then we're potentially going to spread that on out.
Once you've drawn back as much as you can, you then remove that catheter straight away. And then it depends on the what drug has actually been extravisized as to actually how you then manage that. So for doxorubicin or epiruicin, we would apply a cold pack.
We use dextrozone injection, and then we use topical DMSO solution on top of that as well. And, for epiruicin doxo, it is a, it's a progressive, problem. So these wounds will get, get worse, as I will show you in a couple of slides, and we need to consider how quickly we actually potentially go into some surgical debridement to see if we can actually get ahead of this.
Vin christen and then blasting, we need to apply a warm compress instead of a cold compress. Infiltrate with an info at the area where you've actually seen the it below. We infiltrate with maybe 3 to 5 mLs of normal saline.
And then we use hyaluronidase injected into that area as well. And every time you do inject, with the, the hyaluronidase, we would use a different need needle. So you would inject maybe over about 5 different areas around that, site.
And we'd use a different needle, every time. So this is an extraversation of rising or in blasting. So there's, it's kind of turns into a bit of a nasty ulcer, and this can show, that's maybe about 1 to 7 days, and it could be full thickness.
And some of these wounds will, they will potentially be there for months and months and months, and they will take a, they'll take quite a long time to heal, but they should hopefully heal eventually. Doxorubicin, on the other hand, is horrendous, and this these signs will actually start to show at 7 to 10 days and so that it is progressive. So you need to, if, if you notice something's happened, if you're concerned, you do something about that straight away.
And I said, surgical intervention is, is probably going to, it's gonna lead to surgical intervention, potentially even amputation. So the next slides I've got came from a vet vet tech on a on an oncology Facebook page and this this this patient had been treated with doxorubicin, . And hadn't had, I'm not actual reason why the, why the patient didn't have the treatment, straight away, or I'm not sure it's unclear from the, from the lady whether or not it, the vet didn't realise what had happened or just didn't realise what he should do.
So this dog was then referred to this ladies' clinic 5 weeks after the extrovisation, and there was no treatment administered besides this, wound management. And he, this dog had been presented back to the original that 2 days after treatment. And then it had progressed to this, horrible, horrible wound, over 5 weeks before he was then referred.
And he would, this, this leg actually was amputated, because this, this wound wasn't going to get any better anytime soon. So this is the importance of noting that if any, if you're concerned or you're worried or you think something's happened, that you do jump on it straight away, as to how much of a difference that this would have made had the treatment being administered, I, I absolutely do not know. But yeah, we should, we should always still jump on it and actually get some treatment done.
So there's lots and lots of side effects that can come from administering chemotherapy and the veterinary cooperative Oncology group came up with some toxicity guidelines and again I've included these with alongside the notes as well. So they graded them 1 to 5, and they went through pretty much every single . Complication that they could potentially have like GI toxicity, bone marrow toxicity, everything, so everything is all listed on there.
It's quite, it's a very extensive document. So GI toxicity is probably the most common that we will see. So chemotherapy will attack, is, is looking to attack, all the, rapidly dividing cells.
And, GI, the, the cells of the GI tract are one of these alongside the bone marrow. So signs we will tend to see are vomiting, nausea. And diarrhoea.
So from vomiting and nausea, we will tend to pre-med all of our chemotherapy patients before we, before they have their treatment. And we'll use Serea beforehand. But if this is something that is not controlled by just the Serea, we may need to add in multiple medications to control this.
So sometimes then we will add in metoclopramide and then on Dansetron on top of that, especially if we've had to hospitalise. But usually the Serena, fingers crossed, tends to be enough. For diarrhoea, we will use metronidazole for 5 to 7 days if need if they start to have diarrhoea that's lasting over say 24 hours.
And we can use probiotics or the kalin, so it's like the the pro the protein procolo tends to be a favourite. If the diarrhoea is hemorrhagic, we might need to add a broad spectrum antibiotic in as well, just because there is a risk of bacterial translocation, especially in these immune potentially immune compromised patients. Is a medication that could lead to sterile hemorrhagic cystitis.
So cyclophosphamide is metabolised by the liver and then excreted in the urine. The metabolite of cyclophosphamide is aquiline, and this can have an effect on the bladder mucosa causing cystitis. So it is a sterile cystitis.
There's no there's no infection or bacteria in there usually. So we'll aim usually to administer this in the morning, and we will give, give fruzamide alongside to encourage drinking and urinating. And we'll use 3 doses over a course of 24 hours.
We want to make sure these guys have got frequent opportunity to urinate, so they're actually getting rid of, the, the potential complication. We always do a urine sample prior to administering cyclophosphamide just to look for any signs of blood or any. Anyway, and then we'll we'll do a check again the following week.
Any patients that are on metronomic chemotherapy or a daily low dose of me cyclophosphamide, we'll do a urine check weekly and we'll get the owners to do that at home. If the patient does show any signs of cystitis, we need to offer supportive care, and then we have to discontinue the use of that medication and supplement something else instead. He hepatic toxicity is a a side effect potentially from Lomisttein or it's also called CTNU as this is extensively hepatically metabolised.
So chronic administration can lead to this hepatic enzyme innovations and sometimes dysfunction as well. And it, but it can actually occur after a single dose. You can see these liver enzymes jump up after one dose.
This either requires us to have a temporary or permanent discontinuation and sometimes we just need to extend the dosing intervals and just keep an eye on them as well. We always monitor the liver parameters before each dose. May just make usually the ALT and ALD alkaline phosphata.
And we'll use concurrent, denimarin alongside as well, as this can actually help protect the liver as well. Epiruicin and doxorubicin can sometimes cause cardiac toxicity. Both of them, both of them can.
So, there's a, the acute form. And this toxicity manifests as a transient or, lasts for a short time, arrhythmia. And this is usually associated with, the medication being administered too quickly, causing histamine release, and then causing these, arrhythmias.
And it's usually of clinic little clinical significance. And once everything, once you've discontinued, everything usually settles down. The main problems come from the cumulative toxicity, as this, and this can actually then lead to congestive heart failure as it starts to decrease the myocardial myocardial contractility.
The damage is irreversible and then once it actually has started, it does carry a grave prognosis. So both of these medications have a maximum lifetime dose. So when, if we've got a patient who looks like they've they've, they've gone through one cycle of lymphoma treatment and we're having to, like, maybe add something and are having to restart, we would have to make sure that we don't exceed, the 240 milligramme per metre squared over their whole lifetime.
And so, fingers crossed, we, we don't actually need to get there. We always do a pre-treatment echocardiogram just to check the systolic function of the patient's heart, and just to make sure that they're actually suitable to go ahead with treatment. For dogs that do have an impaired systolic function, or if we have actually reached the cumulative dose, there is a potential that you can use dextrozone, immediately before you give the epirus or the doxorubicin to help prevent toxicity.
But this isn't something we've done, at all, really. Toxicity is a side effect potentially from eirrusin or doxorubicin with cats. So we need to be careful if we're using it in cats that have already got an underlying renal disease.
And we always mention we have close monitoring of renal function. So, excuse me, the urine and creatinine before each treatment. And then we'll potentially maybe leave them on fluids for a couple of hours following treatment as well.
All actions and Ein and doxorubicin back again for the side effects have both got the potential to cause anaphylactic reactions if it's administered too quickly. So we should administer this over 15 to 30 minutes. Some people may say that we should treat with antih pre-treat with an antihistamine, but it's not something that we do and that you should not have complications if you are administering get between 15 and 30 minutes.
LSpirogenase, can cause some hypersensitivity reactions, even just after one dose or even just the or after repeated doses. We do pre-treat these, with antihistamines, and then potentially the dexametadone as well. We'll give these, IV or IM, just to make sure that these are on board prior to actually giving the treatment.
We hospitalise these for a couple of hours following treatment, and then advise the owners to monitor for monitor them at home as well to for any signs of reaction. This medication should always be given subcut, some cases I am, but the medication we've got now is subcut, and it should never be given IV cause that can increase the risk of reaction. Bone marrow is suppression is another side effect, as I said it, the chemo will attack these rapidly dividing cells and bone marrow is one of these, one of the areas that is commonly affected.
So it tends to be the the white blood cells, the neutrophils that are attacked are are affected first, then followed by the platelets, so we will see then thrombocytopenia and bloods as well. So the neutropenia is a, a reduced number of the neutrophils, all the the infection fighting white blood cells. And this does actually tend to be the dose limiting toxicity of many chemo agents.
If we're giving them a medication that is then sending causing the patient to be neutropenic to a level where they're potentially going to pick up infections and become unwell, this isn't, this isn't right, and this is something that we need to address by Of ending the, the follow any follow up doses. So mild neutropenia is common and it's not often a clinical problem, so some patients may just dip a little low and we'll be absolutely fine with no clinical signs. Severe neutropenia can be complicated by sepsis, and it can actually be a life threatening.
We've seen some very poorly patients after chemotherapy with this. So patients that have severe neutropenia, where will, and have, will have clinical signs, and they should be treated as an emergency. So if you know some, a patient that's had chemotherapy a few days before and they ring up with any other signs saying they're anorexia, lethargic, dehydrated, they're collapsed, they're really not themselves, they should be seen straight away.
I and then we will always do a chemotherapy or some set points following some medications. So for carboplatin, we give this every 3 weeks. So we would usually do a an Adea blood test, maybe about 7 to 10 days following the treatment.
So we can actually See what level, the white blood cell has gotten to, following that treatment. So this can help us then plan the treatment. So if we've, if, if it's just before a chemotherapy that they're scheduled and their white blood cell count is low, we will always then postpone as well.
So the level of the neutropenia then depends on what action should actually be taken. So based on our, using the app, well, our IEX Prosight machine. So if they've got a neutrophil count of above 3, they should be absolutely fine.
If they're scheduled for treatment, we can continue with the treatment as scheduled. The dose, if this is at the the time, we can keep the dose the same, or increase it even the next time. If they have a neutropenia, if they're mildly neutropenic between 2 and 3, we can double check this on a blood smear.
Sometimes though, those neutrophils just kind of like, like to hide altogether and we just want you to go and do a manual count. Most commonly, this is actually their normal when you actually do a manual smear and then we'll go ahead with the treatment. If it's low on the smear, we would delay treatment if it was scheduled and we check in a few days, usually a day or two and everything's rebounded back on up.
If this is for the Nadir, and they're absolutely fine, we would probably then need to reduce the dose for the next treatment. If they have a count between 1 and 2, and they would do treatment, we would again we delay treatment and then recheck in a few days. We potentially need to use a broad spectrum antibiotic, as the immune system's not actually able to support them anymore.
And depending on how the patient is, it depends whether or not they should be treated in the hospital or actually be sent home. If the patient is well, which is actually quite common, they will come in with this none pretty much no neutrophils, but they're actually really well. They're not pyorexic, and we will just send them home so they're not actually sitting in a hospital, and, potentially gonna pick up something in there.
If they are pyreexic or showing any clinical signs, though they should be hospitalised. And if they had a severe neutropenia of less than one, if they're not febrile, again, we've actually sent some of these guys home, with some broad spectrum antibiotics and then to be monitored at home. But if they do have a fever, they should be admit, be admitted for treatment and bury a nursed and isolated.
And they'd actually do need quite a lot of supportive care and may actually need some feeding tubes and definitely will need some fluid therapy and IV antibiotics, anti-emetics and some antipyretics as well, cos these guys are gonna feel pretty crummy. Make are aware of the potential clinical signs of neutropenia. We've had a few owners that we've, we've known that they're probably gonna dip at some point, and we've advised them, you can get if you get a thermometer, you can always just check their temperature.
But obviously, we don't want them to be checking the temperature every 5 minutes and then upsetting patients unnecessarily. And we've got a few patients that we know despite us having to, with that we've dose reduced their medication, we've we've increased the dose intervals, that they are going to become neutropenic, regardless of what we do. So we will issue some antibiotics to start at a set time post, following the chemotherapy treatment as well.
For patients that are hospitalised, that are persistently neutropenic, that, and they're just kind of not responding as quick as what they should do. There's a medication called Neupogen, and this actually stimulates, the release of the precursor cells, increases the production rate and shortens the mature maturation time. To actually get some more neutrophils back out into that circulation a lot quicker.
It is expensive, and because the chemotherapy induced neutropenia is usually have actually short duration, we should only really use that as absolutely necessary, rather than actually as a, as a routine use. This product is a human origin product, and sometimes the antibiotics, antibodies can form that might actually cause prolonged neutropenia as well. So I think I've only used this maybe once or twice, in the time.
Penia is commonly seen with some of the chemotherapies, carboplatin, cisplatin, Lomastine, and chlorambucil. It's generally safe to continue with medication as long as the platelet count doesn't go too low. And if it does start to, if it is starting to creep down, maybe we should, the medication should be.
Delayed or discontinued as well. Anaemia can sometimes can be associated with chemotherapy, but it does kind of, it rarely manifests clinically with cats and dogs, but it can still occur. And we need to consider is it a GI bleed?
Is there a concurrent disease, going on. If a patient is starting to show, anaemia, thrombocytopenia, a thrombocytopenic, and neutropenic, it could be a sign that the bone marrow has actually been infiltrated by disease. I as I said here.
So it might be, yeah, that there's, there is actually a sign of disease progression if all of the, if all of the blood cells are actually starting to become affected. Hair loss is, it's something that, that they don't tend to end up actually full, with full hair loss. There can be some, delayed growth for some of the hair, some of the coats.
A poodles seem to be the, the, the guys that seem to be most affected. We've actually had a couple of poodles who were, they had, well, definitely one. She had a beautiful, beautiful glowing white poodle coat and After her chemotherapy, it went all it became all thin and wispy, so the owners trimmed it all down.
When we discontinued her chemo, all of her coat grew back apricot, so she went from white to apricot, which was really bizarre. Some cats may lose their whiskers, and we've seen it with a couple of dogs as well, they've lost their whiskers. So it, they can, it's mainly a bit of coat changes rather than full-on, baldness.
Need to consider some of these herding breeds or collies that may be potentially affected by this MDR1 gene mutation. Some of these dogs might be a little bit more sensitive to chemotherapy agents and testing is available, and we would tend to dose reduce these guys, to make sure everything would be OK. So radiotherapy, can lead to a whole load of a couple of impairments, a whole load of complications depending on where, the radiotherapy treatment has been aimed.
So if it's post-surgery, sometimes it can affect the wound healing if it's been done too close to the surgical time. And it can damage a lot of the tissues, inadvertently if you're trying to, Aim for a mass on the, on the thorax. It can actually affect the heart and the lungs as well.
So there's lots of different things that can be affected. And this does require multiple anaesthetics within a shortened period of time. And this can be a couple of times a week, going on for a couple of weeks as well.
So it's quite an intense treatment, but usually with, hopefully with pretty much good effects. Electric chemotherapy is a relatively newish treatment that is available and it's a form of local cancer therapy that we either use bleomycin or cistatin, and this is combined with electrical pulses. That cause reversible oh gosh, permealization of the cell membrane, enabling the drugs to actually enter the cell.
So we will give the chemotherapy, wait a couple of minutes, and then use this electro chemotherapy. And hopefully then the cell cell membrane will let that chemotherapy into the mass to actually do it, do its thing. Requires a GA or sedation.
And there can be some discomfort at the site from the the active chemotherapy as well, and we may end up with some scabs starting to form and it depends on the the site. So if you, if you get an owner on the phone who says, oh, actually, my dog's had chemotherapy and they're starting to show some signs, find out as much as you can from them, the clinical signs, the duration. What have they already done?
Because it might be, if it's one of our patients, they might have already done a couple of days of Serena, a couple of days of metroactin. And if they're not actually getting any better, we need to actually do something about that. And how is the petting himself?
Find out, if you can find out what the treatment was and what day it was as well. We always send our patients home with a guideline, at for the chemotherapy handling so they know exactly what they're supposed to do and what they're not supposed to do. And any medications that we give them to take home, any tablets, we make sure that it's clearly labelled that they shouldn't be crushing or splitting the tablets or the capsules, and that they should wear gloves to administer as well.
So if you're doing any, any help or if you need any more advice than anything that I've, I've said tonight, do actually give us a shout at Northwest. We're happy to do everything for, advice calls for chemo or for a referral. And remember chemo Pett are fantastic.
They, they, they can help you with all, all like the PPE and admit, like the, the actual supply of medications, if you're not wanting to keep all of that in practise. They really do offer an amazing service. And a little bit, just to kind of say, remember, remember to look after yourself.
I like to just make sure that everyone does, does look after themselves and, takes any necessary, steps that they do need to be able to, just to take a little minute to yourself. And if you do need to, absolutely do make that, make that time for yourself. So does anyone have any questions?
Fantastic. Thank you very much for that, Caroline. .
Lots and lots and lots of information in there. There's lots where we're all at you tonight. I'm sure you could probably carried on for another hour or two as well.
Absolutely, yes. I think, well, while you're thinking of, some questions, something else I'd like to pose to you is how many of you listening tonight currently give chemotherapy in your practise? And then, those of you who don't currently do chemotherapy in your practise, how many after tonight's webinar would feel more confident in actually starting to deliver chemotherapy in practise.
So, it'd be great to hear your thoughts on those two bits as well. But obviously, any of the questions that Caroline has covered. So while you're typing them in, I know that Caroline has provided some, really detailed notes to go with tonight's webinar as well.
So they will be available alongside the recording within the next 24, 48 hours. So there's some Caroline's notes, and I think there's also some guidance, isn't there, from the European Veterinary College and bits and other pieces as well. So please do check them out.
When you go to the webinar on our website, there is a, button that says release notes. You'll have to be logged in to access them, but then they'll all be there ready for you to download in PD. Format.
So thank you very much for providing them, Caroline. No problem. If there's anything else I can provide for anyone listening or any further information, please do give me, give me a shout.
My email address is on the notes, or you can contact me directly through North West that Specialists as well. Just give me a shout. I am absolutely more than happy to, to help.
Brilliant. What was I gonna say? I was gonna say then?
Mine's gone blank, but no, it has really been good. I've got a question for you. So it's all right, it's only a it's, it's a warm up one.
Fantastic. So if they're using, chemo for the first time in practise, where can they find the correct PPE protocol to follow? So, chemo said they are brilliant.
They, if you do give them a, if you either give them a call and they can advise you or give them an email, they can advise you about what, what chemo, what PPE they would use. They can also supply it to you, so they can do the gowns and the gloves, the masks. A lot of the, So some of the actual like wholesaler companies are actually starting to do like their own chemotherapy range as well.
As long as it is that it's a specific chemotherapy, gown or glove, they should be absolutely fine. The, the. The med the, gosh, the suppliers that we use are based on what Chemo Pett recommended to us.
I figured if they're happy and they're safe by using them, then this is exactly what we're going to use. If anyone does want the, the wholesalers' names, I'm more than happy to, to supply them if anyone does want to contact, contact me or. That's Hand them on out.
That's great. Thank you very much. And so if like, if they are, if you're a practise that is looking to start in terms of delivering chemo, to the patients.
What your top three tips would you give to a practise? I, I'm, I'm guessing, obviously, you know, make touch base with chemo paths is one of them. But then, you know, what are the couple of top tips would you give to helping them, you know, set themselves up and make sure they can deliver the best service possible to their clients and patients?
I think to definitely make sure you've got your correct PPE to make sure that's an absolute must, Because if you're not administering it safely, then you're putting yourself and your, well, everyone else at risk as well. And, I, I assume at some point there's potentially people who may want to have babies, they, they need to be protected as well. So definitely the PPE.
Read up on the medications as well, and, knowing how these should be administered correctly. And making sure that your, well, IV, your IV catheter skill, is probably something that needs to be fine tuned as well. I.
I think a lot of our, the nurses who, who come through and help me find that that is probably the biggest pressure is actually making sure it's a clean stick catheter. So you should aim, even if it's not for chemotherapy as practise, to make sure that it is actually administered as a, as a clean stick catheter, as a clean stick placement, because then by the time you come to actually start doing chemotherapy, you've already got that nailed, and then the, the stress can actually be reduced then as well. And just trying to make, yeah, yeah, making sure that everything's all done nice and nice and nice and safely, but nice and calmly as well.
And I'm a complete soft touch with our patients as well. And making sure it's as fear-free and as enjoyable for the patients as possible, makes it a lot easier for you and a lot nicer for them as well. And I said, remember that these patients, some These guys are coming back weekly for months and months and months.
You want them to dance down that corridor because they're really excited to come and see you, not actually trying to pick them up in the waiting room and get them in for you. I'm sure they'll dance down the corridor to see you, Caroline. They, they know I've got a biscuit jar in our room, so a lot and some hotdogs as well.
They'll be sprinting there to catch up with you. Well I hope so. Well, it seems that everyone, to be honest, Caroline, has been very quiet on the, questions tonight.
So I always take that as a good sign that you've actually covered all the points and they're busy scribbling down notes and what they can take back into. Practise. That's how I take it.
Correct me if I'm wrong, anyone out there. But no, you know, so I think what we'll do, we'll leave it there for tonight. As Caroline's kindly said, she's happy for you to get in touch with us, if you've got any follow-up questions or if you, you know, this webinar will be available to a recording within the next 24 to 48 hours.
So once again, if there's anything you want to go back over, you can go, revisit the webinar. But then also there's all the comprehensive notes that Caroline has kindly provided as well, along with some multiple choice, along with some multiple choice questions as well that you can test your, learning on it as well. So what it leads me to do is to say thank you to JHP and Tails.com for continuing their support of the nurse programme.
Thank you to yourselves for attending. Thank you to my colleague Lisa for being on hand, and helping set Caroline up to begin with. And then, obviously, last but not least, thank you to Caroline for such a fantastic webinar.
And, no problem, and we look forward to welcoming you all on a webinar soon. So, good night and, take care. Goodbye.
Thank you. Good night.
