Maj Salman

All cytotoxic drugs should be prepared in one central area, located as

near to the distribution area as possible.
If possible, an isolated hood where only chemotherapy agents are
prepared should be designated.
Warning signs designating the area as a chemotherapy agent-
preparation area, which should not be entered by unauthorized staff,
should be clearly posted.
Procedures for handling spills should also be posted.

Personnel should refrain from applying cosmetics in the work area.
Cosmetics may provide a source of prolonged exposure if contaminated.
Eating, drinking, chewing gum, smoking or storing food in areas where
cytotoxic agents are handled should be prohibited. Each of these can be a
source of ingestion if they are accidentally contaminated
Contact lenses may NOT be worn during preparation or administration of
cytotoxic drugs, even if eye protection is worn, contact lenses can absorb
aerosolized material and keep this material in constant contact with the
eye.

All mixing of cytotoxic agents should be performed by only a properly
trained health care worker, in a Class II biological safety cabinet using
appropriate aseptic technique (ie. care must be taken to not obstruct
the aspirating (vertical) airflow). The Class II biological safety cabinet
should have a panel to protect the personnel & should be located in an
area with minimal traffic and air turbulence. The biological safety
cabinet must be certified by qualified personnel semi-annually or any
time the cabinet is physically moved and should be vented outside.
Drug preparations should not be performed within the least efficient
area of the cabinet in terms of product and personnel protection,
which is within three inches of the sides near from opening.
Cabinets should be left running 24 hours per day. If shut off, the
blower should be turned on 15 minutes before beginning work in the
cabinet.
Clean surfaces of the cabinet using Wescodyne & 70% alcohol or
Zochlor and a disposable towel before and after preparation. Discard
towel into a hazardous chemical waste container.
Prepare the work surface of the biological safety cabinet by covering it
with an absorbent pad. This pad should be changed when the cabinet
is cleaned or after a spill.
All materials needed to complete the procedure (ie. drug and required
diluents, labeled syringes, primed IV bags, needles, etc.) should be
placed into the biological safety cabinet before beginning work to avoid
interruptions of cabinet airflow. Allow a two-to-three minute period
before beginning work for the unit to purge itself of airborne
contaminants. A bag should also be placed in the safety cabinet to
collect all the materials that have had drug contact, this includes empty
vials and needles that were used to compete the procedure.
Syringes and IV sets with Luer-lock fittings should be used whenever
possible to avoid spills due to disconnection. Syringes should always be
large enough so that they should never be more than three-fourths full.
Entry into and exit from the cabinet should be in a direct manner
perpendicular to the face of the cabinet. Rapid movements of the
hands in the cabinet and laterally through the protective air barrier
should be avoided.
Protective barrier garments should be worn for all procedures involving
the preparation of cytotoxic agents. These garments should be made of
lint-free, low permeability fabric with a closed front, long sleeves and
closed cuffs (either elastic or knit, with the cuffs tucked under the
gloves). Discard disposable gowns when leaving the work area or after
contamination into a receptacle appropriately marked as hazardous
chemical waste. Protective garments must not be worn outside the
work area.
Hands must be washed thoroughly before gloving and after gloves are
removed.
Disposable surgical latex gloves (without powder) that extend over the
cuffs of the gown and Chemo Plus Latex gloves are recommended for
all procedures involving cytotoxic agents. Gloves should be changed
approximately every 30 minutes when working steadily with cytotoxic
agents. Gloves should be immediately removed after contamination.
Care must be taken to avoid puncturing of gloves and possible self-
inoculation. When a wide variety in permeability in glove lots exists
double gloving is recommended.
Individuals with known or suspected latex sensitivity should use gloves
made from an alternate material such as nitrile, or they should double
glove, wearing PVC gloves under the latex gloves (the patients risk of
latex sensitivity also should be assessed).
Eye and face barriers should be worn if splashes are likely to occur or
sprays or aerosols are used. Protection (eg. face shield) should cover
the face completely. Regular eyeglasses with side shields are not
adequate.
Check drug(s) and solutions used for reconstitution to verify that
expiration dates have not been reached. Examine the vials and
ampules for cracks or particulate matter before reconstitution.
No food or drink is allowed in chemo mixing area or the medication
area. Drinks or snacks are allowed at nursing charting area. Patients
are allowed drinks or food at bedside area.
Before opening ampules, inspect the ampule prior to opening to ensure
that the tip is free of solution. The contents of an ampule should be
gently tapped down from the neck and top portion of the ampule
before it is opened. The neck of the ampule should be wiped off with
alcohol. A sterile, disposable sponge should be wrapped around the
neck of the ampule to reduce aerosolization. Ampules should be
broken in a direction away from the body.
When reconstituting powders in glass ampules or vials, the diluent
shall be added slowly down the wall of the container to thoroughly wet
the powder before to avoid splatter of drug powder. A filtered needle
should be used when withdrawing contents from the ampule to avoid
glass pieces being drawn into the syringe.

The volume of cytotoxic solution shall be adjusted while the needle is
in the vial so that no excess drug shall be drawn up. If excess drug is
drawn up, the excess liquid shall be returned to its vial whenever
possible or in the case of ampules discarded into a closed container (ie.
empty sterile vial should be available in the biological safety cabinet).
Placing excess drug in any type of open container, even while working
in the hood is INAPPROPRIATE. Discarding excess drug into the
drainage trough of the hood is also inappropriate. These practices
unnecessarily increase the risk of exposure to large amounts of
hazardous drug.
To minimize aerosolization utilize negative pressure techniques. Use
large bore needles (ie. 18 or 20 gauge) to ensure that high pressure
build up of solutions during dilution is avoided. Care should be taken
to avoid dripping solutions when large bore needles are used. In order
to minimize aerosolization and avoid needle stick injuries do not clip
or re-cap needles or break syringes.
After completing the preparation, the external surfaces of syringes and
IV bags or bottles and pumps especially the access points shall be
wiped clean of any drug contamination with an alcohol wipe.
All glass bottles should be kept in the nursing preparation/medication
room until ready to be hung and not at patient bedside to avoid
breakage.
The administration sets should be attached and primed prior to the
cytotoxic drug being added to the IV fluid. If the cytotoxic drug has
been added prior to the set being primed, then priming can be
performed by removing the distal tip or needle cover before priming
and releasing only the first drop into a sterile, alcohol dampened gauze
sponge and discarding the gauze pad as cytotoxic waste. Other
acceptable methods of priming such as closed receptacles (ie.
evacuated containers) or back-filling of IV sets may be utilized. Do not
prime sets or syringes into the sink or any open receptacle.
Place contaminated glass vials and needles in a leak-proof, puncture-
proof cytotoxic container appropriately marked as hazardous chemical
waste. All other contaminated wastes, (ie. syringes, paper toweling,
gloves, sterile pads) should be placed in red bio-hazardous garbage
bags.