1. Working Instruction for Intrathecal Chemotherapy Carenx Wai Yee Leung APN, Department of Clinical Oncology

2. The Principle of 3 checks and 5 rights  The medication container should be checked three times during medication preparation.  1 st - checking Before taking the medication out from the container  2 nd- checking After removing the medication from the container  3 rd - checking the medication before disposal/ putting it away/ giving the unit dose to patient  5 rights – to ensure accuracy when administrating medications.  patient, drug, dose, route, time (frequency of administration)

5. Planning (1)  Patient  Ensure patient understand the procedure and valid consent is available  Items  Drug : MAR-ITC should sent to ADU one day before the IT injection  Procedure Trolley  Time  Normal working hours (Monday- Friday)  Environment  Warm, privacy  Identify the protected area and make sure the hanging sign “ Intrathecal chemotherapy in progress” is available

6. Ward Cubicle  IT chemotherapy must only be administered in an area where no other cytotoxic injections are A/V.  Questions?  If “A” bed’s patient is going to receive IT chemotherapy, no cytotoxic injections would be A/V in bed B, C, D, E,F,G, H  If “C” bed’s patient is going to receive IT chemotherapy, no cytotoxic injections would be A/V in bed B,D, F, G, H Door

8. Planning (2)  Nurses  Familiar with procedure  Trained staff (IT procedure)- required to independently verify the patient identification and drug checking procedure  Familiar with patient’s condition  Should be protected from other duty

9. Procedure trolley (1)  Dressing set + OT towels  Masks, sterile gloves, disposable gown  Waste paper bag  Skin anti-septic lotions, e.g. Povidone iodine & 70% Alcohol  Local Analgesic – Lignocaine 2%  Syringes  5ml for normal saline or CSF collection  2.5ml for local analgesic

10. Procedure trolley (2)  Needle or related device  Lumbar puncture: lumbar puncture needle, manometer  Port-A-Cath/ Ommaya Reservoir: Non-coring needle  0.2μm Filter (Perifix)  Specimen bottles- biochemistry, glucose, cell count, cytology  Normal Saline 0.9%- 100ml  Dressing Spray and pressure dressing  Intrathecal drug

12. Implementation (1)  Ensure patient understand the procedure and valid consent is available  Check the drug (+expiry hour) against MAR (1 st check) when drug is available.  Post up the warning sign “Intrathecal Chemotherapy in Progress”  Check the drug against MAR independently (2 nd check) by patient bed side.

13. Implementation (2)  Wear appropriate PPE (Gloves, mask, disposable gown)  Assist doctor to set up the trolley  skin antiseptic lotions  local analgesic  drug  Final check independently against MAR and patient (3 rd check-5 rights) before unit dose given to patient.  Assist the patient in proper positioning

14. Implementation (3)  Port-A-Cath  lying position

15. Implementation (4)  Ommaya Reservoir (Intraventricular device)  lying position

16. Implementation (5)  Lumber puncture  Left lateral near the edge of the bed with hips and knees well flexed  Sitting up leaning over bed table to flex the spine

17. Implementation (6)  Provide constant support and observation throughout the procedure  When the procedure is over, seal and apply pressure dressing to puncture site  Ensure specimen tubes are properly labeled  Arrange patient in a comfortable position after procedure  Advise patient to lie flat for at least two hour or as indicated by doctor

18. Implementation (7)  Observe complications  Headache- may relieve by lying flat or analgesic, inform doctor immediately if severe and increasing  Back pain-may relieve by lying flat or analgesic, inform doctor immediately if severe and increasing  CSF leakage-reported immediately  Fluctuation of neurological observations- inform doctor if any fluctuation in level of consciousness, pulse, RR, BP, pupil reaction  If patient is anaesthetized for the procedure:  Respiratory rate and pattern, Heart rate, Color, Airway, Conscious level

19. Implementation (9)  Record patient condition  Encourage fluid intake if no contraindication  To replace lost fluid  Ensure comfort and safety  Send Specimen for analysis if necessary  Remove the dressing within 24 hours post the procedure  To minimize risk of infection