19 November 2009

† Cytotoxic Drug Reconstitution: Exposure, Spillage †


Cytotoxic drugs are therapeutic agents that inhibit or prevent the function of cells. Such drugs are commonly used in chemotherapy to inhibit the proliferation of cancerous cells. Chemotherapy Drug Reconstitution (CDR) is one of the highly specialized pharmaceutical services performed by the pharmacists only in hospitals that have aseptic rooms, involving preparation and compounding of cytotoxic drugs.


Reasons for concern:
There has been an increase in concern over the potential of cytotoxic drugs to harm personnel who are exposed to them including workers who prepare, administer, or handle cytotoxic drugs. Due to poor selectivity between cancerous cells and normal cells, cytotoxic drugs tend to give several undesirable side effects. It is rather shocking to find out that a measurable levels of cytotoxic drugs have been detected in the hospital compound when cytotoxic drugs were compounded without proper equipments and techniques. Detectable amounts of various cytotoxic drugs in the urine of health care workers were also presented. The hazardous exposure of cytotoxic drugs may cause workers to experience acute symptoms such as mucous membrane irritation, allergic reactions, subjective symptoms including fatigue and dizziness. A long term exposure (occupational) may cause chromosomal damage, which leads to higher risk of delivering malformed babies. Therefore precaution must be followed to minimize such exposures.


Source of exposure:
Workers especially the oncology pharmacists and assistants who compound the drugs, doctors and nurses who administer cytotoxic drugs are most likely to get themselves being exposed via inhalation of drug aerosol, absorption through the skin and very low possibility but undeniably ingestion through contaminated sources. Incidences of needle prick injury may occur if the personnel is not properly trained.


Drug Preparation:
Exposure of cytotoxic drug to the personnel can be minimized during the process of drug preparation through a proper education and training in syringing techniques, as well as the use of appropriate protective equipment and apparatus. It is essential to ensure safe work practices are fully understood and practiced in the premises. Personnel also need to understand the function of each of the equipment (safety cabinet, syringes, gowns, goggles, mask...) and apparatus (syringes, needles, filters, butterfly clip...) used. Practical technique is important in this field as it determines how well a personnel is able to provide a spillage-free drug transferal and delivery while performing closed-system drug syringing.


Drug Administration:
Nurses and medical officers may be involved in administering cytotoxic drug to the patients. Special precautions should be taken while performing cytotoxic drug administration because poor delivery technique may cause leakage or spillage. Therefore it is important to make sure that personnel who perform drug administration are well trained. Uncooperative patients can be a problem during administration, for example, an agitated or mentally unprepared patient who refused to undergo cytotoxic drug treatment and this increases like-hood of spillage. Thus it is very important for the pharmacists to ensure each of the patients are ready for treatment.


Spill Management:
Spillage of cytotoxic drugs should be handled with utmost care. It is important to have a proper procedure getting ready all time and whenever spillage occurs, the cleaning process can be taken place within shortest period of time. Every oncology ward should have at least a box of chemo spill kit standby for use. Whenever spillage occurs, all patients and medical workers should be evacuated from the area and warning sign boards should be placed at all entrance. The medical personnel should immediately put on the chemo protective gowns and equipments provided prior to cleaning of the spillage area.


Disposal of Wastes:
Residuals, syringes, vials, swab, gloves or IV drip bottles that have contacted with cytotoxic drug should be disposed and properly identified. Bags and containers, or even sharp wastes that are used to transport cytotoxic drugs should be designed purple in color. Before discarding the wastes, it is also important to mark the container with a "CYTOTOXIC WASTE" label.


Many reports have shown the relationship between cytotoxic exposure and risk to the personnel's health. Therefore a country's Ministry of Health should always think about health professions who work or having themselves exposed in this field.

My point of view:
A recent debate about cutting the health profession's allowance in Malaysia is rather disappointing. From my point of view as a health professional working in the government sector, I hope that the ministry would seriously think twice before making their decision.

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