known to cause myelosuppression [ 8 ] so the neutrophil count before administration can indicate whether the patient is a candidate for chemotherapy [ 9 ]. Multiple cytarabine administrations may be included in the treatment plan for MUO, and haematology will be required before each dose is given.
The patient receiving the cytarabine CRI will need an intravenous cannula( IVC) placed. As with all IVCs, this needs to be placed in an aseptic manner. The IVC must go directly into the vein and be advanced in one smooth motion. If the IVC does not advance smoothly, it should be withdrawn and placement tried again in a different vein using a new cannula. Extravasation of cytarabine can have extreme effects on the surrounding tissue, such as oedema and pain [ 1, 8 ]. Cytarabine can be given subcutaneously and is not known to cause such effects when administered by this route, but the author advises a‘ clean stick’ IVC placement every time chemotherapy is administered as best practice.
Ideally, a laminar flow cabinet should be used when drawing up a dose of a cytotoxic drug [ 10 ] such as cytarabine. The cabinet ' s airflow is directed into an exhaust unit, for extraction away from the user, helping to protect them from any aerosolised drug inside the cabinet. These cabinets need to be specially installed and validated, and maintained correctly.
Many practices do not have access to a laminar flow cabinet. The next best option is a CSTD( Figure 2), which will help prevent aerosol contamination and possible exposure [ 2, 10 – 12 ]. They are manufactured and marketed for veterinary use by a number of companies, including ChemoClave / Chemolock, Equashield, Onguard, PhaSeal and Spiros [ 3 ].
Once the IVC has been placed, it should be secured with tape to prevent displacement, and a CSTD connector attached. The port attached to the cytarabine should be clearly labelled. The IVC placement must be checked by drawing back on a syringe attached to the cannula to observe a flashback of blood and then flushing it with saline. Once a flashback is seen, the connector is flushed with saline only. Heparin flush should not be used as it can mix with some chemotherapeutic drugs and form a precipitate [ 3 ].
The IVC needs to be monitored and maintained throughout the patient ' s hospitalisation. This includes twice-daily checks for swelling and pain. Vet wrap of a different colour should be used to cover the IVC, to make it easy to distinguish between cytotoxic and noncytotoxic fluid administration; purple is often associated with chemotherapy, so it is a good choice if available.
Top tip
Colour code all chemotherapy equipment with the same colour( the author suggests purple to match the colour of the cytotoxic waste bins and bags). This way, essentials such as vet wrap, stethoscope, thermometer and gloves can all be easily recognised as being for use with the cytotoxic patient.
CRI preparation room
The room designated for chemotherapy drug preparation should be in a quiet area of the practice, with minimal traffic [ 3 ]. It is recommended that a sign be placed on the door to alert staff that it is being used to prepare a dose, and the door locked, if possible.
Figure 2. A closed system transfer device [ 11 ].
The surface on which the cytarabine is prepared should be lined with a layer of absorbent material with a waterproof backing, for example, an incontinence sheet [ 3 ]. This will absorb any spillages( see later for details of how to deal with spillages). The material should always be discarded into cytotoxic waste once the drawing up of the drug dose has been completed.
Necessary materials
Cytarabine is a light-sensitive drug [ 13 ]. When being used, it should be protected from UV light; this includes using special UV-light-protected syringe / giving set / extension lines, and using an opaque plastic bag to cover the saline bag if the cytarabine is to be administered via a saline bag.
The cytarabine CRI can be prepared in a number of ways. The author has used two different approaches, which are outlined on page 47. The prescribing VS will determine the type of administration to be used for the patient.
46 Veterinary Nursing Journal