Cytarabine (Cytosar) Administration SOP

Purpose/ Applicability: The purpose of this SOP is to describe the proper handling and administration of subcutaneous and intravenous cytarabine, a chemotherapy medication.

Scope:
This SOP shall be applied to all small animal patients undergoing subcutaneous or intravenous cytarabine therapy in the Veterinary Teaching Hospital.

Definition(s):

• Cytarabine/Cytosar – An antineoplastic (chemotherapy) drug that is used primarily as an immunosuppressive/antineoplastic therapy for meningoencephalitis/myelitis, and CNS lymphoma.
• Subcutaneous – Administered under the skin, but not within the muscle body.
• Intravenous – Administered in a vein
• Clean – free of organic debris and clutter, with a reasonable expectation of being free of primary infectious pathogens.
• Disinfect – Removal of viable organisms from surfaces using 70% isopropyl alcohol, 10% bleach solution or other appropriate disinfectant. 
• Neutralize – To stop something from having any effect.

Equipment:

• Nitrile or vinyl gloves approved for chemotherapy
• Eye protection
• Gown
• Biohazard bag
• Heska fluid pump if intravenous administration
• 0.9% saline flush
• 70% isopropyl alcohol or10% bleach solution

Procedure:

NOTE: Students may help hold the patient, but cytarabine must be administered by a trained veterinary technician or clinician

Subcutaneous protocol:

1. Don double chemo gloves
2. Don protective eyewear
3. Don gown
4. Confirm the correct patient and amount of cytarabine to be administered
5. Attach the needle to the syringe
6. Administer cytarabine subcutaneously
   a. Properly restrain patient
   b. “Tent” skin at the intended administration site
   c. Insert needle/syringe into the tented skin
   d. Aspirate back to confirm not in a vessel
   e. Administer cytarabine
7. Monitor for any leakage of cytarabine
8. Dispose of the needle and attached syringe in red sharps box
9. Dispose of gloves in red biohazard bag
10. Wash hands with soap and water

Intravenous protocol:

1. Don double chemo gloves
2. Don protective eyewear
3. Don gown
4. Confirm the correct patient and cytarabine to be administered
5. Confirm IV catheter is patent
6. Administration via a Heska pump:
   a. Confirm premixed bag of cytarabine is attached to an Equashield venoset (located in Medication Dispensary or can obtain from the Oncology Service)
   b. Obtain additional extension set and connect to Equashield venoset if needed (most patients will not need the additional extension set)
   c. Ensure line is primed with cytarabine infusion (the VTH dispensary will prime the line under the hood)
   d. Load cytarabine bag in Heska pump
   e. Connect the administration line to the patient’s IV catheter
   f. Input infusion settings per doctor’s directions into Heska pump
   g. Confirm that all clamps are unclamped and that the line is open
   h. Start administration
7. A person must remain in ward area at all times while administration of intravenous cytarabine therapy is in progress! 
8. Once intravenous infusion is finished, clamp off the line and T-port 
9. Disconnect line from IV catheter and flush IV catheter with 0.9% saline
10. Remove the cytarabine bag/line from Heska pump and dispose of in the red biohazard bag if empty or place back in the clear/yellow chemo transport bag and return unused cytarabine infused bag/line to the Medical Dispensary for disposal
11. Clean pumps with appropriate disinfectant and place in an appropriate storage container
12. Dispose of gloves in red biohazard bag
13. Wash hands with soap and water

Cytosar SOP on Treatment Sheets

Laminated copies of the Cytosar SOP have been provided to the Neurology service. These must be placed on the treatment sheet for any patient receiving a Cytosar CRI or, if directed, Cytosar syringes. Copies of the SOP should be returned to the Neurology service for future use.

Pickup of Cytosar

Cytosar must be picked up in the hazardous drug container for Neurology. The container should be brought back upon returning any medication or when picking up the next batch of Cytosar.

Disposal of Cytosar

Any syringes or bags still containing Cytosar should be brought back to the Medication Dispensary in the hazardous drug container for Neurology and can be placed next to the cleanroom door for disposal. If there is no drug remaining, the equipment can be disposed of in the red biohazard bags.

Cleaning: After administration or in the event of leakage/spillage

1. Don PPE (chemo approved gloves or double exam gloves, protective eyewear) prior to any of the following:

Patient

1. Absorb any liquid with absorbent paper towels & dispose of in red biohazard bag
2. Moisten clean cloth with 70% isopropyl alcohol, 10% bleach solution or other approved cleaning solution and wipe contaminated/soiled area(s) on patient thoroughly to neutralize cytarabine
   a. Wipe, do NOT spray in order to minimize aerosolization of any hazardous chemical
3. Bathe patient if needed 

Cage/Run and bedding (in advent of leakage/spillage or after treatment is complete)

1. Remove soiled bedding and place in large blue/green Cintas laundry container
   a. Place any solid material (i.e. feces, vomitus, food) in Red Biohazard bag
2. Absorb any liquids with absorbable paper towels and dispose of in red Biohazard bag
3. Wipe down surface with cloth moistened with 10% bleach solution, 70% isopropyl alcohol or other approved cleaning solution to neutralize cytarabine
4. Dispose of cleaning cloth in large blue/green Cintas laundry container

Exam Table

1. Absorb any liquids with absorbable paper towels and dispose of in red Biohazard bag in the event of any leakage or spillage
2. Wipe down surface with cloth moistened with 10% bleach solution, 70% isopropyl alcohol to neutralize cytarabine
3. Dispose of paper towels in red Biohazard bag or cleaning cloth in a large blue/green Cintas laundry container

Humans 

1. Absorb any liquid with absorbent paper towels and dispose of in red biohazard bag
2. Wipe down soiled clothing with 10% bleach solution or 70% isopropyl alcohol on moistened cloth. Avoid spraying of 10% bleach solution or 70% alcohol to minimize possible aerosolization of cytarabine
3. Remove the gown right away and dispose into red biohazard bag. If any contact made with clothing underneath, remove soiled clothing as soon as possible. This clothing can be bagged in a red biohazard bag and placed in service laundry (this will indicate chemo-exposed clothing to whomever is doing laundry)
4. Wipe down soiled skin with 70% isopropyl alcohol or 10% bleach solution to neutralize cytarabine
5. Rinse skin with water