Safe handling of chemotherapy drugs in veterinary practice

Evidence base and staff training

The ACVIM authors say their recommendations draw mainly on OSHA, NIOSH, and USP directives. They note that large-scale studies of long-term occupational exposure in veterinary medicine are not available [1].

The panel cites human data showing variably increased chromosomal aberrations in healthcare workers who handle these drugs. It also cites a meta-analysis linking occupational exposure to infertility and early pregnancy loss. It cautions that most of the studies in that meta-analysis came before CSTDs were in wide use [1].

According to the statement, Washington, California, and North Carolina require veterinary hospitals to follow NIOSH hazardous drug guidance [1].

The PLOS ONE review covered 61 guidelines in English or Spanish, published from September 2004 to January 2017 [2]:

• Preparation was addressed in 41 (67.2%).
• Training was addressed in 38 (62.3%).
• Administration was addressed in 37 (60.7%).
• Patient care appeared in 24 (39.3%).

Only 6 guidelines extended to sectors such as veterinary clinics [2]. The review's authors acknowledge publication bias, because most references are unindexed grey literature [2].

Training checklist, per the ACVIM panel [1]:

• Allow only trained staff to handle chemotherapy, and record training in personnel files. For owners, record it in the patient's medical record [1].
• Designate a safety officer to run training and documentation and to review the manual at least every 6 months [1].
• Keep written handling policies and Safety Data Sheets accessible, along with a binder of drug inserts [1].
• Train staff on protective equipment, CSTD use, spill kits, and in-house drug transport. Keep cleaning protocols and proper waste containers available [1].
• Staff who are pregnant, breastfeeding, or trying to conceive or father a child should not prepare or give these drugs, handle treated patients, or clean their cages. They should be offered other duties [1].

The NIOSH study shows why written policy matters. Of 13 randomly selected employees interviewed, 11 said no written PPE policies were available. Only 70% said they always double-gloved when administering chemotherapy drugs, and 60% said they always wore disposable gowns [3].

Receiving, storage, and work areas

The ACVIM panel cites studies in which surface contamination on vials arriving from the manufacturer ranged from 0% to 100%. The panel notes that the risk of exposure starts when these drugs are delivered to the facility [1].

• Wear chemotherapy-rated gloves, at a minimum, when handling incoming supplier deliveries [1].
• Label drugs as hazardous on arrival and store them in a separate, marked area. Refrigerated drugs go in a dedicated refrigerator with no food or other drugs [1].
• Prohibit eating, drinking, gum, tobacco, cosmetics, and food storage wherever these drugs are stored, prepared, or used [1].
• Use easily cleaned surfaces and avoid carpet and upholstery [1].
• Limit access to authorized trained staff. The panel prefers negative-pressure rooms and advises against positive-pressure rooms such as surgical suites [1].

Protective equipment and preparation

The panel's PPE list for preparation, administration, spills, waste, and inventory work includes:

• ASTM-rated chemotherapy double gloves
• a long-sleeved, coated, impermeable gown that closes in back
• an eye or face shield when splashing or aerosols are possible [1]

The panel describes the ideal BSC as having vertical laminar flow, a HEPA filter, full venting to the outside, and a fan that runs continuously. It notes that current recommendations also accept class II type A cabinets with 30% recirculation [1].

At the Michigan hospital, the NIOSH team found a BSC that sent all filtered exhaust back into the room. Because "a HEPA filter in a BSC does not capture and remove drug vapors," the team recommended venting to the outdoors. It also advised against preparing volatile drugs such as mustargen in a cabinet that recirculates any exhaust air [3]. The team added that a chemical fume hood is not a suitable alternative, because drug sterility may be compromised [3].

Preparation checklist, per the ACVIM panel [1]:

• Have at least two people calculate and verify each order independently [1].
• Place a plastic-backed absorbent pad under the work. Replace it at least daily and after any spill or contamination [1].
• Do critical steps at least 3 inches above the cabinet surface [1].
• Never split, crush, or open tablets or capsules [1].
• Spike fluid bags and prime tubing with a compatible fluid before adding the drug [1].
• Remove outer gloves before final steps, wipe the container with a deactivating agent, and put on fresh outer gloves before taking the product out [1].
• Label the product as cytotoxic and seal it in a clear bag. Keep transport bags out of the cabinet [1].
• Carry the dose by hand in a clear secondary container, with the carrier in chemotherapy-rated gloves at minimum [1].

The panel states that "a CSTD is not a substitute for the use of PPE or preparation in a ventilated cabinet" [1].

Administration

The consensus statement calls for a non-disrupted environment and a cooperative patient. If safe administration cannot be guaranteed, it leaves chemical restraint, or a decision not to treat, to the prescribing clinician [1].

• Inspect the dose for leaks while it is still bagged. Confirm the patient, drug, and dose [1].
• Put an absorbent pad under the administration site [1].
• Have experienced personnel place the IV catheter with a clean stick, using the smallest gauge and shortest length that will work [1].
• Do not flush lines with heparinized saline [1].
• Avoid IV pumps where practical. The panel cites extravasation and disconnection risk. It allows syringe or infusion pumps for non-hazardous drugs and for long infusions, with frequent checks [1].
• Have the restrainer watch the site for extravasation throughout [1].
• Remove the catheter with lines intact, then peel the outer glove inside-out around it [1].
• Do not wear gowns longer than 3 hours, or earlier if soiled. Discard gloves after each use [1].
• For intralesional injection, the panel recommends a full face shield. It notes that extra containment may be needed depending on the amount of leakage [1].

Treated patients, cleaning, and waste

The ACVIM panel cites dog studies in which drug was detected for these periods after a dose [1]:

Drug	Samples studied	Days detected
Carboplatin	Urine, feces, saliva, sebum, cerumen	21
Cyclophosphamide	Urine	1-4
Doxorubicin	Urine	21
Vinblastine	Urine	7
Vincristine	Urine	3

The panel notes that concentrations fall markedly within 3 days. It also says the true risk from excreta is unknown [1].

• Use dedicated, labeled cages in a low-traffic area. The label should list the drug, main excretion route, and days PPE is needed [1].
• Mark treated animals with colored disposable collars, which both the ACVIM panel and the NIOSH team recommend. NIOSH observed that treated animals moved to other hospital areas could not be identified [1][3].
• Wear safety glasses with side shields and double chemotherapy gloves for excreta and cleaning. Double-bag waste [1].
• Use a separate outdoor elimination area if possible, ideally sunny, and dilute urine with a low-flow hose. Do not use sprayers or pressure washers for initial kennel cleaning [1].
• Clean surfaces with a deactivating agent and a cleaning agent at the start of the day, before and after each task, and at shift end. Use dedicated mops and buckets [1].
• Note that alcohol does not deactivate these drugs. Spray the wipe rather than the surface [1].
• Put trace waste (under 3% of the original quantity) in chemotherapy waste containers with foot-pedal lids, and use a licensed disposal company [1].

The panel acknowledges that no universal cleaner or proven decontamination procedure exists [1]. The NIOSH team analyzed samples for only three drugs, collected over 3 days. It also could not rule out doxorubicin, because the samples were frozen and that drug degrades when frozen [3].

Spills

• Keep a spill kit wherever drugs are received, prepared, or given, and in holding areas for treated patients [1].
• According to the panel, the kit should include:
• PPE
• absorbent supplies for 1000 mL
• plastic-backed pads
• towels
• at least two pre-labeled sealable bags
• a scoop
• a puncture-resistant glass container [1]
• Clean from the less contaminated area toward the more contaminated area. Wet towels before using them on dry spills to limit dust [1].
• Document the drug, approximate volume, cause, procedures used, and everyone exposed, and file exposures in personnel records [1].

Client discharge instructions

• Provide written discharge instructions on handling the pet [1].
• Clients who are pregnant, trying to conceive, or lactating should not give the drug or clean excreta [1].
• Dispense chemotherapy-rated gloves with every take-home drug. Discourage compounded liquids, and ask clients to return empty vials and syringes [1].
• Keep pets out of shared or hard-to-clean elimination areas for at least 48 hours [1].
• For skin contact, the panel advises rinsing and washing with dishwashing detergent for at least 5 minutes [1].
• Clean litter boxes daily, double-bag the litter, and wash soft items twice, separately from other laundry [1].