•Changed position of PAC

•Discontinuation of tube system (detect leakage with contrast agent)

19.3.1.2Considerations for Domestic PAC Management

•Apply anesthetic agent over skin covering PAC approx. 1 h before puncture

•In case of redness, swelling, or blue marks appearing at puncture site, consult the physician

•When PAC is accessed but not used (with inserted needle and tube), sports activities should not be allowed

19.3.1.3Managing PAC

•Duration of needle use, frequency of change of dressing, method used to change dressing, procedure for puncture of PAC, removal of needle, treatment of PAC infection, blood sampling, and administration of drugs differ according to guidelines of local clinic

•PAC is to be used only by qualified, experienced nurses and physicians. A strictly aseptic procedure is absolutely essential. PAC must always be flushed with a heparin solution after use in order to prevent the formation of blood clots and hence an obstruction of the catheter

19.3.2Broviac and Hickman Catheters

•These catheters are usable over the course of several months and are therefore especially suitable for long-term and complex forms of treatment (e.g., stem cell transplantation)

•The catheters have a relatively large lumen. They share the advantage of making possible the numerous necessary blood samplings without having to puncture a peripheral vein

•Both catheters require regular sterile dressings at their point of entry into the skin

•Indicators for catheter infection can be: redness, swelling, pain around area of entry, and fever; positive blood cultures

•Advantages: no punctures, two or three separate lumens

•Disadvantages: infections, obstruction, thrombosis, material defects

•Management as with PAC

19.4Chemotherapy

19.4.1General

•Chemotherapeutic agents are either natural products or chemically synthesized substances that affect tumor cell growth and survival

•Chemotherapy also influences healthy cells, especially those with rapid proliferation such as:

–Cells of hair follicles (hence hair loss in chemotherapy)

–Mucous membrane cells in mouth, throat, and intestines

–Blood-producing cells of bone marrow (depletion of leukocytes, platelets, and red blood cells), which can lead to unwanted effects

•The impact is dependent on the individual drug, dosage, mode of administration, and duration of treatment

•The side effects of chemotherapy are usually reversible

19.4.2 Administration

•Chemotherapeutic agents are prepared under specific conditions of the workplace in the ward or preferably in the pharmacy

•For information on various commercial products, solutions, administration, storage and stability, side effects, information on medication, and specialized information, check reference literature

•According to the physician’s prescription of chemotherapy, the preparation is controlled by two qualified nurses concerning type of medication, accurate dilution solution, correct calculation, exact volume, identified patient, expiry date, shelf life, and calculated infusion speed

•Ahead of every injection or infusion of chemotherapeutic agent, the correct placement of the cannula must be confirmed by infusing physiological saline solution and aspiration of blood

•Injections of chemotherapy drugs are usually administered slowly. In cases of prolonged infusions (30 min to 24 h), chemotherapeutic agents are regularly monitored. Additional measures such circulation checks and urine sampling are performed according to the doctors instructions

19.4.3Protective Measures When Handling Chemotherapeutic agents

•Chemotherapeutic agents can irritate skin, eyes, mucous membranes, and other tissues

•Nursing staff handling chemotherapeutic agents must know the professional guidelines

•Numerous studies and research projects document precautionary measures for the protection of medical staff

•The aim is to reduce to a minimum absorption by way of direct skin contact and inhalation of drugs, using standardized procedures

•Each clinic has its own internal guidelines on personal protective measures in preparation and administration of chemotherapeutic agents (e.g., gloves), disposal of excretions (stools, urine, and vomit), laundry, residues of chemotherapeutic agents, and procedures in cases of contamination

•Pregnant and nursing women must reduce or avoid direct contact with chemotherapeutic agents

19.4.4 Extravasation

•The leakage of certain chemotherapeutic agents outside of the vein into surrounding tissue is serious and occurs in 0.5–6% of all patients receiving chemotherapy

•After intravenous administration of certain drugs such as vincristine and anthracyclines, various local problems may occur:

–Local hypersensitivity. Symptoms: redness, urticaria, itchiness (without extravasation)

–Local irritation; chemical phlebitis. Symptoms: burning pain at injection site, redness and swelling, hardening of tissue and/or vein (without extravasation)

•In cases of extravasation, measures are taken and documented according to clinic-specific guidelines

Risk of tissue damage in the case of extravasation of various chemotherapeutic agents (modified from Margulies et al. 2002)