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Instillation of Intravesical Solutions - ANZUNS

Clinical guidelines | Edited by Trish White APRIL 2012 Instillation OF Intravesical Solutions Clinical Guideline Instillation of Intravesical Solutions 2 Index Page Introduction ..3 Professional Requirements for Nurses Administering Cytotoxic or Immunotherapeutic Intravesical Procedure for Single Postoperative Dose of Intravesical Procedure for a Course of Intravesical Intravesical Combined Interferon/BCG guidelines for Manual Bladder Irrigation (MBI) ..22 guidelines for Postoperative Continuous Bladder Irrigation (CBI) ..26 Appendices Appendix 1 Medication information on Mitomycin-C, Doxorubicin, Appendix 2 Medication information on Clinical Guideline Instillation of Intravesical Solutions 3 Introduction Welcome to the first edition of Clinical guidelines for Intravesical Instillations.

Clinical Guideline Instillation of Intravesical Solutions 3 Introduction Welcome to the first edition of Clinical Guidelines for Intravesical Instillations.

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Transcription of Instillation of Intravesical Solutions - ANZUNS

1 Clinical guidelines | Edited by Trish White APRIL 2012 Instillation OF Intravesical Solutions Clinical Guideline Instillation of Intravesical Solutions 2 Index Page Introduction ..3 Professional Requirements for Nurses Administering Cytotoxic or Immunotherapeutic Intravesical Procedure for Single Postoperative Dose of Intravesical Procedure for a Course of Intravesical Intravesical Combined Interferon/BCG guidelines for Manual Bladder Irrigation (MBI) ..22 guidelines for Postoperative Continuous Bladder Irrigation (CBI) ..26 Appendices Appendix 1 Medication information on Mitomycin-C, Doxorubicin, Appendix 2 Medication information on Clinical Guideline Instillation of Intravesical Solutions 3 Introduction Welcome to the first edition of Clinical guidelines for Intravesical Instillations.

2 In 2011 the Australia and New Zealand Urological Nurses Society Inc ( ANZUNS ) agreed to develop clinical guidelines in this area. Anecdotally there were differences in practice and it was felt we needed a consensus document for our members to access. A project officer was appointed to develop the guidelines and report back at the Darwin conference in April 2012. Trish White has edited this first edition, and our thanks also go to the following who kindly volunteered to peer review the document: Jean Bothwell, Clinical Nurse Specialist Urology Waitemata District Health Board, Auckland, New Zealand Melinda Fieldsend, Urology Nurse Practitioner (Candidate) Urology & Continence Department Mater Health Services South Brisbane, Queensland, Australia Marco Hake Clinical Nurse Consultant Urology/ Continence/ Stomal Therapy WACHS-Great Southern Health Service Albany Hospital, Western Australia Marianne Lyon Auckland District Health Board, New Zealand Billy Allan, Chief Pharmacist Hawke s Bay District Health Board, Hastings, New Zealand We would also like to thank our international colleagues, we were able to access expertise in this area from around the world through the Global Alliance of Urology Nurses.

3 We would especially like to thank Jeff Albaugh in the USA and Lucinda Poulton the President of BAUN who were both happy to collaborate and share their resources. The guidelines have been produced to assist urology nurses in the safe administration of Intravesical instillations. They can be used as a guide to practice but are not definitive and local policy must be followed. Recommended evidence based best practice has been utilised as a basis for this guideline. Alison Overton ANZUNS President April 2012 Clinical Guideline Instillation of Intravesical Solutions 4 Professional Requirements for Nurses Administering Intravesical Cytotoxic or Immunotherapeutic Medicines This guideline applies to Registered Nurses who meet the following criteria: 1. Experienced Urology Nurse working in a urology or oncology department 2. Demonstrates a clear understanding of urological anatomy, physiology and bladder cancer 3. Has completed a training programme, according to local policy, on the administration of cytotoxic medication including Intravesical medication and health and safety requirements 4.

4 Expert skills at urethral catheterisation in both male and females 5. Pharmacological knowledge of medications used in the treatment of bladder cancer 6. A register should be kept of all Registered Nurses certified in this procedure at your place of employment. ANZUNS recommends nurses who are pregnant or trying to conceive should not handle cytotoxic medication, administer it or handle waste products. ) Supporting evidence for ANZUNS Inc statement on professional requirements It is recommended Registered Nurses are assessed annually to maintain competency in the administration of cytotoxic or immunotherapeutic medication. Only Registered Nurses with specific education and training in the safe handling of anti cancer medication and related waste should administer anti cancer therapies. Employers must ensure nurses involved in administering anti cancer medication have access to education, training and environmental factors such as ease of access, light and space and other resources are addressed as a matter of necessity to ensure minimum professional and safety standards are met.

5 Employers must ensure that risk assessments have been conducted and recommended processes are in place to enable nurses to maintain their competency and scope of practice in this field. Cancer Nurses Society of Australia (2010) Cancer Nurses Section, New Zealand Nurses Organisation (2011) Clinical Guideline Instillation of Intravesical Solutions 5 Intravesical Chemotherapy In 2007 there were 369 new registrations of bladder cancer in New Zealand which accounted for of all cancer registrations (MOH, 2011). In Australia there were 2217 new registrations for bladder cancer and 925 deaths. These statistics put bladder cancer in the Top Ten of cancers in Australia. Principles This section applies to those patients with non muscle invasive bladder cancer, Ta, T1 and CIS. The drugs commonly used for Intravesical chemotherapy in Australia and New Zealand are Mitomycin C, Doxorubicin, Epirubicin and these are discussed further in the appendices.

6 Intravesical chemotherapy will be administered safely in accordance with your local policies, which may include: Administration of cytotoxic medications Catheterisation (it is assumed nurses administering Intravesical chemotherapy are competent in catheterisation of both males and females. This guideline will not include step by step catheterisation instructions) Management of Anaphylaxis The nurse will have completed a competency programme for Intravesical chemotherapy. Definitions of non-muscle invasive bladder cancer Ta Non invasive papillary carcinoma T1 Tumour invades lamina propria Carcinoma in Situ (CIS) High grade tumour confined to epithelium, but with a non papillary configuration. Appears as a reddened and velvety mucosa, but sometimes not visible. It can be local or diffuse. Tumour Grading: Papillary urothelial neoplasm of low malignant potential (PUNLMP) Low grade papillary urothelial carcinoma - well differentiated High grade papillary urothelial carcinoma - poorly differentiated Clinical Guideline Instillation of Intravesical Solutions 6 Indications/ Treatment Recommendations Transurethral resection (TURBT) is recommended for all patients with nonmuscle invasive bladder cancer.

7 For low risk disease a single dose, Instillation of chemotherapeutic agent is recommended immediately following TURBT. For intermediate risk disease induction course of Intravesical BCG with maintenance immunotherapy or Intravesical chemotherapy is recommended. For high risk disease BCG induction plus maintenance is recommended. (Brausi M., 2011) Precautions/Contraindications Please see appendices at end of this document for an outline of specific medications and precautions associated with them. This section of the guideline will provide procedures for: Instillation of a single postoperative dose of Intravesical chemotherapy Instillation of a course of Intravesical chemotherapy Clinical Guideline Instillation of Intravesical Solutions 7 Single Postoperative Dose of Intravesical Chemotherapy This may be administered immediately at the completion of surgery in theatre, and then completed in recovery.

8 Alternatively, it may be the Registered Nurses responsibility on the postoperative ward. Equipment Protective equipment for the nurse: impervious protective gown, sterile gloves, eye protection, mask N95 Catheterisation pack Catheter valve and medication container/connection device Medication in a prefilled syringe Skin barrier cream Cytotoxic rubbish bags and labels Protective sheets or plastic draw sheets Cytotoxic spill kit to be available at all times Procedure Rationale Prior to Surgery Gain informed Consent Provide written information on procedure stating reasons for treatment Outline risks, side effects and potential complications of both surgery and chemotherapy medication to be used Shows patient has a good understanding and is well informed of procedure Check current medications and any known allergies Prevent medication reaction Order prescribed medication Must be available on day of surgery, preferably within six hours of surgery Withhold diuretics prior to surgery if requested by Urologist.

9 This is an individual requirement and may differ To prevent overdistention of bladder causing discomfort while patient retaining chemotherapy Complete preoperative preparation Immediately prior to Administration of Chemotherapy Check operation record, prescription and allergies Prevent medication error and ensure treatment has not altered. Identify any potential complications from surgery, there may be specific instructions from Urologist. Confirm patient identity according to your local policy Two Nurses to check identity and prescription prior to administration of chemotherapy Ensure patient privacy and dignity, single room if possible To prevent risk of contamination and provide privacy Clinical Guideline Instillation of Intravesical Solutions 8 Assess urine colour and consistency It is important not to start chemotherapy with heavy haematuria in the postoperative patient as it could be an indicator of perforation following TURBT If frank, moderate or heavy haematuria is present treatment may be delayed until it lessens.

10 Heavy haematuria also has the potential to clot and block catheter Always consult with Urologist if unsure whether to proceed Assess temperature If febrile consult with urologist for confirmation to proceed Assess pain level If uncomfortable, anticholinergic medication may prevent bladder spasm which could cause catheter bypassing / leakage. Check any increase in pain is not due to a blocked catheter If bladder irrigation in place, turn it off but do not disconnect tubing. If not in place set up continuous bladder irrigation (CBI) tubing, and sodium chloride Empty catheter drainage bag and record output Maintain accurate intake and output records in these patients Assemble required equipment as above Instillation Procedure Place protective sheet under penis and above scrotum, or in females tuck it around the labia To prevent skin contamination in case of spillage Wash hands and don protective equipment To maintain sterility and to protect yourself from cytotoxic contamination Place sterile guard on top of protective sheet To maintain sterility Cleanse catheter connection with prescribed solution as per local policy Disconnect catheter from drainage bag and keep tip sterile Attach catheter valve to assist in controlled Instillation Prevent infection Catheter valve reduces the risk of spillage, If drainage bag or valve becomes contaminated replace with a new one Attach the medication container to the end of valve, open the valve.


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