NEW Methotrexate Intrathecal w/ sterile pouch

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• published: 04 Feb 2016
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Intrathecal Optimization Project Using Sterile Pouch 2/9/2016 Intrathecal how to instructions: Supplies required for: Methotrexate or Cytarabine / Hydrocortisone / Elliott’s B Solution • 1- 1ml syringe • 3- 3ml syringes • 1- 5ml syringe • 1- 10ml syringe • 1- 0.22 micron disk filter • 5- 18 gauge needles • 1- 21 gauge needle • 1- pack luer-tip caps • 1- pair sterile chemo gloves • 1- pair sterile surgical gloves • 1- 5 ¼” x 10” sterilized pouch • 1- sterilized syringe label pouch • 1- sterile pen pouch (if needed to write in custom dose) • 1- ampule Elliott’s B solution • 1- vial Hydrocortisone 100mg powder • 1- vial Methotrexate (Preservative Free) or Cytarabine 2g vial Step 1: Wash hands according to the OSUWMC USP 797 cleansing and garbing requirements prior to entering the cleanroom. Clean the interior surfaces of the vertical flow biological safety cabinet (BSC) using OSUWMC standard chemo BSC cleaning procedure. Step 2: Gather all necessary supplies for the preparation of the intrathecal injection. (See supply Note: Supplies may differ depending on the type of IT product you are compounding. Please refer to itemized supply lists at the end of this document. Step 3: replace sterile chemo gloves prior to compounding. Step 4: Remove the medication from its packaging. Place medication, diluent, syringes, alcohol swabs, leur tips, needles, and sterile gloves in the vertical flow BSC. Leave leur tips, the second syringe, and sterile gloves in their original packages. During the process, be sure to attach only one needle to one syringe. Step 5: Allow the vertical BSC to remain undisturbed for approximately three minutes. Step 6: Reconstitute any medication using aseptic technique and withdraw the appropriate dose needed for each medication. Once all items are drawn up, transfer them into the 10mL syringe. After all items are added to the 10mL syringe pull back the plunger to the 10mL mark. (The additional airspace in the syringe is required to help push all the medication through the filter.) Place a 0.22 micron disk filter on the end of the 10mL syringe and apply 18 gauge needle. Place the syringe to the side of the chemotherapy spill pad (standing). Step 7: Aseptically open the package of sterile gloves, the package of leur tips, and the remaining syringe ensuring no physical contact with the sterile gloves. When the items are opened, place them (in their packages) to the side in the BSC. When opening the sterile gloves aseptically open the paper wrap in the center of your compounding area so that use the paper for your sterile field. Step 8: Place a sterile glove over the chemotherapy glove on your dominant hand, ensuring that only the inner portion of the glove comes into physical contact with your hand. This will be your sterile hand throughout the procedure. It is very important not to touch and contaminate the outer portion of the glove. Step 9: Using your sterile hand, remove the sterile syringe from its wrapper, making sure not to touch the wrapper and thus contaminate the glove. Pull back the syringe plunger to the required volume plus an additional 0.2 ml, using only your sterile hand. Step 10: Pick up the syringe containing the medication using your non-sterile hand and allow the needle tip to slide off. Transfer the medication from the non-sterile syringe to the sterile syringe by expressing the medication through the tip. Use aseptic technique to place a leur tip on the sterile syringe. Step 11: Place the final syringe on the paper sterile field. Then aseptically place the other sterile glove on your other hand. Step 12: Now using both sterile hands to peel the correct sterile medication syringe label and place it on the sterile final syringe. (If you have a custom dose you may have to write in the dose using available sterile pens). Step 13: Now using your non dominate hand pick up the - 5 ¼” x 10” sterilized pouch ensuring that the inside of the pouch only comes into physical contact with your sterile hand and the final syringe. Place the sterile syringe in the sterile pouch and secure the end of the pouch with the attached adhesive strip when finished. Step 14: Leave the BSC undisturbed for an additional three minutes. Step 15: Label the pouch with the appropriate label including an antineoplastic or cytotoxic ancillary label and a time/date stamp. The final product is stable for 12 hours. Have the dose double-checked by the pharmacist and co-signed by a second pharmacist. Step 16: Once the final product is checked the final pouch will be placed in an amber “For Intrathecal Use Only” zip bag along with an extra sterilized empty pouch.