Administration and General Safety Considerations
To administer IP therapy, one must access the peritoneal cavity. This procedure is performed using sterile technique. Prior to accessing the IP port, the nurse verifies placement of the port by reviewing the postoperative notes or CT scan report. This catheter lies or floats freely in the peritoneal space. The nurse must be familiar with the regimen, specific agent(s) being administered, and clinical considerations for each agent. At MSKCC, we use a preprinted chemotherapy order set to standardize the IV/IP chemotherapy process and decrease the potential for error. MSKCC has developed administration guidelines for each agent to ensure a standard approach to preparation and administration of the agent. For example, IP cisplatin(Drug information on cisplatin) therapy requires that the patient receive 2 liters of IV hydration and premedication with antiemetics, and the patient must void at least 100 mL/hour for 2 hours prior to initiation of chemotherapy. IP chemotherapy is mixed in 2 liters of normal saline and is administered by gravity. It is recommended that the volume be greater than 1,500 mL, to result in abdominal distention.
Patient assessment is needed prior to initiation of chemotherapy and the patient's medical record must be reviewed (as with any chemotherapy regimen). Some patients may have both an IV and an IP port; it is important to identify the ports correctly prior to accessing them. If an IP port is aspirated, there should be no blood return because the port sits in the peritoneal space.
Prior to administering IP chemotherapy, the nurse verifies that the order is correct by identifying the “five rights”: right patient, agent, dose, route, and frequency. The nurse also ensures that the appropriate supportive medications are ordered for safe administration. The Joint Commission has issued a Sentinel Event Alert regarding tubing and catheter misconnection errors. Several strategies are recommended to prevent/reduce wrong-route errors. One strategy is to educate staff about ways to reduce this risk. Next, always trace a tube/line from the patient to the point of origin before connecting the infusion. As part of the handoff process, recheck connections and trace all tubes/lines to the point of origin when caring for a new patient.
Nurses need to educate patients and families about the importance of connecting the tubing to the correct site. Also, some institutions label the lines, that is, IV vs IP. At MSKCC, prior to initiating IP chemotherapy, two nurses will trace the IP chemotherapy agent and tubing to the patient's IP port and connect the tubing in order to verify the correct route of administration. Both nurses verify the connection of the tubing to the correct site to reduce/prevent tubing misconnection errors. As with any other chemotherapy treatment modalities, staff should wear PPE (personal protective equipment) when administering chemotherapy.
Type of IP Access
IP therapy is administered via a Tenckhoff peritoneal dialysis catheter or an IP port. At our center, we administer IP chemotherapy via an IP port. Two different types of ports are currently used to administer IP therapy. We use an IP implantable port with a fenestrated catheter (14.3 French). Others have recommended the use of a venous implantable port connected to a single lumen venous catheter (9.6 French). See Figure 1 for pictures of both devices.
When comparing ports, note the difference in port size and lumen size of the catheter. Also, the fenestrated end has multiple holes (openings) vs the blunt, open-ended catheter. It has been suggested that use of peritoneal catheters with fenestrations and Dacron cuffs is associated with a greater incidence of bowel adhesions and erosion into the bowel. IP ports do not have Dacron cuffs at this time. To date there is no study regarding the type of implantable port to be used for IP chemotherapy.
The following three studies are based on our experience at Memorial Sloan-Kettering Cancer Center using a fenestrated IP catheter. Black et al. reviewed medical records of all patients who had a fenestrated catheter placed from May 1997–May 2006 at our center. They reviewed 342 patients and identified only nine (3%) who had chemotherapy discontinued because of catheter complications. Other complications included catheter-related infections (three patients), inflow obstruction (five patients), and inability to access the port (one patient). Makhija et al. analyzed the charts of 301 patients and identified 30 (10%) who had catheter-related complications. A total of 19 patients (6.3%) had inflow obstruction and 11 (3.6%) experienced infection. The investigators reported that 93% of the patients completed their planned therapy. Davidson et al. reviewed 227 patient charts and found that 8.8% (20 patients) had inflow obstruction, 5.3% (12 patients) had catheter-related infections, and 3.5% (eight patients ) had a bowel perforation.
These studies show that catheter-related complications have decreased over time, and suggest a learning curve regarding placement technique, administration, and management of IP chemotherapy from 1991 to the present. Use of laparoscopic surgery or different chemotherapy agents to treat this disease also may be factors in the decreased incidence of complications. Further research is warranted to identify the best device with which to administer IP chemotherapy. Markman and Walker stated that fenestrated catheters seem to encourage fibrous sheath formation and bowel adhesions and are difficult to remove in the ambulatory setting. In our institution's ambulatory office setting, however, we remove the IP ports without complications or difficulty.
Two controversial procedural points regarding administration of IP chemotherapy are flushing of an IP port and warming of the IP fluid. At MSKCC, the IP port is not heparin(Drug information on heparin)ized because the catheter is not in a blood vessel. We have not experienced any problems flushing with normal saline.[14–16] Some institutions do heparinize; the heparin-flush dosing for IP ports ranges from 100–2,000 units. There are currently no evidence-based guidelines for solution temperature during IP administration. Those who support warming the solution suggest there is an added therapeutic antitumor benefit and it prevents patients from feeling cold. At MSKCC, we administer the therapy at room temperature. If patients report feeling cooler, blankets provide easy and quick relief.
Nursing Management and Patient Education
Nurses play an essential role in caring for women with ovarian cancer who are receiving IP chemotherapy. It is important for us to understand the diagnosis, treatment plan, and potential side effects of treatment. The unique nursing management for patients receiving IP chemotherapy is outlined in Table 4.[18–23] Women receiving IV chemotherapy also have the potential to experience these problems and/or side effects (nausea, vomiting, alteration in the GI tract, myelosuppression, infection, and peripheral neuropathy), and as oncology nurses we are familiar with these potential problems.
Patients should be educated about what to expect with the IP route of chemotherapy, including possible side effects and complications. At Memorial Sloan-Kettering Cancer Center, the patient information booklet, “Your Guide to Intraperitoneal Therapy,” is the tool that we use to teach patients about this modality. [Editor's note: An updated, 2009 version of this educational tool is available in the online issue of ONCOLOGY Nurse Edition, at CancerNetwork.com.] Patients should be reassured that most of the side effects they will experience subside within 48 hours after completion of chemotherapy.
The combination of IV/IP chemotherapy has demonstrated a significant survival benefit for women with optimally debulked epithelial ovarian cancer. Research still is needed to determine the optimal regimen and scheduling, as well as the best way to administer IP chemotherapy and manage patients receiving it. As healthcare professionals, it is essential for us to look for opportunities to improve patients' outcomes and quality of life. In the care of patients receiving IP chemotherapy for ovarian cancer, there are myriad critical points for nursing intervention that will affect the success of the procedure, the comfort of the patient, and the patient's sense of well being.