Special Feature

Am J Hosp Pharm.1983; 40:1163-71

ReGommendations for handling cytotoxic drugs in hospitals

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Michael H. Stolar, Luc! A. Power, and Carol S. VIele

Recommended proceaures for handling cytotoxic drugs in hospitals are presented.

The recommended procedures are designed to reduce the number of opportunities for un­
necessary contact with cytotoxic agents (CYTAs) by hospital personnel and to prevent con­
tamination of the hospital environment and staff with cytotoxic agents. The recommendations
incorporate elements of previously published and unpublished guidelines; they admittedly are
based on informed judgment as well. Three sets of recommended procedures are presented,
each offering a varying degree of protection. The number of cytotoxic drug doses prepared and
adrninistered is suggested as the determinant of which level of protection is followed. The cvto-
toxic workload index, defined as the number of CYTAs prepared or administered (or both) di-
yided by the number of available staff hours, is proposed as a quantitative method of deciding
which level of protection is required for a particular work station or work shift. The recom­
mended procedures cover the following seven topic areas: general guidelines; apparel, equip­
ment, and facilities; drug preparation; drug administration; housekeeping, waste disposal, and
manapment of spills and contamination; medical surveillance of staff; and legal and personnel
considerations. «
The recommended procedures and associated equipment are considered to be practical and
to adequately protect hospital personnel from risks associated with handling cytotoxic agents.

index terms: Antineoplastic agents; Contamination; Guidelines; Hospitals; Personnel; Safety;

Toxicity, environmental

In recent years the numbers and usage of antineoplastic
. drugs and other cytotoxic agents (CYTAs) have increased
considerably. In vitro and in vivo evidence indicates that
long-term exposure to these drugs may produce teratogenic
or carcinogenic effects, or both. Furthermore, some evidence
also exists showing that direct contact with or inhalation of
• aerosols created during the preparation and administration
of antineoplastic drugs can produce effects such as dizziness,
nausea, headache, and dermatitis. Concentrated solutions
of antineoplastic drugs are known to be extremely irritating
to the skin and.mucous membranes.
Many antineoplastic drugs must be dissolved, transferred
from one container to another, or otherwise physically ma­
nipulated before they can be administered to a patient.
Concern has developed over the possibility that repeated.
Michael H. Stolar, Ph.D., is Director, Professional and Research Services,
American Society of Hospital Pharmacists, Bethesda, MD. Luci A. Power,
M.S., is Assistant Director of Pharmaceutical Services. and Carol S. Vlele,
M.S., is Oncology Nurse Specialist, -University of California Hospitals and
Clinics, San Francisco.
Address reprint requests to Dr. Stolar at ASHP, 4630 Montgomery Avenue,
Bethesda, MD 20814.
These recommendations are a draft of May 1983 and are subject to revision
pending further scientific data and practitioner input. The recommendations
are being developed to assist hospitals in establishing policies and procedures
for the safe handling of cytotoxic drugs. The responsibility for determining
and.implementing the specific practices to be followed, however, ultimately
rests with each individual institution.
Copyright © 1983, American-Society of Hospital Pharmacists, Inc. All rights
reserved. 0002-9289/83/0701-1163$02.25.
chronic exposure to small amounts of cytotoxic drugs will
have long-delayed carcinogenic or teratogenic effects among
hospital personnel who prepare and administer these drugs.
Currently, there is little epidemiologic evidence to support
these fears. However, the prudent hospital will take the steps
necessary to minimize its staffs exposure to cytotoxic
drugs.
Through engineering controls, protective apparel, and
proper safety policies and procedures, the institution can
greatly reduce the chance that a worker, the work area, or
the outside environment will contact or be contaminated by
CYTAs. Carried to extremes, the cost of the ultimate in
protection is great; if applied in hospitals, only a very few
patients ever would be treated. Beyond that, however, one
can argue that such extreme precautions applied to cytotoxic
drugs in hospitals are irrational when viewed against the
background cytotoxic contamination in the environment
(e.g., tobacco smoke, automobile exhaust, and industrial
water pollution). Thus, the precautions hospitals take must
be realistic and practical, and they should be based on an
assessment of the risks involved. Repeated, direct contact
with large amounts of cytotoxic substances is very likely to
be harmful. With certain exceptions, however, the danger
from infrequent exposure to very small amounts of these
drugs—as is the case with hospital personnel following
proper procedure—is thought to be extremely low if proper
precautions are taken.
The' suggested procedures and associated equipment
presented in this paper are thought to be practical and to

VoUO JuM983 American Journal of Hospital Pharmacy 1163

 Cytotoxic drugs
adequately protect personnel. They will result in additional
expenses for safety equipment and supplies, and, produc­
tivity possibly will decrease. Admittedly, in many cases, they
derive from opinion. But, in the absence of hard, valid data,
the only alternative is informed opinion and judgment. The
• recommendations herein incorporate numerous elements
of previously published guidelines and new unpublished
procedures, all of which are compiled in a new ASHP pub­
lication entitled. Procedures for Handling Cytotoxic
_DrugsM We have made every effort to ensure the accuracy
and completeness of these recommendations. However, these
recommendations have not been formally adopted by the
American Society of Hospital Pharmacists or any other
group and should not be construed as a standard of practice
for the profession.
These suggested procedures are based on the simple
premise that the less direct contact with cytotoxic agents,
the better. Therefore, this document assumes that since
these drug products can produce immediate untoward bio­
logical effects and may have long-delayed adverse Conse­
quences, the number of exposures hospital personnel re­
ceive inadvertently from handling cytotoxic drugs should
be as close to zero as possible, and the size of each exposure
should be as small as possible. It follows, then, that hospitals'
should establish procedures for minimizing the exposure of
.their staffs to cytotoxic drugs. The intertwined dual goals
of these procedures will be the following:
• To reduce the number of opportunities for unnecessary
contact with cytotoxic drugs by hospital personnel, and
• To prevent contamination of the hospital environment and ,
staff with cytotoxic drugs.
The latter goal is accomplished primarily by retaining cy­
totoxic drug solutions and powders within the containers and
equipment in which they are stored, prepared, transported,
and administered. The suggested procedures minimize the
generation of and direct physical contact with CYTA aero­
sols, dusts, and solutions.
Procedures, equipment, and facilities for the safe handling
of toxic drug products range from the simple to the elaborate,
from inexpensive to costly. Their relative costs and benefits
vary and may be difficult to determine accurately. For this
reason, hard and fast rules setting forth exactly what safety
procedures and equipment should be used in a given hospital
are not feasible. This document presents three sets of pro­
cedures that could be described as stringent, more stringent,
and very stringent. Each hospital must decide for itself
which will be used, based on its resources, legal requirements,
cytotoxic workload, and judgments of its professional staff.
The number of cytotoxic drug doses that are prepared and
, administered is the prime determinant of which level of
protection is suggested. The safest course is to use the most
stringent (i.e., protective) measure practical. Some of the
suggested procedures have certain tradeoffs; these and other
possible criticisms are presented along with the proce­
dure.
Keep in mind that constant adherence to proper aseptic
technique during the preparation, administration, and dis­
1164 American Journal of Hospital Pharmacy Vol 40 Jul 1983
posal of cytotoxic drugs is by far the most important—and
least expensive—safety precaution that can be taken.
Cytotoxic Workload Index
Definition of the Cytotoxic, Workload Index. For
purposes of this document, the toxicities of all cytotoxic
drugs are considered to be of the same magiiitude.*' There­
fore, the controlling factor in establishing safe-handling
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procedures will be the number and amount of cytotoxic
drugs typically handled during a shift or other appropriate
time period. Three levels of procedures are presented herein,
the level chosen being based on the CYTA workload.
' CYTA workload might be measured as the total number
of doses prepared or administered or botb in a particular
time interval. Ah alternate, more-rational measure would be
the average workload per person per shift. In this Way, a
numerical index for the cytotqxic workload could be used as
tbe basis for selecting from among the three levels of sug­
gested procedures the most appropriate for a particular work
-area and workshiff. Thus, we developed the cytotoxic
workload index (CWI) as a quantitative base for decision
making. The CWI for a workshift (a.m., p.m., night, etc.)
during a given time period is defined as follows:
CWI = No. of CYTA preparations or administrations or
both/No. of available staff hours
Only the staff hours of persons directly involved in the
preparation or administration of CYTAs should be used to
calculataa CWI.
Sample Calculations of the CWI. The following exam­
ples illustrate various ways in which a CWI can be calculated.,
A hospital may have several CWIs; these may be for different
areas witbin the hospital and for different workshifts. CWIs
should be recalculated annually or whenever substantial
changes in the CYTA workload,occur.
Example 1. The centralized i.v. admixture service in a
50.0-bed teaching hospital prepared 2500 doses of injectable
antineoplastic drugs during tbe past three months. This
workload was relatively constant from day to day. The
morning shift prepared 2000 of the 2500 doses, the afternoon
shift 350, and the night shift 150. The total number of
available staff hours for pharmacists and technicians de­
voted to the i.v. admixture service during the three months
were 1440, 960, and 480 for the three shifts, respectively.
Thus, the morning, afternoon, and night shift CWIs would
be determined as follows:
Admixture CWL = 2000 doses/1440,staff-bours
= 1.4 doses/staff-hour
Admixture CWIp.m) = 350 doses/960 staff-hours
= 0.4 doses/staff-bour
Admixture CWInight = 150 doses/480 staff-bours
= 0.3 doses/staff-bour
Example 2. An oncology clinic meets Tuesday and.
Thursday afternoons from 12 noon to 5 p.m. Drugs admin­
istered in the clinic are prepared by a pharmacist and ad-

ministered by an oncology nurse. In the past three months,
370 doses were prepared and administered. The clinic was
open a total of 120 hours; hence, 120 staff hours were avail­
able from each of the two staff members. The CWI for the
period is as follows:
Clinic CWI = (370 doses prepared + 370 doses
administered)/.
(120 Staff-HourSpharmacist + 120 staff-
hoUrSpurse)
= 3.1 doses/staff-hour
Example 3. During the past six months, the pharmacy in
a 100-hed hospital has prepared and dispensed a total of 500
doses of various cancer chemotherapy agents. The pharmacy
is staffed by two full-time pharmacists and two full-time
technicians who share equally the responsibility for pre­
paring i.v. admixtures and related products. The staff
members are available for a total of 180 staff-hours per week.
The pharmacy's CWI is calculated as follows:
Pharmacy CWI = (500 doses/26 wk)/ (180 staff-hours/wk)
= 0.1 dpses/staff-hour
Procedures Based on Three Levels of Control
In this paper, policies and procedures for handling cyto­
toxic drugs are categorized into the following topic areas:
1.General guidelines;
2.Apparel, equipment, and facilities;
3.Drug preparation;
4.Drug administration; .•
5.Housekeeping, waste disposal, and managemeat of spills
and contamination;
6. Medical surveillance of staff; and
7. Legal and personnel considerations.
For each of the, seven topics, three levels of procedures,
designated as levels I, II, and III are provided. Level III
procedures are generally the most protective, elaborate, and
expensive; level I the least. The level chosen for a given
function should be the highest possible. As a guide to se­
lecting the most appropriate procedure; the following arbi­
trary distinctions, based on the CWI for an area or workshift,
are suggested:
• Employ levell or higher if the CWIis <1,
• Employ level II or higher if the CWI is >1 and <3, and
• Employ level III if the CWI is >3.
C. Security and Control, Shipping and Receiving
The adverse effects of cytotoxic substances are not com­
pletely dose related and can vary depending upon an indi­
vidual's susceptibility. This would be considered by many
workers to be strong justification for having a single set of
only the most stringent procedures, which in this case would
be level III. , 2. Damaged goods
Also, in some cases, the CWI for each shift or work area
may be fairly low. However, the CYTA workload in absolute
numbers may be large enough fo make the use of levell or
II procedures open to question. This is illustrated in Ex­
ample 1 in the previous section.
Cytotoxic drag*
General Guidelines
A. Policy and Procedures Manual
1. Written policies and standard procedures
a. Leue//; Written policies and standard procedures must
be developed. Procedures should be based on these
guidelmes, applicable governmental regulations, and the
recommendations of pharmaceutical manufacturers,
hOTpital safety officers, and other knowledgeable parties.
The policy and procedure manual so prepared should
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encompass the seven safety-consideration topics outlined
in these recommendations. Since several hospital de­
partments, such as pharmacy, nursing, maintenance, and
medical staff, will he involved with some aspect of the
CYTA issue, preparation of CYTA policies and proce­
dures must he a collaborative effort. All personnel who
handle cytotoxic agents should receive a copy of the
procedures pertaining to their responsihihties. Deviations
from the standard procedures must not he permitted
except under defined circumstances,
h. Level II:Same as level I.
c. Level Til:Same as level I.
B. Personnel practices
1. Training
a. Level /; All involved personnel must he informed about
the special nature of CYTAs and the importance of fol-
loviang established procedures. They must he adequately
trained, using the relevant portions of the CYTA policy
and procedure manual. Personnel should demonstrate
their imderetanding and competence before working with
CYTAs. Semiannual reevaluation is desirable. (This is
especially important for aseptic technique and use of
laminar airflow hoods.)
h. Level II: Same as level I.
c. Level HL Same as level I.
2. Pregnancy
a. Level I: Staff members who are pregnant or breast­
feeding must not prepare or administer CYTAs.
b. Level II: Same as level L
c. Level III:Same as level I.
3. Workload distribution
a. Level I: If possible the CYTA workload should be dis­
tributed among the appropriate trained personnel in a
way that evens out their daily exposures.'^
h. Level II: Same as level I.
c. Level III: Same as level I. Daily records of the number
of CYTAs prepared should he kept. When an individual
has prepared or administered 2000 CYTAs or after 90
days (whichever comes first), that person should be as­
signed to a non-CY'TA work for one month. (The 2000
CYTAs and 90-day limits are considered reasonable, but,
nevertheless, they are arbitrary.)
A. Quality assurance
a. Level I: The department's quality assurance program
should Cover CYTA preparation,
h. Level II: Same as level I.
c. Level HI: Same as level I.
1. Access
a. Level I: Access to areas where CYTAs are stored or pre­
pared must he limited to authorized personnel.
b. Level II: Same as leyel L
c. Level III: Same as level I.
a. Level I: Shipping cartons received damaged should be
isolated and left unopened. The shipper should be noti­
fied immediately. Damaged cartons should he cautiously
opened by personnel wearing vinyl gloves, closed gown,
. dust and mist respirator, and eye protection. This should
be done in an isolated area, preferably in a vertical-flow
biological safety cabinet. Any damaged packages of fin-
Vol40 Jul 1983 American Journal of Hospital Pharmacy 1165
Cytotoxic drugs
ished dosage forms should be placed in an appropriate
receptacle for disposal as described in Housekeeping,
Waste Disposal, and Spill Management, item B(4).
b. Level II: Same as level I.
c. Level III: Same as level I.
3. Shipping
a. Level I: CYTAs packaged for ship­
ment back to manufacturers or
other institutions should be cush­
ioned in a sturdy carton. The man­
ufacturer should be consulted re­
garding proper labeling for the
package. A supplementary warning
label, such as the one shown here,
should be placed inside the carton.'^ The CYTAs should
be in a sealed 4-mil plastic bag placed inside the outer
shipping carton. CYTA prescriptions shipped to patients
should be well packaged and, if possible, sent by First
Class Certified Mail marked for restricted delivery.
b. Level II: Same as level I.
c. Level III: Same as level I.
D. General Considerations Regarding Aseptic
Procedures
1. Standard aseptic technique
a. Level I: Proper aseptic technique is essential if exposure
to CYTAs is to be avoided. Therefore, standardized
aseptic procedures must be established and followed.
Personnel must demonstrate their proficiency before
being assigned to prepare CYTA solutions.® Semiannual
reevaluations or other quality assurance reviews should
be made. Certain suggested aseptic procedures are de­
scribed in other areas of this paper.
b. Level II: Same as level I.
c. Level III: Same as level I.
E. Drug-specific Information
1. Manufacturers'instructions
a. Level I: The information presented in this paper is ap­
plicable to most CYTAs. However, many of these drugs
will have specific instructions for their storage, prepa­
ration, use, handling of spills, and disposal provided by
the manufacturers or another source, such as the National
Cancer Institute. In these instances, their recommenda­
tions should be followed. A loose-leaf file or other com­
pilation, arranged by drug name, is one method of orga­
nizing such information. Supplemental information, such
as solubility data, chemical inactivators, acute exposure
treatment, and chronic and acute toxicities, should be
kept in tbis file as well.
b. Level II: Same as level I.
c. Level III: Same as level I.
Equipment, Facilities, and Apparel
A. Equipment^
1. Laminar-airflow hoods
a. Level I: A Class II, Type A vertical airflow hoods that
meets current National Sanitation Foundation standards
is preferred for the preparation of CYTAs. The blower
should run continuously. (This will load the HEPA filter
faster than expected unless the cabinet is located in a
clean room.) A horizontal hood may not be used. If a
vertical-airflow containment unit is unavailable, the drug
should be prepared in a quiet work space, away from
heating and cooling vents and away from other personnel.
In addition,
• A disposable NIOSH-approved dust and mist respi­
rator (3M 8710'' or similar) and a plastic face shield or
goggles must be worn.
• A hydrophobic filter needle unit, such as Milex-FG' or
Burron Chemo-Dispensing Pin,i should be used to ma­
nipulate CYTA powders packaged in vials. .
1166 American Journal of Hospital Pharmacy Vol 40 JuM983
• Work should he done on a disposable, plastic-backed
paper liner. If only a few CYTAs are prepared each day,
the liner should be changed after the preparation is
completed. Otherwise, it should be changed after any
overt spills and after each shift. Contaminated liners
should be disposed of as per these guidelines. (Disposable
liners have one drawback—they hide small spills resulting
from, and indicative of, sloppy technique.)
• Also see other preparation procedures presented
elsewhere in this paper.
b. Level II: A Class II, Type A vertical-airflow hood is re­
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quired; a Type B unit is preferred. (Volatile CYTAs or
those that sublime must be manipulated only in a Type
B hood.) If possible the hood should he reserved for pre­
paring CYTAs. Guidelines for the proper use of verti­
cal-flow hoods are as follows:
• Personnel must understand the airflow characteristics
of the cabinet. •
• Only materials needed for tbe preparation at hand
should be placed in the hood.
• Intake or exhaust grills must not be blocked by papers
or other objects.
• All equipment needed to complete the procedure in the
hood should be in place before beginning.The view screen
must be in place in tbe proper operating position. After
tbe equipment and materials are positioned, wait 2-3
minutes before starting work to allow the unit to purge
itself of any airborn contaminants tbat may bave been
introduced.
• Do not place any objects on top of tbe unit.
. • A disposable liner for tbe work surface is suggested (see
level I procedures). (A possible problem with paper liners
is that they generate particles.)
• The unit's blower should run.continuously, 24 hours
a day.
• The interior surfaces of the hood should be wiped daily
with 70% isopropyl alcohol or other suitable disinfec­
tant.
• The cabinet should be located away from heavy traffic
patterns.
• All manipulations should be performed on the solid
work surface away from the exhaust vents. Do not work
or place materials within three inches of the sides of the
hood.
. • The cabinet must be certified upon installation by
qualified personnel and annually thereafter or whenever
it is relocated. The HEPA filter's efficiency and the unit's-
inflow and downflow velocities and the air-barrier Con­
tainment should be tested.
• Movement of the operator's arms in and out of the
cabinet should be minimized to maintain the integrity
of the negative-pressure air barrier along the front
opening.
• Eating, drinking, smoking, chewing gum, and storing
food in or near the hood is prohibited. These activities
can result in inadvertent ingestion of CYTAs. Likewise,
personnel should not apply cosmetics in the work area;
since they can become a source of chronic exposure to
CYTAs if contaminated.
• The proper procedures for use in the vertical-lami­
nar-containment hood are not the same as those used in
the horizoqtal-laminar hood. This is because of the nature
oLthe airflow pattern in the Vertical-flow containment
hood. Clean air descends through the work zone from the
top of the hood toward the work surface. As it descends,
the air is split with some leaving through the rear perfo­
ration and some leaving through the frorit perforation.
The region where the airflow splits is knoivn as the
"smoke split" because smoke introduced into this area
appears to split into two directions.
• 'The smoke split should be determined and marked on
each hood after it is purchased even if the manufacturer
identifies its location. This can be easily done by using
an incense stick to generate smoke and moving it slowly
from front to rear laterally along the work surface of the
hood near the center. Routinely used, large equipment

should be placed in the hood in its normal position when
the smoke split's location is being determined. The
equipment should then be placed in the same position
of the hood every time the hood is used.
• In general, the product being manipulated should be
kept upstream relative to other objects in the hood.
Sterile items should be kept in the center of the hood and
nonsterile items toward the perimeter.
• For additional operator protection, it is recommended
that the area behind the smoke split be used whenever
possible since the airflow direction in that area away from
the operator lessens the chance of accidental kposure.
• Periodic evaluation of the smoke split should be per­
formed on a routine basis. Constantly changing smoke-
split location may'be indicative of problems with the
operation of the hood. Note-that smoke-split evaluation
IS not a substitute for performance certification.
c. Level III: A Class II, Type B unit is required. The ex-
ternal venting system must be sealed, non-recirculating,
and designed and constructed in accordance with the
hood manufacturer's recommendations (if any) and ap­
plicable regulations and codes. Externally vented hoods
. must have an exhaust system that maintains adequate
and constant negative air pressure. The system must he
properly designed and constructed and its performance
(i.e., airflow) monitored. Poorly functioning venting
systems can result in distortions in the cabinet's airflow
pattern and velocity, a, potentially hazardous situation.
Type B cabinets exhaust building air, which has been
heated or cooled, to the outside. Therefore, they are more
expensive to operate than Type A units. Proper proce­
dures for using the hood are the same as level II, except
that only CYTAs should be prepared in the hood.
2. Syringes
a. Level I:Syringes and i.v. sets with Luer-locking fittings
should be used. Syringes must be capped upon filling. The
capped,syringes should contain no air or excess drug so­
lution.
b. Leuef//.• Same as level I.
c. Level HI: Same as level I. • -^
3., Collection vessel
a. Level I: A nonsplash collection vessel (e.g., a clean, dis­
posable plastic or metal tray lined with sterile gauze pads)
to collect excess diluent or drug solution should be at .
hand'. Empty sterile vials are an alternative collection
vessel. Excess solutions should be left in their vials.
b. Level II: Same as level I. -
c. Leuef///; Same as level I.
B. Facilities
. 1. CYTA preparation area or room
a. Level I: The vertical-airflow hood, to the extent possible,
should be isolated from the traffic patterns of other work
stations.
b. Level II: Same as level I. A separate room, preferably with
positive pressure, for the preparation of sterile products
IS recommended. CYTy^ should be prepared in this room
if it exists. (The benefits of a positive-pressure room to
sterile product preparation and ultimately to patients
must be weighed against the risk of transferring CYTA-
contaminated air to the rest of the building.)
c. Level III: An air conditioned, dedicated room for the
preparation of CYTAs is preferred. It should contain the
• electrical hookups and services required
for CYTA preparation and hood operation.
The room should operate at positive pressure. In case
of a major spill, however, the air supply should he able
to be closed off so that the room can operate at negative
pressure during cleanup.
The air supply should be filtered and proper filter
maintenance provided.
Optimal design calls for an anteroom to provide an area
for clothing change and storage, handwashing, and stor­
age and disposal of protective apparel. The CYTA
room-anteroom and anteroom-outside doors should not
Cytotoxic drag*
be able to be opened simultaneously and should be self
closing.
The CY'TA-room structures and surfaces should fa-
cilitate and withstand repeated cleaning and disinfec­
tion.
Only authorized personnel should have access to the
room.
C. Workers' Apparel and Proteetidn
1. Gloves
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a. Level I: Gloves must be worn while preparing CYTAs.
Clare rnust he taken not to cut, puncture, or tear the
gloves. No one glove material is impervious toall CYTAs-
disposable surgical or polyvinyl chloride (PVC) gloves
provide substantial but not complete protection. PVC
gloves probably are more protective than surgical gloves
but they are stiffer and less tactile. Gloves should be .
discarded after each use or each hour if multiple products
are being prepared. Glovesshould be tucked into the cuffs
of the operator*s gown.
b. Level II:Same as level I.
. c. Level III: Same as level I.
2. Face and eye protection
LevelLK not working in a vertical-airflow hood, a dis-
posable dust and mist respirator and either a plastic face
shield (preferred) or chemical splash goggles must be
worn. Ihe face shield or goggles should be wiped clean
with a suitable tissue and water after each use.
An eyewash fountain must be quickly accessible. Also,
a 32-oz bottle of sterile isotonic eyeand face wash should
^ available for emergencies in locations where
0 Y1 As are used infrequently.
b. Level II: With a vertical-airflow hood, the respirator and
face shield or goggles are unnecessary.
c. Level III: Same as level 11.
3. Gowns
a. Level I: A protective garment must he worn when pre­
paring CYTAs. The garment should be made of lint-free
low-permeability fabricand must have aclosed front,long
sleeves, and elastic or knit closed cuffs. Tyvek'' isolation
gowns are one example of an acceptable garment. The
garment must not he worn outside the work area. Dis­
posable gowns are preferred over reusable. Front-but-
toned coats are not recommended.
b. Level II: Same as level I. Shoe and hair coversshould be
worn if CYTAs are prepared in a dedicated sterile-
products room.
c. Leuel///.-Same as level II.
Drug Preparation
A. Drug-Preparation Procedures
1. Preparation of sterile products
a. Level I: Proper aseptic technique for patient safety is
essential (for example, wiping the neck of ampuls with
70% isopropyl alcohol before opening). Additional work
techniques that must he followed to protect personnel
are as follows (the guidelines for using vertical-airflow
containment hoods should be consulted also):
• Hands must be washed thoroughly before donning
gloves and after removing gloves.
• Any liquid remaining in the top of an ampul should be
tapped down before the ampul is opened. When breaking
the ampul top, a sterile gauze pad or cotton pledget
should be wrapped around the ampul neck.
• Vials should be vented as necessary with a hydrophobic
filter-needle unit to eliminate any existing or built-up
pressure in the vial. (A negative pressure procedure de­
scribed by Wilson and Solimando^ eliminates the need
for venting. However, it requires consistent impeccable
technique, which some people think may be difficult to
maintain.) ,
• When dissolving lyophilized powders contained in
Vol 40 JUI1983 American Journal of Hospital Pharmacy 1167
Cytotoxic drugs
ampuls, the diluent should be introduced slowly down
the side of the ampul wall so as to wet the powder and
prevent dusting.
• A sterile gauze or cotton pledget should be wrapped
around the needle and vial top when withdrawing CYTA
solution from a vial. (If the negative-pressure technique
is used, this is optional if working within a hood.) A gauze
or cotton pledget also should he placed at the needle or­
ifice when ejecting air bubbles from a filled syringe.
(Some practitioners, however, think that this practice has
the potential to contaminate the solution with particulate
matter.)
• For vials, final solution volume measurement should
be performed before removing the syringe needle from
the vial stopper and after any pressure differential be­
tween the vial and syringe has been equalized.
• The volume of air or diluent or both injected into a vial
should he the smallest amount that will dissolve the drug '
and permit removal of the solution. This will minimize
pressure build-up within the vial.
• Used needles and syringes should he recapped before
disposal. They should not be clipped or crushed after
use.
• Syringes used should be large enough so that they are
never more than three-fourths full, hut are small enough
to measure the contents with acceptable accuracy.
• Syringes with CYTAs and fluids to which they have
been added should be labeled "Cytotoxic Agent—Dispose
of Properly."
If CYTAs are prepared in a patient-care area (e.g.,
clinic) just before their administration, it may be advis­
able to prepare them out of sight of patients. This will
prevent any apprehension patients might develop from
seeing staff in, for example, plastic face shields. Expla­
nation to the patient of the reasons for using protective
apparel is suggested.
b. Level II: Same as level I. Drug administration sets should
be attached and primed within the hood at the time of
preparation, but before the drug is added to the fluid.
This obviates the need to prime the set in the clinic or at
bedside, which are less well-controlled environments.
Further, any fluid that escapes during priming contains
no drug.
c. Leuel///: Same as level II.
2. Nonsterile compounding
a. Level I: When manipulating nonsterile liquid or pow­
dered CYTAs (e.g., preparing CYTA capsules), a dis­
posable dust and mist respirator must be worn. It should
be discarded after the preparation has been completed,
the workshift is over, or if breathing resistance increases
noticeably. Nonsterile CYTA dosage forms should be
compounded in a vertical-airflow containment hood,
glove box, or area away from drafts and traffic pat­
terns.
b. Level II: Same as level I.
c. Level III: Same as level I.
Drug Administration
A. Drug-Administration Procedures
1. Apparel
a. Level I: Review the preceding recommendations on
safety-cabinet use and drug-preparation procedures. The
following items must be worn by personnel administering
CYTAs to patients;
• Disposable surgical gloves, discarded after each use.
• Surgical mask (this is suggested primarily to protect
immunocompromised patients, but it also provides slight
protection to personnel against CYTA droplets; the
hospital medical staff must determine if surgical masks
should be worn).
• OSHA-approved splash goggles or protective glasses
with side shields (goggles provide superior protection).
• Long sleeve uniform or coat; alternatively, sleeve pro­
,1168 American Journal of Hospital Pharmacy Vol 40 Jul1983 •
tectors and short-sleeve apparel may he worn.
b. Leue///; Same aslevel I except that a protective garment
as described in Equipment, Facilities, and Apparel, item
. C(3), must be worn.
c. Level III: Sarne as level II.
2. CYTA kit '
a. Level I: Use of a "(JIYTA administration kit" may be a
convenient way to provide medical and nursing staff with
most of the materials needed to prepare and administer
CYTAs safely. The kit should be appropriately packaged
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and labeled, and it shquld contain items such as the fol­
lowing:
• An appropriate size disposable plastic tray lined with
plastic-backed absorbent paper; the CYTA should he
prepared on this tray.
• Disposable surgical or vinyl gloves.
• Gauzes (4 X 4 inches) for cleanup.
• Empty vials (5-15 ml) as a receptacle for excess drug
solution, if needed.
• Small carton or pastic jar to use as a receptacle for used
ampuls (if required).
• A.4-mil plastic Ziploc' or wire-tie bag with a CYTA
warning label. It should be large enough to contain the
waste materials as described in Housekeeping, Waste
• Disposal, and Spill Management, item B(4).
• Disposable gown (optional).
• Since eye and face protection apparel is reusable and
would not be in the kit, a reminder card (i.e., "wear eye
' protection") may be advisable.
• Alcohol wipes.
• Any other items commonly used for CYTA adminis­
tration in the institution.
• Accessory CYTA warning labels to apply to syringes,
LVP solution containers, and the like.
• Surgical mask (if deemed desirable) to be worn while
administering the drug and a disposable dust and mist
respirator mask to be worn while preparing the drug for
administration.
b. Level II: Same as level I since a kit is designed to ac­
commodate the preparation and administration of a small
number of medications.
c. Level III: Same as level II.
3. Administration sets
a. ,Level I: Infusion sets and pumps should have Luer-
locking fittings. They should be watched for signs of
leakage during use. A plastic-backed absorbent pad
should be placed under the tubing during administration
to catch any leakage. This pad can be used to bleed the
line although a better procedure is to bleed it into a gauze
inside a sealable plastic bag. When priming i.v. sets or
expelling air from syringes, a sterile gauze should be
placed over the fitting or needle tip to catch any solution
that may be discharged. Alternatively, an empty vial may
be used as a receptacle. Syringes, i.v. bottles and bags, and
pumps should be wiped clean of any drug contamination
with a gauze pad. Hands should be washed after prepar­
ing or administering a CYTA. , • ,
b. Level II: Same as level I.
c. Level III: Same as level I.
5. Written administration procedures
. a. Level I: Written procedures for ordering and adminis­
tering cytotoxic drugs should be prepared. They should
include the following:
• Information that must be included in the physician's
order.
• Information to be reviewed before the drug is admin­
istered (e.g., research protocol instructions)..
• Guildelines for specific administration methods (e.g.,
butterfly injections).
• Relevant items from the institution's CYTA,proce­
dures (e.g., waste disposal).
Any materials and drugs needed to,treat extravasation

should be at hand during the administration process.
b. Level II: Same as level I.
c. Level III: Same as level I.
6. Labels
. a. Level I: All packages of CYTAs must have a CYTA
- warning label. Any drug that is prepared for adminis­
tration but not used immediately must be .completely
labeled with at least the drug name, concentration, and
volume or total dose contained or delivered.
b. Leoel//; Same as levell.
c. LevelIII: Same as level I.
7. Patient waste
a. Level I:Urine and other excreta from patients receiving
CYTAs must be bandied wearing gloves. Contaminated
garments should be changed. Avoid skin contact and
, ' splattering during disposal.
b. Level II: Same as level I.
c. Leue////; Same as level I.
8. Compliance
a. Level I: Staff who will administer CYTAs must be in­
formed about tbe protective, apparel to be worn and
procedures to be followed for drug preparation and ad-
ministration, disposal, spillage, or contact with skin or
eyes [sre Legal and Personnel Considerations, item A(l)].
Compliance with these requireme.nts should be verified
periodically.
b. Level II:Same as level I.
c. Level III: Same as level I. .
Housekeeping, Waste Disposal, and Spill Management
A. Housekeeping
1. Storage
a. Level I: Containers of CYTAs should not be stored or left
temporarily on counters or carts where they can easily
be knocked off and broken. Bins, shelves with wire bar­
riers at front, or other designs that reduce the chance of
CYTA vials or bottles falling to the floor are suggested
for CYTA storage and holding. Bulk or inactive storage
of CYTAs should be designed to reduce dust collection.
This can be accomplished by using closed shelves or by
keeping vials, bottles, and ampuls in closed, clear plastic
bags. The goal is to minimize the introduction of dust into
the laminar airflow hood.
b. LeueL//; Same as level I.
c. Level III: Same as level I.
2, Routine housecleaning
a. Level I: Routine housekeeping procedures should not
generate dust (i.e., do not dust shelves or dry sweep
. floors). In the event of a spill, any scheduled cleaning of
the area must be suspended until it has been properly
cleaned up. Cleaning should not be done near and during
CYTA preparation. Housekeeping personnel must be
oriented to the CYTA hazards. Routine disinfection of
clean rooms or other work areas or surfacesshould be as
established by the institution's housekeeping and infec- '
tion-control'personnel.
b. Level II: Same as level I.
c. Level III: Same as level I.
B. Spills . contaminated, should be put in a sealed CYTA disposal
1. Direct contact with CYTAs
a. Level I: The following action should be taken for overt
contamination of gloves or gowns or direct skin or eye
contact with CYTAs:
• Immediately change the involved gloves or gown.
• Immediately wash the affected skin area with soap and
water; it should be examined by a physician as Soon as
possible.
• For eye exposure, immediately flood the affected eye
• with water or eyewash designated for that purpose.
Medical attention should be obtained immediately.
Cirtoloxic drags
• Accidents involving skin or eye contact should be re­
ported and documented in accordance with hospital
procedures governing staff injuries.
- For those CYTAs that are used frequenUy and for
wmch specific (stable) chemical inactivators exist (e.g.,
sodium thiosulfate solution for mechlorethamine hy­
drochloride), prepackaged ready-to-use inactivator so­
lutions, should be kept on hand.
b. Level II:Same as level I.
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c. Level III:Same as level I.
2. Small spills in hood
a. Level /; Small spills involving under 5 ml of CYTA ma­
terial that occur inside a safety cabinet should be hnnHlpd
as follows:
• Leave blower on.
• Double gloving is suggested.
• If liquid, clean up with absorbent gauze pads or a pro­
prietary absorbent product, such as 3M LSM"- absorbent
sheets. The absorbentshould be gently placed on the spiU
so that liquid is not splashed about the hood.
• If solid, cover and wipe with wet (with water) absorbent
gauze.
• Place the pad(s) with the absorbed CYTA material in
a cytotoxic waste disposal bag [as described in House­
keeping, Waste Disposal, and Spill Management, item
B(4)] and seal.
• The spill area should be wiped clean three times using
sterile water and then 70% isopropyl alcohol.
• Any broken glass fragments should be placed in a gmnll
cardboard or plastic container and then into the CYTA
disposal bag.
• If it is iiecessary to raise the hood's faceshield to clean
up the spill, a dust and mist respirator and splashgoggles
must be worn during the cleanup.
• If a CYTA isspilled into the intake perforations of the
hood, remove the work surface according to the manu­
facturer s directions and thoroughly clean the drain pan
in the proper manner, discarding all cloths and other
materials used in the cleaning process.
• If, for some reason, the HEPA filter of a hood is con-
^inated with CYTA, the unit must not be used. A sign
"Do Not Use—Contaminated" should be placed on the
unit.^ The filter must be changed as soon as possible ac­
cording to the manufacturer's instructions by personnel
wearing protective gloves, goggles, respirator mask,and
gown. Whoever is changing the filter must be informed
that it is CYTA-contaminated. The filter should be
placed in a plastic CYTA disposal bag.
b. Leoe///; Same as level I.
G. Level III:Same as level I.
3. Small spills outside hood
a. Level I:Small spills involving under 5 ml of CYTA ma­
terial on counter tops, floors, or other areas outside the
hood should be handled as follows:
• Mark and isolate the areas of the spill so that it is not
disturbed by other personnel.
• Clean up the spill immediately wearing gloves, respi­
rator, and eye protection; the procedures presented in the
preceding section should be used. Noncleanable items,
including any other drugs or supplies that may have been
bag. Glassware or other contaminated items should he
placed in a plastic bag so that they do notspread the spill,
transferred to the sink, and then carefully washed with
an appropriate detergent. Avoid splashing while
washing. -
, b. Leuei//.• Same as level I.
c. Level III: Same as level I.
4. Spill kits
a. Level I: Use of a "CYTA spill kit" is recommended. This
kit should be suitably packaged and kept in a promi­
nently marked, readily accessible location. It should
contain these items:
Vol 40 JUI1983 -American Journal of Hospital Pharmacy 1169
Cytotoxic drugs
• Disposable dust and mist respirator.
• Chemical splash goggles.
• Vinyl gloves.
• Two or more sheets (12 X 12 inches) of 3M LSM'' Ab­
sorbent (or equivalent material) for small spills..
• 250-ml and 1-liter Spill Control Pillows'' (or equivalent
product) or a 2-pound package of a 1:1 mixture of J. T.
Baker Solusorb"" and fine vermiculite. The Pillows are
very convenient, but the Solusorb mixture is better for
spills that have spread under counters or other hard to
reach areas. Absorbents should be incineratable.
• Two "cytotoxic waste-disposal bags." These bags
should be (1) scalable; (2) colored to distinguish them
from other hospital waste; (3) made of 4-mil thick poly­
ethylene, 2-mil polypropylene, or an equivalent material;
(4) approximately 12 X 18 to 18 X 24 inches; and (5) la­
beled with a "Cytotoxic Hazard" label of approximately
3X4 inches, such as the one shown here. (The term
CAUTION: CHEMOTHERAPY
HANDLE WITH GLOVES
DISPOSE OF PROPERLY
"chemotherapy" or "cytotoxic" is prefeted on the label
rather than the term "cancer.") All materials used in,
cleaning the spill should be placed in tbe bag for disposal.
The bag should be tightly sealed with a wire tie or other
closure.
At least one CYTA spill kit should be placed in each
area where CYTAs are handled.
b. Level II: Same as level I.
c. Level III: Same as level I.
5. Large spills
a. Level I: For spills of amounts larger than 5 ml or 5 gm,
limit the spread of the spill as fast as possible by gently
covering with absorbent sheets or pillows or, if a powder
is involved, by covering it with one or more damp cloths
or towels. Access to the spill area should be restricted.
(The help of another staff member may be required if the
spill is in a hallway or other traffic area.) Protective ap­
parel as described previously is required. All contami­
nated surfaces should be thoroughly cleaned with de­
tergent solution and wiped with clean water. If a specific
chemical inactivator exists for the spilled CYTA, it may
be used, provided that it is nontoxic and nondestructive
to the surrounding area, and that it does not substantially
spread the spill. Generally, applying the neutralizer to
the absorbed CYTA is better than applying it directly to
the spill. Neutralizers that react with splattering should
not be used. Protective goggles should be wiped clean
with water and alcohol after the cleanup; gloves, gowns,
and disposable respirator masks should be discarded in
a cytotoxic waste disposal bag. All contarhinated ab­
sorbents and otber materials should be put' into the.
CYTA disposal bag also. If the spill is in a hood, decon­
tamination of all interior hood surfaces may be required.
A brief report should be prepared that documents the
date, time, and location of the spill; the personnel in­
volved; the material and amount of the spill; and the ac­
tion taken. One copy should be kept in the permanent
files of the department; additional copies should be dis­
tributed per hospital policy for such incidents (if it has
one).
b. Level II: Same as level I. • Medical Surveillance
c. Level III: Same as level I.
: C. Waste disposal
1. Routine waste collection
a. Level I: Housekeeping personnel must wear vinyl gloves
when handling CYTA-waste containers. They must be
1170 American Journal of Hospital Pharmacy Vol 40 Jul 1983
instructed on procedures governing spills and leaks (see
recommendations in this section). The need to handle
bags and boxes of CYTA waste with care must be
stressed. CYTA trash must at all times be kept separate
from other trash. The cytotoxic waste disposal bags
should he used for the routine-accumulation and collec-
. tion of used CYTA containers, syringes, discarded gloves,
etc. All (and only) CYTA-related waste should be put in
these bags. Glass fragments and needles should be placed
in a plastic vial or cardboard box before placing them into
the bag. Bags of CYTA waste must be seded before being
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moved or collected. The bag should be inside a covered
waste container clearly marked, "Cytotoxic Waste Only."
At least one such receptacle should be located in every
area where CYTAs are prepared or administered so that
CYTA waste is not "carried around." The bag should be
changed before it is filled to overflowing. An alternative
to a CYTA bag in a waste basket receptacle is to have the
disposal bag inside a cardboard box labeled with a CYTA
warning label on all four sides and marked, "Cytotoxic
Waste Oiily." Attached to the box is, a piece of tape. When
the inner bag is full, it is sealed, and the carton is closed
and sealed with the tape provided. The box is disposed
of and then replaced with a new unit. With this system,
. there is reduced direct handling of bags of CYTA waste.
(Cartons specifically designed for hazardous wastes are
available commercially.)"
b. Level II: Same as level I, except that because of the larger
• volume of CYTA materials handled, larger waste recep^
tacles may be required. This may necessitate use of
stronger CYTA disposal bags.
c. Level III: Same as level II. , •
'2. Disposalinsink
a. Level I: If not in violation of local or state law, amounts
of CYTA solutions not to exceed 5 rhl/day may be dis-
, carded by carefully flushing down the drain with copious
amounts of water. Larger amounts should be placed in
a CYTA disposal bag for proper disposal. Chemical in-
activation before disposal is recommended when pos­
sible.
b. Level II: Because of the larger CYTA workload, CYTA
waste should not be discarded via the municipal sewer
system'> unless first chemically destroyed or inacti­
vated. . • •
c. Level III: Same as level II.
3. Trash collection, removal, and destruction
a. Level I: CYTA waste (e.g., used drug vials and syringes,
contaminated apparel) must be handled separately from
other hospital trash. Housekeeping personnel must be
instructed on how it is to.be handled- CYTA waste is-
considered toxic waste and must be disposed of in ac­
cordance with all applicable regulations. Currently, in­
cineration at 1000 °C is considered to be the best way of
destroying CYTA waste. Disposal in a licensed sanitary
landfill site is considered an alternative to high-temper­
ature incineration. State, federal, and, in some locales,
municipal regulations govern the disposal and destruction'
of toxic waste. These regulations must be followed if in­
cineration is performed on site. If CYTA waste collected
from the pharmacy and patient-care units is to be picked"
up by a commercial (must be ficepsed) waste-disposal
company, it must be held in a secure area in covered
drums marked with prominent CYTA warning labels.
The drum should have a 65-miI polyethylene (or equiv-'
alent) liner.' " . .
b. Level II: Same as level I.
c. LevelIII: Same as level I.-
A., Medical Surveillance
1. Physical examinations
a. Level I: Medical surveillance of personnel should be as
per standard hospital policy. Employees subjected -to

acute direct exposure to CYTAs must receive a physical
examination with particular attention paid to the eyes,
buccal and nasal mucosal membranes, and the skin.
b. Level 11: A physical examination is required before an
employee is assigned to prepare or administer CYTAs.
The exam should include determination of any specific
risk factors (e.g., smoking, family medical history) and
a complete blood count with differential to establish a
baseline against which changes can be measured. Physical
examinations should he repeated based on the person's
• age (every three years to age 40, every two to age 55,then
annually thereafter) or per hospital policy, and after acute
exposure (see level I).
c. Level III: Same as level II. When it becomes feasible,
medicd surveillance should be expanded to include
screening of employees for evidence of mutagenic
changes. Currently, however, no totally satisfactory
procedure for accomplishing procedure for accomplishing
this exists. Environmental health authorities should he
consulted when policies and procedures for monitoring
mutagenic changes in personnel are being considered.
Legal and Personnel Considerations
A. Legal and Personnel Considerations
1. Information given to staff
a. Level I: All prospective employees must be informed that
they may he required to work with CYTAs (if that is the
case). Note that this and the recommendations that fol­
low apply to temporary as well as permanent staff,
members.
The relevant CYTA policies, and procedures must be
in writing and readily available for reference.Supervisory
•staff should review the procedures with their per­
sonnel.
The toxic nature of CYTAs should be described to
personnel in balanced terms. The rationale for each
CYTA procedure or change in procedure should be given.
That the procedures are thought to provide adequate
safety, hut that 100% protection cannot be guaranteed,
should be noted.'
All personnel must be informed that
• The procedures governing the handling of CYTAs in
the institution must be followed.
• Adherence to these procedures will be monitored, and
noncompliance may result in disciplinary action.
Medical staff members must be informed through the
customary channels about relevant CYTA policies and
procedures and that they will be expected to comply with
thftm'
b. Level II: Same as level1.
c. Level III: Same as level 1.
2. Emergencies
a. Level l: Proper and timely medical treatment for acute
CYTA exposures must be provided.
b. Level II: Same as level 1.
c. Level III: Same as level 1.
3. Unusual situations
a. Level I: The legal considerations in situations such as an
employee's refusal to handle toxic drugs or damages al­
leged to have resulted from CYTA exposure are complex
and will vary from case to case. Thus, no general guide­
lines can begiven other than to state that the institution's
legal counsel must be consulted as soon as a situation of
this type arises.
b.. Level II: Same as level 1.
c. Level III: Same as level 1.
4. Exposure registry
a. Level I: In this category, a registry is desirable.
b. Level II: A permanent registry of all staff who routinely
Cjrtoloxlcdnigt
prepare or-administer CYTAs must be mflintj^ined If
feasible, the numbers of each drug the employee has
prepMed or administered should be recorded. (The
hospital's procedures for documenting radiation exposure
of employees might serve as a model for the CYTA reg-
) istry.)
-^e. Level III: Same as level II.
5. Government regulations
a. Level I: Many aspects of handling hazardous substances
in hospitals are now or will he subject to governmental
Downloaded from https://academic.oup.com/ajhp/article-abstract/40/7/1163/5203051 by University of Waterloo Porter Library user on 05 May 2019
regulation. Local, state, and federal occupational safety
and environmental protection agencies may specify cer­
tain cytotoxic drugs as legally defined hazardous com­
pounds. Hospitals thus might be required to comply with
VMious regulations governing the use, transport, and
disposal of these drug products. In cases where govern­
mental regulations differ from the recommendations in
this document, the more stringent procedure should be
followed. Legal counsel should be consulted as needed.
b. Level II: Same as level 1.
c. Level III: Same as level 1.
• This new publication can be ordered from ASHP for $10. For more in­
formation, contact the ASHP Special Projects Division.
While the recommendations in this paper assume that the toxicities of
various cytotoxic agenU are the same, they actuaUy differ considerably. Op-
toally, the safety precautions used would be based on the CYTA in question.
That IS, a relatively very toxic CYTA might require very stringent precautions
irregardless of the overall cytotoxic workload of the department.
P®""?" should, if possible, prepare close to the average number of
CYTAs per number of qualifiedstaff available. For example,if 30 CYTA doses
or products are prepared or administered in a typical shift hy three employees,
the workload should be distributed so that each will prepare about 10 of the
30. This is preferable to one person doing 20, another 7 and a third, 3. As a
second example, if the monthly CYTA workload is 300 and four qualified staff
me available for their preparation, each person should prepare about 75
CYTAs during the month.
^ Available from Lab Safety Supply Company, Janesville, WI 53547-
1368. DO.
® Since solutions of quinine will fluoresce under ultraviolet (UV) light, these
solutions can be used to detect sloppy compounding tecbnique.2 A UV light
IS briefly shined over the operator's hands, coat, and the involved work sur­
faces after he has manipulated a quinine-test solution (simulating preparation
of a CYTA dose). Spilled and splattered drug solution—indicating poor
technique—fluoresces under the light.
' In general, if a piece of equipment can be used to meet a safety-related
requirement, it should be used in lieu of relying on personnel to perform the
task. ,
8 "Hood" is a common term used for "biological safety cabinet" A Type
A hood discharged exhaust air through a HEPA filter back into the room
environment. A Class II Type B unit discharges the filtered exhaust air di­
rectly to the outdoors via an appropriately designed, dedicated ductwork
system. Several categories of Type B cabinets have been proposed, based on
the amount of air that is exhausted. Thiscan range from about 70% (thus, 30%
of the air U recirculated) to 100%. Because of the supply filter placement. Type
B units of the 70% exhaust/30% recirculated design may provide slightly less
protection to the product heing handled than Type A units.
3M, Occupational Health and Safety Products Division, SL Paul, MN
55144.
i Millipore Corporation, Bedford, MA 01730.
' Burron Medical Inc., Bethlehem, PA 18018.
' Available from Lab Safety Supply Company, Janesville, WI 53547-1368,
or other laboratory, industrial, or hospital supply distributors.
The Dow Chemical Company, Indianapolis, IN 46268.
"I J. T. Baker Chemical Company, Phillipsburg, NJ 08865.
° Biosafety Waste Containers, Biosafety Systems, Inc., San Diego, CA
92101.
"Note, however, that many CYTAs are excreted unchanged or as cytotoxic
metabolites, and tbese represent a 10-15 times greater source of CYTAs in
sewage than waste and excesssolutions disposed of "down the drain."
References
1. American Society of Hospital Pharmacists. Procedures for
handling cytotoxic drugs. Bethesda, MD: American Society of
Hiwpital Pharmacists; 1983.
2. Wilson JP, Solimando DA. Aseptic technique as a safety pre­
caution in the preparation of antineoplastic agents. Hasp Pharm.
1981; 16:575-81.
Vol 40 Jul 1983 American Journal of Hospital Pharmacy 1171