9.2 Safe Handling, Administration, and Vesicant Precautions

USP <800> is the United States Pharmacopeia chapter that governs hazardous drugs (HDs) from the loading dock to the trash. The National Institute for Occupational Safety and Health (NIOSH) identifies which agents are hazardous; USP <800> tells you how to receive, store, compound, administer, dispose, and clean them. CPHON items mix <800> with vesicant policy and home oral-chemo teaching. The dedicated extravasation-emergency section later in this guide covers antidote algorithms in depth; this section is prevention and the first five minutes.

USP <800> chain: receipt through spills

Receipt. HDs arrive in a designated area. Cartons can be contaminated on the outside. Wear chemo-tested gloves to unpack. A damaged package is a spill until proven otherwise.

Storage. Antineoplastic HDs that require manipulation are stored separately from non-HDs, in a negative-pressure room with adequate air changes. They are not stored in a positive-pressure cleanroom that would blow contamination outward.

Compounding. Sterile HDs are compounded in a containment primary engineering control (C-PEC)—a biological safety cabinet or compounding aseptic containment isolator—inside a containment secondary engineering control (C-SEC), a negative-pressure room. Horizontal laminar-flow benches that blow toward the operator are wrong for chemotherapy. Closed-system transfer devices (CSTDs) are used during compounding when the dosage form allows; they supplement the hood, they do not replace it.

Administration. CSTDs are used at the bedside when the dosage form allows. PPE is not optional because you "only spike the bag."

Disposal. Trace chemotherapy (empty bags, tubing, gloves, gowns) goes in designated HD waste. Bulk unused drug follows hazardous-waste rules. Needles are not recapped into a tray of clean syringes.

Spills. Every unit that hangs chemotherapy has a spill kit and staff who have practiced it. Evacuate nonessential people, don full spill PPE (including eye protection and a respirator when the kit or policy requires it), contain, absorb, clean per the kit, and document. A toddler's disconnected tubing on the floor is a spill, not a housekeeping ticket.

PPE for administration

USP <800> and Oncology Nursing Society / Association of Pediatric Hematology/Oncology Nurses practice align on the administration minimum for parenteral antineoplastics:

• Two pairs of chemotherapy-tested gloves (change when torn, contaminated, or at policy intervals).
• A gown shown to resist HD permeability, closed in the back, long sleeves, cuffs.
• Eye and face protection when splash is possible (spiking, disconnects, emesis, splatters).
• A respirator (N95 or better per policy) when there is inhalation risk: aerosols, powder, certain spills. A surgical mask is not a respirator.

Do not eat, drink, or apply cosmetics in HD areas. Remove PPE so the outer gloves come off without smearing drug onto skin, then wash hands.

Pregnancy and staff protection. Hazardous-drug handling is a reproductive-risk job. Many institutions offer alternative duty to workers who are pregnant, trying to conceive, or breastfeeding so they are not compounding or administering antineoplastic HDs. This is an occupational-health process, not a suggestion that one glove is enough if you are careful. Male staff also receive reproductive-risk counseling. Medical surveillance programs exist in <800> facilities.

Two-nurse independent verification

Before any parenteral chemotherapy—and for high-alert oral doses per policy—two nurses independently verify:

1. Patient (two identifiers).
2. Drug (generic name matches the protocol order).
3. Dose (recalculate from current height and weight to BSA or mg/kg, including caps).
4. Route (IV versus IT versus intramuscular versus oral—this is how vincristine deaths are prevented).
5. Rate.
6. Time (right day on the roadmap, leucovorin clock running, hydration infusing).

Independent means two people each do the math, not one nurse reading numbers while the other nods. Special IT timeout: preservative-free, IT label, no vinca on the field.

Vesicants versus irritants

Vesicants cause blistering and necrosis if they leak into tissue. Pediatric exemplars include anthracyclines (doxorubicin, daunorubicin), vinca alkaloids (vincristine), mechlorethamine, and others such as dactinomycin. Irritants cause pain or inflammation without the same necrotic punch; many platinum and alkylator infusions sit in this group. Policy—not convenience—decides central versus peripheral. Vesicants are given through a central line whenever one is available and functional (blood return, no occlusion). Peripheral vesicant administration, when a protocol or emergency forces it, uses a freshly started large-vein IV, continuous blood-return checks, and a nurse who stays with the child. Do not hide a vesicant behind an infusion-pump alarm and walk away.

Prevention: confirm blood return before and during, never ignore pain, burning, or swelling, never flush against resistance, use CSTDs, and teach a child old enough to report "it burns."

Extravasation: first steps only

If you suspect extravasation:

1. Stop the infusion immediately.
2. Aspirate residual drug through the existing catheter if you can; do not flush.
3. Disconnect the tubing; leave or remove the catheter per protocol after aspiration.
4. Notify the provider and mark or photograph the site; elevate the limb.
5. Apply cold or warm compresses by drug class per protocol (commonly cold for anthracyclines, warm for vincas)—do not invent a single compress rule for every drug.
6. Antidotes are class-specific, not universal. High-level concepts: dexrazoxane (systemic) and, in some protocols, topical dimethyl sulfoxide (DMSO) for anthracyclines; hyaluronidase for vinca alkaloids. There is no single universal extravasation antidote. Full emergency staging lives in the later hypersensitivity and extravasation chapter.

Oral chemotherapy at home and body fluids

Families handle mercaptopurine, methotrexate, cyclophosphamide, and other orals. Teaching:

• Wear gloves. Do not crush hazardous tablets carelessly (aerosol and residue). If a liquid or crush is required, pharmacy should prepare it as an HD.
• Store away from food and from siblings' vitamins; never in a labeled candy cup.
• Return unused doses to a take-back program—do not flush or toss in regular trash.
• Pregnant caregivers should not handle crushed or split HD tablets.

Body-fluid precautions. Many pediatric centers teach families to treat urine, stool, vomit, and diapers as contaminated for about 48 hours after chemotherapy (double-flush, gloves for diapers, lined trash). Teach this as common institutional practice, not as an ONCC-published hour. Follow your unit's number if it differs, but do not leave families with zero precautions.

The CPHON product at the bedside is a nurse in the right PPE, a second nurse who recalculated the BSA, a central line with blood return before a vesicant, and a family that can glove, not crush, and return leftover tablets.