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23.9 Cytotoxic therapy: intrapleural instillation of cytotoxic drugs

Essential equipment

  • Sterile chest drain pack containing gallipot, disposable towel, forceps, disposable scalpel and sterile low‐linting gauze
  • Suture material: silk
  • Cleaning solution: chlorhexidine gluconate 0.5% in 70% alcohol
  • Sterile gloves and gown
  • Syringes: 2 × 10 mL

Medicinal products

  • Local anaesthetic: lidocaine 1%
  • Sterile water: 1 litre bottle
  • Needles: 1 × 21 G, 1 × 23 G
  • Chest drain: check appropriate size to be used for insertion
  • Sterile dressing
  • Tape
  • Chest drain tubing
  • Chest drain bottle
  • Chest drain clamps × 2
  • Low‐vacuum suction pump, if required

Pre‐procedure

ActionRationale

  1. 1.
    Explain and discuss the procedure with the patient.
    To ensure that the patient understands the procedure and gives their valid consent (NMC [178], C).
  2. 2.
    Administer premedication to the patient if prescribed.
    To relax the patient. E
  3. 3.
    Prepare the required equipment and cytotoxic drug. Wear protective clothing.
    To ensure the procedure goes smoothly without interruption. To protect the practitioner from exposure (HSE [104], C).

Procedure

  1. 4.
    Assist the doctor with the instillation and provide support for the patient. Place the patient in a sitting position, leaning forward over a strong surface or table which is locked in position.
    To increase the efficiency of the procedure and reduce discomfort for the patient (Shuey and Payne [235], E).
  2. 5.
    At the end of the instillation, clamp the drainage tube and leave for the desired period.
    To prevent backflow of the drug (Weinstein and Hagle [265], E).
  3. 6.
    Observe regularly for patient comfort. Administer analgesic as required.
    To keep the patient comfortable and free from pain. E
  4. 7.
    Record the patient's respirations and colour at least every 15 minutes for 1 hour, then every hour until stable, then 4 hourly or as frequently as the patient's condition dictates. Record temperature at least 4 hourly.
    To ensure there is no change in respiratory function following the procedure. E
    To observe for pyrexia, a common side‐effect that may indicate a developing infection or a reaction to chemotherapy. E
    Administer antihistamine if required. E

Post‐procedure

  1. 8.
    When ready to remove the drain, ensure the patient is in a comfortable position, and is aware of any limitations about movement.
    To prevent discomfort or dislodgement of the drainage tube. E
  2. 9.
    Unclamp the chest tube.
    To allow drainage of the drug instilled. E
  3. 10.
    Record the colour and amount of fluid drained.
    To monitor the immediate effectiveness of therapy (NMC [178], C).
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