St. Tammany Parish Hospital Department of Nursing

ST. TAMMANY PARISH HOSPITAL DEPARTMENT OF NURSING COVINGTON, LOUISIANA

ADOPTED DATE: April, 1994

REVIEW/REVISE DATE: 6/96; 8/99; 10/01; 10/04; 9/05; 7/08

______DIRECTOR OF NURSING

TITLE: INTRAVESICULAR ADMINISTRATION OF TICE BCG VACCINE FOR CARCINOMA IN SITU OF THE BLADDER PROCEDURE

CRITERIA FOR PERFORMANCE:

A qualified physician or a RN with knowledge of immunologic agents may administer live BCG vaccine intravesically. A written informed consent must be obtained prior to initial administration of BCG vaccine.

OBJECTIVE:

To administer intravesicular TICE BCG vaccine in a safe appropriate manner

INDICATIONS FOR TREATMENT:

Treatment and prophylaxis of carcinoma in situ of the bladder and for prophylaxis of primary of primary or recurrent stage Ta and/or T1 papillary tumors after TURP. Not indicated for papillary tumors of stages higher than T1.

CONTRAINDICATIONS:

. Immunosuppressed patients or persons with congenital or acquired immune deficiencies, whether due to concurrent disease (e.g., AIDS, leukemia, lymphoma) cancer therapy (e.g., cytotoxic drugs, radiation) or immunosuppressive therapy (e.g., corticosteroids). . Treatment should be postponed until resolution of a concurrent febrile illness, urinary tract infection, or gross hematuria. . Persons with active tuberculosis. Rule out in individuals who are PPD positive before starting treatment. . Concurrent treatment with antibiotics, since antimicrobial therapy may interfere with effectiveness; concurrent infections.

EQUIPMENT/SUPPLIES:

Short term catheter tray with #16 French red rubber catheter Chemotherapy Waste Disposal Can Chemotherapy protective gown, gloves, and mat 2 – Eye shields, for the nurse administering and for the patient 2 – Masks for the nurse administering and for the patient Absorbent blue pads BCG Vaccine reconstituted from Pharmacy in Biohazard Disposal Bag 50cc sterile, preservative-free Saline 60cc catheter tip syringe 2 cups of Bleach PROCEDURE:

NURSING ACTION 1. Wash hands 1. To decrease unwanted exposure of other patients, including chemotherapy patients. 2. Place patient in private room with no other patients. Get baseline set of vital signs. Assess for the presence/absence of fever or urinary tract infections. 3. Verify results of urinalysis done pre-treatment. Call 3. Patient should not receive BCG if symptoms of UTI, results to physician treating patients. elevated WBC, or blood in urine are evident since it can promote a systemic BCG infection. 4. Have the patient urinate before treatment begins if possible 5. Place blue pad under patient on the bed to decrease the chance of linen contamination 6. Have patient lie supine in bed. Using sterile catheteri- 6. Every effort should be made to make the catheterization procedures, drape and catheterize the patient with a zation non-traumataic. short term catheterization tray and a #16 French red rubber catheter. 7. Empty the bladder of any residual urine. 7. To enable the patient to hold the bladder instillation the required 1 – 2 hours. 8. Don chemotherapy administration protective 8. To decrease possibility of exposure to live BCG gown and gloves. In addition, don a face mask and eye Vaccine during instillation. Gown, gloves, and mask may shield. Have Chemotherapy Waste Disposal Can in room. be removed after administration, but should be used in cleaning up after procedure also. 9. The patient should don a mask and eye shield during 9. To decrease possibility of exposure to live BCG the instillation of solution and then they may be removed. Vaccine.

10. Draw up 40cc of preservative-free Normal Saline into 10. Gently swirl the syringe to mix after adding TICE BCG a 60cc catheter tip syringe. Using chemotherapy Vaccine. The reconstituted TICE BCG must be used absorbent mat, dispense the cloudy BCG suspension into immediately. the end of the catheter tip syringe containing 40cc of preservative-free Normal Saline 11. Place empty BCG syringe in Chemotherapy Waste 11. Decrease possibility of room contamination. Can and close lid. 12. Attach the 60cc syringe to the catheter and gently 12. DO NOT DEPRESS THE PLUNGER AND FORCE remove the plunger. THE FLOW TO THE TICE BCG. 13. The reconstituted TICE BCG should be allowed to enter the bladder by gravity flow over 3 – 4 minutes. 14. Once the instillation is completed, withdraw the 14. Discard immediately into the Chemotherapy Disposal catheter into an absorbent blue bad to catch any droplets Can and snap lid. that may exit the catheter tip. 15. The patient should lay prone for 15 minutes, supine 15. Turning ensures that all bladder surfaces are coated for 15 minutes, right lateral position for 15 minutes, then with the solution. The solution should be held for up to 2 left lateral position for 15 minutes for the first hour. The hours to maximize bladder wall contact and drainage patient should hold the solution in the bladder for at least 1 effectiveness. hour, preferably up to 2 hours. 16. The nurse should stay with the patient the first 15 16. To monitor for possible local or systemic reactions. minutes, then check on the patient every 15 minutes x 3 to remind the patient to turn, then check every ½ hour x 2. 17. At the completion of the instillation, the patient should 17. Bleach kills the TICE BCG live vaccine. Allowing the be instructed to void in a sitting position in a commode bleach to sit for 15 minutes allows time for the live virus to where 2 cups of bleach has been added before voiding. die. Adding bleach BEFORE the patient voids minimizes The toilet should not be flushed for 15 minutes. contaminated urine splashing on or outside the commode.

18. All chemotherapy equipment and blue pads should be 18. Containers should not be reused for other placed in the Chemotherapy Disposal Can. Housekeeping chemotherapeutic waste. Goggles may be cleaned with should be called to remove the hazardous waste disposal. 70% Isopropyl Alcohol solution using a disposal towel. 19. Linen and gowns may be handled in routine fashion. The room and bathroom are cleaned with disinfectant in the routine fashion. 20. The patient should be instructed to: 20. Most reactions that are seen with BCG Vaccine are a. Use 2 cups of bleach in the commode with each local versus systemic and results from irritation to the voiding for 6 hours after completion of bladder wall. Forcing fluids will keep the patient voiding treatment. Wait 15 minutes after voiding before frequently, decreasing the chance of bladder irritation, flushing. Wash hands well after each voiding. bleeding, or urinary tract infections. The patient should a. Force fluids for 3-4 days after treatment (8-12 understand that if any symptoms of UTI persist or become glasses of fluid/day) to flush out bladder. worse or if flu-like symptoms are present, the physician b. Burning and frequent urination for the first day needs to be notified at once. or two after instillation is normal. Slight flu-like symptoms are also possible. d. If the patient experiences severe urinary side Provide patient Micromedex patient information on effects – blood in the urine, a fever of 103 medication before discharge. degrees or greater and/or flu-like symptoms that last more than 48 hours – the patient should contact the treating urologist immediately. 21. Discharge vital signs, tolerance of treatment, and patient understanding of discharge instructions should be recorded.

RELATED STANDARDS:

Foley Catherization Procedure Chemotherapy Safety Management Protocol

REFERENCES:

Manufacturer’s Drug Insert – TICE BCG Vaccine, Organon Teknika Corporation, Dec. 2006. Drug Information: Bacillus Calmette-Guerin (BCG) vaccine. Medline Plus website: www.nlm.nih.gov/medlineplus

DISTRIBUTION: Infusion Suite; Medical Oncology Unit

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