NURSING PATIENT CARE POLICY & PROCEDURE
To safely access and administer chemotherapeutic agents intrathecally via subcutaneous
reservoir and ventricular catheter (Rickham, Ommaya) and/or obtain Cerebral Spinal
Fluid (CSF) fluid for lab studies.
Only providers who have been trained to administer chemotherapy at UWHC, and had
special training in accessing Central Nervous System (CNS) reservoirs may perform this
procedure. Order process and administration of chemotherapy should conform to UW
Health Clinical Policy 6.1.3, Intrathecal Chemotherapy Ordering, Administration and
A. Order for intrathecal chemotherapy as appropriate (see procedure)
B. Laboratory requisition and patient labels as appropriate for specimen processing
C. Fenestrated towel (optional)
D. Sterile drape
E. Sterile gloves
F. Sterile specimen cups/tubes as needed
G. Masks – One (1) for patient, one (1) for each person involved with the procedure or in
H. Two (2) Chlorhexidine swabs
I. One (1) 5-10 mL sterile syringe
J. One (1) Sterile 25 gauge butterfly needle with attached extension tubing
K. Two (2) Sterile 2x2 gauze pads
L. One (1) adhesive bandage
N. Sterile normal saline or Preservative-Free Lactated Ringers, Sodium Chloride (NaCl)
or Hydrocortisone for flushing - volumes to approximate volume aspirated using CSF
or if extra fluid is needed to equalize volumes of aspirate and flush.
A. Obtain consent according to UWHC Hospital Administrative Policy 4.17, Informed
Nursing Manual (Red)
Policy #: 10.14AP
Title: Access to Intrathecal Reservoirs &
Administration of Medications Including
Chemotherapeutic Agents (Adult & Pediatric)
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B. Order chemotherapy drug(s) and flush via Beacon Treatment Plan or paper order
form, "Intrathecal Chemotherapy Order Form, Pre-Printed Chemotherapy Order."
C. Perform hand hygiene according to UWHC Hospital Administrative Policy 13.08,
Hand Hygiene, and gather equipment.
D. Perform Universal Protocol according to UWHC Hospital Administrative Policy
8.48, Operative, Invasive & Other Procedures.
E. Identity the patient prior to specimen collection using at least two (2) forms of patient
F. Don appropriate Personal Protective Equipment. The patient, staff and any observers
in the area need to wear a mask.
G. Position patient comfortably (supine is best) to provide ready accessibility to
reservoir and comfortable position for staff. Trendelenburg may be necessary to
increase intracranial pressure and encourage flow of CSF.
H. Trim, as needed, any hair growth on or around the reservoir.
I. Examine area over reservoir for signs of infection or trauma.
J. Locate and palpate reservoir noting landmarks. If accessing an Ommaya Reservoir,
gently pump the septum 7-8 times to prime the reservoir.
K. Prepare a sterile field and open equipment onto sterile barrier.
L. Put sterile gloves on.
M. Prep area of reservoir starting from the center moving outward to approximately
create approximately a three inch (3") diameter with two (2) chlorhexidine swabs,
scrubbing with each swab for one to two (1-2) minutes. Allow to dry before accessing
N. Drape with fenestrated towel if desired.
O. Palpate the center of the reservoir. Insert the 25 gauge butterfly needle, bevel down,
into the center of the septum. CSF should flow into the tubing if the needle is
properly placed. (If CSF does not flow into the tubing, attempt gentle aspiration or
Trendelenburg positioning before repositioning the needle. Pressure may be low.)
1. Use an oblique angle of 30 degrees or less to achieve the greatest yield of
cerebral spinal fluid and to prevent the needle from piercing the ventricular
catheter. If gross blood appears in the tubing, a capillary may have been
punctured. Remove the needle and re-access with a new needle in a new site
on the reservoir. Make a note on the lab card "TRAUMATIC STICK" if
multiple attempts are made, to account for possible red cells in specimen.
2. DO NOT INSERT THE NEEDLE PERPENDICULAR TO THE SCALP. It is
possible to puncture the catheter that is attached to a nipple at the base of the
P. Attach sterile syringe to butterfly tubing and very gently at a rate of no more than one
(1) mL/minute, aspirate up to ten (10) mL of CSF (see below to calculate exact
1. Amount of CSF will depend on the volume of medication to be infused and
the need for samples to be sent for culture, gram stain, cell count, cytospin,
protein, etc. (1 – 2 mL/specimen cup)
2. Amount of aspirate = Amount of fluid instilled (medication & flush)
a. For Pediatrics, amount of aspirate is equal to one-half the amount of
Q. Pinch off butterfly tubing and disconnect specimen syringe and connect medication
syringe. Inject slowly over 5-10 minutes, monitoring patient for adverse reactions.
Follow with slow flush.
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R. Remove needle and apply gentle pressure with sterile 2x2 gauze to injection site.
Apply adhesive bandage or sterile 2x2 dressing.
S. If accessing an Ommaya Reservoir, gently pump the septum 7-8 times to circulate
medication. The patient may hear a whooshing or squishing sound, and may
experience headache, nausea, and dizziness.
T. Provider will document amount of fluid removed, medication instilled and other
information in appropriate places.
A. Nursing Monitoring
1. Instruct patient to remain supine or semi-recumbent for 30 minutes following
2. Assess neurologic status following the procedure as ordered and document.
3. Label specimen containers and appropriate lab slips and take specimens
directly to Core Laboratory. Refer to UWHC Clinical Laboratories Policy
1502.5.06, Acceptance Policy for Specimen Identification.
VI. UWHC CROSS REFERENCES
A. Clinical Laboratories Policy 1502.5.06, Acceptance Policy for Specimen
B. Hospital Administrative Policy 4.17, Informed Consent
C. Hospital Administrative Policy 8.48, Operative, Invasive & Other Procedures
D. Hospital Administrative Policy 13.08, Hand Hygiene
E. UW Health Clinical Policy 6.1.3, Intrathecal Chemotherapy Ordering, Administration
Oncology Nursing Society (2011). Access Device Guidelines: Recommendations for
Nursing Practice and Education (3
Ed.). Pittsburgh, PA: Oncology Nursing Society.
VIII. REVIEWED BY
Clinical Nurse Specialist, Oncology
Hematology Providers, Pediatric and Adult
Oncology Practice Committee
Nursing Patient Care Policy and Procedure Committee, November 2016
Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer