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Al & Lois Website - Carcinoid Cancer - PROCEDURES

Carcinoid Cancer - Procedures

A Carcinoid Cancer Resource for the Layperson

In this section will be found more detailed information, including photos, of tests and procedures that I have experienced and have an interest in. Interest in may be that it is something that I see in the future for me. It also may be things which I hope that I never have to experience. There is no significance to the order in which the items are presented.

Sandostatin LAR - I have switched to this every 28 day version. My wife gave me the first injection in the Doctor's office under the supervision of two nurses. She did an excellent job. We did the second shot in the Docs office also and the nurse drew the "safe" locations on my buttocks. The following LAR brocure is OK but their method for locating the injection site is an older technique and involves some risk of hitting the sciatic nerve - something you must NOT do. My suggestion would be to let your Doc or Nurse instruct you in the more modern method of locating the injection site. If you have a digital camera and know how to use a good graphics program the following technique for checking your location at home may be helpful.
LAR Location Checking Method for home use - Digital camera and Graphics program capable of copying a selected portion of a photo needed - I use PSPaint. 1. When the nurse instructs your spouse or other person on locating the injection site, have her draw on both sides of your bare rear end a circle that is safe to do the injections. 2. When you get home have the person who is going to do your injections take a photograph with your digital camera of your rear end. You should be standing, the camera should be level with your buttocks, the markings should be visible and you should be able to duplicate the position of both you and the camera next month. A light colored background will work best for a light skinned person and a dark background for a dark skinned person. 3. Load the photo(s) into your computer and graphics program. 4. Crop the photo to show only your buttocks and a little bit of clear background on each side. 5. Draw lines (black/light skin, white/dark skin) along the outside edges of your buttocks, the lower edge and center crease of your buttocks. Also redraw the lines that the nurse has drawn. 6. Copy those lines and paste them into a new image with a background that is opposite of the color of your lines. In order to automatically copy those lines and nothing else, my graphics program also requires that the lines be connected. 7. Save the image with a title of "shotmap.jpg" or something else identifiable. 8. Next month when you prepare for your injection, have the person doing the injection to locate the site, draw a small circle around the site with a pen and then take a picture the same as was taken in step 2 above. 9. Load the picture and the "shotmap.jpg" into your graphics program. 10. Copy the "shotmap" lines and paste them into the picture using the side and folds of your buttocks lines to locate them. 11. If the target (small circle) falls within one of the circles that the nurse drew then you can procede safely with the shot. If not relocate it and try again. Comment: Sound like a lot of trouble? Possibly, but considering the injury that could be caused by a mistaken location, I think that it is worth the trouble and it certainly takes less time than going to the Docs office for every injection. Let me know if you find this useful.

There is important new information from Novartis on the mixing of Sandostatin LAR. It is valid for all dosages but is especially important at the higher 30mg level. They plan to reprint the brocure but have done so yet. I have inserted the new information into the brocure procedure below at the proper points; It is red and bold. The main points of the new info are: Bring to room temperature - 4 hours or more out of the refrigerator. LAR forms "clumps" easily; it does not harden. Do not rush unduly; You have 15 minutes or more "work time." You must agitate in the syringe to maintain the suspension. To properly agitate in the syringe you must draw air into the syringe. LAR is light sensitive - Leave the package closed until you are ready to use it. You may reinject the suspension into the vial if too much residue is left in it.

Package Contents Vial containing Sandostatin LAR Depot Vial containing diluent 5ml locking syringe Two 1.5" long, 20gauge needles Three alcohol wipes	Step 1 Allow the vials containing Sandostatin LAR Depot and the diluent to reach room temperature (4 to 24 hours) Cold LAR particles clump easily and may clog your needle! Remove the plastic caps from both vials.	Step 2 Remove the syringe cap. Attach one of the supplied needles to the empty syringe Use only 1.5" long 20 gauge needles.

Step 3 Clean the diluent vial stopper with supplied alcohol wipe Slowly inject 2ml of air into the diluent vial Draw entire contents of diluent vial into syringe Remove any air from the syringe and adjust for 2ml delivery	Step 4 Gently tap the LAR vial to ensure that all powder has settled to the bottom Clean the LAR vial stopper with the supplied alcohol wipe	Step 5 Insert the needle the needle through the rubber stopper of the LAR vial Without disturbing the LAR powder, gently inject the diluent down the inside wall of the vial Remove the syringe from the vial

Step 6 Do not disturb the vial while the diluent saturates the LAR powder After 2 to 5 minutes, without inverting vial, check sides and bottom of vial for dry spots Powder must be completely saturated before proceeding If dry spots exist, allow wetting to continue and check vial every 30 seconds until saturation is complete TIP: Allow the full 5 minutes or more for "wetting." One of the main reasons for failure is unwetted particles and it is very dificult to see these particles.	Step 7 Once wetting is complete, swirl vial moderately until a uniform suspension is achieved (30 to 60 seconds) Do not shake the vial The suspension will be "milky" TIP: I find it easiest to "roll" the vial back and forth between the palms of my hands. Do not invert though as doing this would allow some particles to stick to the top of the vial and be lost.	Step 8 Immediately draw 2ml of air into the syringe, insert the needle through the rubber stopper and slowly inject all of the air into the LAR vial With the bevel down and the vial tipped at a 45 degree angle, slowly draw the suspension into the syringe without inverting vial Some residual suspension will remain; vials contain overfill If you feel that there is too much residual LAR left in the vial, you may inject the solution back into the vial, agitate again and draw it out again TIP: Keep the bottom edge of the angled vial on the table rather than trying to hold it in your hand as you draw out the suspension. It is easier to control this way.
		The instructions on this website have been copied from the package instruction booklet. It is very important that the package instructions be followed precisely to prevent failure of the drug or it's delivery.
Step 9 Immediately change the needle, discarding the first needle and attaching the second supplied needle Note: Failure to use a new needle for the injection could result in a painful second injection if the first needle is clogged with "clumped" LAR Draw air into the syringe and rock it back and forth until you are actually ready to do the injection, to maintain a uniform suspension. TIP: It may be helpful to have the patient hold and "rock" the syringe while you locate and prepare the injection site.	Step 10 Clean the injection site with the supplied alcohol wipe Eliminate air from the syringe Insert the needle deep into right or left gluteus and draw back to ensure that no blood vessel has been penetrated. (If a blood vessel has been penetrated, attach a new 1.5" 20 gauge needle and select another injection site) Immediately inject IM entire contents of the syringe If needle clogs, replace it with a new 1.5" 20 gauge needle, draw air into the syringe, reagitate to restore the suspension, eliminate the air and redo the injection as above Record and alternate injection sites monthly	Things to Remember Allow the suspension to reach room temperature - 4 hours or more Do not shake the suspension Do not invert the suspension vials Use only 1.5" 20 gauge needles Change the needle before injecting The package comes with only 2 needles. Get a prescription from your doctor and have a third and spare needle on hand Do not rush - you have 15 minutes or so "work time". Sandostain LAR does NOT harden when exposed to air but rather tends to form "clumps" which can be dealt with as above. When you rock the syringe to maintain the suspension there must be air in the syringe to be successful.

Sandostatin Subcutaneous - this is the version that I used (and that you will probably use) for the first several months. I am in the process of switching to the LAR version which should provide a more stable level and better symptom control and hopefully will also have a tumor size controlling effect. Why not use LAR at first? Because if you are one of the people who cannot tolerate Sandostatin you are stuck with it for a month. The SubQ version will be out of your system in less than a day. Also the subq version is still needed for the occasional failure of the LAR.



SANDOSTATIN - The Main Treatment - I use the daily version which must be injected subcutaneously (in fat) and the method shown is for it only. The LAR version is different. There are many methods to do the injections. Following is my method...works great and usually does not hurt. I do them in the stomach when I am out and about and for pictures. At home I use my buttocks or the inside of my thighs. I don't have enough fat to do them anywhere else. Several hints follow. 1. RELAX - Do it slowly and carefully - Forget everything that you have seen in the movies or on TV - Forget some of what you have seen nurses do too. Learn to do it yourself - you will be an expert in a few days!! 2. Chose a clear site that is at least an inch away from the previous injection and at which you can "pinch an inch". Avoid the blue color of veins or hematomas(bruises). Also rotate sites so that you leave as much time as possible between injections. 3. Before you "stick it", touch your cleaned skin with the tip of the needle. If it hurts, you may be on top of a nerve ending. Move the needle over about an eighth of an inch and touch again. This part of the technique is why self injected shots hurt less. Someone else giving you a shot cannot tell if they are on a nerve - only you can do that. This is the reason that self-injected shots are less painful than shots that someone else does for you and is why you should learn to do it yourself. 4. Pinch an inch of skin and apply gentle pressure to your skin with the needle perpendicular to the skin and watch it slide, usually painlessly in. Push gently until the needle is all the way in. Do not push it into the muscle layer below your skin. A subcutaneous injection is in fat, not muscle. When I do my buttocks injections I am not able to use both hands and so cannot "pinch" but the fat is thick enough there so that this is not neccessary. 5. Release the pinch, push the plunger and slowly inject the Sandostatin. 6. Gently remove the needle and dispose of it properly. If the site bleeds this means that you have nicked a small blood vessel and you may get a bruise in a day or two. Don't worry about it. They don't hurt and will go away in a few days. If a small drop of Sandostatin comes back out of the hole don't worry about that either. It is probably only a couple of micrograms. Should you actually inject into a blood vessel this is not a major crisis either. The shot will take effect quicker and may not last quite as long but it will still work - better luck next time. 7. Going to work or for a walk? Since Sandostatin needs to be refrigerated, I use the insulated yellow childs lunch box and a refreezable ice pack for work - it will fit in a corner of my brief case and will fit in my desk drawer at work. For a short hike I use the black insulated soft pack. WARNING: On a hot day the refreezable ice packs last only 4 to 6 hours. I keep a second one in a refrigerator at work. And on a trip or longer outing use a small cooler with ice.

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