Table 3.

Proposed technical standard operating procedure for administration of intra-CSF anticancer pharmacotherapy

	Administration via the ventricular route (ventricular device in place)	Administration via the lumbar route
Specific contraindications	•Local skin infection •Dehiscence of the scar •Neurological symptoms or signs suggestive of intracranial hypertension (headache, nausea, vomiting, visual disturbances, vigilance disorders) or spinal cord compression •Cerebral lesion with mass effect on imaging	•Local skin infection •Major haemostatic disorders: thrombocytopenia <20 000 per mm3; therapeutic anticoagulation •Symptoms or signs suggestive of intracranial hypertension (headache, nausea, vomiting, visual disturbances, vigilance disorders) or spinal cord compression •Cerebral lesion with mass effect on imaging
Medial technical procedure	•Check the material •Wash hands, carry out hand hygiene using a hydroalcoholic solution •Get dressed: put on a single-use overcoat, a mask, eye protection, sterile gloves •Clean the skin area to be punctured according to local SOP (for example, antiseptic soap such as Betadine Scrub, rinse the antiseptic soap with saline, then dry the area to be punctured and apply dermal Betadine) •Prick into the ventricular device to the bottom with the Huber needle. A butterfly cannula may also be considereda •Fit an empty 10-ml syringe •Slowly withdraw a minimum of 6 ml CSF, at least the volume that will be injected (treatment and rinsing—see below) (1 ml in 30 s maximum) •Distribute the CSF in sterile tubes (for example, 5 ml of non-haemorrhagic in one sterile tube for CSF cytology and 1 ml in the other sterile tube for other standard analyses—or as indicated per study protocol, as applicable). If more CSF must be withdrawn, use a new syringe The patient should not have any complaints during the procedure. If headache occurs, stop the withdrawal and wait. •Adapt the pharmacotherapy syringe •Slowly inject the pharmacotherapy (1 ml in 1 min) •Prepare (with technical support) the physiological saline syringe for rinsing before disconnecting the pharmacotherapy syringe •Disconnect the pharmacotherapy syringe •Adapt the pre-filled syringe of saline solution as quickly as possible •Rinse the reservoir by injecting saline solution; the volume of the ventricular device (and potentially connector) and the catheter (with or without side holes) should be considered to decide what volume should be used to rinse the reservoir. The type of material used by the surgeon should be communicated to the treating team •Remove the syringe and the needle •Proceed to a new round of antiseptic cleaning of punctured skin area •Apply a compress and press smoothly for 1 min	•Check the material •Wash hands, carry out hand hygiene using a hydroalcoholic solution •Get dressed: put on a single-use overcoat, a mask, eye protection, sterile gloves •Clean the skin area to be punctured according to local SOP (for example, antiseptic soap such as Betadine Scrub, rinse the antiseptic soap with saline solution, then dry the area to be punctured and apply dermal Betadine) •Prick with lumbar puncture needle until CSF returns •Take a minimum of 6 ml CSF, at least the volume that will be injected •Distribute the CSF in sterile tubes (for example, 5 ml of non-haemorrhagic in one sterile tube for CSF cytology and 1 ml in the other sterile tube for other standard analyses—or as indicated per study protocol, as applicable). •Adapt pharmacotherapy syringe •Slowly inject the pharmacotherapy (1 ml in 1 min) •Disconnect the pharmacotherapy syringe •Remove the syringe and the needle •Proceed to a new round of antiseptic cleaning of punctured skin area
Comments	No pressure should be necessary for the withdrawal of CSF or the injection of intrathecal pharmacotherapy. If no CSF can be withdrawn, stop the intervention and explore with the neurosurgeon on call whether neuroimaging is required.
Main risks	•Malaise •More rarely local haematoma, infection, subdural haematoma, brain herniation, thrombophlebitis	•Painful paresthesias (electric shock) in the lower limbs •Orthostatic headaches •Malaise •More rarely: local haematoma, infection, subdural haematoma, brain herniation, thrombophlebitis

Patients must only receive intrathecal pharmacotherapy in designated areas where staff are routinely involved in the administration of drugs by the intrathecal route. The nurse should first install the patient comfortably (seated position, leaning well forward, arched back or in left lateral decubitus). The whole procedure must respect rigorous aseptic conditions. The patient should remain lying in decubitus position for 1 h (strict decubitus after lumbar administration, as feasible). The absence of possible immediate side-effects should be checked before discharge.

CSF, cerebrospinal fluid; SOP, standard operating procedure.

^aA three-way connector can also be used, depending on the physician’s preferences.