Professional Documents
Culture Documents
Learning Outcomes
Describe basics of intravenous drug therapy
Describe key elements of working in laminar
airflow workbenches
List types of contamination in a laminar flow
hood & describe how to minimize their risks
Perform basic manipulations needed to
prepare a sterile product by using aseptic
technique
Describe the risks of handling cytotoxic &
hazardous drugs
Learning Outcomes
List steps in drug preparation & handling that
Key Terms
Aseptic technique
Biological safety cabinet
Coring
Free flow protection
HEPA filter
Laminar airflow workbench (LAFW)
Large volume parenteral (LVP)
Total parenteral nutrition (TPN)
Small volume parenteral (SVP)
Parenteral Drug
Administration
Parenteral not through digestive tract
Intravenous (IV)
Intramuscular (IM)
Intrathecal (IT)
Epidural
Intraarticular
Intraarterial
Intraocular
Intraperitoneal
Subcutaneous (SQ, SC, SubQ)
Risks of Intravenous
Therapy
Infection
Air embolus
Bleeding
Allergic reaction
Incompatibilities
Extravasation
Particulate Matter
Pyrogens
Phlebitis
Types of IV
Administration
Infusions
Continuous
Intermittent
IV Containers
Large Volume Parenterals (LVPs)
Small Volume Parenterals or Piggyback
Systems
Add-Vantage
Vial Spike Systems
Flexible Plastic Bags
Glass Containers
Basic Continuous IV
Therapy
Large volume parenteral (LVP)
hung on an IV pole 36 inches above patients
bed
flow maintained by gravity
LVP
Usually a simple solution of
dilute dextrose
sodium chloride
or combination of both
Additives
swab rubber stopper with alcohol & let dry
inject drug into fluid
remove bottle vacuum
Non-coring Technique
Administration Systems
Continuous Infusions
more effective & less toxic than when given
intermittently
basic fluid & electrolyte therapy
blood products
drugs that require tight administration control
Intermittent Injections
periodic administration increases efficacy
reduces toxicity
Pre-Mixed Admixtures
Manufactured LVPs with additives
stable in solution for longer periods of time
available in many of sizes (250 mL, 500 mL,
1000 mL)
Examples
lidocaine
potassium
nitroglycerin
dopamine
aminophylline
RTU Advantages
Reduce handling by pharmacy
Reduce potential for contamination
Emergency situations-stocked in patient care
area
Standard concentrations of IV medications
decrease potential medication errors in
Pharmacy Prepared
Admixtures
Volumes (100 mL, 250 mL, 500 mL, or 1000
mL)
Containers (glass, plastic, bag, bottle or
syringe)
Syringe Systems
syringe pumps
volume control chambers
gravity feed
intravenous push systems
Syringe Systems
Pharmacy fills syringes with drugs & labels
stability in syringes related to drug concentration
Syringe Pumps
adjusted to administer volume over given period of
time
pumps are operated by battery or compressed
spring
may administer single dose or pre-programmed
intervals
doses must be sent from pharmacy in standard
syringe sizes & concentrations
Electronic Infusion
Devices
Electronic infusion devices
increase precision & accuracy
in fluid restricted patients
when drug must be administered at precise rate
Volume Control
Chambers
Buretrol or Volutrol
Syringes used to administer drugs through
volumetric chamber
drug injected through port on top of chamber
solution added from primary LVP
minimal amounts of fluid can be given per dose
beneficial in fluid-restricted or pediatric patients
important that medication is followed by IV
flush
Gravity Feed
Syringes can use gravity to administer drugs
vented set allows air to enter syringe
inexpensive & requires no other special
equipment
Intravenous Push
injected directly into IV tubing
primary IV set is usually clamped off
Patient Controlled
Analgesia
Very effective in managing pain
Patient administers dose as soon as pain felt
Reduces nursing time
Pump programmed
Basal rate
Bolus when patient pushes button
Example: max 1 mg of morphine every 15
minutes
tubing
Administration Sets
Primary IV Set
attached to the LVP
can be one of several varieties
Drip chamber-estimate administration rate by
Drip Sets
Macro-drip sets deliver 10-20 drops per 1 mL
Minidrip sets deliver sixty drops per 1 mL
Rate controlled by roller clamp or electronic
infusion device
Drugs injected through ports
either Y-sites or flashballs
concentration of drug
rate of administration
time venous access can remain in place
Peripheral Catheters
Plastic-flexible & most comfortable for patient
Steel needle with short end of tubing
scalp vein or butterfly
may be left in the patients vein if flushed
Central catheters
temporary or permanent
access vein with high blood flow
Catheter Examples
Permanent catheters
Hickman
Broviac
Port-a-cath
Peripheral catheter
peripherally inserted central catheter (PICC)
IV Miscellaneous
Information
Heparin Lock
maintain catheter access to vein
resealable rubber diaphragm
provide port for intermittent use
concentration of heparin used in heparin locks
Needleless Systems
reduce risks of needle sticks
required in some states & some healthcare
systems
IV Misc. Information
Continued
Final Filters
located in the tubing
used to remove particles in IV solution
used with drugs that have a risk of particulate
Aseptic Preparation
Admixture preparation program includes:
Aseptic Technique
Manipulating sterile products without
Sterile Compounding
Area
Compounded sterile products (CSPs) must be
free of
living microorganisms
pyrogens
visible particles
Sterile Compounding
Area
Segregate compounding area
minimize traffic in sterile compounding area
remove trash d frequently & regularly
Sterile Compounding
Area
Use anteroom for non-aseptic activities
order processing
gowning
handling of stock
environment
Laminar Airflow
Workbenches
Principle of LAFWs
twice-filtered laminar layers of aseptic air
continuously sweep work area inside hood
prevents entry of contaminated room air
IV Hoods
Vertical Hoods used for
preparing hazardous
medications
Designed to protect
preparer from exposure to
hazardous medications
Horizontal Hoods most
common for sterile
preparation of IV solutions
Horizontal LAFW
Air moves from back to front
Electrical blower draws room air through a
prefilter
Removes gross contaminants
Should be cleaned or replaced on regular basis
Prefiltered air moves through final filter
Entire back portion of hoods work area is HEPA
high efficiency particulate air
micron or larger
Vertical LAFW
Air emerges from the top and passes downward
Exposure to airborne drug particulates minimized
Used for preparation of antineoplastics
Referred to as biological safety cabinets (BSCs)
Space between the HEPA filter and the sterile object
critical area.
LAFW Principles
Position away from excess traffic, doors, air
vents, etc.
Must run for 15 -3o minutes if turned off &
back on
All interior working surfaces should be
cleaned
70% isopropyl alcohol/other disinfecting agent
clean, lint-free cloth
Cleaning LAFWs
Clean sides of hoods using up & down
direction
start at HEPA
work toward outer edge of hood
Order of cleaning
walls 1st
floor of hood 2nd
Cleaning LAFWs
Frequency
beginning of each shift
before each batch
not longer than 30 minutes following previous
Cleaning LAFWs
If materials not soluble in alcohol, initially use
water
follow with alcohol
Additional LAFW
Instructions
Nothing should come in contact with HEPA filter
Nothing in hood that is not essential IV
preparation
no paper, pens, labels, or trays
Additional LAFW
Instructions
Must test LAFWs at least every 6 months
Also test if hood moved, or if filter damage
suspected
Specific tests
airflow velocity
HEPA filter integrity
Aseptic Environment
Personal Attire -Cover
Shoes, head & facial hair, use face masks/eye
shields
cover scrub suits when leaving pharmacy
Handwashing
touch is most common source of contamination
scrub hands, nails, wrists, forearms to elbows for at
Gloving
only sterile until they touch something unsterile
Syringes
Volume of solution- 1/2 to 2/3 of
syringe capacity
Measuring-line up final edge to
calibration mark on barrel
Open syringe package in hood to
maintain sterility
Peel wrapper & discard out of
hood
Leave syringe tip protector in
place until time to attach needle
To attach needle to Luer-lock-type
syringe turn is usually sufficient
to secure needle to syringe
Needles
Note components
Often color-
coded=gauge
Vented needles
Filter needles
Dead space
Vials
Rubber stopper
Powders or liquids
70% isopropyl alcohol
Avoid coring
Normalize pressure
Reconstitution
SDV or MDV
Preservative considerations
Ampules
Move fluid to body
of ampule
Swab neck with
alcohol pad
Break at neck
Tilt ampule,
needle bevel down
Use filter needle
Prefilled Syringes
Manufactured ready-to-inject syringes
Commonly given IM, IV, or subcutaneously
Convenient for administration
emergency situations
Most likely to be kept in patient care areas
Preparation of IV
Admixtures
Pharmacist inputs order into computer system
Assemble all materials & visually inspect
Clean hood-only needed products in hood
Disinfect all injection surfaces
Withdraw & measure drug fluid
Remove air bubbles from syringe
Discard syringes & uncapped needles
Recapping needles is generally unsafe practice
use one-handed scoop method if recap needed
IV port seals
Tamperproof caps
Automated Compounding
Sterile product preparation is technically
complex
Verification challenging
Automation can eliminate preparation errors
Enclosed IV preparation environments &
robotics
used in high volume situations
or may prepare patient specific doses
Labeling of IV
1. Patient name, identification #, room #
Preparations
2. Bottle or bag sequence number
3. Name & amount of drug(s) added
4. Name & volume of admixture solution
5. Final total volume of admixture
6. Prescribed flow rate (in milliliters per hour)
7. Date & time of scheduled administration
8. Date & time of preparation
9. Expiration date
10. Initials of person who prepared/checked IV admixture
11. Auxiliary labeling
12. Bar coding
transport
special clothing
Biological Safety Cabinets (BSCs)
special handling of spills & waste
Protective Apparel
Disposable coveralls 0r or solid front gown
Low-permeability, lint-free fabric
Long sleeves & tight-fitting elastic or knit
cuffs
Wash hands before putting on the gloves &
after removing them
One or two pairs of gloves may be required
Tuck one pair under cuffs of gown & place
second pair over cuffs
First Aid
Eyewash fountain in work area with hazardous
drugs
Appropriate first aid equipment
Follow established first aid procedures
Obtain medical attention without delay &
document injury
BSC
Front air barrier-protects handler from contact
BSC
Disinfect work surface with 70% isopropyl
alcohol
Do not to use excessive amounts of alcohol
Treat cleaning supplies as hazardous waste
Decontaminate on weekly basis/immediately
after spill
Refer to facilitys procedure on hood
maintenance for specific cleaning procedures
& schedules
Preparing Hazardous
Drugs
Same as regular drugs EXCEPT
attach & prime IV sets before adding hazardous drug
maintain slight negative pressure inside vial or use
protective gear,
eye protection
respirator
utility & latex gloves
disposable gown or coveralls
shoe covers
scoop, plastic container for glass fragments, absorbent
spill pads, gauze & disposable toweling, absorbent
powder, & sealable, thick plastic waste disposal bags
TPN Therapy
Meets nutritional needs for patients
who cant eat
who will not eat
who should not eat
who cannot eat enough to sustain their needs
due to increased nutritional requirements from
their medical condition
Components of TPNs
Base components
dextrose (carbohydrates)
amino acids (protein)
may also include fat & water
Additives
electrolytes
vitamins
trace elements (micronutrients)
drugs such as heparin, insulin, H2 antagonists
Components
Dextrose -usually a 50% or 70%
final dextrose concentration ~25% if via central vein
maximum of 1012.5% for peripheral administration
Protein usually 8.5%, 10%, or 15%
special formulations for pediatric patients, kidney
Components
Water
Electrolytes to meet daily metabolic needs
sodium, potassium, chloride, acetate,
phosphate, magnesium, calcium
administered as a specific salt of product
can cause precipitation: wrong sequence or
concentrations of electrolytes are added to bag
Vitamins- MVI for multiple-vitamin infusion
Vitamin K (phytonadione)
Trace elements for proper enzymatic reactions
250 g
Amino acids
42.5 g
Sodium chloride
60 mEq
Potassium chloride
40 mEq
Potassium phosphate 20 mEq
Calcium gluconate
1g
Magnesium sulfate 1 g
Trace elements
2 mL
MVI
10 mL
Total volume
1000 mL
Infuse at 100 mL per hour. Also give: Vitamin K 10 mg
intramuscularly (IM) every week,
10% fat emulsion 500 mL intravenously three times per week.
TPN Form
Preprinted order
forms
Reduce error
May be required in
some
hospitals
Each facility designs
components of
preprinted forms
Preparation of TPN
Solutions
Automated compounder
2 primary versions of TPN compounders
Administration
Central line
immediate dilution of administered solution by
blood
allows use of very concentrated solution
Peripheral parenteral nutrition (PPN)
same components as TPN
not as concentrated
may not meet all the patients nutritional needs
Pediatric IV Drug
Administration
Doses individualized
calculated based on patients body weight
checked
Epidural Administration
Special catheter into epidural space of spine
Drug injected at nerve ending-dose greatly
reduced
All solutions must be free of preservatives
Epidural patient controlled analgesia
Continuous infusions
Bolus injections
Admixture Programs
Policies & Procedures
Space
Training
Equipment
Standard & Non-Standard Preparations
Labeling
Handling
Quality Assurance
Program
ASHPs Technical Assistance Bulletin on Quality
Assurance for Pharmacy-Prepared Sterile Products
preparation
expiration dating
labeling
facilities
equipment
personnel education
training
evaluation
end-product testing
CompoundingSterile Preparations
recommendations & regulations regarding IV
admixture programs
different levels of risk for products
fourth class, immediate-use CSPs
training
policies & procedures
garb, aseptic technique, process validation,
end-product evaluation