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IV Admixture: Parenteral Products and Total

Parenteral Nutrition
Required Reading Thompson, Chapters 7, 32, 33
Objectives:
IV Admixture
1. Compare the mechanisms and utility of
o Laminar Flow Hood

aka Laminar Flow Workbench (LAFW)


A multi fliter system designed to provide a uniform, continuous flow of
particle (and baterium) free air across a worksurface, creating an aseptic
environment. The first filter removes large particles (dust, etc). Then the
flow of air is standardized and run through a high efficiency particulate
air (HEPA) filter.
Class 100 environment
Protects pharmacist and product using a controlled air flow
Horizontal Flow from the back of the work surface toward the front

Masks required for horizontal flow

Vertical Flow from the top to the bottom

Extra protection from chemotherapy agents


More difficult to work with, but safer

Barrier Isolation Devices


Class 100 environment
Provides a sterile environment using solid walls instead of laminar air
flow
Uses a HEPA filtration System
Protects product and pharmacist
AKA Glove box
Hood Descriptions

2. Describe USP 797 Requirements for the preparation of sterile products


criteria of and preparations in Low, Medium, and High risk categories.
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All levels require

. Identify

Class 100 work environment (See above)


LAFW re-certification every 12 months
Anteroom

Should be "Clean" but not necessarily Class 100


Non-shedding dress
Positive Air Pressure
Written monitoring plan
Low Risk (LR)

Sterile products provided by a mfg


Closed system transfers
Buffer Room Class 100,000
less than three products
High Risk I (HRI)

Numerous manipulations
Multiday infusions or pumps
Automated Total Parenteral Nutrition
Buffer Room Class 10,000
30 hours room temp, 7 days cold storage
High Risk II (HRII)

Buffer Room Class 10,000 or 100


Non-Sterile starting materials
24 hours room temp, 3 days cold storate
3. Demonstrate proper placement of items in a given hood.

Horizontal LAFW requires items be at least 6 inches from the edge


Vertical LAFW requires items be at the air flow split point on the table and stay
behind the shield
4. Demonstrate aseptic formulation techniques
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Do not touch the critical surfaces of the delivery devices


Do not obstruct laminar flow
Pay particular attention to position of hands. Make sure hands are not
blocking critical surfaces when handling objects
Grab neck of bottle grasped between two fingers
Do not work in turbulence zones create by products or devices
Dont allow vials/objects to block work
Always work in the most direct flow of air

Turn on hood and let it run for a minimum of 30 minutes


Perform all calculations
Gather supplies
Wash, Glove and Gown
Dry hands w/ none particulate towels
5. Wipe down LAFW with alcohol and sterile gauze
1.
2.
3.
4.

Wipe from the back to the front in a long, smooth and continuous motion
6. Must work at least 6 inches into hood
7. Spread supplies out with thought
Make sure and maximize the number of surfaces exposed
e.g. turn needle into flow of air. Turning needle against air flow

blocks an entire side of the needle from flow of air.


Dont leave free paper lying around it will blow off unless prevented
Do not block objects
e.g. do not put one vial in front of another vial
remove all possible wrappers with care
e.g the needle wrapper, syringe wrapper
8. Swab the vial diaphragm, injection ports with alcohol
9. Penetrate
With beveled needle penetration should be done at ~45 o until the bevel
heel has passed through the diaphragm the quickly but gently straighten
needle to 90o vertical
This technique will prevent coring of the diaphragm
10.
Push an equal amount of air into the container before attempting to
withdraw anything
Vial/object should be on table when inserting needle and during
equalizations of atmospheres
Pay attention to air flow and hand position so air flow is maximized
around all objects in hood
Grasping neck of vial with the V of two fingers and the syringe with
other hands fingers on the syringes top collar and the flat end of the
plunger pick up the connected syringe and vial turning both over with the
bottom of the vial pointed up
This technique will maximize air flow around the objects being grasped
by the hands

11.

Withdraw product
With an even pressure on the flat end of the plunger and resistance on the
top collar.
Pay attention to the fluid level in the vial; drawing vial liquid not the vial
air
Since atmospheres have been equalized can push fluid in and pull fluid
out w/o consequence.

If air bubbles acquired two methods to remove


Flick the needle barrel with one hands forefinger while
supporting needle and vial in other hand
Push fluid back into vial
1. take a slower pull on the plunger stopping incrementally
to allow needle barrel vacuum to pull fluid into the
needles barrel
2. tap needle barrel to remove any bubbles
if pressure not equalized between needle and vial you will create a
friggin mess when removing the needle shaft from the vial
however much air volume placed into vial, then must remove the
same volume of liquid
if injecting into sealed container, must remove equal volume of
air to compensate for the increased pressure added by injecting
volume of fluid
12.
Label Product (should have at least the following information)
For px specific products
px name, any other pertinent px i.d info, batch prepared products
should have control or lot number
all solution and ingredient names, amounts, strengths, and concentrations
(when applicable)
expiration date and time, when applicable (half-life on cancer drug)
prescribed administration regimen, when appropriate (including rate and
route of administration)
Appropriate auxiliary labeling (including precautions)
Storage requirements
Identification (e.g. intials) of the responsible pharmacists and tech
Device specific instructions (drip rate)
Any other additional information in accordance with state or federal
requirements
13.
If any adjustments made to parent solutions must make proper note of
adjustments on parent product
If unsure of parent product status must dispose of parent product
If parent vial should be in powder form, but is in its liquid form without
any notification of solution concentration must dispose of parent product.
14.
Dispose of waste
Sharps go to sharps container
Do not need to recap needle if giving needle and syringe directly
to sharps container
Regular waste can into designated waste receptacle

1. Recognize syringe and needle differences and be able to choose an appropriate syringe
and needle for a given procedure.
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Always take the lowest error route

Injecting 8mL sterile water into vial to remove 2mL solution choose the
10mL syringe

E.g using a five mL will require two injections of sterile water


increasing the error factor

E.g using a 20mL will increase error factor as the 20mL will not
be as accurate when drawing a 2 and 8mL volume as compared
to a 10mL syringe

Needles distinguished by length and gauge, with various sizes for various routes

Intradermal

Subcutaneous

25-28 gauge
3/8 to 5/8 length
Syringe 0.02-0.5mL
30-32 gauge
1/2 to 5/8 length
Syringe 1-3 mL

20-22 gauge
Intramuscular 1/2 to 1-1/2 length
Syringe up to 5mL
Intravenous
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20-22 gauge
1/2 to 1-1/2 length
Syringe up to 60mL

Critical Parts of the syringe

Needle

This a sterile surface keep it that way


Easy to dull the tip
exposed plunger
touching this can directly contaminate the inside of the syringes
barrel

2. Determine therapeutic, physical, and chemical incompatabilities for a given formulation.


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MicroMedix
United States Pharmacopoeia/National Formulary (USP/NF);
American Hospital Formulary Service;
Trissel's Handbook on Injectable Drugs
King's Guide to Parenteral Admixtures

3. Identify the major components of a parenteral prescription label


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Pharmacy Name and location


Rx Number
Control number
Patient name and ID
Additives

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Solvent
Administration Rate
Prep Date/Signature
Check Date/Signature

4. Calculate the amount of a drug solution to be added to a given IV prescription.


o

Powders requiring addition of liquid usually indicate the concentration of the


final product

5. Develop skills necessary to prepare a sterile product for IV administration.


1. Washes hands: removes jewelry/watch, scrubs hands vigorously including nails,
forearms, between fingers, rinses, dries
2. Dons gown, head cover, gloves. Avoids touching contaminated objects henceforth
3. Cleans work area starting at the back and working forward (away from the filter)
4. Cleans all supplies or removes all outer wraps as they are placed in the hood
5. Inspects all materials for integrity and expiration dating prior to using
6. Cleans all septa and injection ports with alcohol
7. Withdraws content of vial: inserts needle at an angle with opening acing up, injects
HEPA air into vial and withdraws ___mls solution.
8. Removes air bubbles from syringe
9. Transfers solution: Vials: inserts needle at an angle with opening facing up, Ports:
inserts needle straight through port. Injects solution
10. Performs all operations at least 6 inches inside the hood
11. Does not touch critical sites: needle shaft, opening of hub, syringe tip, or stem of
plunger
12. Does not place items or allow fingers to come between the clean air source
(HEPA filter) and critical sites
13. Inspects the solution for particles against light and dark backgrounds
14. Does not reach out of the hood to discard trash until finished
15. Disposes of sharps and glass in appropriate containers
Total
6. Demonstrate the ability to calculate IV rates and component quantities.
7. Identify the information required on an IV admixture label.
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For px specific products


px name, any other pertinent px i.d info, batch prepared products should
have control or lot number
all solution and ingredient names, amounts, strengths, and concentrations (when
applicable)
expiration date and time, when applicable (half-life on cancer drug)
prescribed administration regimen, when appropriate (including rate and route of
administration)
Appropriate auxiliary labeling (including precautions)
Storage requirements
Identification (e.g. intials) of the responsible pharmacists and tech
Device specific instructions (drip rate)
Any other additional information in accordance with state or federal requirements

8. Information on injectable drugs


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United States Pharmacopoeia/National Formulary (USP/NF);


American Hospital Formulary Service;
Trissel's Handbook on Injectable Drugs
King's Guide to Parenteral Admixtures

Exercises:
IV Admixture
1. Calculate the volumes of solutions you will need to prepare the assigned IV order.
Write out your calculations on the IV order.
2. Prepare the assigned IV order using aseptic technique. Have the TA or instructor
observe your technique and check your calculations.
3. Prepare a complete label for the finished product and attach it to the IV order.
4. Write your name on the order and turn it in to your instructor.