5. Intravenous Admixture Systems
Intravenous admixture system is referring to sterile intravenous solutions that are prepared by using one or more medications or electrolytes and will be administered via the parenteral route. In addition to IV solutions, an admixture system may also encompass irrigation, ophthalmic, and intrathecal solutions.
Starting a Program
Contamination: a clean area must be maintained out of the direct flow of traffic with vertical or horizontal laminar air-flow hood to prepare IV admixtures.
Compatibility: a pharmacist’s education and training should prepare him or her to deal with problems of physical, chemical and therapeutic incompatibilities and to design suitable alternatives in these cases
Stability: drug stability information must be readily accessible to pharmacist in order to determine optimum conditions for drug storage prior to and after preparation.
Cost: it is more economically to prepare parenteral medications in pharmacy than individual nurses on patient unit. Cost of drug procurement, storage, preparation time and waste is less when a pharmacy IV admixture program is used.
Errors: the potential for medication error is reduced in a pharmacy-based admixture program. Pharmacists are more educated to perform medication calculations. In addition, the uses of standardized dosing charts for drug doses and dilutions reduce the potential for error.
Quality: pharmacy policy and procedures governing IV admixtures can be enforced more efficiently in centralized and decentralized IV programs. Compatibility, sterility and labeling of admixtures are addressed in a typical pharmacy control system.
Components of an IV Admixture Program
Preparation Area
Ideally, parenteral products should be prepared in a separate room in the pharmacy. Table 5-1 provides several recommendations regarding the preparation area for parenteral products.
Policies and Procedures
Guidelines for preparing parenteral products should be outlined in the pharmacy policy and procedure manual. Detailed information regarding the preparation (stability, incompatibility, and aseptic technique), IV profiling, labeling and storage should be readily available in the pharmacy. These policy help to provide quality control for the parenteral products that are prepared and dispensed by the pharmacy.
Table 5-1 Preparation area
· Tiled, washable floor covered with a coat of vinyl or epoxy sealant to provide a continues surface· Hand-washing facilities
· Laminar air-flow hoods: horizontal and or vertical
· Refrigerator
· Preparation equipment: needles, syringes, alcohol prep pads, gloves, masks, gowns, receptacles,
small-volume parenterals, diluents and solutions
· Good lighting
· Adequate counter space
· Restricted area or minimized traffic flow
· Prohibition of smoking, beverages, food and unauthorized personnel
Equipment
Laminar air-flow hoods: these devices use high-efficiency particulate air (HEPA) filtration. A vertical air-flow biological safety cabinet should be used for preparing cancer chemotherapeutic and other hazardous agents.
Refrigeration: most compounded parenterals need to be refrigerated for optimal stability. Microbial growth is retarded under refrigeration. The PCU is another area in which refrigeration will be needed.
References: adequate references are essential component of an IV admixture program. The latest edition of the Handbook on Injectable Drugs is one of the most widely used references. Institutional specific standardized charts for compounding will facilitate the preparation of parenteral products by listing precalculated doses, diluents, concentration, and administration rate.
Personnel
Pharmacies that use bulk medication to prepare individualized doses will require an increase in personnel. If manufacturer-prepared products are used, additional personnel may be minimized. However, the proper training of personnel in aseptic technique and sterile product information is necessary.
Process
A typical IV order for a patient would entail the following activities:
1. A pharmacy copy of the physician’s original order is prepared, containing the patient’s name, room number, IV fluid, additive(s) and flow rate
2. The prescription order is entered into the patient’s profile (Figure 5-1) by a pharmacist who checks for drug interactions, proper dose, compatibility, duplication of medication (includes medication ordered by the oral route), allergies, length of therapy compared to automatic stop order policies, and other patient therapies
Figure 5-1 A sample of one type of IV patient profile card
IVNo. / Start
Date / Therapy
Dates / Solution / Additives / Rate / Time
RPh Techs Initials
Room / Name / Solutions/Additives
3. A label is prepared and checked against the original order
4. The parenteral product is prepared
5. The prepared product is then checked against the label and original order by a pharmacist (Table 5-2). Dosage, ingredients, auxiliary labels, compatibility, route, rate, absence of particulate matter, discoloration and container integrity are verified. Usually, each IV dose is numbered in consecutive order.
6. After delivery to the PCU, the solution is once again checked by the person who will be administering the drug
7. IV admixtures should be refrigerated until shortly prior to use. If it is not used within 24 hours, it should be returned to pharmacy to be redistributed or destroyed
Table 5-2 Labeling and checking system
The following information suggested to be placed on all IV admixtures following preparation· Patient name, identification number, and room number
· Bottle sequence number
· Name and a mount of drug added
· Name and volume of admixture solution
· Approximate final total volume of the admixture
· Prescribed flow rate (ml/hour)
· Date and time of scheduled administration
· Date and time of preparation
· Expiration date
· Initials of the person who prepares and/or checks the IV admixture
· Auxiliary labeling: supplemental instructions and precautions (e.g. protect from light, for epidural
use only)
Small-Volume Intravenous Infusions
Manufacterer’s Drug Packaging
Sterile dosage forms are prepackaged in: single-dose or multidose vials, ampoules, syringes, glass bottles, or plastic container. These products may also be classified according to their therapeutic use: IV or irrigating solutions, IM, S.C, intradermal, intrathecal, sterile ophthalmic solutions, diagnostic agents, or allergenic extracts.
Intravenous Admixture System
Syringes: containing single or multiple doses of an individual drug may prepared by pharmacy. The correct dose is drawn into a syringe (usually 5-60 ml), labeled and delivered to the patient unit.
Small-volume IV systems: IV admixture solutions may be administered by intermittent doses by means of a secondary or “piggyback” IV. A piggyback refers to a second IV solution, usually in small volume of diluent than the primary IV.
Large-Volume Intravenous Infusions
Parenteral solutions that are administered continuously over 24 hours should also be included in the pharmacy’s IV admixture program. These differ from intermittent infusions because they can be used to deliver large quantities of fluid to patient. Several continuous IV solutions are available commercially in large volume (500-1000 ml). Often, a specific concentration of a drug or electrolyte (e.g. potassium, magnesium) must be added to dextrose or sodium chloride IV solutions.