IV Admixtures and Preparation Standards (ASHP)

• Intravenous (IV) admixtures are IV solutions used in hospitals, long-term care facilities, home care programs/infusion centers, and emergency transport vehicles.
• IV solutions replace body fluids and act as vehicles for injectable drugs.
• Personnel require special education and training to prepare and administer sterile IV solutions.
• One or more drugs are added to the IV solution to prepare the final sterile product.
• The added drug is called the additive, the final product is referred to as the admixture.
• Compounding IV admixtures is the responsibility of the pharmacist, according to standards from the Joint Commission and ASHP.

IV Admixtures Preparation Standards (ASHP)

• Staff must use safety materials and equipment when preparing hazardous medications, including gowns, gloves, eyewear, and face protection.
• Staff must assure accuracy in medication preparation using dilution charts, standardized concentrations/formulas, and double-checking calculations/quantities.
• Staff must avoid contamination during medication preparation by:
  • Using clean/sterile techniques
  • Maintaining clean, uncluttered, functionally separate areas
  • Using a laminar airflow hood or Class 100 environment for IV admixtures, sterile products made with non-sterile ingredients, or sterile products not used within 24 hours
  • Visually inspecting medication integrity

ASHP Guidelines for Pharmacies in Hospitals

• Standards state all sterile medications must be prepared/labeled by trained personnel in a suitable environment.
• Quality assurance procedures for sterile product preparation are essential.
• Pharmacists are responsible for compounding/dispensing sterile products with correct ingredient identity, purity, strength, and sterility.
• Sterile products must be dispensed in appropriate containers, accurately labeled for the end-user.

Technician Responsibilities

• A pharmacy technician who compounds I.V. admixtures under the direct supervision of a pharmacist serves as an example of the way support personnel in healthcare organizations are assuming increasingly important roles.

I.V Admixture Technician Duties

• Enters orders from prescribers into the pharmacy order entry system
• Orders are subsequently checked by a registered pharmacist.
• Generates complete and uniform labels and/or worksheets.
• Gathers and assembles necessary drugs and solutions.
• Reconstitutes drug additives and compounds the admixture using aseptic technique.
• Utilizes automated compounding equipment to prepare complex admixtures.
• Checks the admixture for clarity and labels it.
• Delivers completed admixtures to the patient care area, returning unused admixtures to the pharmacy.
• Restocks the admixture area and maintains it in a neat, orderly manner.
• Maintains departmental quality control/quality improvement practices for ongoing quality assessment.

Pharmacist Responsibilities

• A pharmacist working with a pharmacy technician is responsible for coordinating admixture preparation and supervising the technician's activities.
• Pharmacist duties include:
  • Interpreting physician orders, consulting with nurses/prescribing physicians when necessary; every new admixture prescription must be checked by a registered pharmacist.
  • Overseeing proper drug storage and handling.
  • Assuring proper labeling practices and that technicians follow proper aseptic technique when preparing IV admixtures.
  • Checking completed IV admixtures for accuracy and clarity.
  • Performing the final check of the end product with ultimate responsibility for its accurate preparation.
  • Providing documentation with identification (initials) of the responsible pharmacist.
  • Coordinating the nursing and medical staffs' overall needs for pharmaceutical services, like delivery schedules, emergency/specially-prepared admixtures.
  • Maintaining departmental quality control and improvement practices for ongoing quality assessment.

Injectable Medication Administration Routes

• Medications intended for injection can be administered via intravenous, intramuscular, or subcutaneous routes.

Advantages of Intravenous Administration

• Rapid onset of action.
• Useful when patients cannot take medication orally due to being unconscious, uncooperative, nauseated, or vomiting.
• Suitable when a medication is unavailable for oral administration or if it is not absorbed when administered orally.

Disadvantages of Intravenous Administration

• Dose errors are magnified.
• Effects is difficult to stop once it is administered.
• Risk of infection.
• May cause pain, irritation, local tissue damage, or soreness at the injection site.
• Medications must be sterile.

Types of Intravenous Administration

• IV push involves administering a relatively small solution volume directly from a syringe over a short time.
• IV Infusion involves introducing larger volumes of solution directly into a vein, allowing it to flow over a longer period.
• Infusions are given to overcome dehydration, restore blood volume, and administer medications.
• Continuous infusions administer solutions slowly at a constant rate, e.g., 40 mEq potassium chloride in 1L D5W over 8 hours.
• Intermittent infusions administer small volumes (≤250 mL) over short intervals, e.g., 1 gram ampicillin in 50 mL 0.9% sodium chloride injection over 15-20 minutes every 6 hours.

Setup for Continuous Intravenous Infusion

• IV solution (usually in a plastic bag or glass bottle)
• Administration set including a spike, drip chamber, plastic tubing, clamp, and needle adaptor
• Needle or catheter, inserted into the patient's vein
• Supported solution container

Inermittent I.V. Infusion Administration

• Involves infusing a medication in a small solution volume at regular intervals.
• A large-volume continuous infusion is administered during non-delivery times to maintain an open vein.
• Piggyback administration (IVPB) is when solutions from two containers flow into the patient’s vein through common tubing and the same injection site.
• The two solutions must be compatible.
• How piggyback administration works:
  • The primary solution drip rate is established.
  • When given the medication, open the clamp to allow the piggyback solution to flow through the tubing.
  • A one-way check valve on the primary set prevents the piggyback solution from flowing up into the primary container.

Advantages of Piggyback Administration

• An additional venipuncture is not necessary.
• Provides higher blood levels of the drug more quickly.
• The solutions aren't mixed except within the tubing.

Administration Sets Components

• Spike
• Drip chamber
• Needle adapter
• Tubing
• Check Valve
• Clamps
• Connector
• Injection ports

Catheters

• I.V. catheters are a common alternative to needles for vein insertion.

Heparin/Saline Lock

• Attaches to an I.V. catheter or needle with a resealable rubber diaphragm.
• Facilitates intermittent I.V. infusions and avoids multiple venipunctures.

Needleless Systems

• Newer I.V. systems that prevent accidental needle sticks to patients and healthcare workers.
• Advantages include:
  • Preventing accidental needle sticks and simplifying safe disposal by using cannulas rather than needles
  • Reduces costs associated with needle stick injuries
  • Requires minimal technique change from conventional systems.
• The disadvantage is increased product costs.

Final Filters

• IV admixtures may contain small, potentially harmful particles undetected by the naked eye.
• These particles can get trapped and accumulate in the lung capillaries.
• Filters can thus remove these particles.

Volume Control Chambers

• These are plastic cylindrical devices with graduation marks to measure solution volume.
• Useful to ensure accurate fluid volume measurement.

Temperature of the Infusion

• IV admixtures may be compounded in advance and refrigerated to prolong stability and retard bacterial growth.
• Admixtures should never be mechanically heated in a microwave or on a hot plate, which can alter the drug and leach plasticizers from the I.V. bags.

Intravenous Pumps and Infusion Devices

• These devices control the delivery of an IV solution at a selected rate.
• Pumps are used to:
• Assure accurate solution delivery.
• Provide enhanced safety through built-in alarms.
• Store data on volume, infusion rate, etc.
• Infusion pumps are commonly used in the hospital.

Syringe Pumps

• Commonly used with pediatric patients.
• Smaller, hand-sized pumps are available for ambulatory patients.

Smart Pumps

• Infusion pumps with dose calculation software.
• Hospitals can pre-program standard concentrations for I.V. medications, as well as upper and lower dose limits.
• These pumps alert nurses if programmed outside of safe limits.

Elastomeric Infusion Devices

• Devices consist of a balloon-like drug reservoir encased in a hard plastic shell.
• The elastic reservoir contracts upon activation, forcing medication through a pre-attached tubing set.
• The tubing set is connected directly to the patient's catheter.
• These are used by home infusion companies and some cancer centers.