Parenteral and Enteral Preparations PDF

REYES, ROBLES, TOLENTINO | CLINICAL ASPECTS 1 PARENTERAL AND ENTERAL SMALL INTESTINE FEEDING Pr...

REYES, ROBLES, TOLENTINO | CLINICAL ASPECTS 1 PARENTERAL AND ENTERAL SMALL INTESTINE FEEDING Preferred for conditions such as: PREPARATION o Gastric outlet obstruction ENTERAL THERAPY o Gastroparesis ▪ paralysis of the stomach Commonly referred as enteral feeding or tube feeding o Increased risk of aspiration Route of the drugs and nutrients through mouth to the anus o Pancreatitis GASTROJEJUNAL AND GASTRODUODENAL TUBE Inserted at the stomach and continues to the small intestine Allows simultaneous gastric decompression and small bowel feeding Indication: o Gastric outlet obstruction o Severe GE reflux o GE regurgitation o Gastroparesis Indications Contraindications WHEN TO GIVE ENTERAL FEEDING Anorexia GI obstruction Ileus When oral feeding is not an option o Possible obstructions condition wherein the body cannot Head and Neck Cancers push the food and waste out of the o Deformities body (digestive system and muscles Nutritional requirements are not met with oral feeding around that area are not moving If the patient is in the ICU or a long-term care patient naturally) Neurologic and psychiatric If a patient requires nutrition to be delivered via feeding Conditions Severe diarrhea tubes, medications are also delivered in this route (e.g. advanced dementia, Parkinson’s the body will not absorb the feed, so it’s not advisable for enteral feeding disease, lateral sclerosis) FACTORS FOR CHOOSING OPTIMAL DEVICE AND Extensive burns Vomiting LOCATION Enterocutaneous fistula Patient age Critical Illness abnormal connection between the o Pediatric patients - preferred to be direct in the intestinal tract and stomach that sticks stomach to prevent restriction of movements with the skin ▪ suggested to be put directly into the stomach Lifestyle DURATION OF THERAPY o for example, an athlete's type of enteral feeding should not restrict his movement SHORT TERM Gastric motility Less than 4 weeks Risk for aspirating gastric content Often through NG, ND, NJ, NGJ o nasogastric, nasoduodenal, nasojejunal, nasogastric-jejunal Alteration in GI motility Nasoenteric feeding tubes are contraindicated for patients Pre-existing medical condition o example: if the patient has diabetes, the healing of the wounds is slow, with: the incision to be made for the patient should be small, and the type of o Head and Neck obstruction tube to be given should be planned carefully o Esophageal pathology or injury Anticipated length of therapy LONG TERM Greater than 4 weeks TYPES OF ENTERAL ACCESS DEVICE Via enterostomy (into stomach or small intestine) STOMACH FOR GASTRIC FEEDING Long term percutaneous enteral devices (EADs) may be Reserved for patients with normal gastric emptying and low placed with local anesthetics in the abdominal wall risk of pulmonary aspiration o since this is long-term, it may be uncomfortable for the patient, so local o selecting a proper enteral feeding device depends on gastrointestinal anesthetics accompany the medications to lessen the pain since the area anatomy and function, anticipation of duration, and potential risk for would be sore aspiration Indication/s: o Facial trauma ▪ nasogastric is not recommended since it’s painful, we have to choose the enteroscopy (could be in the stomach or small intestine) o Nose bleeds o Anticoagulant therapy CONTINUOUS INFUSION Pump-assisted critical care Initiated with full strength formula o full-strength formula - it could destroy the veins and it could be painful for the patient causing anxiety or being uncomfortable  REYES, ROBLES, TOLENTINO | CLINICAL ASPECTS 2 o Diluting with water increases the risk for bacterial ISOTONICITY contamination Isotonic o Initiate at a slow rate and titrate every 8-12 hours until o to reduce patient discomfort and damage to RBCs treatment goal rate is achieved ▪ Isotonic - 0.9% NSS Disadvantage: cost and inconvenience associated with ▪ Hypertonic - crenation (shrink) ▪ Hypotonic - 0.45%, hemolysis (burst) pump and administration set TYPES OF IV SOLUTION PARENTERAL THERAPY Small volume parenteral Large volume parenteral PARENTERALS 50 to 250mL Higher than 250mL Generally 1000mL Medications given by any route other than the alimentary Used as a vehicle for Used mainly to provide fluid medication canal and electrolyte replacement Most cases via injection TYPES OF IV ADMINISTRATION Most common route is IV or directly into the veins o We also have the intracellular fluid compartment that we need to take IV PUSH OR IV BOLUS care of. It composes 40%-50% of your body weight, while the extracellular fluid compartment 20% of your body weight. Injection of a small amount of drug by means of a needle or syringe TYPES OF INTRAVENOUS SOLUTIONS o IV push - given in emergencies (e.g. morphine) o IV bolus - fast acting but would take several minutes rather than seconds CRYSTALLOIDS compared to IV push (e.g. PNSS with medication) Non-colloid substance that resembles crystals INFUSION Readily passes through cell membrane o example: Dextrose and NSS Administration of a large amount of fluid over a prolonged ▪ dextrose - the source of calories (carbohydrates) while the water period of time is the source of hydration PIGGYBACK Administration is via secondary line with an established running IV solution or a primary line Used to deliver medications like lipids COLLOIDS Large molecular weight substances composed of protein, carbohydrates or gelatin Causes a shift of fluid from the interstitial space into the intravascular space or circulation Used to provide plasma volume expansion Increases intravascular volume to restore normal blood volume Example o Human albumin PARENTERAL PREPARATIONS o Plasma protein factor IV ADMIXTURES o Dextran Consists of one or more sterile drug products added to an CHARACTERISTICS OF IV SOLUTIONS IV fluid As much as possible, these characteristics should be followed, especially the first Used for drugs intended for continuous infusion two. Disadvantage: causes irritation or toxicity when given as a STERILITY rapid effect IV injection Free from any pathogen or disease-causing microorganisms IV FLUIDS AND ELECTROLYTES CLARITY Used in the preparation and administration of parenteral Free from unintentional particulates such as glass, rubber, products cloth fibers Serves as a vehicle for IV admixture PH Example o Sterile water Should be close to physiological pH (7.4) o Sodium chloride o Ringer’s solution Some medications must be checked to see if they’re compatible with the vehicle. We need to look at the package insert to double-check.  REYES, ROBLES, TOLENTINO | CLINICAL ASPECTS 3 DEXTROSE RINGER’S SOLUTION Most frequently used glucose solution Appropriate for fluid and electrolyte replacement Serves as a hydrating solution o most commonly administered to post-surgical patients o since it contains water LACTATED RINGER’S SOLUTION (HARTMANN’S SOLUTION, D5W RINGER’S LACTATE) used as a vehicle in IV admixture Contains sodium lactate, NaCl, KCl, CaCl2 Frequently combined with dextrose D50W provides a source of carbohydrate in parenteral nutrition RINGER’S SOLUTION solution Does not contain sodium lactate and has slightly different concentration of NaCl and CaCl2 ELECTROLYTES SODIUM Key role: o interstitial osmotic pressure o Tissue hydration and dehydration o Acid-base balance o Nerve impulse transmission o Muscle contraction Example remember the color of the packaging of dextrose, which is red o Sodium Chloride o Sodium Acetate SODIUM CHLORIDE o Sodium Phosphate Given as 0.9% solution - isotonic with blood POTASSIUM SODIUM CHLORIDE FOR INJECTION Key role: used as a vehicle in IV admixture and for fluid and o Participates in carbohydrate metabolism electrolyte replacement o Protein synthesis BACTERIOSTATIC SODIUM CHLORIDE FOR INJECTION o Muscle excitability intended solely for multiple reconstitution and it contains Example agents that inhibit bacterial growth o Potassium acetate o in cases, large volume is prepared and multiple aspirations are done o Potassium chloride o Potassium phosphate Recall: Major intracellular cation: Potassium Major extracellular cation: Sodium CALCIUM Key roles: o Essential for nerve impulse transmission o Muscle contraction o Cardiac function o Bone formation o Capillary and cell permeability Example WATER o Calcium chloride Used for reconstitution o Calcium gluconate Used for dilution of IV solutions (ex. Powders) o Calcium gluceptate Sterile Water for Injection MAGNESIUM Bacteriostatic Water for Injection Key roles: Vital in enzyme activities Neuromuscular transmission Muscle excitability Example o Magnesium sulfate CHLORIDE Key roles: o Regulate interstitial osmotic pressure o Helps control blood pH/blood acidity levels  REYES, ROBLES, TOLENTINO | CLINICAL ASPECTS 4 Example IV tubing are usually amber-colored and should be primed o Sodium Chloride before adding the drug o Potassium Chloride o One of the requirements when handling chemotherapeutic agents is o Calcium Chloride mixing them with your vehicle, like sodium chloride. You usually prime the tube first. Priming refers to flushing the tube with the vehicle to PHOSPHATE remove the unwanted contents of the tube or other chemicals. Key roles: o Critical to various enzyme activities o Influences calcium levels o Acts as a buffer to prevent marked changed in acid- base balance Recall: Major intracellular anion: Phosphate Major extracellular anion: Chloride ACETATE Proper disposal of materials used in preparation and Key roles: administration o Bicarbonate precursor o Provide alkali to assist in preservation of plasma pH Example o Potassium acetate o Sodium acetate PARENTERAL CHEMOTHERAPEUTIC AGENTS May be toxic to the personnel who prepare and administer May be given directly IV injection, short term or long term infusion Sharps container (left pic) - this is where used needles and broken ampules are o could also be given subcutaneous, intramuscular, intrathecal, or disposed intraarterial, depending on doctor’s orde Orange bag/trash bag (right pic) - this is where used vials and other wastes are disposed PROBLEMS ENCOUNTERED DURING PARENTERAL TREATMENT PHLEBITIS inflammation of the veins around the site of administration Causes pain, swelling, redness and heat sensation Usual causes o highly concentrated drugs ▪ you need to dilute the concentrated drug with the vehicle like dextrose or sodium chloride, to reduce the pain of the patient o large particles ▪ it is common with the biologicals; you need to add a filter that regulates the flow (slow down the flow and shrink the particles) Drug classification of cisplatin: platinum derivative Bevacizumab (Avastin): newly released antineoplastic HANDLING CHEMOTHERAPEUTIC AGENTS EXTRAVASATION All personnel preparing or administering antineoplastics the administered drug infiltrates the subcutaneous tissues should receive special training Vertical laminar flow hood should be used during preparation o so that the air will not be going in the direction of the operator or personnel All syringe and IV tubing should have a Luer-Lock fitting Personnel should wear PPE o Closed-front cuffed gown resistant to liquid permeation o Latex or nitrile gloves ▪ sometimes, the personnel need to wear double gloves, a cap, and boots  REYES, ROBLES, TOLENTINO | CLINICAL ASPECTS 5 PARENTERAL ANTIBIOTIC PREPARATION Reconstituted with sterile water, normal saline or D5W o Used to treat infections that are serious and require high antibiotic level Co-amoxiclav (Augmentin) Cefuroxime (Zinacef) PARENTERAL BIOLOGIC PREPARATION Recombinant technology to the generation of therapeutic agents o usually, diseases that do not have a cure are given this type of medication and are approved by the FDA for this particular reason o Cancer therapy o Infections ▪ since it is alarming that there is antimicrobial resistance o Transplant rejection - immunosuppressants o Rheumatoid arthritis ▪ there are medicines for swelling but no cure Contraindications: o IBD/Inflammatory Bowel Disease o Adequate nutrition stores and expected GI function ▪ combination of diarrhea and constipation and still have no reason returning 5-7 days as to why it’s happening o GI function is not impaired ▪ usually given with recombinant technology (biologics) o If there is no need for nutritional intervention o Respiratory disease o Malaria END Protein and peptide biotechnology drug that have a shorter half-life TOTAL PARENTERAL NUTRITION Hyperalimentation o nutrition given through the vein Provides a complex form of nutrition Contains dextrose, amino acids, electrolytes, and additives Indication o Enteral nutrition is not possible due to GIT malfunction o Gut is not accessible o Tube feeding is not safe or ineffective ROUTE OF ADMINISTRATION CENTRAL VENOUS ROUTE Hypertonic parenteral foundation (dextrose >10%) o it can withstand hypertonic solutions since the vein is thick, which is superior vena cava PERIPHERAL VENOUS ROUTE (Dextrose < 10%) o since the thinner vein cannot withstand hypertonic solutions (which could cause phlebitis or extravasation)