hospital pharmacy report intravenous admixtures

INTRAVENOUS ADMIXTURES

Guide Questions:What are intravenous fluids?

What are the different types of intravenous fluids available in the Philippines?

What are the different components of an IV fluid?

What are the conditions where IV fluids are used?

Define isotonic, hypotonic and hypertonic solution.

When to use hypotonic, hypertonic and isotonic solution?

What are the different types of IV administration set/ equipments?

What is intravenous admixture?

How are IV admixtures prepared?

What are the different types of incompatibilities encountered in the preparation of IV admixtures?

What are the complications associated with IV theraphy?

What are Intravenous fluids?Are large-volume injections

intended to be administered by intravenous infusion.

• Included in the group of sterile products refered to as Large Volume Parenterals (LVPs).

• Consists of single-dose injections having a volume of 100mL or more and containing no added substances.

Remington, 21st Edition

What are Intravenous fluids?Are sterile solutions of simple

chemicals such as sugar, amino acids, or electrolytes- materials that easily can be carried by the circulatory systemand assimilated.

•Prepared with Water for Injection, USP•Pyrogen-free solutions

A solution (usually a balanced electrolyte solution) administered directly into the venous circulation.

Intravenous Fluids may be classified into:• Crystalloid Solutions• Colloidal Solutions

Crystalloid Solutions•contain small molecules that pass freely through cell membranes and vascular system walls. •Are primary fluids used for IV theraphy.• These solutions are useful as fluid expanders and are stored at room temperature. •Useful source for electrolytes and a temporary source of fluid volume.

Saline Solutions- is a solution of sodium chloride, or salt, in sterile water.

A. 0.9 % Normal Salinecontains 9g/L sodium chloridehas osmolarity of 308 mOsmol/L (calc). It contains 154 mEq/L sodium and 154 mEq/L chloride.is a solution commonly used for medical purposes such as intravenous therapy for severe dehydration. It is also used as a rinse for contact lenses, and is used in wound care for irrigating, cleansing and hydrating wounds.Has green label

B. 0.45% Normal Saline SolutionHypotonic Salinecontains 4.5 g/L Sodium Chloridehas osmolarity of 154 mOsmol/L (calc). It contains 77 mEq/L sodium and 77 mEq/L chloride.

C. 1.8, 3.0, 7.0, 7.5 and 10% Saline SolutionHypertonic Saline

Dextrose Solutions- used to supply water and calories to the body. It is also used as a mixing solution (diluent) for other IV medications.

A. 5% Dextrose (D5W)is a parenteral fluid and nutrient replenisher.Each 100 mL of 5% Dextrose Injection, USP, contains dextrose, hydrous 5 g in water for injection. The caloric value is 170 kcal/L. The osmolarity is 252 mOsmol/L (calc.), which is slightly hypotonic.has red label

B. 5% Dextrose in 0.9% Saline (D5NS)is a sterile, nonpyrogenic solution for fluid and electrolyte replenishment and caloric supply in single dose containers for intravenous administration.has yellow label

C. 5% Dextrose in 0.45% Saline (D51/2NS)

D. Dextrose 5% in Lactated Ringer’s (D5LR)

has purple/ pink label

Lactated Ringer’s Solution- is an intravenous (IV) solution used to supply water and electrolytes (e.g., calcium, potassium, sodium, chloride), either with or without calories (dextrose), to the body. It is also used as a mixing solution (diluent) for other IV medications.

has blue label

Colloidal SolutionsIt contains molecules that are frequently very complex and much larger than those in the crystalloid solutions. It is needed when a solution is required to remain in the vascular system. It generally require refrigeration and can be stored for a limited period. Whole human blood U.S.P. and Hetastarch are examples of colloid solutions.

What are the different components of an IV fluid?Water- for patients with dehydration

Amino Acids- for tissue growth and repair, replacing body cells, healing wounds, and synthesizing vitamins and enzymes

Vitamins (A, D, E, K, B & C)- for the restorative and replacement theraphies.

pH- for the acidity and alkalinity of a solution.

Electrolytes- major additives for replacement and restorative therapies.

-any compound that, in solution or in molten form, conducts electricity and is decomposed (electrolyzed) by it. It is an ionizable substance in solution

-is any substance that contains free ions that behaves as an electrically conductive medium (conducts electricity).

Electrolytes Functions Sources

Sodium • Regulation for water regulation

• It helps with electrical signals in the body, allowing muscles to fire and the brain to work

Sodium Acetate

Sodium Phosphate

Potassium • Regulation of acid-base balance

• It is essential in the generation of the electricial impulses in the body that allow muscles and the brain to function

Potassium Chloride

Potassium Phosphate

Magnesium • is involved with a variety of metabolic activities in the body, including relaxation of the smooth muscles that surround the bronchial tubes in the lung, skeletal muscle contraction, and excitation of neurons in the brain.

•It acts as a cofactor in many of the body's enzyme activities.

Magnesium Sulfate

Magnesium Phosphate

Calcium • Used in building and maintaining bones and teeth. • Aids in blood clotting, nerve function, and muscle contraction. • Maintains normal levels of blood pressure and stomach acid.

Calcium Gluconate

Calcium Chloride

Phosphate • It helps form strong bones and teeth in the human body. • It helps filter waste from the kidneys and plays a vital role in the production and storage of energy in the body.

• It is responsible for maintaining the balance of other nutrients since it combines with other minerals to form phosphate salts or compounds.

Phosphate salt of sodium and potassium

Chloride •It travels primarily with sodium and water and helps generate the osmotic pressure of body fluids.

•It is an important constituent of stomach hydrochloric acid (HCl), the key digestive acid.

•It is also needed to maintain the body's acid-base balance.

•It may also be helpful in allowing the liver to clear waste products.

Chloride salt of cations

Nutrient Solutions- carbohydrates (dextrose, glucose or fructose)

- water

Example: D5W (5% dextrose in water) 5% dextrose in 0.45% NaCl (dextrose in

half-strength saline)

Electrolyte Solutions- cations and anions

Example: NSS (0.9% NaCl solution) Ringer’s Solution (Na, Cl, K and Ca) Lactated Ringer’s Solution (Na, Cl, K, Ca and Lactate)

Alkalizing Solutions- for metabolic acidosis

Acidifying Solutions- for metabolic alkalosis

Blood Volume ExpandersExample:DextranPlasmaHuman serum albumin

What are the conditions where IV fluids are used?

Intravenous fluids commonly are used with the following conditions:

Correction of disturbances in electrolyte balance (Na, K, Ca, PO4, Mg imbalance)Correction of disturbances in boy fluids (volume expander, blood loss)Means of providing basic nutrition(provide patients with difficulty in taking food and fluids orally)Basis for the practice of providing Parenteral NutritionVehicles for other drug substances (mixed with fluids for medication needed in the body)

Define hypotonic, hypertonic and isotonic solution.Hypertonic- is a solution having a larger concentration

of a substance than is found within the cells themselves.

-it causes the cell to shrink, or crenate.

Hypotonic-it contains a lesser concentration of impermeable solutes on the external side of the membrane.

-it causes the cell to swell

Isotonic- a solution which has the same concentration of dissolved substances as the blood cells do.

Define hypotonic, hypertonic and isotonic solution.

When to use hypotonic, hypertonic and isotonic solution.

have a lesser concentration of soluteshave an osmolarity lower than 250 mOsm/Loften given to correct cellular dehydration and hypernatremiaUsed by patients for:-hypertonic dehydration-for water replacement-diabetic ketoacidosisExamples are:-0.45% NaCl (half strength saline)-0.33% NaCl-2.5% Dextrose in water

Hypotonic Solution

When to use hypotonic, hypertonic and isotonic solution.

have a greater concentration of solutes than plasmaHave greater tonicity than blood.Uses:

-to replace electrolytes-to treat hypotonic dehydration-temporary treatment of

circulatory insufficient and shockExamples are:

-5% Dextrose in 0.45% NaCl-5% Dextose in 0.9% NaCl-5% Dextrose in lactated Ringer’s-10% Dextrose in water-Colloids (albumin 25%, Plasma

protein fraction)

Hypertonic Solution

When to use hypotonic, hypertonic and isotonic solution.Isotonic Solution

Have the same concentration of solutes (osmolarity) as blood plasma.Prevents sudden shifts of fluids and electrolytes in the bodyUsed for:

-treatment of fluid loss-dehydration-hypernatremia (sodium excess)

Examples are:-0.9% NaCl-5% dextrose in water-Lactated Ringer’s Solution

What are the different types of IV administration sets and equipments?

IV Infusion can be administered either by:

1) Gravity alone

Example: Gravity Infusion set

2) With the use of an electronic infusion device

Example: Infusion pumps Volumetric pumps

IV Administration Sets

What are the different types of IV administration sets and equipments?IV infusion administered by gravity:Gravity Infusion Set

The height of the IV solution is of greater importance than the tubing.

Most basic types of IV tubes/tubing can be used in this type of set.

The higher the solution, the faster the solution infuses.

Preferred elevation of the solution from the site of infusion: 18 to 24 inches (45 to 60 centimeters).

What are the different types of IV administration sets and equipments?IV infusion administered with the use of an electronic infusion device:

Infusion Pump

Pressure is used in order to infuse solutions

Requires special tubing that contains a device such as cassette to create a sufficient pressure to push fluid into the vein.

Advantage: Programmed to deliver a preset volume per hour.

Disadvantage: If catheter or needle within vein becomes misplaced, the pump will still continue on infusing fluid into the site.

What are the different types of IV administration sets and equipments?IV infusion administered with the use of an electronic infusion device:

Volumetric PumpDo not depend upon gravity to force the

fluid into the vein. All volumetric pumps generally involve

the nurse entering the infusion rate in mL/hr. The volumetric pump then automatically maintains that rate.

Volumetric pumps should still be checked regularly to ensure that they are infusing the medication correctly.

Infiltration is possible when using a volumetric pump because it forces the fluid into the vein, even when it encounters resistance.

IV Administration EquipmentsBasic IV Setup consists of the following important

parts/equipment:

a) Drip chamber c) Slide clamp

b) Roller clamp d) Injection port

Other IV equipment:

c) IV Tubing d) Central IV Lines

d) Hypodermic needle e) Tunneled Lines/Broviac Line

e) Catheter needle f) Peripherally inserted central catheter

A) Drip Chamber Located just below the IV bag. Inside this chamber, we can see

the fluid drip down from the bag into the IV tubing.

This is where we measure the speed of a manual IV setup; we look at this chamber and count the number of drops we see per minute.

B) Roller Clamp is what we use to control the rate

at which the IV fluid infuses. All roller clamps on a set of IV

tubing should be closed before we attach a bag of IV fluid to the top of the tubing; this ensures that no air gets into the tubing.

Basic Parts & Equipments

What are the different types of IV administration sets and equipments?Basic Parts & Equipments

C) Slide Clamp slide clamp is used when we

want to completely stop the IV from flowing without having to adjust the roller clamp.

D) Injection port A place where medicine or

fluids other than those in the current IV bag can be injected so that they will infuse into the patient's vein through the IV tubing.

a)Drip chamberb) Roller clampc) Slide clampd) Injection port

Other IV EquipmentsA) IV Tubing Plastic conduit used to

administer various fluids to patients through a needle inserted into one of the patient’s vein.

B) Hypodermic Needle Commonly used with a

syringe to inject substances into the body or extract fluids from it.

C) Catheter Needle Used for the injection of

fluids into the human body. This device is widely used in hospitals.

Other IV EquipmentsD) Central IV Lines Have the capacity to

deliver fluids that are considered to be irritating to peripheral veins. Also, medications introduced in this manner are quickly distributed throughout the body.

E) Tunneled Lines/Broviac Lines

A type of central line in which Hickman line or Broviac catheter is inserted into the target vein then tunneled under the skin to emerge a short distance away.

F) Peripherally Inserted Central Catheter

Used when IV administration requires to be in a prolonged period or when the substance to be infused would cause damage if infused quickly.

G) More Equipments:

What is Intravenous Admixture?

It is a combination of one or more sterile products added to an IV fluid for administration.

Intravenous admixtures must be sterile and free from pyrogens since it will be administed into the body.

Aseptic technique is used to mixed the products.

How are Intravenous Admixture prepared?

The pharmacist must be knowledgeable in preparing a form for the combination of drugs and IV solutions that will be suitable for administration to the patient.

Products used in preparing the admixture must be sterile and not contaminated.

Proper conditions for aseptic handling can be provided by laminar-flow hoods.

IV push and IV infusion dose forms are prepared in the laminar-flow hoods.

Before the preparation of admixtures:Both hands must be thoroughly cleaned.Accessories/jewelries must be removed.Gloves must be used during the procedure.Laminar-flow hoods must be kept running.All surfaces of the work area must be cleaned and

disinfected.

During the preparation of admixtures:One must work in the center of the area within the

laminar-flow hood.Proper procedures must be followed in handling sterile

devices and containers.

The plunger and the tip of the syringe must not be touched for they are sterile.

One must use the smallest syringe which can hold the desired amount of solution.

Additives may be packaged in vials or ampules.

After the preparation of admixtures:Properly dispose used gloves and syringes. Clean the work area

Drawing liquid from a vial:

Choose the smallest gauge needle and handle carefully the rubber top of the vial thus, preventing particulates from entering.

Attach needle to the syringe.

Draw into the syringe an amount of air equal to the amount of solution to be drawn from the vial.

HOW ARE INTRAVENOUS ADMIXTURES PREPARED?

Swab alcohol on the top of vial. Enter the laminar flow hood. Puncture the rubber top of vial with needle bevel up. Bring needle and syringe straight up.

Penetrate the stopper then depress the plunger of the syringe, emptying the air to the vial.

Invert the vial with the attached syringe then draw up the required amount for the preparation.

Withdraw the needle of the syringe from the vial.

Remove and properly dispose the needle and the cap of the syringe.

Prepare the product by introducing the withdrawn drug from the vial into the IV container.

Carefully tap the top of the ampule so that medication will settle on the lower portion of the ampule.

Clean the neck using an alcohol swab then, grasp the ampule between the thumb and index finger at the neck with the swab still in place.

Forcefully snap the neck away from you.

Opening an ampule:

Tilt the ampule then place the needle bevel of a filter needle or tip of a filter straw in the corner near the opening. Withdraw the medication.

Use a needle with a filter to filter out any glass particles, fibers, or other materials which may have fallen in the ampule.

Before putting the contents of the syringe to an IV, needle must be replaced with a filter device to prevent introduction of particulates into the admixture.

Drawing liquid from an ampule:

Labeling of the admixture:Labels for admixtures should contain the following

information:- Patient’s name and identification number- Room number- Fluid and amount- Drug name and potency- Infusion period- Flow rate (e.g. 50mL/hr or infuse in a 30 minute period)- Expiration date and time- Any needed additional information

Intravenous fluids incompatibilities are the undesirable reactions that can occur when two or more drugs must be administered through single IV line or given in a single solution.

Types:1) Physical Incompatibilities2) Chemical Incompatibilities3) Therapeutic Incompatibilities4) Drug IV Container Incompatibilities

What are the different types of incompatibilities encountered in preparing IV admixtures?

Physical IncompatibilityThe incompatibility that is more on solubility

changes and container interactions.

Type Ways to Prevent

INSOLUBILITY - Do not administer a precipitate forming drug.- Avoid mixing drugs

prepared in special diluents with other drugs.

- In administration of multiple intravenous

medications, prepare each drug in a separate syringe.

SORPTION PHENOMENA

GAS FORMATION

SOLUTION PH

Chemical IncompatibilityResults from the molecular changes or

rearrangement and leads to chemical decomposition.

Type Ways to PreventHYDROLYSIS Store drugs in relatively

water-proof containers.OXIDATION REACTION Store drugs in amber bottles.

This will minimize oxidation reaction.

REDUCTION REACTION Keep away from suspected reducing agents.

PHOTOLYSIS Storing drugs in lightproof containers can usually prevent

photolysis.

Therapeutic IncompatibilityResult of antagonistic pharmacological effects of

several drugs in one patient.

Example Intervention

Heparin and antibiotics It is best to avoid mixing heparin with

antibacterial preparations because Heparin can affect the

stability of certain antibiotics.

Drug-IV Container IncompatibilityIncompatibility that arise from the chemical reaction

of the drug and the Intravenous container.

Type DefinitionADSORPTION The property of a

solid/liquid to attract and hold to its surface a gas,

liquid, solute or suspension.

ABSORPTION The act of taking up liquids or other substances

through a surface of the body into body fluids and

tissues.

INTRAVENOUS INCOMPATIBILITIES

Factors causing IV Incompatibility

Type InterventionDifference in pH Refer to drug

incompatibility tables.

High Concentration Determine the chemically compatible concentration

of both drugs.

High Temperature Refrigerate the IV admixture if not used

within 1 hour after mixing.

Order of Mixing Alternate the administration

Length of Time in Solution

The Iv drug should be mixed and discarded if not

used within 24 hours.

INTRAVENOUS INCOMPATIBILIES

1. Mix thoroughly when a drug is added to the preparation

2. Minimize the number of drugs mixed together in an IV solution.

3. Solutions should be administered promptly after mixing so that occurrence potential reactions can be minimized.

4. Always refer to compatibility references.

Ways to prevent or minimize incompatibilities

What are the complications associated with the IV therapy?

Local Complications

InfiltrationPhlebitisThrombosisThrombophlebitisBruisingHematoma

Systemic Complications

SepticemiaFluid overload and

pulmonary edemaAir embolismCatheter embolismSpeed shock

Infiltrationo Happens when the needle or

catheter in which the product is entering the blood vessel (vein) is dislodged from the vein.

o Remedy: Product should be administered in another site.

Phelibitiso Inflammation of vein caused

by mechanical, bacterial or chemical irritation.

o Characterized by redness and pain at the administration site.

o Remedy: Solution should be administered in another site.

Local Complications

Thrombosiso Occurs when blood flow

through a vein is obstructed by a local thrombus.

o Remedy: remove IV device, restart infusion, apply warm soaks.

Thrombolphlebitiso Similar to phlebitis but a

clot (thrombus) is involved.o At times, the IV cannula

staying inside the body can cause irritation which can trigger clotting mechanisms.

Local Complications

• Bruisingo A type of minor hematoma

of tissue in which capillaries and sometimes venules are damaged due to trauma allowing blood to collect to the surrounding tissues.

• Hematomao Collection of blood caused

by internal bleeding. This can happen when a catheter punctures through the vein and cause bleeding.

• Septicemiao A febrile disease process that

resulted from the presence of microorganisms or their toxic products in the circulatory system.

• Fluid Overload and Pulmonary edemao Excessive administration of

intravenous fluids is the main cause.

o High blood pressure may result due to increased fluid volume.

o Also, pulmonary edema may also happen due to abnormal fluid accumulation in the lungs.

w/ edema

Normal

• Air embolismo Results when a sizeable

volume of air enters the circulatory system.

o This may happen when air from the intravenous administration set enters the bloodstream.

• Catheter embolismo Happens when a piece of

the catheter breaks off and travel through the circulatory system.

• Speed Shocko Occurs when a foreign substance (e.g

medication) is rapidly infused or introduced into the circulation.

Remember:

“Early detection and good communication between patient and healthcare provider are

both important in minimizing IV therapy complications.”

THANK YOU! XD

Group 1

AYCO, IVY LENADONGGON, JOHN JEFFERSON BALLESTA, MARIA ZARABULAONG, KRISTINEDAILEG, KRISTINEDURO, GALE MICAHRAMIREZ, RHEAVILLANUAEVA, MARIA PIAVILLACORTE, ILY

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