Preparing Sterile Intravenous Products

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Chapter 11
Preparing Sterile Intravenous Products
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Chapter 11 Topics

• Intravenous Preparations
• Equipment Used in IV Preparation
• Preparing IVs
• Calculations for the Hospital Pharmacy Technician

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Learning Objectives

• Describe the characteristics of intravenous
  solutions including solubility, osmolality, and
  pH
• Identify common vehicles for intravenous
  solutions
• Describe the equipment and procedures used in
  preparing parenterals
• Identify the components of an intravenous
  administration set
• Convert from Fahrenheit to Centigrade and vice
  versa
• Calculate the molecular weight and
  milliequivalents of certain substances used in
  the pharmacy
• Compute the specific gravity of liquids
• Calculate intravenous rates and administration

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Intravenous Preparations

• The IV route of administration is used
• to reach appropriate drug serum levels
• to guarantee compliance
• for drugs with unreliable gastrointestinal (GI)
  absorption
• for the patient who can have nothing by mouth
• for the patient who is unconscious or
  uncooperative, and for rapid correction of fluid
  or electrolytes
• Most parenterals are introduced directly into the
  bloodstream
• must be free of air bubbles or particulate matter
• have many characteristics including solubility,
  osmolality, and pH

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Characteristics of IV Preparations

• Intravenous (IV) preparations are either
• solutions (in which ingredients are dissolved)
• suspensions (in which ingredients are suspended)
• Most parenteral preparations are made of
  ingredients in a sterile water medium
• Some parenteral preparations may be oleaginous
  (oily)

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Characteristics of IV Preparations

• Parenteral IV preparations must have chemical
  properties that will not
• damage vessels or blood cells
• alter the chemical properties of the blood serum
• With blood, IVs must be
• iso-osmotic (having the same number of particles
  in solution per unit volume)
• isotonic (have the same osmotic pressure, meaning
  the pressure produced by or associated with
  osmosis)

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Characteristics of IV Preparations

• The osmolality is the amount of particulate per
  unit volume of a liquid preparation
• measured in milliosmoles (mOsm)
• osmolality of blood serum 285 mOsm/L
• An isotonic solution is a solution in which body
  cells can be bathed without a net flow of water
  across a semipermeable membrane
• 0.9 normal saline (NS)

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Characteristics of IV Preparations

• Pharmacists sometimes must adjust tonicity of
  parenteral preparations to ensure they are near
  isotonic
• A hypertonic solution has a greater number of
  particles than the blood cells themselves
• 50 dextrose or 3 sodium chloride
• A solution of less than normal tonicity is
  hypotonic, which has fewer numbers of particles
  than blood cells
• 0.45 NS

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Characteristics of IV Preparations

• The pH value is the degree of acidity or
  alkalinity of a solution
• acidic solution pH of less than 7
• alkaline solution pH value more than 7
• Human blood plasma has a pH of 7.4
• slightly alkaline
• parenteral IV solutions should have a pH that is
  neutral (near 7)

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Methods of Injection

• The bolus, or injection, is one of the most
  common routes of IV administration
• The injection is performed using a syringe
• prepackaged in the form of filled, disposable
  plastic syringes
• injectable drug must be taken up into the syringe
  from a single- or multi-dose glass or plastic
  vial, or from a glass ampule
• Sometimes the solid drug in the vial has to be
  reconstituted by addition of a liquid before use

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Methods of Injection

• IV infusions deliver
• large amounts of liquid into the bloodstream over
  prolonged periods of time
• IV infusion is used to deliver

blood electrolytes
water drugs
other fluids nutrients

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Discussion
What are some characteristics of parenteral
preparations, and why are they important?
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Discussion
What are some characteristics of parenteral
preparations, and why are they important? Answer
Tonicity, osmolality, and pH are characteristics
of parenteral preparations. It is important that
they be adjusted to be as close as possible to
the values for human blood, to prevent damage to
blood cells and organs.
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Terms to Remember

• osmotic pressure
• osmolality
• isotonic solution
• hypertonic solution
• pH value

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Equipment Used in IV Preparation

• Pharmacies use plastic disposable products to
• save time and money
• provide the patient with an inexpensive sterile
  product
• Often the entire system sent out to the patient
  floors is composed of plastic
• thin, flexible plastic catheters are replacing
  metal shafts that deliver the medication into the
  vein
• in many cases the only durable, nondisposable
  product used to deliver IV medication is the IV
  pump or controller

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Commonly Used IV AbbreviationsFluids
IV Component Abbreviation
2.5 dextrose in water D2.5W
5 dextrose in water D5W
5 dextrose and lactated Ringers solution D5RL or D5LR
10 dextrose in water D10W
5 dextrose and normal saline D5NS
2.5 dextrose and 0.45 normal saline D2.5½ NS
5 dextrose and 0.45 normal saline D5 ½ NS
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Commonly Used IV AbbreviationsFluids
IV Component Abbreviation
normal saline NS
0.45 normal saline 0.45NS or ½ NS
lactated Ringers solution RL or LR
sterile water for injection SWFI
bacteriostatic water for injection BWFI
sterile water for irrigation SW for irrigation
normal saline for irrigation NS for irrigation
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Commonly Used IV AbbreviationsElectrolytes
IV Component Abbreviation
potassium chloride KCl
potassium phosphate K phos or KPO4
potassium acetate K acet
sodium phosphate Na phos or NaPO4
sodium chloride NaCl
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Commonly Used IV AbbreviationsAdditives
IV Component Abbreviation
multivitamin for injection MVI
trace elements TE
zinc (a trace element) Zn
selenium (a trace element) Se
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Syringes and Needles

• Syringes are used for IV push and in the
  preparation of infusions, are made of glass or
  plastic
• Glass syringes are more expensive
• use limited to medications that are absorbed by
  plastic
• Plastic syringes
• are less expensive
• are disposable
• come from the
  manufacturer sterile

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Syringes and Needles

• Needles are made of stainless steel or aluminum
• needle lengths range from 3/8 of an inch to 6
  inches
• needles come in gauges ranging from 30 to 13
  (higher the gauge, smaller the lumen)
• After use, needles must be discarded in a
  designated sharps container

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IV Sets

• An IV administration set is a sterile,
  pyrogen-free disposable device used to deliver IV
  fluids to patients
• The set may
• be sterilized before use by means of radiation or
  ethylene oxide
• come in sterile packaging and a sealed plastic
  wrap
• Sets do not carry expiration dates
• Sets carry the following legend
• Federal law restricts this device to sale by or
  on the order of a physician.

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IV Sets

• Nurses generally have the responsibility for
• attaching IV tubing to the fluid container
• establishing and maintaining flow rate
• overall regulation of the system
• Pharmacy personnel must assess aspects of IV
  systems, including infusion sets
• A complete understanding of IV sets and their
  operation is important to pharmacists and
  pharmacy personnel

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IV Sets

• IV sets are sterile and nonpyrogenic
• Each unit is supplied in packaging that ensures
  the maintenance of sterility
• Flanges and other rigid parts of an IV set are
  molded from tough plastic
• Most of the length of the tubing is molded from a
  pliable polyvinyl chloride (PVC)
• PVC sets should not be used for
• nitroglycerin, which is absorbed by the tubing
• IV fat emulsions, which may leach out of the
  tubing

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IV Sets
Safety Note
A damaged package cannot ensure sterility, even
if all protectors are in place. It is best to
discard sets that are found in unoriginal,
opened, or damaged packages.
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IV Sets
Safety Note
Do not use PVC IV sets for nitroglycerin or fat
emulsions. Special types of plastic sets are
required for such infusions.
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IV Sets

• The length of sets varies from 6-inch extensions
  up to 110- to 120-inch sets used in surgery
• the priming of tubing depends on the length of
  the set
• Standard sets have a lumen diameter of 0.28 cm
• varying the size of the lumen diameter achieves
  different flow rates
• regulation of flow rates is critical in neonates
  and infants

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IV Sets

• The tubings interior lumen may contain particles
  that flush out when fluid is run through the set
• Use of final filtration has reduced the need for
  flushing the line with the IV fluid before
  attaching the set to the patient

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IV Sets

• A spike to pierce the rubber stopper or port on
  the IV container
• A drip chamber for trapping air and adjusting
  flow rate
• A control clamp for adjusting flow rate or
  shutting down the flow
• Flexible tubing to convey the fluid

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IV Sets

• A needle adapter for attaching a needle or a
  catheter
• A catheter, or tube, may be implanted into the
  patient and fixed with tape to avoid having to
  repuncture the patient each time an infusion is
  given

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IV Sets

• Most IV sets contain a Y-site, or injection port
• a rigid piece of plastic with one arm terminating
  in a resealable port
• used for adding medication to the IV
• Some IV sets also contain resealable in-line
  filters
• protection for the patient against particulates,
  including bacteria and emboli

Go to www.baxter.com to see IV tubing products
from a major manufacturer
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IV Sets

• The spike is a rigid, sharpened plastic piece
  used proximal to the IV fluid container
• covered with a protective unit to maintain
  sterility
• generally has a rigid area to grip while it is
  inserted into the IV container
• If an air vent is present on a set, it is located
  below the spike
• the air vent points downward and has a bacterial
  filter covering
• the vent allows air to enter the bottle as fluid
  flows out of it
• necessary for glass bottles without an air tube

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IV Sets

• The drip chamber is a transparent, hollow chamber
  located below the sets spike
• drops of fluid fall into the chamber from an
  opening at the uppermost end, closest to the
  spike
• number of drops it takes to make 1 mL identifies
  an IV set

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IV Sets

• The most common IV drop sets are
• 10 (10 gtt/mL)
• 15 (15 gtt/mL)
• 20 (20 gtt/mL)
• 60 (60 gtt/mL)

• An opening that provides 10, 15, or
  20 gtt/mL is commonly used for adults
• An opening that provides 60 gtt/mL is used for
  pediatric patients and is called a mini-drip set

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IV Sets

• The person administering the fluid starts the
  flow by filling the chamber with fluid from an
  attached inverted IV container
• the chamber sides are squeezed and released
• fluid flows into the chamber
• procedure is repeated until an indicated level is
  reached or approximately half the chamber is
  filled
• entering drops are counted for 15 seconds
• adjustments made until approximate number of
  drops desired is obtained
• rate should be checked five times, at 30-second
  intervals, and again for a last count of 1 minute

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IV Sets

• Clamps allow for adjusting the rate of the flow
  and for shutting down the flow
• Clamps may be located at any position along the
  flexible tubing
• Usually a clamp moves freely, allowing its
  location to be changed to one that is convenient
  for the health professional administering the
  medication

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IV Sets

• Types of clamps used for IV solutions include
• slide clamp has an increasingly narrow channel
  that constricts IV tubing as it is pressed
  further into the narrowed area
• screw clamp consists of a thumbscrew that is
  tightened or loosened to speed or slow the flow
• roller clamp a small roller that is pushed along
  an incline
• moving down the incline, constricts tubing and
  reduces fluid flow
• moving up the incline, increases the flow

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IV Sets

• Clamp accuracy can be affected by
• creep tendency of some clamps to return to a
  more open position with increased fluid flow
• cold flow tendency of PVC tubing to return to
  its previous position
• The needle adapter
• usually located at the distal end of the IV set,
  close to the patient
• has a standard taper to fit all needles or
  catheters
• is covered by a sterile cover before removal for
  connection

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IV Sets

• A set may have a built-in or in-line filter
• Final filtration should protect the patient
  against particulate matter, bacteria, air emboli,
  and phlebitis
• a 0.22-micron filter is optimal
• a 5-micron filter removes particles that block
  pulmonary microcirculation but will not ensure
  sterility
• A Y-site is an injection port found on most sets
• the Y is a rigid plastic piece with one arm
  terminating in a resealable port
• the port, once disinfected with alcohol, is ready
  for the insertion of a needle and the injection
  of medication

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Filters

• Filters are devices used to remove contaminants
  such as glass, paint, fibers, and rubber cores
• will not remove virus particles or toxins
• will occasionally become clogged, thus slowing
  expected flow rates
• Filter sizes include
• 5.0 microns random path membrane (RPM) filter,
  removes large particulate matter
• 0.45 microns in-line filter for IV suspension
  drug
• 0.22 microns removes bacteria and produces a
  sterile solution

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Catheters

• IV administration for fluids and drug therapy can
  be accomplished through needle-like devices
  called catheters
• Catheters are devices inserted into veins for
  direct access to the blood vascular system and
  are used in two primary ways
• peripheral venous catheters, which are inserted
  into a vein close to the surface of the skin
• central venous catheters, which are inserted
  deeper in the body

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Catheters

• A peripheral venous catheter is inserted into
  veins close to the surface of the skin and used
  for up to 72 hours
• unit is inserted into a vein
• needle portion is withdrawn
• flexible, Teflon catheter is left in place
• Peripheral catheters are easy to insert, and most
  nurses can do this at a patients bedside
• usually inserted in sites on the arms or hands
• can be inserted in the feet and scalp if the
  nurse or physician cannot locate good veins in
  the arms or hands

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Catheters

• Peripheral venous catheters will likely cause
  problems 20 to 50 of patients
• pain
• irritation
• infiltration
• Infiltration is a breakdown or collapse of a vein
  that allows the drug to leak into tissues
  surrounding the catheter site, causing edema
  and/or tissue damage

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Catheters

• A central venous catheter is one placed deep into
  the body
• more complicated to place
• inserted by a physician to minimize the risk of
  infection
• Central catheters are commonly used for therapy
  of 1 to 2 weeks or even longer
• A central venous catheter is used to administer
• hypertonic solutions such as total parenteral
  nutrition (TPN) solutions
• potentially toxic drugs such as cancer
  chemotherapeutic drugs

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Catheters

• The most common sites of insertion are
• subclavian vein, lying below the clavicle and
  joining the jugular vein
• jugular vein, in the neck
• femoral vein, in the groin area
• Placed deep in the vein so that the end enters
  the superior vena cava close to the heart where
  the blood flow is the greatest

Visit the Web site of the American Society of
Enteral and Parenteral Nutrition, a good source
for information and networking
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Catheters

• Problems with subclavian catheters are
• possibility of subclavian vein laceration (i.e.,
  missing the vein and puncturing a lung)
• greater risk of infection because the procedure
  is more invasive
• A larger blood flow in the subclavian vein will
  dilute a more concentrated solution such as TPN
• TPN solutions provide
• needed calories in the form of amino acids and
  dextrose
• vitamins, minerals, trace elements, and
  electrolytes

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Catheters

• A multiple-lumen catheter is used to separately
  administer potentially physically incompatible
  drugs
• comes with one, two, three, or four lumens
• Each lumen exits the catheter at a different
  location
• no opportunity exists for the drugs to mix before
  being diluted in the bloodstream

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Catheters

• Midline catheters are longer peripheral catheters
  that go from insertion site into a deep vein
• designed to stay in place 1 week or longer
• The peripherally inserted central (PIC) line is a
  very fine line that is threaded through the
  peripheral vein into the subclavian vein
• has the same characteristics as a central line
• can be inserted by a skilled nurse at the bedside

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Catheters

• Some patients may be on TPN therapy for months or
  even years in the hospital or at home
• Infusion devices are surgically implanted to
• provide long-term therapy
• reduce the risk of infection

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Catheters

• Implantable infusion devices include the Hickman
  and Broviac external catheters
• Surgeon inserts the catheter below the breast and
  tunnels it under the skin into the subclavian
  vein
• catheter has a cuff to which the bodys
  connective tissue heals, sealing off bacterial
  entry
• lower point of body insertion makes the catheter
  easier for the patient to see and clean

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Catheters

• Another form of implantable device is the
  internal port, such as the Port-A-Cath, Life Port
  
• when implanted the only evidence is a bump in the
  skin
• drugs, especially cancer chemotherapeutic drugs,
  are administered by a small needle through the
  skin in an injection port in the device

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Pumps and Controllers

• Fluids and drugs are often delivered to catheters
  by some form of device, including electronic
  devices, to control the infusion rate
• The first system to deliver a drug IV was the
  syringe system
• Care must be taken when administering drugs that
  have to be diluted or given very slowly
• The syringe system is very nurse labor-intensive
  and pharmacy labor-intensive

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Pumps and Controllers

• The Buretrol or Soluset were in use before
  infusion pumps and replaced the syringe system
  and has a built-in graduated cylinder
• fluid is run into the cylinder
• nurse can add a drug in the top of the cylinder
  injection port for dilution and mixing before it
  is infused
• Safer than the syringe system because the drug is
  being diluted in the cylinder and it can be
  infused over a long period of time

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Pumps and Controllers

• The Buretrol or the Soluset have the following
  problems
• labor intensive
• potential drug incompatibility
• controllers are low-pressure devices (2 to 3
  psi)
• pressure of controller is generated by gravity
• flow rate is controlled by rate of fluid drops
  falling through a counting chamber
• alarms sound with a kink in a line or even
  interruption of blood flow when patient bends an
  elbow

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Pumps and Controllers

• Infusion pumps are preferred by both nurses and
  physicians
• produce a positive pressure of 10 to 25 psi
• are more accurate than controllers
• have fewer flow interruptions
• Infusion pumps control the flow of IV
  medications
• Maximum flow is 999 mL/hr
• provides a higher rate of infusion
• higher pressure increases possibility
  of infiltration

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Pumps and Controllers

• A patient-controlled analgesia (PCA) device is a
  type of medication delivery that uses a
  parenteral route and allows the patient to
  administer analgesics by pressing a button
• controls the medication so the patient cannot
  overdose or give the medication too soon after
  the previous dose
• Often, after surgery or severe injuries, a
  physician will order a PCA for the patient for 24
  to 72 hours

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Pumps and Controllers
Safety Note
PCA pumps should carry the following label This
PCA pump button should be pushed only by the
patient.
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Discussion
What is the most important characteristic that
all equipment used in IV preparation and
administration have in common?
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Discussion
What is the most important characteristic that
all equipment used in IV preparation and
administration have in common? Answer Sterility
is a requirement for all equipment used in IV
preparation and administration.
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Terms to Remember

• IV administration set
• filter
• catheter
• peripheral venous catheter
• infiltration

• central venous catheter
• subclavian vein
• multiple-lumen catheter
• peripherally inserted central (PIC) line

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Preparing IVs

• Pharmacists and technicians prepare drugs and IV
  solutions in a form ready to be administered to a
  patient
• IV push (i.e., bolus) and IV infusion dose forms
  should be prepared in laminar airflow hoods using
  aseptic techniques
• products used during the preparation must always
  be sterile and handled in such a manner as to
  prevent contamination

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Preparing IVs

• Preparation should always
  be done under the
  supervision of a
  licensed pharmacist
• Medication that is prepared by the technician
  must be reviewed and approved by the pharmacist

Visit the ASHP Web site for a standard for
quality assurance of sterile products
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IV Preparation Guidelines

• Begin any IV preparation by washing your hands
  thoroughly using a germicidal agent such as
  chlorhexidine gluconate or povidone-iodine
• All jewelry should be removed from the hands and
  wrists before scrubbing and while making a
  sterile product
• Wear gloves during procedures
• Laminar airflow hoods are normally kept running
• Eating, drinking, talking, or coughing is
  prohibited in the laminar airflow hood
• Working in the laminar flow hood should be free
  from interruptions

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IV Preparation Guidelines

• Before making the product, thoroughly clean all
  interior working surfaces
• Gather all the necessary materials for the
  operation and make sure they are
• not expired
• free from particulate matter such as dust
• check for leaks by squeezing plastic solution
  containers
• Only essential objects and materials necessary
  for product preparation should be placed in the
  airflow hood

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IV Preparation Guidelines

• Work in the center of the work area within the
  laminar airflow hood
• at least six inches inside the edge of the hood
• make sure nothing obstructs the flow of air from
  the high-efficiency particulate air (HEPA) filter
  over the preparation area
• nothing should pass behind a sterile object and
  the HEPA filter in a horizontal airflow hood or
  above a sterile object in a vertical airflow hood

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IV Preparation Guidelines

• Follow proper procedure for handling sterile
  devices and medication containers
• Remember that the plunger and tip of the syringe
  are sterile and must not be touched
• For greatest accuracy, use the smallest syringe
  that can hold the desired amount of solution
• syringe should not be larger than twice the
  volume to be measured
• syringe is considered accurate to half the
  smallest measurement mark on its barrel

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IV Preparation Guidelines

• The volume of solution drawn into a syringe is
  measured at the point of contact between the
  rubber piston and the side of the syringe barrel
• Additives are commonly added to IV solutions
• medications, electrolytes, vitamins and/or
  minerals
• Additives may be packaged in vials or ampules
• Proper technique in using vials and ampules is an
  important skill for the pharmacy technician to
  learn

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Vials

• Powders are reconstituted by introducing a
  diluent (e.g., sterile water for injection)
• Vials are closed systems
• the amount of air introduced should be equal to
  the volume of fluid removed
• an exception to this guideline is the withdrawal
  of cytotoxic drugs from vials

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Vials
Safety Note
With the exception of cytotoxic drugs, inject an
equal amount of air into the vial with the
syringe and needle before withdrawing the
medication.
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Vials
Use a Syringe to Draw Liquid from a Vial

• Choose the smallest gauge needle appropriate for
  the task, and avoid coring the rubber top of the
  vial and thus introducing particulate into the
  liquid within it
• 2. Attach the needle to the syringe.
• 3. Draw into the syringe an amount of air equal
  to the amount of drug to be drawn from the vial.

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Vials

1. Swab or spray the top of the vial with alcohol
   before entering the laminar flow hood allow the
   alcohol to dry. Puncture the rubber top of the
   vial with the needle bevel up. Then bring the
   syringe and needle straight up, penetrate the
   stopper, and depress the plunger of the syringe,
   emptying the air into the vial.

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Vials

• 5. Invert the vial with the attached syringe.
• Draw up from the vial the amount of liquid
  required.
• 7. Withdraw the needle from the vial. In the case
  of a multidose vial, the rubber cap will close,
  sealing the contents of the vial.
• 8. Remove and properly dispose of the needle, and
  cap the syringe. A new needle will be attached at
  the time of injection into a patient.

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Ampules 

• An ampule is a single-dose-only drug container
• The glass ampule offers another challenge because
  one must first break the top off the ampule
  before withdrawing the medication

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Ampules
Opening an Ampule

1. Gently tap the top of the ampule to bring the
   medication to the lower portion of the ampule.

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Ampules
Opening an Ampule

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

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Ampules
Opening an Ampule

1. Forcefully snap the neck away from you.

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Ampules

• To withdraw from an ampule, tilt the ampule,
  place the needle bevel of a filter needle or tip
  of a filter straw in the corner near the opening,
  and withdraw the medication
• Use a needle equipped with a filter for filtering
  out any tiny glass particles, fibers, or paint
  chips that may have fallen into the ampule

79
Ampules

• Before injecting the contents of a syringe into
  an IV, the needle must be changed to avoid
  introducing glass or particles into the admixture
• A standard needle could be used to withdraw the
  drug from the ampule it is then replaced with a
  filter device before the drug is pushed out of
  the syringe
• Filter needles are for one directional use only

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IV Solutions

• Most IV, intrathecal, intra-arterial, and
  intracardiac injections will be solutions
• A diluent is a sterile fluid to be added to a
  powder to reconstitute or dissolve the medication
  
• check the medication package insert to verify
  which diluent and what volume should be added to
  the medication vial to make a sterile solution
• Alternative routes of administration may also
  require special preparation, storage, and needles
• it is best to check with the pharmacist if such a
  medication order is received

81
IV Solutions

• The vehicles most commonly used for IV infusions
  are
• dextrose in water
• NS solution
• dextrose in saline solution
• The two main types of IV solutions are
• small-volume parenterals (SVPs) of 50 or 100 mL
• large-volume parenterals (LVPs) of more than 100
  mL

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IV Solutions

• SVPs are typically used for delivering
  medications at a controlled infusion rate
• Large-volume parenterals (LVPs) are used
• to replenish fluids
• to provide electrolytes (i.e., essential
  minerals)
• to provide nutrients such as vitamins and glucose
  
• LVPs are commonly available in 250 mL, 500 mL,
  and 1000 mL sizes

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Different Types of IV Containers
84
IV Solutions

• A piggyback is a small-volume parenteral
  admixture that is attached to an existing IV line
  
• The piggybacked solution is infused into the
  tubing of the running IV
• usually over a short time, from 30 minutes to 1
  hour
• Some IV piggybacks are prepared in 250 mL
  solution because they contain a medication that
  is irritating to the veins
• In some cases, syringes are used instead of
  piggyback containers to deliver medication into a
  running IV

85
IV Solutions

• A LVP usually contains one or more electrolytes
• potassium chloride is the most common additive
• other salts of potassium, magnesium, or sodium
  can be added
• Additives to IV solutions can also be
  multivitamins or trace elements

86
Preparing a Label for an IV Admixture

• Labels for IV admixtures should bear the
  following information
• patients name and identification number
• room number
• fluid and amount
• drug name and strength (if appropriate)
• infusion period
• flow rate (e.g., 100 mL/hr or infuse over 30
  min)
• expiration date and time
• additional information as required by the
  institution or by state or federal guidelines

87
Examples of Pharmacy-prepared Labels

• for a minibag
• for a large-volume parenteral (LVP)

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Discussion
What principle guides the techniques and
procedures applied to IV solution preparation?
89
Discussion
What principle guides the techniques and
procedures applied to IV solution
preparation? Answer IV preparation is based on
aseptic technique and all dosage forms and
equipment must be handled in a way that prevents
contamination.
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Terms to Remember

• ampule
• diluent
• small-volume parenterals (SVPs)
• large-volume parenterals (LVPs)
• piggyback

91
Calculations for the Hospital Pharmacy Technician

• In preparing sterile IV preparations in the
  hospital or home healthcare setting, it is
  important to
• understand math skills somewhat unique to these
  environments
• double- and triple-check calculations and flow
  rates for IV admixtures or TPN solutions

92
Calculations for the Hospital Pharmacy Technician

• Important math skills are needed in the areas of
• reading time
• temperature and temperature conversions
• electrolyte replacement therapy
• specific gravity
• IV infusion flow rates

93
Calculations for the Hospital Pharmacy Technician
Safety Note

• Always carefully check and double check all
  calculations.

94
Time Conversions

• Hospital medication orders are often stamped with
  international or military time
• dose administration schedules for unit dose and
  IV admixtures also use this method
• This time is based on a 24-hour clock, with
  midnight being considered time 0000
• time in hours are the first two digits
• time in minutes are the last two digits
• no A.M. or P.M. are used

95
Time Conversions

• Examples
• 0000 Midnight
• 0600 6 AM
• 1200 Noon
• 1800 6 PM

96
Temperature Conversions

• The United States is one of the few countries in
  the world where the Fahrenheit temperature scale
  is commonly used
• The Fahrenheit temperature scale uses 32 F as
  the temperature when ice freezes and 212 F as
  the temperature that water boils
• the difference between these two extremes is 180
  F

97
Temperature Conversions

• The Celsius temperature scale is commonly used in
  Europe and globally in science, and it is often
  the scale used in the pharmacy
• the Celsius temperature scale uses 0 C as the
  temperature when ice freezes and 100 C as the
  temperature that water boils
• the difference between these two extremes is 100
  C

98
Temperature Conversions

• Storing drugs under the proper refrigeration and
  maintaining refrigerating equipment at the
  appropriate temperature are responsibilities of
  the pharmacy technician
• most refrigerators in the pharmacy need to
  maintain a temperature of 5º C to 10º C
• Temperatures in the drug package inserts or in
  the policy and procedure manual are often in
  centigrade
• pharmacy technicians will need to know how to
  convert between the Celsius scale and the
  Fahrenheit scales

99
Temperature Conversions
Temperature Equivalencies

• Every 5 C change in temperature is equivalent to
  a 9 F change

Celsius Fahrenheit
0º C 32º F
5º C 41º F
10º C 50º F
15º C 59º F
20º C 68º F
100
Temperature Conversions

• These equations allow conversions between the two
  temperature scales
• º F (1.8 º C) 32
• º C (º F 32) 1.8
• An alternative method uses this equation
• 5F 9C 160
• The final temperature is usually rounded up to
  the closest whole number

101
Electrolytes

• Many IV fluids used in pharmacy practice contain
  electrolytes
• dissolved mineral salts
• so-named because they conduct an electrical
  charge through the solution when connected to
  electrodes
• Electrolytes are measured in millimoles (mM) and
  milliequivalents (mEq)

102
Understanding Millimoles and Milliequivalents 

• Milliequivalents (mEq) are related to molecular
  weight
• Molecular weights are based on the atomic weights
  of elements
• the atomic weight of an element is the weight of
  a single atom of that element compared with the
  weight of one atom of hydrogen
• the molecular weight of a compound is the sum of
  the atomic weights of all the atoms in one
  molecule of the compound

103
Understanding Millimoles and Milliequivalents 

• A millimole (mM) is an amount of a substance
  weighing its molecular weight in milligrams
• The valence of an element is a number that
  represents its capacity to combine to form a
  molecule of a stable compound
• an element can exist in various forms
• valence may vary depending on an elemental form

104
Valences and Atomic Weights of Common Elements
Element Valence Atomic Weight Rounded Value
hydrogen (H) 1 1.008 g 1 g
carbon (C) 2, 4 12.011 g 12 g
nitrogen (N) 3, 5 14.007 g 14 g
oxygen (O) 2 15.999 g 16 g
sodium (Na) 1 22.9898 g 23 g
sulphur (S) 2, 4, 6 32.064 g 32.1 g
chlorine (Cl) 1, 3, 5, 7 35.453 g 35.5 g
potassium (K) 1 39.102 g 39.1 g
calcium (Ca) 2 40.08 g 40.1 g

• For pharmaceutical calculations, atomic weights
  are usually rounded to the nearest tenth (i.e.,
  one unit to the right of the decimal point).

105
Understanding Millimoles and Milliequivalents

• One mole (M) of an element weighs its atomic
  weight in grams
• one mole of sodium (Na) is 22.9898 (rounded to 23
  g)
• Compounds are also measured in moles
• one mole of salt or sodium chloride (NaCl) would
  weigh its molecular weight in grams
• atomic weight of sodium (23 g) atomic weight of
  chlorine (35.5 g) 58.5 g
• 1 mM is an amount equal to the molecular weight
  in milligrams
• because 1 g equals 1000 mg, 1 mole equals 1000 mM
• 1 mM of sodium chloride equals 58.5 mg

106
Understanding Millimoles and Milliequivalents  

• One equivalent (Eq) is equal to one mole divided
  by its valence
• One milliequivalent (mEq) is equal to 1 millimole
  divided by its valence
• thus one equivalent equals 1000 mEq, or one
  thousandth of a gram equivalent

Equivalent weight molecular weight (expressed
in milligrams)
valence

107
Determining Milliequivalents of Compounds 

• To determine the number of milliequivalents of a
  compound
• (1) identify the formula of the compound
• (2) separate the formula into atoms
• (3) determine the moleclular weight of the
  compound
• multiply the weight of each atom by the number of
  those atoms
• add the products together, the sum is the
  molecular weight

mEq molecular weight (expressed in milligrams) valence
108
Measuring Electrolytes 

• Milliequivalents (and sometimes millimoles) are
  used to measure electrolytes in the bloodstream
  and/or in an IV preparation
• Example
• You must add 44 mEq of sodium chloride (NaCl) to
  an IV bag. Sodium chloride is available as a 4
  mEq/mL solution. How many milliliters will you
  add to the bag?

109
Measuring Electrolytes 

• You must add 44 mEq of sodium chloride (NaCl) to
  an IV bag. Sodium chloride is available as a 4
  mEq/mL solution. How many milliliters will you
  add to the bag?
• set up a proportion, comparing the solution you
  will need to create to the available solution,
  and solve for the unknown

110
Measuring Electrolytes 

• Set up a proportion, comparing the solution you
  will need to create to the available solution,
  and solve for the unknown

x mL 44 mEq 1 mL 4 mEq
(44 mEq) x mL 44 mEq (44 mEq) 1 mL 4 mEq
x mL 44 mL 4
x mL 11 mL
111
Specific Gravity

• Specific gravity can be defined as the ratio of
  the weight of a substance to the weight of an
  equal volume of water when both have the same
  temperature
• Final weight can be measured in grams because 1
  mL of water weighs 1 g
• 1 mL, volume of water 1 g, weight of water
• specific gravity of water 1

specific gravity weight of a substance weight of an equal volume of water
112
Specific Gravity

• When the specific gravity is known, certain
  assumptions can be made regarding the physical
  properties of a liquid
• liquids that are viscous or have particles
  floating in them often have a specific gravity
  higher than 1
• solutions that contain volatile chemicals (or
  something that is prone to quick evaporation),
  such as alcohol, often have a specific gravity
  lower than 1

113
Specific Gravity
Safety Note

• Usually numbers are not written without units
  however, no units exist for specific gravity.
  Therefore, you must label specific gravity
  carefully.

114
Calculation of IV Rate and Administration

• IV flow rates are usually described as
  milliliters per hour or as drops per minute
  (expressed as gtt/min)
• pharmacy usually uses milliliters per hour
• nurses sometimes prefer drops per minute
• The formula used to determine the rate in drops
  per minute is as follows

x gtt/min (volume of fluid delivery time in hrs) (drop rate of administration set) 60 min/hr
115
Calculation of IV Rate and Administration

• Example
• A physician orders 4000 mL of a 5 dextrose and
  normal saline (D5NS) IV over a 36-hour period. If
  the IV set will deliver 15 gtt/mL, then how many
  drops must be administered per minute?
• Begin by identifying the amounts to insert into
  the equation.

volume of fluid 4000 mL
delivery time 36 hr
drop rate of the administration set 15 gtt/mL
116
Calculation of IV Rate and Administration
x gtt/min (volume of fluid delivery time in hrs) (drop rate of administration set) 60 min/hr
x gtt/min (4000 mL 36 hr) (15 gtt/mL) 60 min/hr
x gtt/min 111 mL/hr) (15 gtt/mL) 60 min/hr
x gtt/min 27.75 gtt/min, rounded to 28 gtt/min
117
Calculation of IV Rate and Administration

• The number of hours that the IV will last can be
  determined by dividing
• the volume of the IV bag (expressed in
  milliliters)
• by
• the flow rate (expressed in milliliters per hour)

118
Calculation of IV Rate and Administration

• Example
• A 1 L IV is running at 125 mL/hr. How often will
  a new bag have to be administered?
• Begin by converting 1 L to 1000 mL, and then
  divide the volume by the volume per hour rate.

hours the IV will last 1000 mL 125ml/hr 8 hr
119
Discussion
What are some of the special areas of
calculations skills that are important for
technicians preparing IV solutions?
120
Discussion
What are some of the special areas of
calculations skills that are important for
technicians preparing IV solutions? Answer
Skills for accurate conversion between time and
temperature systems, electrolyte measurement,
specific gravity determinations, and infusion
flow rate calculations are vital in IV
preparation and labeling.
121
Terms to Remember

• Fahrenheit temperature scale
• Celsius temperature scale
• electrolytes
• atomic weight
• molecular weight

• millimole (mM)
• valence
• mole (M)
• equivalent (Eq)
• milliequivalent (mEq)