Compounding in hospitals.pptx

Bulk compounding is defined by the FDA as the combination, mixing or alteration of drug ingredients to create medications to fulfil the need of patient.

1. Compounding in Hospitals Chapter… 5

2. Bulk compounding Bulk compounding is defined by the FDA as the combination, mixing or alteration of drug ingredients to create medications to fulfil the need of patient. Need of bulk compounding- Patients who cannot take commercially prepared formulations of a drug. Patient requiring limited dosage strength (very small dose for infants) . Patient requiring different formulation such as turning pill/tablet into liquid.

3. Patient requiring allergen free medication e.g. gluten. Patients facing supply shortage of their normal drugs. Children who want flavoured additives in liquid drugs. Formulations that are compounded in hospital pharmacy include: Mixtures - Expectorant mixtures, antidirrhoeal mixtures, sodium citrate mixture. Syrups - Vasaka , codeine, & ipecacuanha syrup. Solutions Suspensions

4. Topical semisolids- Ointments: Sulphur ointment, zinc oxide ointment. Creams: Calamine cream, cetrimide cream. Paints: Crystal violet compound paint. Pastes: Zinc gelatin paste. Gargles- Potassium permanganate gargle. Lotions- Calamine lotion. These formulations are compounded in hospitals in accordance with the National Formulary of India (N.F.). Labelling requirements & storage conditions should be observed as per Drugs & Cosmetics Act & Rules.

5. Planning for Bulk compounding

6. Intravenous Admixture Services & Incompatibilities Intravenous admixtures Intravenous admixtures are sterile solutions prepared by mixing one or more medications with intravenous fluid & are administered via IV- administration set directly to patient’s vein . IV set

7. Following objectives expected to achieve by the pharmacist Preparation of final product under specific condition. Rational choice of additive & mixing techniques for avoiding drug interactions. Appropriate labelling, dispensing & storage of final product.

8. IV fluids commonly used for IV admixtures

9. Environment for IV admixture preparation Laminar Air Flow Air is filtered through HEPA ( H igh efficiency particulate air) filter. Air is moved with the velocity of 90 ft. per minute. Efficiency: 99.97% Removes particle larger than 0.3 µm. Inside of the hood is wiped down with a suitable disinfectant & allowed to run for at least 30 min. Operator should wash hands thoroughly. For evaluating proper functioning of HEPA filters, the Dioctyl Phthalate (DOP) test should be used. HEPA filters should be evaluated every 6 months.

10. Laminar Air Flow

11. Additives for IV Admixtures Additives are injections packaged in ampoules or vials or sterile solids to be reconstituted by adding suitable diluent before addition to IV fluid. A fresh sterile disposable syringe is used for each additive. Before withdrawing contents from ampoule, the ampoule is to be wiped with disinfectant solution. In case of vials, the exposed area of rubber closure is to be disinfected. A sterile syringe is removed from its protective wrapping . The syringe needle is with its cover separated from syringe aseptically & may be replaced with a sterile aspirating needle. Aspirating needle bear a stainless steel or nylon filter.

12. The filter removes glass particles & other particulates from the injection. Then the aspirating needle is replaced with regular needle. Now the injection is ready to be added into IV fluid to form IV admixture. Regular needle Aspirating needle

13. Medication errors in IV drug preparation & administration

14. Incompatible parenteral Admixtures When one or more additives are combined with an IV fluid their presence together may together modify the inherent characteristics of the drug substance resulting in parenteral incompatibilities.

15. Pharmacist has to detect incompatibilities if more than one parenteral product is prescribed for a patient. The pharmacist should encourage use of few additives as possible in IV fluids since the number of potential problems increases as the number of additives increases. Incompatibilities can be avoided by selecting another route of administration for one or more of the drugs involved.

16. Total Parenteral Nutrition (TPN) Definition: Total Parenteral Nutrition (TPN) is the method of infusing nutrition to the patients through Intravenous (IV) route. The nutrition is in the form of fluids. OR Parenteral nutrition refers to feeding of nutritional products to a person intravenously, bypassing the usual process of eating and digestion. When nutrition mix containing glucose, salts, amino acids, lipids and vitamins is administered to a person, it is called as total parenteral nutrition.

17. Contents of TPN TPN is mixture of separate components which contain: Carbohydrates, Lipids (fat), Amino acids, Electrolytes, Trace elements, Vitamins and Fluids. TPN composition adjusted as per requirement of individual patient.

18. Carbohydrates : Carbohydrates is the main source of energy. Dextrose and monohydrates of glucose used as primary source of carbohydrate in TPN. Lipids (Fat): Linoleic acid is used as primary source of essential fatty acid in TPN. Electrolytes: Sodium (Na) - 100 to 200 mEq , Potassium (K)- 80 to 120 mEq , Magnesium (mg) - 8 to 16 mEq , Calcium(Ca) - 5 to 10 mEq , Chloride (C)- 100 to 200 mEq . Vitamins: Vitamins are required for the metabolism of carbohydrates, proteins, fats. Water soluble (B1, B2,B3, B5, B6, B7, B9, B12 & C) & fat-soluble vitamins (A, D, E & K) used in TPN formulation

19. Indications For TPN: 1. Gastrointestinal disorders- Inflammatory Bowel disease (Inflammation of digestive tract), Gastrointestinal ulcers, Small or large intestinal obstructions (Blockage of small/large intestine), Intestinal Ischemia (Insufficient blood supply to intestine due to blockage of blood vessels), Intestinal perforation (ruptured bowel, a hole in the wall of part of the GI tract), Prolonged Diarrhea, Severe pancreatitis, Paralytic ileus (Food isn’t moving properly), Crohn’s disease (ulcer on the mucous membrane of the mouth). 2. Cancer patients on Chemotherapy 3. Geriatric population- Cardiac, renal impairments, insulin resistance, vitamin deficiencies. 4. Conditions like accident and surgery

20. Complications of TPN: Most common complications- Hypophosphatemia , hypokalemia , hyperglycemia , hypercapnia / hypercarbia ( too much carbon dioxide (CO 2) in bloodstream), decreased GI motility. Possible complications- Infection: Infection due to catheter. May lead to death due to septic shock (Severe drop in B.P). Catheter complications include pneumothorax ( air leaks into the space between your lung and chest wall), accidental arterial puncture, catheter related sepsis (body's response to infection causes injury to its own tissues and organs).

21. Blood Clots: Chronic IV access leaves a foreign body in vascular system & blood clot on this IV line are common. Such clot upon breaking if travels to lungs may lead to pulmonary embolism & death. Fatty liver/ Liver failure: Linoleic acid (omega-6-fatty acid) is responsible for liver disorders. Hunger: In TPN the taste, smell & physical fullness of stomach requirements are not fulfilled & so the patient experiences the hunger.

22. Cholecystitis ( inflammation of the gallbladder, flow of bile from the liver to the duodenum is impaired.): Due to complete disuse of GIT, there may be cholecystitis & other hepatobiliary dysfunctions such as steatosis (fat in liver), steatohepatitis (advanced stage of fatty liver) Hypersensitivity: Hypersensitivity reactions may occur. Rare . Medication incompatibility

23. Substance Normal patient High stress Fluid- restricted Amino acids 85 g 128 g 75 g Dextrose 250 g 350 g 250 g Lipids 100 g 100 g 50 g Na+ 150 mEq 155 mEq 80 mEq K+ 80 mEq 80 mEq 40 mEq Ca++ 360 mg 360 mg 180 mg Mg++ 240 mg 240 mg 120 mg Acetate 72 mEq 226 mEq 134 mg Cl - 143 mEq 145 mEq 70 mEq P 310 mg 465 mg 233 mEq MVI-12 10 mL 10 mL 10 mL Trace elements 5 mL 5 mL 5 mL Standardized TPN solutions