Intravenous admixtures

Intravenous admixtures are a parenteral formulations that must be sterile

1. Intravenous admixture

2. Content : Introduction. D efinition . Preparation of IV admixtures. Incompatibility of IV admixture . Advantages and disadvantages of IV admixture . Examples of intravenous admixture. References.

3. Introduction . Intravenous admixture compounding is common practice in most hospitals throughout the world, regardless of the country in which one is practicing. Compounding intravenous medications involves risk, as there is a high potential for error due to their complexity in compounding and working in an aseptic environment, Numerous studies concerning the contamination rate in use intravenous admixturehave been appeared,

4. so the intravenous admixture are prepared in laminer Flowand there is no generate that the product will be sterile . The hospital pharmacist's professional responsibility is to make sure that intravenous admixture he prepared for adminstration to patients are of highest quality, and one of paramters of this quality is sterility .

5. Definition : Intravenous admixtures are the preparations consisting of sterile drug products added to an IV fluid (s) for medication purposes. Intravenous admixture means a sterile parenteral solution to which one or more additional drug products have been added.

6. Preparation of IV Admixtures 1 Interpretation of the Order Upon receipt, the pharmacist interprets the order, checks the dosage, and checks =for incompatibility, instability, and contraindications by consulting available reference sources.

If clarification of the order is needed, the pharmacist calls the physician, and then notifies the nurse of the resultant clarification or change.

The pharmacist also checks the order against patient allergies and diagnosis, addressographs the Profile Card with the patient's name and room number, and records the name and dose of drugs added, and the name and volume of IV solutions used. The intern or technician who prepares the solution records the time of preparation and initials the IV Profile Card.

7. 2 Preparation of Labels All IV admixtures prepared by the pharmacy are labeled according to the format illustrated in Figures 3 , Sufficient labels are typed for a 24 hour period and paper clipped to the IV Profile Card. Continuous IV Label Requirements : 1. Patient name. 2. Patient room number. 3. Additive strength and amount. 4. Primary IV solution. 5. Expiration date and time. 6. Prepared by. 7. Preparation time and date. All labels are checked against the IV Profile Card before releasing to the IV assembly area.

8. 3-Assembly and Preparation The medication order and the IV Profile Card are attached to the completed label. These are assembled with the needed IV stock solution, additives and any transfer devices (syringes, nee dles , etc.) on a plastic tray prior to preparation so that no additional items will be needed once the preparation begins.

The prepared assembly tray is brought into the laminar hood and the IV ad mixture is prepared. Work flow is from left to right in the hood. Only one admixture is prepared at one time. Particu lar attention must be given to the order in which drugs are added to the solution to prevent additive errors. Attention must also be given to the additive list showing those additives that (1) must be pro tected from light, (2) must be reconstituted with non-preserved water, (3) must be buffered and (4) have limited stability.

9. All intravenous admixtures are pre pared in the laminar flow hood using aseptic technique. All operations are car ried out in such a way as to minimize the possibility of contamination of the admixture.

All paper wrappings covering drugs or utensils should be removed before setting down on the surface of the laminar flow hood. Routinely, the laminar flow counter is swabbed with alcohol, starting from the back and working forward. 4-Aseptic Technique

10. 5-Labelling and Check The prepared label is stamped with the appropriate expiration date and at fixed to the inverted IV bottle over the manufacturer's label so that the one line identification of the IV solution label re mains visible.

Routinely, a 24-hour expiration date is stamped on the admixture label. How ever, in the case of drugs which are stable for shorter periods (e.g., Ampicillin) the powdered form of the drug is dispensed in a plastic bag attached to the solution to which it is to be added and dispensed with directions for the nurse to reconstitute immediately prior to administering.

11. A registered pharmacist performs the checks:

1. The original order is checked against the label on the completed IV admixture for accuracy and completeness. Particular attention is given to patient identity, identity of drugs, amounts added, and solution used. The original order is checked against the label for accuracy of volume of solution and accuracy of expiration date.

2. The original order is checked against the additive and amounts actually used by the person preparing the admixture, as evidenced by the empty vials or ampules and the used syringes.

3. Finally, the complete admixture is re checked against the candling unit and against a dark background for particulate matter. Any evidence of foreign particles, coring or precipitated material is cause for the admixture to be discarded.

If the pharmacist approves the admixture for use, he places his initials on the IV Profile Card next to the initials of the person who prepared the admixture. The cards are then filed in the IV Card Box in the Pharmacy.

12. Incompatibility of intravenous admixture . I V admixture incompatibilities :- Incompatibility may be between drugs, drugs and solutions, drugs and container. Types of incompatibility: 1-physical incompatibility: it means incompatibility between drugs and i.v solution or drugs with container and this lead to physical phenomena as color change, precipitation,gas formation (effervescence)

13. 2-Therapeutic incompatibility: this is due to using of two drugs have antagonist effect e.g : metoclopramide, this drug increases GIt motility and drug hyoscine, anticholinergic drug that decrease GIT motility The previous two drugs shouldn't be mixed together in the same syringe and the better is to wait half an hour between them. 3- drug i.v container incompatibility e.g : nitroglycerin, it's not better to put in back made polyvinyl chloride to prevent the adsorption of nitroglycerin on the surface of polyvinyl chloride and this lead to loss of doses and concentration and therapeutic failure and should be made from glass

14. 4- chemical incompatibility means that the drug is chemically degraded, due to oxidation, reduction, hydrolysis, or decomposition. Chemical reactions can manifest themselves through turbidity, precipitation and color changes drugs and inappropriate IV solutions as diluent two drugs (drug-drug incompatibility) when they are mixed together, e.g. within the same infusion line(simultaneous infusion) and/or IV container administered one after the other, but within the same infusion line drugs and adjuvants (preservative, buffer, stabilizer, solvent)

15. To reduce incompatibility
1- we should mix drugs and solutions as possible and to minimise the number of drugs added
2-preparation should be freshly prepared
3- store it in relatively waterproof container
4-store it in place far from light

16. There are two forms of intravenous admixtures large volume Parenterals : it is usually (500-1000 ml) containers used for hydration or continous infusion of medications. B) small volume Parenterals : mini bags containing diluents And has some advantages: Wide availability of products-simple preparation-low cost-availability to individualize doses .

17. Advantages of IV admixtures: 1- Lengthen expiration date 2- Time saving preparations 3- Provide nutritive fluids (glucose, electrolytes) 4- Quick onset 5- Supply large amount of nutrients to the body 6- Vomiting and unconscious patients could take 7- They provide effective, safe and high quality patient care 8- Poor absorption or instable in GIT drugs are suitable to be taken through this preparation 9- Accurate and proper reconstituted drugs

18. Disadvantages IV admixture: 1-High risk of incompatibility 2-Need of skill and time 3-Requiring aseptic area, special equipment such as refrigerator for storage 4-Requiring trained pharmacist 5-possibility of bacterial contamination

19. PH consideration The effect of pH on solubility and stability is a critical factor in the formulation of parenteral dosage forms and becomes more complicated in intravenous admixtures since the additives and the vehicle may have different pH values. This is especially important as a significant number of parenteral medications require some compounding involving dissolution of lyophilized powders, dilution of drug doses for infusion, mixing of dextrose, amino acids, vitamins, and electrolytes for parenteral nutrition, etc. A change in the acid-base environment of a drug involves both the solubility and stability characteristics and can be critically related to pH as follows: (1) as a solution goes away from the pH of maximum solubility, the drug can precipitate out of solution, and (2) as the solution goes away from the pH of maximum stability, the drug can degrade more rapidly and have a short beyond-use date.

20. Examples of IV admixture Amphotericin B. Amphotericin B Cholesteryl Sulfate Complex Ampicillin Sodium. Epinephrine Hydrochloride. Erythromycin Lactobionate . Hetastarch . Hydrocortisone Sodium. Digoxin. Dopamine Hydrochloride.

21. Intropin (dopamine hydrochloride) intravenous admixture The stability of dopamine hydrochloride ( intropin several large-volume partentral solutions was studied. Admixtures of dopamine were assayed by colormetric and chromatographic procedures Admiras (800 og dopamine per in) as the tollowing intravenous tuds i gass bottles a 6.115 or below were found to be chemically and physically stable for at least 48 hours at room temperature: detine 5%, dextrose 5% and sodium chloride D5% 5% dextrosen 045% sodium chloride, dextrose 5% an lactated Ringer's sudion , lactated Ringer's injection 0.9% sodium chloride, 15 molar sodium lactate and 20% mannel .

22. The admixture of dopamine in 5% dextrose was state for a minimum of seven days at 5 C. & 3% dextrose-dopamine adute polyvinylchonde bag was stable for at least 24 hours at room temperature. The adriature of dopamine 5% sodium bicarbonate solution produced an unstable solution of pH 520. A chemical and physical change (development of a pink color) was observed in this admixture . It is recommended that dopamine not be added to 5% sudium bicarbonate salution or any alkaline intravenous solution .

23. References 1) Bachman, S. 1 (1973). Intravenous Admixture Service Policy & Procedure Manual Drug Intelligence de Clinical Pharmacy, 721, 84-87. 2) Ausman, R. K. Holmes, C. J. Walter, C. W. & Kundsin, R. B. (1980) The application of a freeze-microwave thaw technique to central admixtime services. Drug intelligence d clinical pharmacy, 14(4), 284-287. 3) Buth, J. A. Coberly, RW.& Eckel, F. M. (1973). A practical method of sterility monitoring of IV admistures and a method of implementing a routine sterility monitoring program. Drug Intelligence & Clinical Pharmacy, 7(6), 276-279. 4. Miller, W. A., Smith, G. L. & Latiolais, C. 1 (1971).

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