Compounding Sterile Products

Study Unit

Compounding ofSterile Products 1By

Deborah Berlekamp, R.Ph.

Reviewed By

Gary Mead, R.Ph., M.H.A.

About the Author

Deborah Berlekamp, R.Ph., graduated cum laude with a five-year

bachelor of science degree in 1981 from the University of Toledo

College of Pharmacy in Toledo, Ohio. After graduation, she worked

in a variety of pharmacy practice settings, including retail, hospital,

and nursing home facilities. She has worked with and trained many

pharmacy technicians while on the job. Berlekamp was the original

coordinator of the Pharmacy Technology Program at Mercy College

of Northwest Ohio. She also supervised the pharmaceutics laboratory

in the Pharmacy Practice Department at the University of Toledo.

Deborah has been a member of the Pharmacy Technician Educa-

tors Council, the American Society of Health System Pharmacists,

the Ohio Society of Health System Pharmacists, and the Ohio

Pharmacists Association. She is a past president of the Toledo

Area Society of Hospital Pharmacists and a past president of the

University of Toledo College of Pharmacy Alumni Association. She

has been active at local and state levels of pharmacy organizations

and maintains an enthusiastic interest in the pharmacy profession

and the formal education of pharmacy technicians. Deborah cur-

rently manages the pharmacy department at The Pharm in Bowling

Green, Ohio.

This study unit was reviewed by Gary Mead, R.Ph., M.H.A.

Copyright © 2008 by Penn Foster, Inc.

All rights reserved. No part of the material protected by this copyright may bereproduced or utilized in any form or by any means, electronic or mechanical,including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the copyright owner.

Requests for permission to make copies of any part of the work should be mailed to Copyright Permissions, Penn Foster, 925 Oak Street, Scranton,Pennsylvania 18515

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All terms mentioned in this text that are known to be trademarks or service marks have been appropriately capitalized. Use of a term in this text should not beregarded as affecting the validity of any trademark or service mark.

This unit describes the methods used to prepare injectabledrugs and parenteral admixtures in a hospital pharmacy set-ting. You’ll be introduced to IV systems, packaged parenterals,devices and equipment, and methods of IV administration.You’ll become familiar with the appearance and purpose of bothsmall- and large-volume containers found in the IV therapyroom. You’ll also learn about aseptic technique and the devices,equipment, and methods used for preparation and labeling of intravenous fluids. You’ll learn appropriate terminologyand master necessary mathematical calculations. Examplesof the most commonly made IV solutions will also be presented.

iii

Previe

wPrevie

wWhen you complete this study unit, you’ll beable to

• Explain the differences between ampules, vials, and prefilled syringes, and other container systems

• Describe the types of base solutions most often used inmaking IVPBs and LVPs

• Explain the labeling requirements for a final IV admixture

• Identify the concepts of microbial contamination andaseptic technique

• Explain how to use and care for the equipment and supplies used in the IV room

• Describe how to locate and use the practical informationin package inserts for IV products

• Explain how to properly store medications in the IV area

• Discuss the differences between intermittent and continuous infusions

• Explain how to reconstitute and add drugs to larger volumes

• Describe how needles and syringes are used and identifytheir basic components

• Explain when and why to use final filtering devices

Remember to regularly check “My Courses” on your student homepage.

Your instructor may post additional resources that you can access to

enhance your learning experience.

PACKAGED PARENTERALS 1Small-Volume Containers 2Larger Container Systems and Components 6Labeling of Containers 9

METHODS OF INTRAVENOUS ADMINISTRATION 14Intravenous (IV) Infusions 14Intermittent Therapy 17Hookups 19Irrigations 20

DEVICES 22Syringes 22Needles 24Final Filtering Devices 26

EXTEMPORANEOUS IV PREPARATION 28Parenteral Preparation in Hospital and

Home Care Settings 28Environmental Control 29Aseptic Technique 38

TERMINOLOGY 47

IV CALCULATIONS 54Concentrations of Solutions 54Reconstituted Vials 57Concentrations as Percentages 59Rate Problems 61Metric Conversions 63

COMMON PARENTERAL ADMIXTURES 67Antibiotic Solutions 67Nonantibiotic Admixtures 72

SELF-CHECK ANSWERS 75

v

Contents

Contents

1

PACKAGED PARENTERALSYou’ll recall from earlier study units that parenteral refers toinjectable medications and fluids. The subject of injectable andintravenous fluids and medications might sound intimidating,but by the end of this study unit, you’ll be comfortable withthe types of packaging, systems, equipment, and methodsused to prepare injectable medications. In this first sectionwe’ll discuss the way that injectable medications are packaged.

Remember that injectable medications may be given by differ-ent injectable routes of administration, depending upon themedication. Intramuscular (IM), subcutaneous (SC or SQ),intradermal (ID), and intravenous (IV) medications may comein ampules, vials, and prefilled syringes. These and all otherinjectable solutions must be sterile, or free from microorgan-isms. If microorganisms enter the bloodstream, an infectioncan result, causing great harm and even death to the patient.It’s absolutely essential that great care in the practice ofaseptic technique be used when preparing and administeringparenterals, especially intravenous drugs. Aseptic techniqueis a special way of handling containers and supplies thatprevents contamination of the final product. This techniquewill be discussed in detail later in this unit.

Compounding of SterileProducts 1

Compounding of Sterile Products 12

Small-Volume Containers

AmpulesAmpules are made entirely of glass and contain sterile medication in solution. The drugs contained in ampules arealways in a solution. (Remember that solutions are liquidsthat contain completely dissolved ingredients.) These sealedglass containers are used for drugs that will interact withplastic, because the reaction can destroy the effectiveness ofthe drug. Ampules must be handled with great care becausethey’re made of such thin glass. They break easily whendropped.

The shape of an ampule is similar to that of an hourglass. It has a cylindrical base that curves into an indentation thatcreates a narrow neck and curves out again to form an elon-gated cone-shaped top. The glass is very thin around theindentation, or neck, of the ampule, and all ampules must be broken at the neck area to access the medication. Afterthe neck of the ampule is broken, the solution is then drawninto a syringe for use.

Ampules are available in a variety of sizes, ranging fromabout 1 ml to 20 ml. The smaller 1 ml or 2 ml sizes are themost common. Ampules may be made of clear, colorless glassor of amber (brown) glass. Amber-colored glass is used fre-quently for medication packaging to protect the contents from light, because many drugs are affected by light.

VialsVials look different from ampules. Whereas ampules aremade entirely of glass, vials are available in plastic or glass.The top of the vial is sealed with a rubber stopper that’s heldin place by a metal band (Figure 1). A needle may be insertedthrough the rubber stopper to either withdraw the contentsor add solution to the vial (Figure 2). When the vial is pack-aged by a drug company, a small plastic lid is attached to thetop of the vial, which must be removed before use. The lidprotects the rubber stopper from damage and contaminationduring shipping. This lid also serves to indicate whether thevial has been tampered with.

Compounding of Sterile Products 1 3

FIGURE 1—The top of a vial is sealed with a rubber stopper that’s held in place by a metal band.


Glass vials, like ampules, may be clear, or amber to protectthe drug from light. Vials come in many sizes that range from2 ml to over 100 ml (Figure 3). The most common sizes seenin the pharmacy are between 5 ml and 30 ml.

Medications in vials may be in solution or in a powder form. If the medication is in a powder form, then it must be reconstituted, or mixed with a solvent (diluent) before use. The diluent dissolves the powder, and the reconstituted powder

FIGURE 2—A needle isinserted through the rubber stopper of a vialto either withdraw thecontents or add solutionto the vial.


then becomes a solution. Powdered medications are usuallyreconstituted with sterile water or sterile normal saline that’sinjected into the vial. Solutions are then drawn into a syringebefore use.

Prefilled Syringes

Prefilled disposable syringes contain medication in a liquidform that’s ready to use. In some cases, the medication maybe administered directly to the patient without any furtherpreparation. In other cases, the medication may need to beejected from the syringe into a larger volume of sterile fluidbefore administration to the patient.

Prefilled syringes are useful in emergency situations becausethey come ready to use, so no time needs to be spent in thepreparation of IV admixtures. “Crash carts” (emergency carts)contain medications that are needed in emergencies, and manyof the drugs on a crash cart are available in prefilled syringes.

FIGURE 3—A 500 ml SizeVial


Prefilled syringes often have an outer package and may comein a box. Because the solutions have already been preparedin a prefilled syringe, this type of container is more expensivethan an ampule or vial. Examples of medications that are avail-able in prefilled syringes include sodium bicarbonate, 50%dextrose, epinephrine, atropine, isoproterenol, and phenytoin.

Larger Container Systems and ComponentsAmpules, vials, and prefilled syringes all contain a relativelysmall amount of medication in solution or in powdered form.As mentioned, some of these must be added to larger amountsof sterile fluids before use. There are three basic kinds of largervolume containers to which drugs from ampules or vials maybe added:

• Large-volume parenterals (used for IV infusion)

• Small-volume parenterals (used for IVPB administration)

• Irrigations (used for rinsing or washing wounds or infections)

Large-Volume Parenterals (LVPs)

You already know that parenteral means injectable. The“large” part of the term large-volume parenteral (LVP) refers to the size of the glass bottle or plastic bag that’s used to con-tain the injectable medication. Large volumes of solutions forinjection come in a variety of sizes and types of containers.LVPs are available in the following sizes: 250 ml, 500 ml,1000 ml, 2000 ml, and 3000 ml. The 250, 500, and 1000 ml are the most common.

The containers may be made of polyvinyl chloride (PVC), asoft, flexible, yet strong plastic substance. These particularcontainers are referred to as bags. Viaflex bags are an exampleof this type of packaging. Solutions that come in Viaflex andother PVC bags must be stored in an outer wrap, or outersleeve, until just before use. This outer sleeve provides protec-tion from tampering, contamination, and evaporation. You’ll


encounter LVPs in plastic bags made by different companies.The appearance of the bags may be slightly different, but thebasic function is the same—to deliver IV fluids to the patient.

As common as they are, PVC bags should not be used whenthe drug being added—such as cyclosporine—is capable ofsolutionizing components of the bag. In these instances, acontainer made of ethylene vinyl acetate (EVA) should be used.

The plastic bags have a hole at the top that allows them to behung from a pole during preparation and use. There are twoprojections called ports located at the bottom of the bag. Oneport has a small rubber tip through which IV drugs may beadded with a needle. The other port is covered by a smallpiece of blue plastic. This is where the IV administration tub-ing, or any transfer tubing, can be attached. The small pieceof plastic protects against tampering and is removed justbefore tubing is attached. (We’ll discuss tubings later in this section.)

LVPs may also come in glass or hard plastic containers.Glass containers are used when adding drugs that interactwith plastic, which would destroy the effectiveness of the drug.The glass bottle has a wire at the bottom that allows it tohang from a pole for administration.

Glass containers may or may not be vented. A tube inside the container acts as a vent, allowing air to flow back into the container as the medication is being administered to thepatient. As fluid leaves a flexible plastic container, the bagcollapses, as when a balloon loses air. Glass containers obviously can’t collapse, and a vacuum is formed when thesolution leaves the bottle. The vacuum becomes stronger asmore solution leaves the bottle. If the glass container doesn’thave a vent, vented administration tubing can help prevent avacuum from forming.

Plastic and glass containers are also available empty, with-out any solution in them. These empty containers are sterileand are used for special preparations. Empty glass containerscalled evacuated containers already have a vacuum createdinside the bottle, so that solutions are easily transferred intothem.


Small-Volume Parenterals (Piggybacks)

Intravenous piggyback (IVPB) containers have the same generalappearance as LVPs except that they’re smaller in size. MostIVPBs are either 50 ml or 100 ml in size. They’re sometimesreferred to as minibags. Some piggybacks are 25 ml and afew are 250 ml. The containers used most often are madefrom PVC, as are the larger bags that we discussed. Minibagsalso have a plastic hole at the top so they can hang on apole, and two ports at the bottom. Again, one port is used for adding drugs with a needle, and the other is sealed with a plastic covering that’s removed immediately before attachingthe administration tubing. See Figure 4 for types of solutionsavailable in the containers.

IVPB solutions are available as base solutions or as premixedsolutions. The base solutions don’t contain any active medica-tion. They’re intended to dilute the medication from a vial orampule. (We’ll discuss the technique for doing this later.)

The premixed IVPB solutions already contain active medica-tion. Premixes are convenient but are more expensive thanbase solutions and may require special storage conditions.Many premixes must be kept frozen until use and take upstorage space.

Type of Solution Synonyms Sizes Available

Dextrose 5% in water 5% dextrose Large volume: 250, 500, 1000 ml

5% glucose in water Piggyback: 25, 50, 100 ml

D5

D5W

0.9% sodium chloride Normal saline Large volume: 250, 500, 1000 ml

0.9% NaCl Piggyback: 25, 50, 100 ml

Dextrose 5% & 0.9% sodium chloride D5 & 0.9 Large volume: 250, 500, 1000 ml

D5/NS

Dextrose 5% & 0.45% sodium chloride D5 & 1/2 Large volume: 250, 500, 1000 ml

Dextrose 5% & 0.33% sodium chloride D5 & 1/3 Large volume: 250, 500, 1000 ml

Lactated Ringer’s solution LR Large volume: 250, 500, 1000 ml

Dextrose 5% & Lactated Ringer’s solution D5LR Large volume: 250, 500, 1000 ml

FIGURE 4—Common Base Solutions Used for Large- and Small-Volume Parenterals for Intravenous Use


Labeling of ContainersAll ampules, vials, prefilled syringes, and other packages containing drugs or fluids for injection will have the follow-ing items on the label from the manufacturer:

• The generic name of the medication or fluid (The brandname shouldn’t be used; however, if it is used, it shouldbe placed in parentheses following the generic name.)

• The strength and amount of medication or solute

• The lot number and expiration date of the product

• Precautionary comments such as “For IM use only” or“Not for IV use”

• Directions for proper storage of the medication

• The federal caution label—Caution: Federal law prohibits

dispensing without prescription. (Nearly all injectabledrugs require a prescription or physician’s order for use.)

• The directions for mixing and dilution, either on the labelitself or in the package insert

Brand and Generic Name

You should recall from previous study units that all medicationcontainers must be labeled with the name of the medication.This is also true for ampules, vials, and larger volumes of fluids.The name of the manufacturer or distributor of the medicationmust also be on the package. The manufacturer is the companythat actually makes the drug, and the distributor is the com-pany that markets, or sells, the drug.

Strength and Amount

All drug packages, including those in solution in ampules,vials, and other fluids for IV use, must be labeled with thestrength and amount of medication. If the drug is in powderform, the label will state how much drug is contained in thevial, expressed in metric weights such as grams or milligrams.If the drug is in solution form, the drug strength can beexpressed in the following ways:


• Weight of drug per volume of solution (e.g., mg/ml)

• Percentage (e.g., 5%)

If the drug is in solution, the total volume, or amount, of liq-uid is also given on the label. Remember that the strength, orweight of drug per volume, still remains the same even if thetotal volume of liquid may change.

Lot Number and Expiration Date

For safety and the protection of the public, the lot numberand expiration dates must be listed on the container of theproduct. You may have already learned that a lot number isthe number assigned to a “batch” of product when it’s made.If the need arises, the exact date and time of manufacture ofa drug may be determined from the lot number. This identifi-cation can be important if a question arises as to the safety oreffectiveness of a drug. Drug recalls can occur when doubtsabout safety, strength, effectiveness, or contamination havebeen expressed. The recall order will identify specific lot num-bers of products that are being recalled. Drugs are very seldomrecalled, but the ability to do so accurately and quickly isextremely important when public safety is at stake.

An expiration date is assigned to every packaged drug product. This date is similar to the “use by” date on foodproducts. Drugs can lose their potency over time. Nothing in the pharmacy should be used past its expiration date.

Precautionary Comments

Precautionary comments are frequently seen on injectablecontainers. You might assume that a drug contained in a vialor ampule may be given IV, but this assumption is extremelydangerous. Many drugs contained in vials or ampules are forintramuscular (IM), subcutaneous (SC or SQ), or other use.These drugs should not be given intravenously, and wouldcause harm to the patient if given that way. Bold letteringthat declares “Not for IV use” or “For IM use only” is a help-ful reminder that prevents accidents.


Directions for Proper Storage

All drugs, including those in vials and ampules, have specificstorage requirements. These directions are explicit about the temperature range and light sensitivity of the medication.Most drugs kept in the IV room are stored at controlled room

temperature, which is defined as 59–86°F (15–30°C). Some drugsmust be kept refrigerated or frozen between 36–46°F (2–8°C).

Federal Caution Label

The law requires that the following warning appears on drugcontainers:

Caution: Federal law prohibits dispensing without prescription.

Injectable drugs, with few exceptions, require a prescriptionor physician’s order before they’re administered to a patient.

Directions for Mixing and Dilution

Sometimes the package label contains brief directions for thereconstitution and further dilution of the drug contained in avial. If the instructions are too long or complicated to placeon the label, a package insert will provide detailed instruc-tions for dilution and use. A package insert is a separatepiece of paper that describes the characteristics, uses, prescribing recommendations, precautions, mixing and dilution instructions, compatibilities, and available sizes and strengths of that drug. A package insert comes withevery medication product. With parenteral medications, thetechnician will be concerned mostly with the mixing, dilution,and compatibilities of the drug with various solutions.

The Final Pharmacy Label

The final pharmacy label is placed on the container beforethe container is distributed to a patient. The final label,which can be typed or computer generated, should containthe following information:

• Patient name and room number (or home-care location)

• Name and concentration, amount, or strength of drug(s)used


• The name of the base solution the drug has been placed in

• The final volume of the preparation

• Date and time preparation was made

• The expiration date and other storage information (suchas “stable” for seven-day refrigeration)

• The rate at which the IV fluid is to be administered

• Any other special instructions that will be helpful forproper administration

The labels on the large-volume containers obviously are able to contain quite a bit of information. Labeling on vials andsyringes can be more difficult. If all of the necessary informationwon’t fit on a small label, at least the name, room number, drug,strength, amount, and date should be placed on the label that’sattached to the syringe or vial. The syringe or vial can then beplaced in a zippered plastic bag, which may be labeled with morecomplete information for administration.

It’s important to note that the expiration date of the finalproduct will be different from the expiration dates assignedby the manufacturer to the individual drugs or solutions used.Once a container has been manipulated or entered by a nee-dle, the expiration date of the final product becomes close tothe date it has been prepared. The actual date depends uponthe type of final product (ranging from less than one day toapproximately one month). The final expiration date alsodepends on how the product will be stored after preparation.Many IV fluids made in the pharmacy must be refrigerated,and may even be frozen, after preparation.

Take a few moments now to complete Self-Check 1.


Self-Check 1

At the end of each section of Compounding of Sterile Products 1, you’ll be asked to pause

and check your understanding of what you’ve just read by completing a “Self-Check” exer-

cise. Answering these questions will help you review what you’ve studied so far. Please

complete Self-Check 1 now.

1. Which of the following best fits the description of a large-volume parenteral?

a. A glass container with a cylindrical base and an elongated top containing a drug in solutionb. A plastic container that holds a solution or powder for reconstitutionc. A glass bottle in the 50–100 ml sized. A Viaflex container in the 250–1000 ml size

2. Which of the following best fits the description of an intravenous piggyback solution?

a. A glass container with a cylindrical base and an elongated top containing a drug in solutionb. A plastic container that holds a solution or powder for reconstitutionc. A PVC container in the 50–100 ml sized. A Viaflex container in the 250–1000 ml size

3. Explain the differences between vials, ampules, and prefilled syringes.

__________________________________________________________

4. Explain what kind of information is found in a package insert. Which parts of the packageinsert will a pharmacy technician most likely use?

__________________________________________________________

5. What kind of information is found on the manufacturer’s label of a larger-volume container(piggybacks and large volumes)?

__________________________________________________________

6. What kind of typed or computer-generated information should be placed on the final IV container before dispensing to a patient?

__________________________________________________________

Check your answers with those on page 75.


METHODS OF INTRAVENOUSADMINISTRATION

Intravenous (IV) InfusionsIntravenous infusions are fluids or solutions that drip into apatient’s vein through a needle and tubing at a constant rate.Special solutions are needed for intravenous administration.To prevent serious health complications, the fluids must havethe following characteristics:

• Be sterile, or free from microorganisms

• Have approximately the same pH as body fluids (Thisrefers to the acidity of a solution.)

• Have approximately the same concentration of particles,or solutes, that human blood and body fluids contain

These solutions are isotonic; that is, they usually have thesame isotonicity (concentration of particles) as body fluids.Some solutions are hypertonic, and others are hypotonic, as compared to body fluids. Hypertonic fluids have a higherconcentration of particles dissolved than body fluids, whereashypotonic solutions have a lower concentration of particlesthan body fluids.

IV fluids are used to treat patients for a variety of conditions.This treatment is called both infusion therapy and intravenous

therapy. Intravenous infusions are normally used in the fol-lowing situations:

• When patients need rehydration

• When patients need electrolyte replacement

• When patients need drugs that require larger volumes fordilution

• When patients need additional nutrition

Infusions for Patients Needing RehydrationDehydration is a serious condition. The blood in the bodycan’t circulate properly without an adequate amount of


fluids. When the body is dehydrated, it has lost much of the fluid it needs to function. If a patient is unable to drinkenough water or other fluids to maintain proper function,intravenous fluids can help. There are several ready-madesolutions used for rehydrating the body.

Infusions for Electrolyte ReplacementOur bodies need many electrolytes (which are “salts”) in theright amounts in order to function properly. Our nerves, ourheart, and our brains use electricity, and the electrolytes pro-vide the electricity our bodies need. If a patient can’t obtainthe necessary electrolytes through normal eating and drink-ing, electrolytes can be given by the IV infusion route. (Someexamples of common electrolytes can be found in Figure 23in the last section of this unit.)

Infusions for Drug DilutionSo far we’ve discussed infusion therapy for basic rehydrationand electrolyte replacement. Intravenous infusion also maybe needed to further dilute drugs before administering themto a patient. Two reasons drugs may need further dilution are that (1) the drug causes irritation in a more concentratedform and (2) the drug may even be poisonous if not furtherdiluted. If a drug usually causes redness or pain when it’sgiven, further dilution will help prevent the irritation. A toxic,or poisonous, drug may be more safely administered whengiven very slowly. Dilution in a large volume of fluid allowsthe slow administration of the drug, preventing unwantedside effects that may occur during more rapid administration.

Infusions for NutritionPatients who either can’t eat or are underweight need toreceive nutrition in other ways besides eating and drinking.Specialized IV solutions referred to as total parenteral nutrition,

or TPN, solutions can be made that provide all the nutrientsa body needs to survive if the patient can’t or won’t eat. Thesesolutions are complicated and aren’t available ready to use.Many micronutrients must be added to a base solution,including carbohydrates, proteins, fats, vitamins, minerals,and electrolytes. (These additives will be discussed in depthin another study unit.)


Rate of Infusion

Intravenous infusions, as you’ve learned, are sterile solutions,usually in large volumes, that drip into a patient’s vein at aconstant rate. This procedure is referred to as a continuous

infusion. The patient’s physician knows the needs of the patientand will decide why the infusion is needed, which fluids to use,and how much is needed.

The infusion rate is the rate at which an infusion is given to a patient through the IV tubing. The rate is determined bythe physician. The rate of infusion depends upon the drug,the solution, and the needs of the patient. Infusion rates areusually expressed in milliliters per hour, abbreviated as ml/hr.

IV infusion rates can range from about 10 ml/hr to over 200ml/hr, depending on the solution or medication that’s beingused. See Figure 5 for an example of a physician’s order foran IV infusion. In Figure 5, the rate at which the dextrose 5%in water is administered to the patient is 40 ml/hr.

PHYSICIAN’S ORDER FORM

Jones, Mary

Room 411–1

#961271030

Age 70

10-24-96 11:00 A.M.

Begin D5W 1000 ml at 40 ml/hr

Dr. John SmithFIGURE 5—Physician’sOrder Form


Intermittent TherapyIntermittent intravenous therapy is the opposite of continuousintravenous infusion. Intermittent means from time to time or at regular intervals. This implies that the IV isn’t runningcontinuously into the patient’s vein, but that the solution isgiven periodically. As with oral and other routes of adminis-tration, intermittent intravenous medications are given on aschedule. The drug may be given one time only, once a day,every 6 hours, every 8 hours, every 12 hours, and so on.Intermittent therapy may even be given once a week or once a month, depending on the drug and the patient. Both intravenous piggybacks and IV push (IVP) drugs aregiven intermittently. These two types will be discussed next.

Piggyback Method

We’ve discussed the package size of intravenous piggybacksalready. IVPBs aren’t used for continuous infusion; they’regiven by intermittent infusion. The entire contents of an IVPBare usually given to, or infused into, a patient over a 15- to60-minute period. This is done to avoid vein irritation or togive the drug at a slower rate than IV push. Some drugsrequire a longer period of administration. When the entirecontents of the bag have been given, the dose is complete forthe time being. Another IVPB is given to the patient at a latertime, depending on how often the drug must be administered.

IVPBs are used to dilute drugs that come in ampules andvials before giving them to the patient. Once a drug is addedto an IVPB solution in an institutional setting, it’s sent to thenursing unit and administered to the patient according to thephysician’s prescription. It’s usually “piggybacked” into, or givento the patient through the port at the Y-site of the primary tub-ing from the large-volume parenteral. (This setup is consideredto be a little bit like giving a piggyback ride to a youngster,hence the name IV piggyback.)

The drug from the ampule or vial is added by a pharmacistor technician to the base IVPB solution. Base IVPB solutionsare either 5% dextrose in water (D5W) or 0.9% sodium chlo-ride (NS). The fluids in IVPB containers, either D5W or NS,must be compatible with, that is, must not react with, any


drug that’s added to it. D5W and NS are isotonic, have theapproximate pH of human body fluids, and are also compatiblewith most drugs. The most common sizes of IVPBs are 50 mlor 100 ml, but they also come in 25 ml or 250 ml.

The type and size of IVPB solution chosen depends on the drugand the strength that will be diluted, and can be determinedfrom reading the package insert. For ease and efficiency ofpreparation, many IV therapy rooms in hospitals providecharts that show the sizes and types of IVPB solutions usedfor the most common IV drugs. Figure 6 is an example of abasic chart that may be used. When looking at this table, keepin mind that most of the drugs made in the IV therapy areaof the pharmacy are antibiotics, which come as powders invials. These powders must be reconstituted before furtherdilution in the piggyback container.

In home care, the type and size of IVPB solution also depends on the stability of the drug. Often, a seven-day supply of medication or more can be sent to the patient’shome. Systems are used to mix the drug in the home withoutcompromising sterility. Examples of these include the ADD-Vantage® System and the MINI-BAG Plus® Container. Theseare then administered by the caregiver according to thephysician’s prescription.

Direct IV Push

Some drugs need no further dilution before IV administrationto a patient. The drug solution is “drawn up” into a syringeand may be injected into the port on the primary tubing, as mentioned earlier. The nurse pushes the plunger of the

Drug and Strength Type of Solution Size of Piggyback

Ampicillin 500 mg 0.9% NaCl (NS) 50 or 100 ml

Ampicillin 1 g 0.9% NaCl (NS) 100 ml

Cefazolin 1 g 5% Dextrose (D5W) 50 ml

Cefazolin 2 g 5% Dextrose (D5W) 100 ml

Erythromycin 500 mg 0.9% NaCl (NS) 50 or 100 ml

Erythromycin 1 g 0.9% NaCl (NS) 250 ml

FIGURE 6—SomeCommon IVPB Drugs,Solutions, and Sizes


syringe, thereby expelling the contents of the syringe into the IV tubing. IV push drugs may be in solution in ampules,vials, or prefilled syringes. They may also be in powder formin a vial, which must be reconstituted with normal saline

or sterile water before being given IV push by the nurse.

HookupsEven though the pharmacy is concerned mainly with supply-ing intravenous medications, it’s a good idea for you to knowhow IV infusions are given to a patient. When an IV infusionis given to a patient, it’s first hung on an IV pole. The pole is constructed to keep the IV bag elevated. One end of anadministration tubing is attached to the IV solution. The other end of the tubing has a needle that’s placed in thepatient’s vein by a nurse.

IVs are hooked up to the patient using IV tubing. There aredifferent types of tubings available, but all have some basiccomponents. Every type of tubing has a spike, a small pointedplastic end that’s inserted into the IV bag. A small piece ofplastic may cover the udder (port) on the bag that receivesthe spike. “Spiking” the bag allows the fluid from the bag toflow through the tubing. A needle is attached to the oppositetip of the tubing.

Tubings are often referred to as sets, because they containseveral components: spike, tubing, needle, and hanger. Thesesets are stored in boxes until use. Tubings are also referred toas lines. Anytime you hear “IV line,” you’ll know that it refersto the tubing that connects an IV bag to a patient.

Although there are hundreds of different kinds of tubings, thepharmacy is concerned with only a few types. The tubings usedin the pharmacy for product preparation are used to transfersolutions from one large container to another container whennecessary. These are called transfer sets or tubings.

Patient administration tubings are different from the transfertubings used in the IV room. Each type of tubing used forpatients has a different-sized opening at the end. The openingat the end of the tubing determines the size of the drops offluid that come out. Each tubing delivers a different numberof drops per milliliter. Some drugs, like morphine or heparin,


are given by subcutaneous infusion. These require a specialport (called a Sub-Q port) as well as special tubing. Pharmacytechnicians don’t need to be concerned with the size of thetubings, except when the pharmacy is the supplier of tubingto the hospital. If this is so, be sure to read the box correctlyto supply the right type of tubing.

The basic tubings used for patients are either primary or secondary tubings. The tubings used for LVPs that will begiven by continuous infusion are called primary tubings orprimary sets because the tubing carries fluids from the primary, or main, solution to the patient.

Secondary tubings, or secondary sets, are designed for IVPBuse. These tubings also have a spike that enters the piggybackcontainer at the udder. The other end will have a needle thatwill enter a port located on the primary tubing called the Y-site.

The port at the Y-site on the primary set can receive the nee-dle from the tubing on the secondary set. This allows thesolution from the IVPB to flow into the same tubing that’sattached to the patient.

IrrigationsAlthough irrigations aren’t given intravenously, all irrigationsmust be made under sterile conditions in the hospital. Anirrigation is used to wash something. Irrigations aren’t inject-ed into the vein, but should be free from microorganisms.Irrigations may be made of plain sterile water or normalsaline, or medications may be added to the sterile water ornormal saline. In healthcare situations, sterile irrigations areoften used to wash wounds or infected areas of the skin, eye,bladder, or other parts of the body. Irrigation containers havelabels that state that they may only be used for irrigation.Irrigation solutions may not be used for injection. Otherlabels may be placed on irrigation bottles to make sure that the irrigation isn’t used for injection.

Subcutaneous infusion—The injection of fluidinto tissue justbeneath the skin.


Self-Check 2

1. How is the rate of an IV infusion usually expressed?

a. In milliliters c. In milliliters per hourb. In hours d. In milligrams

2. Which of the following choices best describes the characteristics that a fluid for IV administra-tion should have?

a. It must have a small volume, be sterile, and match approximate isotonicity and pH of thehuman blood and body fluids.

b. It must have a secondary set, be sterile, and always be given IV push.c. It must be sterile and match approximate isotonicity and pH of the human blood and body

fluids.d. It must always be given IV push and match approximate isotonicity and pH of the human

blood and body fluids.

3. The tubing used to administer LVPs to a patient is called

a. primary tubing. c. a transfer set.b. secondary tubing. d. a needle set.

4. The tubing used to administer IVPBs to a patient is called

a. primary tubing. c. a transfer set.b. secondary tubing. d. a needle set.

5. Explain in general terms what an electrolyte is.

__________________________________________________________

__________________________________________________________

6. What two methods are used to administer intermittent IV therapy to a patient?

__________________________________________________________

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DEVICESSpecific equipment is required to prepare and administerinjectable drugs. Various types of syringes, needles, and filtering devices are used when working with parenterals.

SyringesSyringes are needed to both prepare and administer IV med-ications. The pharmacy is concerned with the preparation ofIV medications, and personnel who work in the IV admixturearea must be familiar with the different kinds of syringes usedto prepare the drugs in that area.

General Description

Syringes are made of hard plastic or glass, and come in manysizes. There are three basic parts to a syringe: the barrel, theplunger, and the tip (Figure 7). The barrel of the syringe holdsthe liquid. The plunger may be pulled to draw up fluid into thebarrel and pushed to expel the contents of the barrel into anIV tubing or into another container. The tip of the syringe iswhere the needle is attached. Some types of syringes alreadyhave the needle attached, and some don’t.

FIGURE 7—A syringe consists of three basicparts—the barrel, theplunger, and the tip.


The tip of the syringe may be a catheter tip or a luer lock tip. A catheter tip syringe is a straight and smooth cone thatcomes to a point. A needle is attached only by firmly pushingthe needle and syringe together. Friction helps to keep theneedle attached. A luer lock tip syringe has threads like thosefound on a screw or a jar lid. The needle is attached by twist-ing it onto the syringe tip until it locks in place. (We’ll discusstypes of needles a little later in this section.)

Every syringe has markings—called increments or graduations

—on its side that indicate the volume of solution that it maycontain. These markings make it possible to measure volumesin milliliters and fractions of milliliters. If the syringe is large,the heavier marks designate the 5 ml or 10 ml points and thelighter marks measure single milliliters. On smaller syringes,the heavy marks measure the single milliliters and the lighteror smaller marks measure fractions of a milliliter. Each small-er increment usually designates 0.1 ml or 0.2 ml, dependingon the syringe. These markings allow very precise measure-ments of small volumes of solution. Even more precise meas-urement can be obtained from insulin and tuberculin syringes.(Insulin and tuberculin syringes will be discussed separately.)Syringes range in size from 0.5 ml to 60 ml. The syringe youchoose to use when making IV admixtures will depend on thevolume of solution that you’ll be reconstituting.

Most syringes are packaged in “blister” or “bubble” packs.This familiar type of packaging looks like a plastic bubble orblister firmly attached to a thick paper backing. The backingis labeled to indicate the size and type of syringe. The blisterpack protects the syringe from contamination before use, sothe syringes should always be stored in their original packag-ing. Syringes shouldn’t be opened until immediately beforethey’re ready to be used.

Once a fluid is drawn up into a syringe, the fluid is usuallytransferred to another container, such as a large-volume par-enteral (LVP) or an intravenous piggyback (IVPB). Sometimes,medications are drawn up into syringes and sent to the patientcare area for use by a nurse. In essence, the pharmacy createsa “prefilled syringe” for the nurse. When this is done, thesyringe must be capped. All syringes come with a cap. The


syringe may be capped, or, if the needle is attached, the nee-dle is capped. There are different types of syringe caps, butthey all perform the same function—to protect the contentsfrom contamination.

Insulin and Tuberculin Syringes

Insulin syringes are small syringes (1 ml or less in size) with very small attached needles. These syringes are given topatients along with the drug insulin, which is used to treat theblood sugar condition called diabetes. Many diabetics know howto give themselves insulin injections and must use these verysmall syringes to measure the correct amount of insulin. Thesyringe helps the patient to know how many “units” of insulinto inject.

Tuberculin syringes are also very small syringes with needlesattached to them. They’re often used in patient care areas ofthe hospital and in doctors’ offices. Tuberculin syringes areused to inject a very small volume of tuberculin test solutionunder the skin. This test will show if the patient has, or hashad, tuberculosis.

In addition to their primary intended use, insulin and tuber-culin syringes are also used in the IV admixture area whenvery small volumes of other drugs need to be measured.

NeedlesCannulae are very small tubes that aid in the administrationof intravenous medication. Needles belong to this category ofdevices. There are other types of cannulae that will be dis-cussed after you’re introduced to needles. Needles are theonly cannulae that are used in preparation of IV fluids, butother types of cannulae are available for administering IV fluids to patients.

Needles are placed at the end of a syringe or tubing. The needle can be described as having a shaft, a bore (or lumen),and a hub. The shaft of the needle is the long metal part. Thetip of the shaft is cut at a slant, or beveled. This beveled tipallows the needle to easily pierce the surface of the skin orrubber stopper on a vial. The hub of the needle is the partthat attaches to the syringe.


The bore (or lumen) of the needle is the hole that the solutiontravels through. There are several different sizes of bores.Some are very large to make it easy to draw up thicker liquids into the syringe or expel them from the syringe.Midsized-bore needles are the kind that are usually used in the IV admixture area. Some needles are very slender, likea thin straight pin, with bores that are very small. Small-bore

needles are used to minimize pain upon injection into thepatient. Small-bore needles are rarely used in the pharmacy.

Sizes of needles are expressed in gauge size and length. Thelarger the gauge size, the smaller the bore. The smaller thegauge size, the larger the bore. The smallest gauge (largestbore) needle is around 12 gauge, and the largest gauge(smallest bore) is around 24 gauge. The length of a needleshaft ranges from about 1/2 inch to over 3 inches.

As a pharmacy technician, you’ll use syringes and needles to prepare IV admixtures. The bore size of the needle used is usually between 16 and 19 gauge. This size allows most fluids to flow freely from the vial to the syringe, or from thesyringe into a larger volume. Smaller-bore needles make itdifficult to transfer drugs in solution. Larger-bore needles,however, can be a source of coring. Coring is what happenswhen a piece of a rubber stopper (a core) is removed by theneedle and contaminates the solution. Coring can also becaused by inserting the needle through the rubber stopper of a vial at an improper angle. Any solution being admixed in the pharmacy must always be checked for cores, even ifcare has been taken not to cause coring.

Like syringes, needles are packed individually in blister pack-aging to protect them from contamination. The needle shouldbe kept in this package until just before use. Additional meas-ures for protecting against contamination include the use ofneedleless systems, which help minimize the risk of hepatitisor HIV transmission.


Final Filtering DevicesA final filtering device is a needle, disk, tube, or administra-tion device that’s used to remove particulate matter from asolution. Particulate matter refers to any substance in an IVsolution that’s undissolved. Filtering devices are occasionallyneeded to remove unwanted particles from the solution. Filterneedles are used after removing solution from an ampule.When breaking open ampules, tiny particles of glass may getinto the solution. The filter needle is used to withdraw thesolution from the ampule. It’s then replaced with anotherneedle before the solution is expelled from the syringe. It’simportant to note, however, that some drugs should never be used with filtered needles. Filter tubes or straws are like needles, except that they’re plastic and can’t be used totransfer the solution into a larger volume. These are rarelyused but are available for special uses.

A filtering disc, such as a 0.22 micron filter, may be attachedto a syringe or tubing to remove microscopic particles, includ-ing most bacteria. This type of disk has two openings. Oneopening attaches to the syringe, and the other end may beleft open or have another needle attached. The solution fromthe syringe is expelled through the disk and may be injectedinto another container. This process is frequently used tosterilize, or remove bacteria from, intravenous products.

Some intravenous administration tubings have in-line filters

built into them. These are useful when nurses administersolutions that tend to react easily with other solutions. An in-line filter is the “final checkpoint” for intravenous fluidadministration, and there are some drug package inserts that specifically state to use an in-line filter with the drug.The pharmacist should be familiar with the few drugs thathave this requirement in order to alert the nurse to be ade-quately prepared.


Self-Check 3

1. Name the three parts of a syringe.

__________________________________________________________

2. How is the volume in a syringe measured?

__________________________________________________________

3. Describe a catheter tip syringe.

__________________________________________________________

4. Besides their intended use to measure insulin and tuberculin tests for patients, what else are insulin and tuberculin syringes used for?

__________________________________________________________

5. Name the parts of a needle.

__________________________________________________________

6. How is the size of the bore of a needle expressed?

__________________________________________________________

7. Name four kinds of final filtering devices.

__________________________________________________________

8. What size of filtering disc is needed to remove bacteria from a solution?

__________________________________________________________



EXTEMPORANEOUS IV PREPARATION

Parenteral Preparation in Hospital andHome Care SettingsNow that you’re familiar with the basic types of supplies andproducts used in the making and administration of intravenoustherapy solutions, you’re ready to learn how to use these prod-ucts to make IV admixtures. Making IV admixtures is sometimesreferred to as extemporaneous IV preparation. Extemporaneous

preparation basically refers to anything that’s made or com-pounded outside the walls of the manufacturing plant.

In this section you’ll be introduced to the supplies, equipment,and sterile technique used to prepare IV preparations . You’lllearn the specific methods of diluting drugs, withdrawing thedrugs, and adding the drugs to other containers.

An important thing to remember is that a medication in anampule or vial is sometimes given directly to the patient afterbeing drawn up into a syringe with a needle. The pharmacymay be asked to prepare only the syringes containing med-ication withdrawn from ampules or vials. The pharmacy willalso use contents from ampules and vials to add to largervolumes of solution as required.

Pharmacists and technicians preparing intravenous medica-tions in a hospital pharmacy work in the IV therapy room whereIV admixtures are prepared. Because drugs in ampules andvials are added to larger volumes of solutions in the IV therapyroom, it’s sometime referred to as the IV-add area. Intravenous

admixtures are those preparations that result after carefuladdition of drugs to larger volumes of solution. These productsmust be free from microorganisms and other contaminants, andare therefore called sterile products. Other types of sterile prod-ucts are also made in the IV room.


Accurate and timely preparation of drugs for IV use oftenmeans life or death to a patient. Errors are unacceptable inthe IV room. Once a drug is given by the IV route, it can’t betaken back out. As a pharmacy technician working in the IVroom, you must be a motivated, conscientious, and responsi-ble individual. You’ll help the pharmacist make many differentkinds of IV preparations. You’ll be diluting drugs in vials usingsyringes and needles. You’ll be adding drugs to large volumesof solution. You’ll use aseptic technique to prevent microbialcontamination of the products you make. You’ll be relied uponto perform accurate calculations. You’ll label the final contain-ers as to their final ingredients. All of this must be done in anaccurate and timely manner. All IV products made must have

double and triple checks at each stage of preparation.

Environmental ControlThe IV room where admixtures are made must meet specif-ic standards of cleanliness. The standards of cleanliness areestablished and enforced by organizations such as the JointCommission on Accreditation of Health Care Organizations(JCAHO). These standards are set to ensure that bacterialand any other contamination of intravenous products will beavoided. These standards have evolved over time. As you readabout some of the standards discussed, remember that thesestandards weren’t always in place and that some institutionsdon’t strictly enforce them even now. As part of your respon-sibilities, you’ll be entrusted to see that the standards arebeing followed.

As mentioned, all products prepared in the IV room must be sterile and free from bacteria. Many kinds of bacteria andviruses exist and are often referred to as microorganisms, ormicrobes. Some are more harmful to the human body thanothers. Some microbes cause many kinds of illnesses.


Other types of bacteria live on the outside of our skin. If anymicrobe enters the body by coming into contact with blood or mucous membranes, it can cause an infection. Infectionsinside the body can be dangerous and life-threatening. Microbesmultiply very quickly, and even one bacterium can divide intotrillions within a couple of days.

When a bacterium or virus enters an injectable solution, thiscondition is called microbial contamination. If an injectableproduct containing microbes is given to a patient, the microbescan multiply inside the patient’s body and cause a severe infec-tion. Infection of the blood, called septicemia, can cause death.Obviously, contamination of injectable products must be com-pletely avoided. This is done using special equipment andaseptic technique. (Aseptic technique will be described indetail a little later in this section.)

Bacterial or viral contamination of sterile products can occur in many ways. Microbes can be carried into the area on clothing, skin, and hair and can then be transferred to the product. They may be growing on other surfaces in the IVroom, like the counters, floors, and sinks. Dust and lint float-ing in the air may contain microbes. Microbes may exist onthe surfaces of the ampules, vials, and other containers.Touching tips of needles or syringes to the skin or to anyother surface contaminates the solution. If the container iscracked or leaking, microbes can easily enter the contents.Although it’s rare, contamination may even occur at the manufacturer level, prompting recalls of the product.

Great care must be taken to ensure that microbial contami-nation isn’t a problem. There are a number of considerationsand procedures to follow to ensure that the standards ofcleanliness in the IV room are maintained.


Work Area

The work area (IV room) must be separate from the rest of thepharmacy. It should have a wall or partition that preventsairflow from other areas from reaching the IV room. Manyhospitals don’t allow non-IV room personnel to walk beyond a designated point in the room.

Although the types of IV rooms vary from institution to insti-tution, minimum standards must be met. Some institutionsuse a clean room, in which special HEPA (high-efficiency

particulate air) filters are installed in the ceiling and air circulation grates in the floor. Entrance into these rooms is prohibited unless personnel have met all preparationrequirements. You’ll learn more about clean room specifi-cations a little later in this study unit.

All supplies kept in the IV room should be clean and free oflint and dust. Cardboard storage boxes shouldn’t be allowed.All boxes in the room that contain supplies and drugs shouldbe made of metal, plastic, or other material that doesn’t pro-duce dust.

Surfaces

All surfaces in the IV room must be cleaned frequently with an antimicrobial substance, such as alcohol or other disinfec-tant. Floors, counters, and other surfaces should be cleanedregularly.

The surfaces of products (the rubber stoppers of vials andlarger containers, and necks of ampules) must be swabbed or sprayed with alcohol before use. No surface that has beenswabbed should be touched with fingers or contaminated inany way. If the surface of a product has been touched afterswabbing or if you’re uncertain whether it’s been touched,reswab it. If it’s a needle or a product that can’t be swabbed,throw it away.


Clothing/Apparel

All persons entering the IV room must wear clothing that hasn’t been exposed to the outside or must wear a clean lab coat. Many personnel wear scrubs and sterile surgicalattire (Figure 8). Lab coats and scrubs are made of relativelylint-free material that doesn’t easily absorb or shed bacteria-containing particles. Many hospitals require IV room personnelto wear latex gloves and coverings for their hair, face, and feet.

FIGURE 8—Technicians must wear the proper attire when working in the IV room.


HandwashingHandwashing in the IV room is a strict requirement. Thisprocedure is considered to be one of the first lines of defenseagainst the spread of microorganisms. All personnel mustthoroughly wash their hands with an antimicrobial cleansersuch as chlorhexidine (Hibiclens) or povidone-iodine (Betadine)for at least 15 seconds upon entering the IV room (Figure 9).They also must wash their hands before beginning any prep-aration procedure and every time they return to the preparationarea after leaving. IV room workers use a plastic brush to scrubunder their fingernails, and they never touch the faucet orhandles with their bare hands after washing. The waterfaucet should be turned off while holding a paper towel.

Behavior, Apparel, and MakeupFood, drink, and chewing gum aren’t allowed into the IV room.While in the process of preparing admixtures, talking shouldbe avoided. Talking not only distracts a person from the workbeing performed, but microscopic spittle can contaminate both

FIGURE 9—Techniciansworking in the IV roommust follow the correcthandwashing procedure.


the product and work surfaces. Jewelry must be kept to thebare minimum. Large rings or earrings, nose rings, necklaces,watches, and bracelets shouldn’t be permitted in the IV room.Bacteria can grow in the crevices on jewelry, so it can be asource of contamination. Leave these items at home. In mostinstitutions, IV personnel are permitted to wear small dotearrings and a wedding band. Makeup, especially mascara,can also be a problem in the IV room because it can flake off and contaminate the area.

Laminar Flow HoodsLaminar flow hoods provide a clean work area by filteringmicroorganisms and other particles out of the normal roomair. A laminar flow hood is the special area in the IV roomwhere sterile admixtures are prepared. The principles previ-ously discussed must be followed while working inside a laminar flow hood. Although available in different sizes andmodels, there are two basic types of flow hoods: the horizon-tal flow hood and the vertical flow hood. The hood, whichresembles a cabinet, is a partially enclosed boxlike area with a counter. A pole, with hook rings, is located near the backand top of the hood. It reaches from one end of the hood tothe other. This pole can hold the bags and bottles to whichthe drugs are added. An example of a vertical flow hood canbe seen in Figure 10.

Horizontal laminar flow hoods. The majority of admix-tures in the IV room are prepared in horizontal flow hoods.

A HEPA filter is located at the back of the hood. Air circu-lates from the top of the hood, behind the filter, and comesout in a horizontal direction toward the worker. Over 99.7percent of the particles larger than 0.3 micron in size arecaught in the filter, reducing the risk of airborne contami-nants in the hood area.

Vertical laminar flow hoods. A vertical flow hood is verysimilar to the horizontal hood, except that the air flows in avertical direction. The HEPA filter is located at the top of thehood, and airflow is from top to bottom.

Vertical flow hoods are used to prepare cytotoxic drugs, whichare those that may be harmful to healthy human tissue. Cyto-toxic drugs include cancer chemotherapy drugs that are used


to treat cancer cells. The worker needs to be protected fromany stray particles or droplets containing the cytotoxic drug.The vertical airflow prevents these particles from being blowntoward the worker. The hoods also have a Plexiglas front,providing a clear window that further protects the workerfrom the drugs being prepared inside the hood. Techniciansand pharmacists in this area must use even more specializedtechniques when preparing products. If employed in this spe-cialized area of pharmacy, you’ll receive training according to the policies and procedures in place in the institution’spharmacy department.

FIGURE 10—Vertical Flow Hood


Care of laminar flow hoods. Laminar flow hoods run con-tinuously. If they’re turned off for some reason, they must beallowed to run for at least 30 minutes after being turned backon before being used again. The filters in the hoods need tobe changed every month. The hoods themselves must beinspected and certified regularly to prove that they’re work-ing properly. Records must be kept in the pharmacy to showthat this is done.

The laminar flow hoods must be cleaned regularly. A thoroughcleaning with an antimicrobial cleaning solution should beperformed every day. Before every work shift and after eachpreparation, the hood should be swabbed with isopropyl alco-hol. Use cheesecloth that has been saturated with the alcoholto wipe the counter of the hood. A back-to-front and side-to-side(not circular) motion should be used. Isopropyl alcohol in aspray bottle may also be used to spray the counter, which iswiped in the same motion as described. All metal surfacesshould also be washed.

If there are sticky substances on the surface of the hood(from spills), the surface should first be washed with an anti-bacterial cleaning solution, rinsed, allowed to dry, and thenswabbed again with isopropyl alcohol.

The Plexiglas sides and front should not be cleaned with alcohol. These surfaces should be cleaned with another anti-bacterial cleanser. Also, don’t spray alcohol at the filter or itwill be damaged.

USP 797

New pharmacy regulations that govern the preparation ofsterile products are being implemented as of this writing.USP 797 is a far-reaching regulation that governs a widerange of pharmacy policies and procedures. It’s designedboth to cut down on infections transmitted to patientsthrough pharmaceutical products and to better protect staff working in pharmacies in the course of their exposure to pharmaceuticals.

Issued by U.S. Pharmacopoeia (USP), the regulation governsany pharmacy that prepares “compounded sterile prepara-tions.” Many pharmacies fit this description, and many large


hospitals have several pharmacies—a main one and severalsatellite pharmacies—that will be affected. The USP has theauthority to set regulations on how drugs are mixed duringthe manufacturing and compounding process for both sterileand nonsterile products.

The cleanliness of the air in the area in which the compound-ing is done is now classified and regulated by the InternationalStandards Organization, better known as ISO. These standardsnow replace the old method of determining how many particlesare in the air.

Here are some more facts about USP 797:

• The Food and Drug administration gave the UnitedStates Pharmacopoeia the authority to regulate the waythat sterile compounding areas are to be designed andbuilt.

• The way the items are prepared and the purpose of theirpreparation are divided into low-, medium-, and high-risk categories. For example, mixing three ingredients or fewer in a conventional laminar flow area is consideredlow risk, while products that involve many ingredientsand take a long time to mix fall into the medium-riskcategory.

• Personnel who prepare compounded sterile productsmust be provided with appropriate training from expertpersonnel, audio-video instructional sources, or profes-sional sources before beginning to prepare products.

• Clean rooms must have an anteroom but don’t need tobe separated with a physical wall. Air classification orquality must meet ISO Class 8 standards. Walls, floors,fixtures, and ceilings should be smooth, impervious, freeof cracks/crevices, and nonshedding. Surfaces should beresistant to damage from sanitizing agents.


Aseptic TechniqueThe following procedures embody the practice of aseptic tech-nique. We can’t emphasize enough how important it is thateverything possible be done to ensure a sterile product. It’sessential to practice aseptic technique while working in theIV room.

Setting Up

Start with a clean hood and wash your hands and glove aswe’ve described. Before beginning the admixture process,gather all materials that you’ll need: drugs, syringes, needles,bags, tubings, and alcohol swabs. All of the materials shouldbe located on metal carts in the IV room (Figure 11). Thisprevents any contamination of clothing or hands after hand-washing has taken place. Wash your hands again after you’vegathered all your supplies because the packaging materialsaren’t sterile.

When working in a laminar flow hood, you’lleither stand or sit in front of it. Place all theproducts you’ll need at the center of thehood. Keep your hands and arms towardthe center of the hood. Place all products(vials, ampules, bags, bottles, alcohol swabs,syringes, and needles) side by side, keepingthem six inches from the front edge of thehood and away from the sides and back.None of the products should touch oneanother. Arrange all items so that the air-flow isn’t obstructed; that is, none of theitems should be placed in front of any other drug or supply in the hood.

Sometimes you’ll be working with many sup-plies (ampules, vials, bags, or bottles) in thehood at once. Other times you may onlyneed one or two. The more supplies you’reworking with, the greater the chances ofcontamination.

FIGURE 11—The materials you need should belocated on metal carts in the IV room.


You must now handle the drugs and supplies without touch-ing any unnecessary surface. Remove all drugs and suppliesfrom their protective coverings. Carefully remove the outerwrap from needles, syringes, and any IV bags. Discard thesequickly without touching the surface of the refuse containerwith your hands.

Once you remove a needle or syringe from the outer wrap,carefully replace it in its original position, side by side withthe other supplies in the hood. Be very careful not to touchthe tips of the needles or syringes to the surface of the hood.Attach the needles to the syringes.

Once the needles and syringes are back in place, you maybegin opening the ampules or vials that contain the drugsand diluents. (Remember, a diluent is the liquid, such assterile water or normal saline, that may be needed to recon-stitute a powdered drug.) The following steps demonstrate the withdrawal of solution from an ampule.

Using Ampules

As already mentioned, all work must be done six inchesinside and away from the back and sides of the hood. Whenbreaking open ampules, you must be careful not to allowanything to block the clean airflow to the surface of the con-tainer. This includes any bags or bottles hanging from thepole and your own hands or fingers.

First, remove an alcohol swab from its package. Swab theneck of the ampule using the tips of your fingers to hold theswab. Make sure that you move the swab completely aroundthe neck of the ampule.

To avoid being cut and to avoid contaminating the product,you must use the proper technique to break open the ampule.Hold the ampule firmly in both hands away from your face andeyes. Your left and right thumbnails should meet each otherat the neck of the ampule. Using a quick and firm snappingmotion and, applying pressure from the thumbs, snap theampule in an outward direction at the neck (Figure 12). It’susually very easy to break open an ampule, but a few prac-tices with an inexpensive ampule will probably be necessaryto perfect your technique.


Before the medication from an ampule may be used or transferred to another container, you must withdraw it fromthe ampule into a syringe with an attached needle. Becausemicroscopic glass fragments may enter the medication solu-tion when the ampule is broken, a filter needle must be usedto remove any glass particles that may have fallen into themedication.

Using your thumb and forefinger, remove the cap from the filter needle. Carefully set the cap down on the hood’s surfacein its original place. Don’t block airflow. Holding the ampulein one hand, use the thumb and forefinger of your other handto insert the needle into the ampule until the bevel of theneedle is below the surface of the solution. The needle will be upside down. At this point, use your thumb to depress the plunger of the syringe so it’s completely down.

Now, use the thumb of the same hand to pull back on theplunger to withdraw the fluid from the ampule. Draw back on the plunger until the correct amount of fluid is in thesyringe. Since the syringe will be upside down, it’s difficult todetermine the exact volume of fluid in the syringe. You mustset down the ampule and hold the syringe upright. A largebubble and smaller bubbles of air may rise to the surface ofthe liquid in the syringe. Tap the syringe gently to force anymore air bubbles to the surface. Then push the plunger untilthe black mark at the end of the plunger is even with the vol-ume you need.

FIGURE 12—Always weargloves when you breakopen an ampule.


Once you have the correct volume, you must change the needle on the syringe before you transfer the drug intoanother container. To do this, carefully replace the cap on the filter needle without touching the surface of the needle.Do this slowly so that you don’t poke yourself with the needle. Remove the capped needle from the syringe.

You should still be holding the syringe in one hand, expos-ing the tip to clean airflow. With your free hand, pick up the needle you’re replacing the filter needle with. Place it on thesyringe with its cap still in place.

To add the contents of the syringe to another container, suchas a bag, hang the bag from the horizontal bar in the hood.Alternatively, you may place the bag sideways on the surfaceof the hood so that the clean air is flowing over the port.Swab the rubber port of the IV bag with an alcohol wipe.

Uncap the needle on the syringe and hold the needle underthe bag that’s hanging from the pole (or lying on the hoodsurface). Carefully insert the needle into the tip of the rubberport, being careful not to pierce the sides of the port or thecontainer. Slowly depress the plunger of the syringe, expellingits contents into the bag.

If you’re putting the additive into a glass vial rather than anIV bag, you must first remove the tamper-evident metal wrapfrom the top of the bottle. Remove the metal disk withoutblocking airflow to the top of the bottle. Underneath themetal disk is a thin rubber shield, or diaphragm. Insert the needle into the shield and inject the drug into the bottle.Figure 13 demonstrates the correct method for inserting aneedle into a glass vial.

Once you’ve injected the contents of the syringe into the largervolume (bag or bottle), you must shake the final solution gentlyto ensure complete mixing. When all additives have beeninjected and the solution is thoroughly mixed, you’ll place a small foil sticker on the port. The sticker discourages nurs-ing staff from adding drugs to the prepared solution in thepatient care area.


Using Vials

Prepare a syringe as you did for withdrawing fluid from anampule. When opening a vial you must work carefully so thatyou handle the vial without disturbing airflow to any otherpackage in the hood. With your thumb, flip off the protectivecap(s) of the vial in the hood to expose the rubber stopper.Remember to do this without disturbing airflow to any other supplies.

FIGURE 13—Carefully insert the needle into the rubber shield, being careful not to core the rubber.


Withdraw the liquid medication from the vial by inserting a needle through the rubber stopper and into the solution(Figure 14).

Often the contents of a vial are in powder form that must be reconstituted. In this case, you must first withdraw sterilewater or normal saline from another vial and inject the properamount into the vial containing the powder. Recap the needle,and place it carefully back on the hood. When you recap aneedle, you must ensure that the outer part of the capdoesn’t touch the shaft of the needle.

FIGURE 14—To withdraw the contents of a vial, insert the needle through the rubber stopper and intothe solution.


After you’ve added liquid to the powder in the vial, you mayneed to gently shake the vial until all the powder is dissolved.The resultant solution may be withdrawn using the samesyringe, unless the syringe was contaminated while recap-ping. You must use strict sterile technique when doing this.Don’t block airflow to the needles. Don’t place your hands orany object in front of vials or ports under the hood that willreceive the injection.

To summarize what we’ve covered up to this point, aseptictechnique in a sterile compounding area includes the follow-ing procedures:

• Start with clean products, areas, apparel, and hands.

• Work six inches inside the front of the hood and awayfrom the back and sides.

• Swab all surfaces of ampules, vials, and rubber stoppersof larger volumes with isopropyl alcohol.

• Never block airflow to any surface.

• Never touch the needle insertion point on a rubber stopper with your hands.

• Never touch the needle or syringe tip to any surfaceother than the insertion point.

Final Inspection

We’ve discussed that most drugs prepared by the pharmacyin the IV admixture area are in solution. Solutions are clear

and free from particulate matter. This is a very important distinction. Particulate matter can be described as solids,

or precipitates.

A precipitate is what forms when two or more incompatibledrugs are mixed in a solution, or when a drug is added to anincorrect base solution. The precipitate is a solid chemicalthat forms when the incompatible ingredients come into contact with each other. The appearance of a precipitatedepends upon the ingredients. It may appear as a fine, snowlike substance, usually white or yellow in color. It mayalso appear as general cloudiness, causing the clear solutionto have a foglike appearance.


Cores (pieces of rubber stopper), undissolved drug, lint, dust,precipitates, or any solid are considered to be particulatematter. If a solution containing extra particulate matter isadministered to a patient, he or she can become very ill. Anyparticle, if large enough, can block a blood vessel and causebrain or heart damage and even death. It’s usually obviouswhen a precipitate forms, but each and every solution madein the IV admixture area must be visually inspected (lookedat very closely) for any evidence of a precipitate or other solidparticulate matter.

If a core or piece of dust or lint is present in the solution, a final filtering device may be used to remove it. If a cloudyprecipitate has formed, the solution should be discarded andthe pharmacist must determine the cause of the precipitate.These occurrences should rarely take place if workers arecareful to exercise aseptic techniques and good pharmacypractice.

Occasionally, you’ll work with sterile parenteral suspensions.A suspension, by definition, contains undissolved solids. Asuspension is cloudy, not clear. You must be aware of theinjectable drugs that will have this cloudy appearance afterpreparation. There are only a few, and Primaxin, an antibiotic,is one of them.


Self-Check 4

1. What does the acronym HEPA stand for?

__________________________________________________________

2. How often must HEPA filters be changed?

__________________________________________________________

3. What distinguishes a vertical laminar flow hood from a horizontal laminar flow hood?

__________________________________________________________

4. Describe good handwashing technique.

__________________________________________________________

5. Describe the proper attire in an IV room and explain its importance.

__________________________________________________________

6. Describe the ways in which bacterial contamination may occur in an IV room.

__________________________________________________________

7. What could happen to a patient if a contaminated IV product is administered?

__________________________________________________________



TERMINOLOGYThe following words are commonly used in compoundingsterile products. You may refer to these words as a goodreview.

airborne Refers to anything that’s carried in the air, such as airborne contaminants like dust or bacteria.

alcohol, isopropyl A type of alcohol that’s commonly usedto clean and sterilize surfaces in the IV room. It may besprayed, poured, or used as prepackaged individual wipes.All surfaces such as countertops, hood counters, and rub-ber stoppers should be swabbed with isopropyl alcoholbefore use.

ampule A small glass package, usually from 1 ml to 20 ml,containing a drug in solution. It has an elongated shapethat becomes very narrow at the neck, where it must bebroken to withdraw the contents.

antibacterial Refers to anything, such as a solution orcleanser, that kills bacteria or inhibits bacterial growth.

aseptic technique A set of specific practices and proceduresperformed with the goal of minimizing contamination bypathogens. Aseptic technique is used to prepare sterileproducts to prevent contamination of the final product.Aseptic technique involves the observance of a “no-touch”policy. Sterile surfaces such as needles, the plunger andtip of syringes, and rubber stoppers shouldn’t make anycontact with fingers, hands, or any other surface otherthan to add or withdraw solution through an intendedopening. Sterile airflow filtered through the laminar flowhood shouldn’t be blocked by hands or supplies at any time.

bacteria Living microscopic organisms that can cause infection and disease.

bacteriostatic sodium chloride 0.9% A diluent used in IVproduct preparation that contains mostly sterile 0.9% NaClfor injection and a small amount of chemical, called a bacteriostat, that inhibits bacterial growth within the vial.This product is usually available in small vials (10–30 ml).


bacteriostatic water A diluent used in IV product prepara-tion that contains mostly sterile water for injection and a small amount of chemical, called a bacteriostat, thatinhibits bacterial growth within the vial. This product is usually available in small vials (10–30 ml).

chemotherapy The procedure of using drugs to treat cancer. The drugs used are called cytotoxic agents,

antineoplastics, and cancer chemotherapy agents.

chemotherapy flow hood See vertical laminar flow hood.

chlorhexidine gluconate An antibacterial cleanser that canbe used in the IV room for hand and surface cleansing. (Acommon trade name is Hibiclens.)

clean room A separate room in an institution where a highlevel of cleanliness must be maintained with strict adherenceto dress code limits placed on personnel who are admitted.Also a separate walled-off area within a larger room thatmaintains air quality by major reduction in airborne con-taminants using HEPA filters in the ceiling.

compounding The act of mixing two or more ingredients toprepare a final product.

contamination The introduction of bacteria or particulatematter into a sterile product.

controlled room temperature The normal temperaturerange of a room, between 59°F and 86°F or between 15°Cand 30°C. The temperature shouldn’t be permitted to fallbelow or rise above the range limits.

core A piece of rubber stopper that may break off and entera sterile solution. This breakage is caused by improperneedle insertion or large-bore needles.

diluent A substance that’s mixed with a powder to dilute itinto a liquid such as a solution or suspension. The mostcommon diluents used in preparing IVs are sterile water forinjection, bacteriostatic water for injection, sterile normalsaline for injection, and sterile bacteriostatic normal salinefor injection.


electrolyte A salt, made up of positive and negative ions,that the body needs to perform certain electrical processessuch as impulse transmission through the brain, nerves,and heart.

evacuated container A glass container that has little or noair inside, creating a vacuum. Large volumes of IV solutionmay easily be transferred into an evacuated container.

extemporaneous compounding See compounding.

filtering device (final filtering device) Any device—includingfilter needles, discs, and in-line filters—that filters outbacteria or unwanted particulate matter from a solution.

flow hood See laminar flow hood.

HEPA filter A filter used in hoods and clean rooms that canfilter out particles, including dust and bacteria, that are0.3 microns or more in size. These filters help to maintainan area relatively free of airborne contaminants.

hood See laminar flow hood.

horizontal laminar flow hood A hood that uses a HEPA fil-ter placed at the back of the cabinet, allowing the sterilizedair to flow toward the worker in a horizontal direction. Thisis the type of hood that most admixtures are prepared in.

hyperalimentation An IV solution that’s made to give nutritional therapy to patients who are unable to eatenough food to keep them well. The solution contains manyingredients that increase the number of particles in solu-tion, causing the solution to be hypertonic, hence the namehyperalimentation. Also referred to as hyperals.

hypertonic The designation used for a solution that’s moreconcentrated (i.e., contains more particles or solute) thannormal blood or body fluids.

hypotonic The designation used for a solution that’s lessconcentrated (i.e., contains fewer particles or solute) thannormal blood or body fluids.

intermittent From time to time, or on a regular schedulesuch as every 6, 8, or 12 hours. Not continuous.

intravenous (IV) Entering by way of the vein.


isotonic The designation used for a solution that’s the sameconcentration (i.e., contains the same number of particlesor solute) as normal blood or body fluids.

IV admixture Any preparation containing two or more ingredients that’s intended to be given as IV therapy and ismixed in the pharmacy.

IV infusion A method or product used to administer large-volume IV fluids (250–3000 ml) at a relatively slowcontinuous rate.

IV piggyback (IVPB) A method or product used to adminis-ter intermittently smaller volumes of IV fluids (50–100 ml)containing drugs. IVPBs are usually given through a sec-ondary tubing into the Y-site of a primary tubing that’sattached to a large-volume continuous infusion. If there’sno continuous infusion, IVPBs may sometimes be given asintermittent infusions directly into a needle attached to thepatient.

IV push (IVP) A method of IV administration that uses asyringe containing a drug in solution, without the furtheruse of larger volumes. The plunger is depressed over a veryshort period of time (one second to five minutes) into thepatient’s vein or tubing.

IV therapy The use of drugs that are given through the IVroute.

IV therapy room The clean area in the pharmacy that’s setapart as a place to make sterile products.

laminar flow hood A cabinet used in an IV room to makesterile products. It permits clean air, which is sterilized bypassing through a HEPA filter, to flow over, in, and aroundthe inside of the cabinet, creating a work area that’s rela-tively free from airborne contaminants. This is the area inwhich IV admixtures are prepared in the IV room.

large-volume parenteral (LVP) A product made for IV infu-sion, usually between 250 ml and 3000 ml.

microorganism Any microscopic bacteria, virus, or fungus.

needle A cannula used in the preparation and administra-tion of intravenous products. It consists of three parts: the shaft, the bore, and the hub.


parenteral Refers to a method of or product for injection(e.g., a parenteral route, a parenteral admixture).

povidone-iodine A cleanser or solution used in hand-washing, cleaning, and sterilizing surfaces in the IV room. (A common trade name is Betadine.)

precipitate Any unwanted solid matter in an IV solutionthat’s formed by the reaction of two chemicals.

prefilled syringe A syringe that contains medication in solution that has been added during production at themanufacturer.

primary set See primary tubing.

primary tubing Administration tubing that’s used to give a continuous intravenous infusion to a patient.

pyrogen Any item or chemical in an IV solution that maycause a fever in a patient.

reconstitute To mix or dissolve a powder with a diluent.

secondary set See secondary tubing.

secondary tubing Administration tubing used to give anintermittent IVPB infusion to a patient.

solution A liquid containing completely dissolved ingredi-ents. An IV solution is completely sterile and containsingredients that may be given by the intravenous route.

solvent A diluent used to dissolve something and create a solution.

sterile product Any sterile preparation made in the IV room,including IVs (LVPs, IVPBs, syringes), irrigations, and otherproducts that should be free from microorganisms.

sterile sodium chloride 0.9% A solution of 0.9% NaClthat’s free of microorganisms. Also referred to as sterile

normal saline (NS) or just sterile saline. Sterile saline forinjection differs from sterile saline for irrigation in thestrictness of packaging and use. It’s also free from the preservative that’s used in bacteriostatic saline for injec-tion. It can be used as a diluent or as a base solution fordrugs to be added for IV infusion.


sterile water Water that’s free from microorganisms andcontaminants. Sterile water for injection differs from sterilewater for irrigation in the strictness of packaging and use.Sterile water for irrigation doesn’t contain the preservativethat’s used in bacteriostatic sterile water for injection. Sterilewater for injection is normally used as a diluent, but not as a base solution for IV infusion.

suspension A drug product that intentionally contains undis-solved particles of drug. There are a few IV products andother sterile or injectable products that are available as asuspension. These should be shaken before use.

syringe An instrument that’s used to measure and preparerelatively small quantities of IV drugs that are to be addedto larger volumes or to be administered directly to thepatient by IV push with the use of an attached needle. A syringe is composed of three parts: the barrel, theplunger, and the tip.

vertical laminar flow hood A hood that has the HEPA filterlocated at the top of the cabinet, allowing sterilized air toflow from top to bottom in a vertical direction, protectingthe worker from cytotoxic drug particles. This is the type of hood in which cancer chemotherapy drugs for injectionare prepared.

Viaflex A type of flexible plastic (polyvinyl chloride, or PVC)that’s used to make many sizes of IV bags.

vial A small container made of glass or plastic that containsa sterile drug in solution or powder form, which is intendedto be used for addition to larger volumes of fluid or directIV push by withdrawing into a syringe.

virus A type of microorganism that isn’t considered to be aliving thing but can cause disease.


Self-Check 5

Match the terms on the left with their descriptions on the right. Indicate your choices in

the spaces provided.

______ 1. antineoplastics

______ 2. isopropyl alcohol

______ 3. laminar flow hood

______ 4. 0.3 micron

______ 5. polyvinyl chloride


a. Area where most IV admixtures are prepared

b. Size of particle filtered out by a HEPA filter

c. Prepared in a vertical laminar flow hood

d. Material used to make flexible bags

e. Used to swab surfaces in the IV room


IV CALCULATIONS

Concentrations of SolutionsBecause solutions are being made in the IV room, calculationsmostly involve the use of ratio and proportion-type problems.The concentration of a solution is often expressed as a ratioand proportion. For practical purposes, the concentration ofany solution is the total weight of the powder or drug dividedby the total volume of the solution. For example, ampicillinoral suspension is available in the concentration of 500 mg/5 ml. An ampicillin IV solution, after reconstitution, can be 1 gram/10 ml. Almost every liquid product (solution or sus-pension) that you deal with will have its strength expressedas a concentration.

When dealing with concentrations in solution, “in” means thesame as “per,” which means the same as “divided by,” whichmeans the same as “over.” These terms all mean the samething (Figure 15).

10 mg per ml can also mean:

10 mg in 1 ml

10 mg � 1 ml (10 mg divided by 1 ml)

10 mg/ml or 10 mg/1 ml (10 mg over 1 ml)

250 mg per 5 ml (which is also the same as 50 mg per 1 ml) can also mean:

250 mg in 5 ml

250 mg � 5 ml (250 mg divided by 5 ml)

250 mg/5 ml (250 mg over 5 ml)

1 gram per 10 ml can also mean:

1 g in 10 ml

1 g � 10 ml (1 g divided by 10 ml)

1 g/10 ml (1 g over 10 ml)

FIGURE 15—Equivalent Expressions


To help you to read and then set up the math for the exam-ple problems that we’ll be doing together, it’s useful to saythe following sentence to yourself, emphasizing the wordsthat are in italic type:

Concentration is usually expressed in weight per volume,weight in volume, weight divided by volume, and weight over volume.

This way of looking at problems will help you to use the wordsand concepts in the following examples to mathematically setup your calculations. All ratio and proportion problems areset up in the same way. The numbers are arranged in frac-tion form. If you do these problems the same way each time,you’ll always obtain the right answer. Each problem shouldbe done stepwise (step 1, step 2, etc.), as the following exam-ples illustrate.

Example 1:

One gram of a drug is in a total of 10 ml of solution. Howmany grams of drug are in 2 ml of the solution?

Solution:

Step 1. Always put the weight (in this case, grams) over thevolume (ml) in fraction form (remember that 1 g in 10 ml isthe same as 1 g over 10 ml). Place an equal sign next to thefraction like this:

Step 2. On the other side of the equal sign, place the otherfraction. One of the numbers in this fraction will be the“unknown,” which we’ll represent by x. This is the answeryou’re looking for. Always place x directly across from theother number that has the same kind of units, such asgrams or milliliters. In these examples we’ll “find x,” or “solve for x.”

Set up your equation like this:

mlg=

ml01g1

2

x

ml 10g1


As you can see, the same units are directly across from each other. Grams are directly across from grams (both arenumerators), and milliliters are directly across from milliliters(both are denominators).

Step 3. Cross multiply to solve for x. To cross multiply, youmust multiply the numerator from one side of the equationby the denominator of the other side, making the problemlook like this:

1 � 2 = 10 � x

2 = 10x

You’ll notice that we dropped the units for the time being.We’ll put the correct unit with the answer when we’ve fin-ished our calculations.

Step 4. To solve for x, we need to have x by itself on oneside of the equation. Divide each side of the equation by 10 to get

2 = 10x

2 ÷ 10 = 10x ÷ 100.2 = x

0.2 g = x

Since x needs to be in gram units (see step 2), your answer is 0.2 grams. Therefore, the answer to the original question isthat 2 ml of solution will contain 0.2 grams of drug. Alwaysremember to use the same units in your calculation as aregiven in the problem. The question asked for grams, so youset up your calculations to find the answer in grams.

If this problem had asked for the answer in milligrams,even though the concentration was given to you in gramsper milliliter, you could convert (i.e., change) your finalanswer in grams to milligrams by taking what you just didone step further. You need only to convert 0.2 grams into milligrams by using what you know about conversions(Figure 16).

mlg=

ml01g1

2

x


Since there are 1000 milligrams per 1 gram, it can also be said that there are 1000 mg in 1 gram, 1000 mg over

1 gram, or 1000 mg divided by 1 gram. If the question hadasked for the number of milligrams in 2 ml, you could stillset up your problem in the same way, using fractions andratio and proportion for an answer in grams as you did insteps 1 through 4. For step 5, set up the problem in fractionform again, instead putting the milligrams across from mil-ligrams, and grams across from grams. This is the principleof ratio and proportion.

Step 5. Convert 0.2 g to milligrams.

Cross multiply:

1000 � 0.2 = 1 � x

Solve for x:

200 = x

Your answer is 200 mg, which is the same as 0.2 grams, theanswer in step 4.

gmg=

g1mg1000

0.2

x

Weights

1 kilogram (kg) = 1000 grams (g)

1 gram (g) = 1000 milligrams (mg)

1 milligram (mg) = 1000 micrograms (mcg or mg)

1 microgram (mcg) = 1000 nanograms (ng)

Volumes

1 liter (L) = 1000 milliliters (ml)

(Note: A milliliter is equivalent to a cubic centimeter or “cc” or c3)

1 deciliter (dL) = 100 milliliters (ml)

FIGURE 16—Conversionswithin the Metric System


Reconstituted VialsNot all drugs in the IV room are already in solution. Some are sterile powders that must be reconstituted, or mixed. Youmust keep in mind that the final volume of a reconstituted

solution may not be the same as the volume of diluent thatwas added, because the powder takes up some space in thevial.

For example, cefazolin comes in a powder for reconstitution.The 0.5 g vial size must be reconstituted using 2.0 ml of dilu-ent. The final volume of the mixture is approximately 2.2 ml.

The approximate concentration of the solution is 225 mg/ml (0.5 g ÷ 2.2 ml = 227 mg/ml). This information is in thepackage insert. Remember, the concentration of any solutionis the total weight of the powder or drug divided by the totalvolume of the solution.

Example 2:

You need to reconstitute an antibiotic. The concentration in the vial will be 2 g in 5 ml once it’s mixed with 4.7 ml ofdiluent. You want to withdraw from the vial a certain amountof solution that contains only 0.5 g of antibiotic. How manymilliliters will contain 0.5 g?

Solution:

Step 1. Set up the problem in fraction form (2 g in 5 ml isthe same as 2 g over 5 ml). Then place grams across fromgrams and milliliters across from milliliters:

Step 2. Cross multiply:

2x = 0.5 � 52x = 2.5

Step 3. Solve for x:

x = 1.25 ml

Your answer is that 1.25 ml of solution will contain 0.5 g ofdrug. This is the amount of solution you’ll need.

mlg0.5=volume)(total

ml5g2

x


Example 3:

What is the final concentration of a solution that has 3 g of powder and a total solution of 9 ml?

Solution:

Step 1. Set up the problem:


0.33 g per ml = x

This is the concentration, expressed in grams per milliliter.

Concentrations as PercentagesNot all concentrations are expressed as weight over volume.Many times large-volume solutions are expressed as a percent-age. For example, we’ve discussed isotonic sodium chloride,which is 0.9% sodium chloride. When a concentration isexpressed in this way, it’s assumed that the sodium chloride(or whatever the substance) is in water, unless otherwise statedon the container. Therefore we can safely assume that a 0.9%solution of sodium chloride contains only two ingredients: salt(sodium chloride, NaCl) and water. This is also true for dextrosesolutions. A 5% dextrose solution contains two ingredients:glucose (dextrose) and water.

The percentage actually refers to the solute (in these cases,sodium chloride or dextrose). Remember that the solute is the substance (powder or drug) that’s dissolved, the solvent

is what the solute is dissolved in, and the solution is theentire product.

Percentages can be turned easily into a weight over volumeexpression. Just remember that percentage can be expressedas follows:

x percent solute is x g in 100 ml of solvent.

In other words, 0.9% sodium chloride is

0.9 g in 100 ml of water.

x=ml9g3


5% dextrose is

5 g in 100 ml of water.

Now, you may be asking yourself, But what if I have 1000 mlof these solutions? The answer is, no matter how much youhave, the concentration will be the same throughout thesolution. The total amount of dissolved substance may bemore in a 100 ml bag than in a 1000 ml size, but in eachand every 100 ml of the solutions in our examples, there’s0.9 g of NaCl or 5 g of dextrose.

You can easily calculate the total amount of solute when apercentage is given if you (1) remember that percentage of aweight in volume solution is grams per 100 ml and (2) set upthe problem in ratio and proportion, as we’ve described.

Example 4:

How many total grams of sodium chloride are there in a 1000 ml bag of 0.33% solution?

Solution:

Step 1. Set up the problem. Remember, always put yourgrams over milliliters first, then grams across from grams.(Hint: 0.33% is the same as 0.33 g per 100 ml.)

Step 2. Cross multiply and solve for x:

(0.33)(1000) = 100x

3.3 g = x

Your answer is that there are 3.3 g of sodium chloride in a1000 ml bag of 0.33% solution.

Example 5:

How many total grams of dextrose are there in a 50% syringethat’s 10 ml in size?

Solution:

Step 1. Set up the problem. (Hint: 50% is the same as 50 g in 100 ml.)

ml1000g=

ml001g33.0 x



(50)(10) = 100x

500 ÷ 100 = x

5 = x

Your answer is that a 10 ml syringe of 50% dextrose containsa total amount of 5 g of dextrose.

You can use this same process when answering the oppositetype of question.

Example 6:

What is the percentage of a solution if you’ve dissolved 8 g in 20 ml of solute? (Hints: Remember that 8 g in 20 ml is thesame as 8 g over 20 ml. If you set up the problem so that xis over 100 ml and is expressed in grams, then x will be thepercentage.)

Solution:



(8)(100) = 20x

800 ÷ 20 = x40 = x

Your answer is that you have a 40% solution.

Rate ProblemsThere are several types of situations where you may need touse an infusion rate (the rate at which an IV is being admin-istered to a patient, usually expressed in ml/hr). Sometimesyou’ll be called upon to figure out about how long it will takefor an IV bag to become empty. Other times you may need todecide how large of a bag to use. Still other times, you may

ml100g=

ml20g8 x

ml10=

ml001g50 x


need to figure out the rate itself if you know the size of thebag and amount of time that the infusion will take. The general formula for determining these values is

Rate = Volume/Time

The unknown, or answer, that you’re looking for is alwayscalled x.

Example 7:

If you have a 1000 ml bag that’s to be infused over 24 hours,how fast should the IV rate be set on the pump?

Solution:


Step 2. Solve for x, which is rate:

x = 1000 ml ÷ 24 hr = 41.7 ml/hr

Notice the units will be in milliliters per hour, which is mlover hours, the same way as they appear in the problem. Alsonotice that the answer has a decimal point. Solving calcula-tions will often give you an answer as a decimal. This is allright for most types of problems (such as determining strengthor volume). Answers for rate problems need to be in wholenumbers, however, because the IV pumps and tubings canonly be set using whole numbers such as 1, 2, 3, or 40, 42,45, and so on. In Example 7, you need to round up to thenearest whole number, which is 42. Therefore, your answer is that the rate should be set at 42 ml per hour.

Example 8:

An IV is running at the rate of 100 ml per hour. How long willit take for the IV to run out if it’s a 500 ml bag?

Solution:

Step 1. Set up the problem. In this problem, since you weregiven the rate, you can do it one of two ways. First, use theratio and proportion method:

hrml500

=hr1ml100

x

hr24ml1000

=x


Step 2. Solve for the unknown, which is time:

100x = 500x = 5 hr

You can also solve this example by using the rate formula:


This formula can be rearranged to read:


x = 500 ÷ 100x = 5 hr

Metric ConversionsEven though conversions were mentioned before, this topicdeserves additional attention. Many times a problem requiresthe conversion from grams to milligrams or milligrams backto grams, micrograms to milligrams, and so on. You need

to know your metric conversions. In the pharmacy, almosteverything is measured using the metric system, with veryfew exceptions.

The most common metric units of weight used in the phar-macy are grams, milligrams, and micrograms. The most common metric units of volume used in the pharmacy areliters and milliliters. You’ll rarely see kilograms, decigrams,nanograms (weights), or kiloliters and deciliters (volumes)when working with any pharmacy product.

If you need to convert milligrams to grams, you can easily dothis by using the ratio and proportion method, as illustratedin Example 9.

ml/hr)(1000 Timeml)(500 Volume=hr)(Time x

hr)( Timeml)(500 Volume=ml/hr)(100Rate

x


Example 9:

Convert 190 mg to grams.

Solution:

Step 1. Set up the problem. (Hint: Make sure the milligramunits are across from milligrams and grams are across fromgrams.)


1000x = (1)(190)x = 190 ÷ 1000

x = 0.190

Therefore, 190 mg is the same as 0.190 g.

Example 10:

Convert 1500 mcg to milligrams.

Solution:

Step 1. Set up the problem (mcg across from mcg, mgacross from mg):


1000x = (1500)(1)1000x ÷ 1000 = 1500 ÷ 1000

x = 1.5 mg

Something that you should be aware of is that because theabbreviations for grams (g), milligrams (mg), and micrograms(mcg or mg) are so similar, they’re easily confused. This isespecially true for handwritten orders, which are often hard to read. Physicians are notorious for having bad handwriting.Even the best handwritten abbreviations, however, can be mis-taken for another. Read all labels and orders very carefully.You must also be knowledgeable about the available strengthsand concentrations of the drugs that you’re working with. Ifyou have any doubt whatsoever, ask.

mgmcg0051

=mg1

mcg1000x

gmg901=

g1mg1000

x


Self-Check 6

Solve the following problems. Be careful to express your answers using the correct unit of

weight or measurement.

1. 2 g of a drug are in a total of 10 ml of solution. How many grams of drug are in 8 ml of the solution?

__________________________________________________________

2. 3.7 g of a drug are in a total of 15 ml of solution. How many milligrams of drug are in 10 ml of the solution?

__________________________________________________________

3. 5 g of a drug are in a total of 10 ml of a solution. How many milliliters are needed to obtain 2.3 g of drug?

__________________________________________________________

4. When reconstituted, 3 g of a drug are in a total of 10 ml of solution. How many milliliters of solution are needed if an order asks for 170 mg of the drug?

__________________________________________________________

5. You’re to reconstitute an antibiotic. The concentration in the vial will be 1 g in 5 ml once it’smixed with 4.7 ml of diluent. You want to withdraw only 0.5 g from the vial. How many ml will contain 0.5 g?

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6. What is the final concentration (in g per ml) of a solution that has 3 g of powder and a totalsolution of 9 ml?

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(Continued)


Self-Check 6

7. How many grams total of sodium chloride are there in a 250 ml bag of 0.33% solution?

__________________________________________________________

8. How many total grams of dextrose are there in a 50% syringe that’s 50 ml in size?

__________________________________________________________

9. If you’ve dissolved 10 g of drug in 200 ml of solution, what is the percentage of the solution?

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10. If you have a 1000 ml bag that’s to be infused over 12 hours, how fast should the IV rate be set on the pump?

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11. An IV is running at the rate of 60 ml per hour. How long will it take for the IV to run out if it’s a 1000 ml bag?

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12. How many micrograms are there in a milligram? Express this as a fraction.

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13. How many milligrams are there in a gram? Express this as a fraction.

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14. Convert 200 mg to grams.

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COMMON PARENTERAL ADMIXTURESThis section will introduce you to a variety of admixtures that you’ll probably come into contact with in the IV room.The categories of drugs that you’ll probably see are

• Antibiotics

• Electrolyte solutions

• Cardiac drugs

• Pain medications

• Pulmonary drugs (used to improve breathing)

• Nutritional solutions (TPNs)

• Chemotherapy drugs (used to treat cancer)

Antibiotic SolutionsThe majority of antibiotics that you make will be in the IVpiggyback (IVPB) size. The most common ones will be coveredin this section. There are very few antibiotics mixed in largevolumes (LVPs).

Antibiotic drugs are available in different forms in the IVarea. The two general categories of antibiotics are those that must be reconstituted and those that are ready-made.Antibiotics that must be reconstituted are available in severalforms. Single-dose vials contain one dose and are added to a larger volume (50–100 ml) piggyback. Single-dose vials areconvenient when only one dose needs to be mixed for a neworder. Multiple-dose vials, or “bulk” vials, contain more thanone dose. Their contents are added to several larger-volume(50–100 ml) piggybacks. Multiple-dose vials are convenient touse when several doses of the same drug must be prepared.The antibiotic vials usually contain powders for mixing, andthe resulting solution has a short expiration date, usually24–48 hours. If it isn’t used within that time, it should bediscarded.


Antibiotics are also available in glass bottles that contain anantibiotic to be reconstituted. The glass bottle may be usedas the piggyback container. The drug is reconstituted but maystay in the original bottle, which is larger than a normal vialsize. The last form that we’ll mention is a system that mustbe reconstituted but can be transferred to the IVPB containerby special means, such as with the Add-Vantage System.

Antibiotics that are ready-made are available as either non-frozen or frozen premixed drugs. The premixes contain drugsalready in solution in a flexible plastic bag. Premixed piggy-backs are available in standard strengths for antibiotics thatare used frequently, but are more expensive to use. Some mustbe kept frozen until use to prolong the expiration date. Oncea frozen premix is defrosted, the expiration date is shortened.The package insert for any premix may be checked for theexact expiration date information.

Antibiotics can be classified in several groups. Under eachclassification are several specific drugs that have chemicaland therapeutic properties similar to other drugs in that category. The generic names of each of the drugs in the same group may sound a little (or a lot) like the other namesin that category. Penicillin-type antibiotics and cephalosporins

are the most frequently used. There are also other types thatwe’ll discuss.

Common cephalosporin antibiotics that are made in the IVroom are listed in Figure 17. Notice that all of the genericnames of the cephalosporin antibiotics start with the letters“cef,” because many of these drugs are available from genericdrug companies. Another similarity is that the usual strengthof most of the cephalosporins is 1 g or 2 g. These similaritiesoften lead to confusion and errors, however. Anyone workingwith these drugs must be very careful to select the appropri-ate drug from the shelf.

Penicillin-type antibiotics are all derivatives of (i.e., are chemically related to) the drug penicillin. Almost all penicillingeneric drug names end with the letters “illin.” See Figure 18for common penicillin-type antibiotics that are used in the IVroom. Again, care must be taken when selecting these drugsfrom the shelves.


Generic Name Brand Name Available Vial Premix

Strengths

cefazolin Ancef, Kefzol 250, 500 mg 500 mg or

1, 5, 10, 20 g 1 g/50 ml

cefotaxime Claforan 1, 2, 10 g (bulk) frozen,

Add-Vantage 1, 2 g 1, 2 g

cefotetan Cefotan 1, 2, 10 g (bulk) frozen,

Add-Vantage 1, 2 g 1, 2 g

ceftazidime Fortaz, Tazicef, 500 mg frozen,

Tazidime 1, 2, 6 g (bulk) 1, 2 g

10 g (bulk)

Add-Vantage 1, 2 g

ceftriaxone Rocephin 250, 500 mg, 1, 2 g frozen,

10 g (bulk) 1, 2 g

Add-Vantage 1, 2 g

cefuroxime Zinacef, Kefurox 750 mg, 1.5 g, frozen,

7.5 g (bulk) 750 mg,

Add-Vantage 750 mg, 1.5 g

1.5 g

FIGURE 17—Common Cephalosporin Antibiotics Found in the IV Room


Strengths

penicillin G potassium Pfizerpen 1,000,000 units 1, 2, 3 million

penicillin G sodium units/50 ml

ampicillin Polycillin, Omnipen 125, 250, 500 mg —

1, 2, 10 g (bulk)

ampicillin/sulbactam Unasyn 1.5, 3 g —

Add-Vantage 1.5 g

piperacillin Piperacil 2, 3, 4 g —

40 g (bulk)

piperacillin/tazobactam Zosyn 2, 3, 4 g frozen,

2, 3 g

ticarcillin Ticar 1, 3, 6 g —

30 g (bulk)

ticarcillin/potassium Timentin 3.1 g, 31 g (bulk) —

clavulanate

FIGURE 18—Penicillin-Type Antibiotics


Erythromycin is a macrolide-type antibiotic that many peopleare familiar with. This drug is available in many “salts” in the oral form, but only one salt in the IV form, which iserythromycin lactobionate. Figure 19 shows the strengthsavailable in the IV form of the drug. Two of its derivations,clarythromycin and azithromycin, are also listed.

Except for erythromycin (a macrolide-type antibiotic),aminoglycoside antibiotics often end with the letters “mycin.”These include gentamycin, tobramycin, netilmicin, and amikacin.

Although these may come in standard strengths (Figure 20),these types of antibiotics are frequently dosed on an individ-ual, or per patient, basis. This is because a patient’s height,weight, and diseases can strongly affect how the body willdeal with these drugs. The other antibiotics can be affectedby a patient’s height, weight, and disease as well, but not tothe same extent as aminoglycosides.

Antifungals treat infections caused by fungi rather than bybacterial infections. Antifungals include fluconazole (Diflucan),

and micafungin (Mycamine) (Figure 21).


Strengths

erythromycin lactobionate Erythrocin 500 mg, 1 g —

clarythromycin Biaxin, Klaricid — —

azithromycin Zithromax 1 g —

FIGURE 19—Erythromycin


Strengths

gentamycin Garamycin 40 mg/ml in 2 and 20 ml vials —

10 mg/ml in 2 and 20 ml

2 mg/ml in 2 ml amps

tobramycin Nebcin 40 mg/ml in 2 and 30 ml vials —

10 mg/ml in various sizes

FIGURE 20—Aminoglycoside Antibiotics


Miscellaneous antibiotics that are commonly encountered aregiven in Figure 22.


Strength

fluconazole Diflucan — 2 mg/ml in 100 and 100 ml glass

micafungin Mycamine 50 mg —

FIGURE 21—Antifungals


Strengths

metronidazole Flagyl 500 mg 500 mg/100 ml

flex plastic

imepenem/cilastin Primaxin 250, 500 mg —

Add-Vantage 250, 500 mg

aztreonam Azactam 1, 2 g frozen/1, 2 g

ciprofloxacin Cipro 200, 400 mg 200 and 400

flex plastic

doxycycline Vibramycin 100, 200 mg —

vancomycin Vancocin 500 mg, 1, 5, 10 g (bulk) frozen,

Add-Vantage, 500 mg, 1 g 500 mg, 1g

moxifloxacin* Avelox 400 mg 400 mg/200 ml

ciprofloxacin* Cipro 200, 400 mg 200 mg/100 ml

400 mg/200 ml

levofloxacin* Levaquin 250, 500 mg 250 mg/100 ml

500 mg/200 ml

gatifloxacin* Zymar 400 mg 400 mg/200 ml

daptomycin Cubicin 500 mg —

ertapenem Invanz 1 g —

meropenem Merrem 1 g —

quinupristin/dalfopristin Syneroid 500 mg —

tygecycline Tygacil 50 mg —

linezolid Zyvox 600 mg 600 mg

*quinolone antibiotic

FIGURE 22—Miscellaneous Antibiotics


Nonantibiotic AdmixturesNow that you’ve seen examples of different antibiotics,let’s examine some other types of additives. Electrolytes, cardiac drugs, pain medications, pulmonary drugs (to im-prove breathing), nutritional solutions, and chemotherapydrugs are common categories of drugs that may be added to some of the base solutions listed back in Figure 4. Most of these additives are added to large-volume parenterals, butsometimes are placed in piggybacks as well. Some are avail-able as premixed solutions.

As with any other drug, you must be extremely careful toselect the proper salt when preparing electrolyte solutions.Names of these salts are easily confused, and mixing up electrolytes is a common source of error in the IV room.Examples of electrolytes are listed in Figure 23.

Examples of cardiac drugs made in the IV room includedopamine, procainamide, and diltiazem. Examples of painmedications added to LVPs include hydromorphone (Dilaudid)and morphine. Aminophylline is a breathing medication addedto LVPs. Examples of cancer chemotherapy drugs includemethotrexate, cisplatin, vincristine, and vinblastine. Intra-venous nutritional products will be discussed in the nextstudy unit. Some of these are available in single or multipledoses as powder for reconstitution or solution. These are onlya few examples of the most common drugs. You’ll encountermany more in your experiences.

Sodium Salts Potassium Salts Calcium Salts Magnesium Salts

Sodium chloride Potassium chloride Calcium chloride Magnesium sulfate

(NaCl, or table salt)

Sodium acetate Potassium phosphate Calcium gluconate —

Sodium bicarbonate Potassium acetate Calcium gluceptate —

Sodium phosphate — — —

FIGURE 23—Common Electrolytes


Self-Check 7

1. Explain the differences between single-dose vials, multiple-dose vials, and premixed IV fluids.

__________________________________________________________

2. What happens to the expiration date of an antibiotic that has been reconstituted or a frozenpremix that has been defrosted?

__________________________________________________________

3. Antibiotics are usually placed in what kind of container?

__________________________________________________________

4. List two electrolytes that are potassium salts.

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5. List two electrolytes that are sodium salts.

__________________________________________________________

6. List three calcium salts.

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7. List three cephalosporins.

__________________________________________________________

8. List three penicillin-type antibiotics.

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NOTES

Self-Check 1

1. d

2. c

3. Vials may be plastic or glass and may contain powder for reconstitution or solution. They’re entered through a rubber stopper with the use of a needle. Ampules aremade only of glass and contain drugs in solution. They’reelongated and must be broken at the neck area to removethe contents. Prefilled syringes come ready to use from themanufacturer, already containing the drug in solution.

4. A package insert, which comes with every medicationproduct, describes the characteristics, uses, prescribingrecommendations, precautions, mixing and dilutioninstructions, compatibilities, and available sizes andstrengths of that drug. The technician is concerned withthe mixing, dilution, and compatibilities of the drug.

5. The brand and generic names, strength and amount of drug, company name, lot number, expiration date,precautionary comments, storage instructions, federalcaution label, and sometimes directions for mixing

6. Patient name and room number, name of drug(s) andstrength, base solution used and final volumes, date andtime preparation was made, expiration date, and rate ofIV administration.

Self-Check 2

1. c

2. c

3. a

4. b

5. An electrolyte is a salt that the body needs to performelectrical functions.

6. The IVPB and IV push routes

75

Answers

Answers

Self-Check 3

1. Barrel, plunger, and tip

2. In milliliters or fractions of a milliliter, designated bymarks on the syringe

3. A catheter tip syringe has a pointed tip and the needle isheld on by friction.

4. To measure very small volumes of drugs in solution

5. Shaft, bore, and hub

6. In gauge size and length

7. Filter needle, filter straw, filter disc, and in-line filter

8. 0.22 micron

Self-Check 4

1. High-efficiency particulate air (filter)

2. Once a month

3. The direction of air flow

4. Hands should be washed upon entering the IV room and before beginning any preparation procedure. An antimicrobial cleanser such as chlorhexidine or povidone-iodine should be used for at least 15 secondsto wash hands and scrub under the nails. The faucet

should be turned off with a paper towel.

5. Sterile surgical attire should be worn instead of streetattire. Hair, face, hands, and feet may need to be cov-ered. No jewelry or excessive makeup should be worn.Bacteria can grow on clothing lint and in crevices ofjewelry.

6. Bacteria can be carried in on clothing, skin, and hair. It can grow on surfaces and on dust. Bacteria can enterby touch contamination or through cracked or leakingcontainers.

7. The patient could become very ill and even die.

Self-Check Answers76

Self-Check 5

1. c

2. e

3. a

4. b

5. d

Self-Check 6

1. 1.6 g

2. 2466.7 mg (2467 is an acceptable answer.)

3. 4.6 ml

4. 0.57 ml

5. 2.5 ml

6. 0.33 g/ml

7. 0.825 g

8. 25 g

9. 5%

10. 83.3 ml per hour

11. About 16.7 hr

12. There are 1000 micrograms in a milligram. This can beexpressed as 1000 mcg/mg.

13. There are 1000 mg in a gram. This can be expressed as1000 mg/g.

14. 0.2 g

Self-Check Answers 77

Self-Check 7

1. Single-dose vials are convenient for making one dose of a drug. They usually must be reconstituted and added toa larger volume. Multiple-dose vials are convenient formaking several doses of the same medication and areusually reconstituted before adding to several larger vol-ume containers. Premixed IV fluids are ready to use;some may be frozen and are defrosted before use.

2. The expiration date becomes shortened and the productmust be discarded usually within 24–48 hours.

3. IV piggyback, usually between 50 ml and 100 ml

4. Any two of the following: potassium chloride, potassiumphosphate, or potassium acetate

5. Any two of the following: sodium chloride, sodiumacetate, sodium bicarbonate, or sodium phosphate

6. Calcium chloride, calcium gluconate, or calcium glucepate

7. Any three cephalosporins from Figure 17 are acceptableanswers.

8. Any three penicillin-type antibiotics from Figure 18 areacceptable answers.

Self-Check Answers78

Compounding Sterile Products

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