chapter 12 a septic technique in sterile compounding we'll skip over the terms and definitions because we'll cover them in the chapter and there's quite a few from this chapter proper preparation of Parental medications is one of the most crucial responsibilities of a pharmacy technician that works in a hospital because these medications enter the bloodstream directly usually through injection so basically we have to make sure that we are using every sterile process available to not contaminate these medications because they're going directly in the bloodstream um if we accidentally give you the wrong dose or the medication is not correct um or not sterile we can introduce you to bacteria in your bloodstream and we could possibly give you the wrong dosage which if you inject a medication into somebody directly and it's too high of a dose it's really hard to fix that if we take a medication by mouth if it's not the right dose or something happen you got the wrong medication um we can fix that because it's going to take a while for it to get here um system so the school side note a septic technique involves procedures used to eliminate the possibility of the drug becoming contaminated with microbes or other unwanted particles the pharmacy technician may come may prepare a compounded sterile products in Pharmacy settings such as Home Health Services and long-term care facilities the regulations of United States pharmacopia 797 pharmaceutical compounding stale preparations are explored as our policies established by other organizations to monitor compliance in the sterile preparation of compounded products wider varieties of Parental medication are used in a hospital than in any other setting so that we have box 12.1 that has the abbreviations and descriptions of Pharmacy Stock Solutions medications and supplies may be required when preparing sterile products the terms used to identify these items often are abbreviated in prescribers orders and on supply lists pharmacy technicians need to understand these terms and abbreviations to interpret orders and fill stock levels in the intravenous room lists box 12.1 lists some of the most common terms and abbreviations for IV supplies so when you see amp that's an ampule it's a 1 to 50 ml class container that contains medication a flexible bag mdv which is a multi-dose vial it holds multiple doses of medication sdv it's a single dose vial holds only one dose of medication or a vial that can go anywhere from 0.5 to 100 ml D5 and s five percent dextrose and normal saline D5 won't happiness uh five percent dextrose and 0.45 percent normal saline so normal saline is 0.45 percent half normal saline is 0.45 and the full strength is 0.9 percent D5W means five percent dextrose in water um and like d10w is 10 dextrose and water we have dilute lactated ringer solution normal saline that has a concentration of 0.9 sodium chloride one half normal saline 0.45 which we've already talked about and then we have routes of administration or these are really important for the Hospital pharmacy technician intradermal injections ID I am intramuscular into the muscle I.T interest fecal into a sheath such as the lumbar sheath located at the base of the spine IV intravenous into the vein IV push into the into the vein directly from a syringe subcut subcutaneously under the skin miscellaneous terms for Parental medications drip or infusion an IV bag that is infused over a specific amount of time but is not given IV push NPO means nothing by mouth on call means the physician physician wants to dose to be ready when he or she decides to give them medication most anesthesiologists order on-call pre-operative medications post-op is medication to be given after surgery like pain control or anti-ametics like on that's going to stop you from throwing up pre-op drugs medication to be given before surgery like sedatives or antiemetics PRN you should hopefully know by now that it means to be given as needed and Qs quantity sufficient when working in a hospital setting all employees must comply with the standard precautions universal precautions to prevent the dissemination of highly contagious diseases hospitals usually require an employee to receive both tuberculosis tuberculosis testing and in an immunization against influenza annually and you can probably add in covet I don't know that places are mandating it they were I don't know what the rules are but probably have that in this book is a little bit older based on I need to pay the exposure to potentially infectious substances each area in the hospital has specific infection control guidelines employees are expected to meet these requirements including hand washing or delete orderliness and cleanliness the pharmacy does not supply Supply blood or blood products however Pharmacy personnel must participate in training sessions on bloodborne pathogens so that they know not only understand various aspects of contamination but also where ways to prevent exposure and transmission of infections for example training includes the interpretation of room signs that indicate patient isolation droplet or contact isolation and the precautions and procedures that should be followed if access to these rooms is necessary other hospital-wide standards employees are not to use patient restrooms they should use only employee restrooms medication refrigerators and freezers may only hold medication they should not be used to store food or drink eating is prohibited in any drug preparation or patient care area foreign drugs and other compounded sterile products must be made in a clean room under laminar flow hugs all flow hoods are re-certified every six months by an independent contractor or anytime the hood is moved excuse me routine maintenance of hoods includes cleaning all work surfaces and pre-filters records of all inspections are to be kept on file in the pharmacy Department different types of equipment are available for IV preparation depending on the amount or volumes to be prepared for instance many different types of automated pumps automatically fill IV bags and other sterile containers these pumps range in complexity and costs for example if large multi-editive automated machines are rented by the pharmacy only the tubing required for the specific pump needs to be purchased small pumps such as back says repeater pump are used to administer smaller reconstitution volumes into single dose vials or larger volumes into multi-dose vials in addition a wide variety of supplies used in the clean room must be kept in stock for daily use for this reason the technician must inventory these supplies and reorder stock daily anticipating the stock needed for the next day commonly used intravenous room supplies so we have 70 percent isopropyl alcohol that's an antiseptic for cleaning the hood among the other things amp Bill Breakers a device you can put on one end to break the ampule filter needles it prevents last from entering the final solution when drawing from an ampule filter straws used for withdrawing medications from ampoules filters used for specific medication to trap particles from entering IV fluids forceps instruments that lack used to obstruct tubing while transferring medication meal male and female adapters Universal size fits on a syringe on each end for mixing two contents mini spikes large bore Spike that is pushed into a vial with the syringe attachment at the other end sterile 70 alcohol pads syringe caps uh sterile cap used to prevent contamination of syringes during transportation out of Pharmacy syringe needles most common bore sizes used in Pharmacy are 16 to 20 gauge syringes instrument that holds 0.5 to 60 ml for administration of medications transfer needles a needle on both ends used to transfer a vial to a bottle tubing for pumps tubing is specific to the manufacturer's machine and tubing transfer sets blood transfer sets used to transfer the condoms of large containers into empty containers syringes used in the pharmacy are available in eight basic sizes so 0.5 135 10 20 30 and 60 ml as the size of the syringe increases the accuracy decreases so if we measure something that's 0.5 ml it's going to be more accurate if we measure it in the 0.5 ml versus like a 60 ml per inch or whatever syringe tips are available in two types attention type syringe has a 1ml volume in this case the needle is attached by friction only this type of syringe can be used for withdrawing insulin and other medications that require volumes equal to or less than 1 ml however these tension type tips cannot be used when preparing doses of chemotherapeutic drugs because of the risk of the needle detaching from the syringe and causing a spill or possible needle stick to the technician on all other sizes of syringes the needle is held in place by a locking mechanism commonly referred to as a lure lot this ensures a safe seal for withdrawal of the medication so kind of see the anatomy of a syringe and the anatomy of the needles another type of syringe is a tubex or carpi Jack these cartridge systems can hold a variety of medications and are available in volumes from 0.5 ml up to 3 ml the bottom of the cartridge is screwed into the system's syringe holder the syringe cartridge holders for these systems are reusable and normally are dispensed to the nursing units by the pharmacy on request the tubex or carpi Jack cartridge is discarded after use if desired the holders may be Auto clay for sterility needles are made of aluminum or stainless steel and are available in many different gauge sizes and lengths higher gauge needles like 20 to 25 gauge are used by nurses to administer injections the nurse determines which gauge and needle length to use according to the injection site and the pharmacy needles are used to draw solutions into a syringe not to administer to patients a limit limited number of needle gauges are available in the pharmacy and the lower gauge needles make drawing medications easier the most common needle size is used for preparing IV medications are 19 18 and 16 gauge which are used to draw solutions from vials or other containers the bore size refers to the circumference of the needle opening as this increases so does the probability of coring or cutting out a piece of rubber from the wild rubber stopper when a vial is cored a chunk of rubber is dislodged and may fall into the vial to avoid coring the bevel Edge should face upward if coring does occur a filter needle must be used to prevent the piece of cord rubber from entering the parental solution no part of a needle below the Hub should be touched the point in shaft must remain sterile so just a tech note you should not wipe needles with sterile alcohol anything you talk to that needle with alcohol or something unintended like something outside of the vial the needle must be discarded and replaced with the new one typical filter sizes are 10 5 1 and 0.45 micrometer the smallest filter is 0.22 micrometer which removes all in one particles from the solution if use of a filter needle is necessary the technician must follow the manufacturer's guidelines regarding falter needles suggested for the specific medication some medications should never be filtered because filtering would remove the active drug from the solution filter needles are for single Direction use only and cannot be used to withdraw and inject a solution another type of filter is the filter straw the straw like needle can withdraw a larger amount of solution quickly sifting it through a filter in the hub of the needle the filter straw often is used to remove any fine particles of glass from an ampule the filter straw must be replaced with a normal needle before the medication is pushed into the container so here's all the different filters and everything we just talked about up there all the items stored in the ivy room must be kept in stock above their minimum levels at all time current USP standards require that a minimum number of supplies be kept in the clean room only items that will be used immediately for direct compounding should be in the clean room Supply items must be wiped down with an appropriate cleaning solution before they are brought into the clean room before and after each shift the IV technician is responsible for reordering restocking the clean room for the next shift some of those supplies can come from Central Supply area of the hospital and Ride by the next shift however some of them are going to come directly from the pharmacy wholesaler and can take two days to a week many IV antibiotics are available in pre-made bulk packs for example 12 or 24 packs are frozen in boxes although these are convenient they are more expensive than those prepared by technicians most of the time technicians prepare the IVs needed throughout the week certain IV medications can be frozen in either IV solution or syringes but each bag must be marked with the date of the reconstitution the Beyond New State the concentration strength and the prepares initials because prepared Solutions differ in their volumes inner concentrations understanding the routes of administration are important the role of administration of each type of medication must be stated on the label many different types of containers are used to deliver medication advanced technology includes smart pumps which contain databases of drug information concentration and dosing units and limits flexible bags and bottles are the two main types of piggyback containers the sizes and types of piggyback containers and solutions range from 50 to 250 ml so here's a figure 12.7 shows you the gravity pump system intravenous piggyback setup large volume drips include via Flex bags and 500 mL in one two and three liter volumes volumes greater than one liter are often reserved for use with parental nutritional formulas printer nutrition is a combination of essential nutrients that is administered through a drip system for several hours up to 24 hours small volume piggyback containers are in Solutions are available in 50 100 150 and 250 ml volumes small volume drips can be piggybacked onto large volume drips foreign surgery and individuals who are in hospice normally have their medications prepared in the pharmacy in the hospital setting nursing stations stack various strength of Controlled Substances intended to relieve extreme pain depending on the physician's order the nurse can prepare IM or IV push doses from the Controlled Substances cabinet when a patient is in severe pain Physicians often order analgesic medications such as morphine or fentanyl on a schedule like every six to eight hours when the strength of analgesic is given in larger doses to patients who have no history of opioid use the initial effects of the medication can be extreme causing side effects such as nausea vomiting and in some cases difficulty breathing toward the end of the six or eight hours some patients are once again experiencing pain and waiting for the next dose to be administered to provide a more constant degree of comfort and to limit unwanted side effects some patients may be given either an implantable port or catheter system attached to a portable electronic pump system which administers a steady flow of analgesics that controls the patient's pain more effectively these pumps are used to dispense Controlled Substances at a rate at a specific rate of infusion patient-controlled analgesia is a method of administration that allows the patient to control the rate at which the drug is delivered for the relief of pain the PCA pump holds a syringe of pain medication that is attached to the IV line and regulated by a computerized device that automatically dispenses the medication the pump may be programmed to deliver a small constant dose of pain medicine and the patient has the option of receiving additional doses if necessary this is done by depressing a button attached to a line on the machine the boluses are preset for amount and frequency even if the patient presses the button many times he or she only receives the predetermined amount of drugs and here's just more about patient controlled enageseal syringe systems because that pumps are another type of PCA system that can be used at home the program pumps work similarly to the syringe pumps in that they are preset for dosage Administration additional boluses may be programmed into the pump for the physician's order and cannot be altered by the patient a bolus is a predetermined amount of drug that can be administered by the patient at one time when pain intensifies foreign pharmacopoeia is responsible for providing safety guidelines for the preparation of Parental and other sterile medications in the 1970s because of the dramatic increase in non-scomial infections the national Coordinating Committee on large volume controls provided guidelines for the preparation of Parental medications a non-schomial infection or Health Care Associated affection is an infection that originates in a hospital in 2004 the USP 797 regulations were written with the intent that they would constitute an enforceable standard the OSP 797 standards must be met in all practice settings where stale products are compounded the USP ashp and The Joint Commission outlined a timeline tool for total compliance realizing that it would take time for pharmacies to implement all the changes mandated pharmacies in other areas that prepare compounded steel preparations must research create and document their standard operating procedure for meeting USP 797 regulations in 2008 the USP 797 regulations were updated effective June 1st 2008 a number of changes were made including clarification regarding the use of alternative Technologies when preparing a component sterile product a comprehensive list of definitions including the terms used in this chapter was provided the risk categories of CSP were revised in a new low-risk 12-hour Bud category was added foreign two shows the environmental Cleaning Solutions so we're going to clean the laminar flow Hood biological safety cabinet compounding a septic isolator and compounding a septic containment isolator at the start of each shift start of each batch at least 30 minutes and after spills are when the surface is contaminated daily we're going to clean the counters and work surfaces and the floors monthly we'll do the wall ceilings and storage shelves the USP has three major sections one responsibilities of personnel the risk levels of classification of component sterile products two verification accuracy and sterility of component sterile preparations three training individual training and continued evaluation of personnel with respect to compounded products including both quality and control of the preparation environment other areas under USP 797 include any medication prepared by nurses Physicians or other practitioners attended for patient use regardless of the setting the types of products include Diagnostics nutrients irrigations radio Pharmaceuticals and otic and ophthalmic Solutions so 12.3 shows terms and abbreviations using the pharmacy so anti-area an area in which all preparations for IV and mixture are gathered including labels gowning and Drug materials the critical site and area exposed to error touch such as a vial or needle or an ampule first air the air from the HEPA filter that passes over materials this air is contaminate contaminant free and we'll go over the rest of them throughout the remaining parts of the chapter so USP 797 has identified three risk levels low medium high which are based on various criteria additional requirements include the amount of space between the hood areas and sink and the storage location of products so you can look at here we have the low risk medium risk and high risk risk level one encompasses medications and procedures used to prepare component sterile products including sterile medications needles and syringes sterile technique and a use of International Organization for standards ISO classified Hood the technique must require only minimal manipulation these items of clothing are typically referred to as a as personal protective equipment and must be provided by the facility the technician must verify all ingredients and instructors and instructions and visually inspect the solution after preparation each person's knowledge of a septic technique and proper manipulations must be monitored and verified annually an annual media fill test must be done for each person compounding products in the hood safety measures include proper testing and certification of the hood medium risk level 2 it encompasses bulk compounding this includes multiple IVs prepared for several patients or multiple compounded products to be used for one patient over several days this includes preparing a hyper elementation to use over one week wrist level 3 includes all the requirements for levels one and two plus additional guidelines the types of products that this level encompasses are those that are susceptible to contamination because of the preparation of non-sterile products and or delaying sterilation an example is the preparation of morphine and be beep the cane solution from a bulk powder for use in an intrathecal pump the requirements for this level include semi-annual certification of a septic technique as the length of time a component IV is exposed to temperature increases so does the risk of bacterial growth in addition Refrigeration temperatures must be monitored at least once daily to ensure constant conditions so we have the storage risk levels temperature ranges and expiration dates for compound and medication all personnels who prepare parental medications are required to be trained and monitored for compliance with techniques on a periodic basis this includes ensuring that the drug ingredients containers labeling and Equipment are corrupt table 12.6 shows the United States pharmacopoeia 797. air standards based on 0.5 micrometer particle size we meet the educational and training aspects of USP 797 however that is not true of the new regulations related to the areas where these products are prepared studies like according to science conducted by USP using a laminar flow Hood in an open room is no safer than preparing products on a countertop this has been one of the most significant changes in Pharmacy as a result of the enormous expense required to create these new areas many hospitals now now contract out to specialized pharmacies to prepare their component sterile preparations facilities that have been able to meet USB standards must also test the air periodically to ensure that guidelines are met the terms and definitions used to describe types of environments are listed in box 12.2 so we have all the different stuff that was basically just another chart we have airlock a space of separation between two different air pressures air pressure can be either positive or negative the anti-room the space adjacent to the cleaner buffer room biological safety cabinet a hood that should be used for hazardous hazardous sterile preparation in the clean room cleaner buffer room space Jace space adjacent to the primary engineering control room where sterile preparation takes place compounded a septic containment isolator another type of class three ca1 glove box that exhausts 100 of the air through a high efficiency particulate air filter a compounding a septic isolator a Class III glove box that can have either negative or pressure negative or positive air pressure a laminar airflow Hood a hood that should be used for non-hazardous sterile preparation in the clean room the primary engineering control spacer Hood where sterile preparations take place the anti the ante room is adjacent to the buffer room or clean room and is sometimes called the gowning in di gowny area the minimum size of air particles allowed in the ante room is 0.5 micrometers and air pressure is monitoring all dining of PPE occurs in the ante room the clean room where the technician actually prepares component stale preparations they must meet stringent requirements for Air particulate size USP 797 also requires specific types of hoods to be used for compounding specific sterile products laminar flow hugs that have only positive horizontal airflow may be used to prepare non-hazardous medication where a negative vertical airflow environment may be used to prepare hazardous drugs per the USP guidelines a biological safety cabinet is a totally enclosed environment that is available in either positive or negative airflow these cabinets are known as glove boxes or barrier isolator hoods all types of hoods have high efficiency particulate air HEPA filters although they the way in which they expel the air difference the hoods must be verified and certified every six months or whenever moved to ensure their ability to filter contaminants both anti-rooms and clean rooms must be within standards assessments must be completed annually in any movement of the equipment requires additional assist inspection okay talking about the airflow now there we just kind of covered that in the above paragraph for chemotherapeutic agents we use a vertical flow Hood known as a BSC or a caci because the direction of the airflow and the specific the specifications of the hood a vertical flow Hood provides negative air pressure circulating the air through an additional HEPA filter and then through a vent away from the preparer lay their hoods known as glove boxes are closed systems that use a HEPA filter in a sophisticated venting system these provide the greatest amount of safety to the preparer because of the containment ability in a horizontal flow the outside air cool starts in the back of the hood passes through a special filter and circulates out towards the opening across the deck or direct work area this special filter is a HEPA filter that traps all particles larger than 0.2 micrometers the sides of the hood and items within the hood Create A disruption of airflow for this reason the technician must work six inches from the sides in front of the hood in addition movement within the hood should be kept to a minimum to reduce disruption of airflow the concept is similar for a vertical flow Hood although air cannot be released back into the room for this reason vertical hoods have a Plexiglas Shield that separates the technician from the inside work surface in a vertical flow Hood such as a BSC or caci for compounding a hazardous drug the air enters the HEPA filter vertically flows down passing into the HEPA filter and then onto the workspace area a grid at the front of the tabletop draws in the air and filters it out once again through a HEPA filter before it is released into the workspace area where it is vented to the outside depending on the type of venting system used regardless of vertical or horizontal hoof airflow and let's also say Hood regardless of a vertical or horizontal Hood airflow the technician must not block the flow of air while working the air is considered first air and it must remain free of obstruction to ensure the critical areas are free of microbes a horizontal flow Hood should be turned on at least 30 minutes for use every 30 minutes while continuous use when there are spills or when there are suspected contamination as mentioned there is also a PEC known as a Glove boxer barrier isolator it is becoming the most popular type of hood for sterile preparation it reduces the risk of contamination caused by accidental mishandling of drugs during compounding and reduces the number of environmental microbial contaminants thus increasing the sterility of the prepared product so table 12.7 shows high efficiency particular air filtering system standards absc must be turned on at least 10 minutes before use procedure 12.1 shows you how to clean a horizontal laminar airflow Hood so all the steps are in here your if you end up working in a hospital or X turning in a hospital they could have different rules and they're going to teach you their way but you should at least know a little something about that and then again 12.2 is cleaning the vertical airflow Hood and 12.3 is cleaning the biological safety cabinet all right when csps are prepared a septic techniques must be used normally nurses do not have the advantage of using a laminar flow Hood however they sometimes must prepare products for immediate use and they still must use strict aseptic technique universal precautions are guidelines followed by all health care workers when exposure to bodily fluids or blood products is likely similar similarly a septic technique is used when both hazardous and non-hazardous products are prepared products that have been tested and shown to cause adverse or toxic effects in human are classified as hazardous some examples are chemotherapy radioactive and various hazardous chemicals do not touch your face with glasses with sterile gloves because touch contamination is the common way to introduce microbes to csps a medication that contains any microbes or unwanted debris can cause a dangerous infection or even death when administered to a patient the steps in a septic technique begin with hand hygiene followed by proper donning of gloves and gown cleaning of the flow hood and finally preparation of the parental medication procedure 12.4 shows proper hand hygiene again just a little disclaimer for your facility if that you end up working it or if you're externing at a hospital facility you might have different procedures they have their own standard operating procedure and they will go over that or they should go over that with you 12.5 shows personal cleansing and garbing order again same disclaimer you could they could have a different order they should pretty much be the same but they could have a different order regardless of the type of hood use the placement of the hands as one of the most important aspects to consider when preparing sterile medications the technicians should practice some simple yet important techniques that reduce the possibility of contamination and errors when preparing csps to avoid compromising first air when working in a horizontal Hood you must not block the airflow or contaminate a critical site or area at any time to prevent this grasp the vial or ampule by the front avoid placing the hands or fingers right behind the top of the container when holding up the vile or amp you'll keep the fingers from blocking airflow this technique takes time to perfect and should be practiced constantly until it becomes second nature and it just kind of shows you the process never recap to use needles instead discard each syringe in a Sharps container along with the uncapped needle after use surges cannot be reused when changing from One Drug to another this reduces the chance of drug to drug contamination IV push or intramuscular medications can be prepared by the nurse at the nursing station or at the patient's bedside however the pharmacy does prepare some IV push and IM medications these agents are placed in a syringe and sealed with a syringe cap until it's time to administer the medication figure 12.16 shows the proper manipulation of an ampoule so you can grab a gauze and break it with your hand like they did um or you if your facility allows ankle breakers you can do that so when a solution is pulled from an ampule there is no positive or negative pressure because this is an open system that is the container is open and able to allow air to enter it replacing the missing volume of solution however it is important to remember to use a filter needle when transferring drug from an ampule because small pieces of the ampule May detach and fall into the solution when the ampule is broken a filter needle may be used only for one draw push or pull either it can be replaced by a regular needle before the drug is pushed into a piggy bank or a regular needle can be used to withdraw the solution and then a filter needle can be used to push the filtered solution into the piggyback otherwise the glass trapped in the filter needle is pushed into the final solution foreign the two types of vials are those intended for immediate use single dose files and those that can be used more than once multi-dose files reconstituting a medication is the addition of dilutin such as sterile water to convert the medication into a solution form from Powder if an antibiotic mdv portion has been used the following information must be indicated on the vial the date the vial was open the data expires the dilutin used the concentration and the technician's initials specialized types of vials such as the Advantage system can be placed on a small piggyback solution via an adapter these are not mixed with the solution until immediately before Administration the pharmacy technician is responsible for proper attachment of the vial to the proper solution both the nurse is responsible for breaking the adapter seal between the vial and the piggyback and mixing the powder drug with the solution because the medication does not mix with the solution until the seal is broken the IV can be returned to the pharmacy if it is not used this greatly reduces the amount of waste medication foreign the manufacturer's guidelines are determined by which microbe is targeted pharmacies have a chart that instructs the person preparing the medication as to the type of amount of dilute needed the normal dosing times and expiration dates antibiotics also differ in how they should be prepared and how long it takes the powder to dissolve in the dilute once the dog has been reconstitution once the drug has been reconstituted the solution should be checked for color and clarity so we have examples of suggested dosing time Solutions and appropriate volumes for antibiotics in table 12.8 when a dilute is added to a powder an equal amount of air must be removed from the vial or positive pressure is created which causes pressure resistance in the syringe for example if you are adding 10 mL of dilu into a powder push on the syringe until you feel a very slight resistance and then stop and withdraw an equal amount of air from the vial to relieve the positive pressure repeat this until all the dilute has been added to work with negative pressure first withdraw air from the vial until you feel resistance and then allow the vial to pull dilute out of the syringe never let go of a syringe this type of technique works well because there's a less chance of a spill hyper elementation or parental feeding is a term for large volumes of Parental nutrition Solutions normally prepared for individuals who cannot orally consume nutrition so they can't eat for a recent stomach or intestinal surgeries and conscious various conditions that may adversely affect the gastrointestinal system so um cancer also my friend um that had pancreatic cancer she was on a hyper alimentation solution daily for months before she passed away so it is used for a variety of things two main types of hyper alignmentation are prepared in the pharmacy tpn total parental nutrition and peripheral parental Nutrition a peripheral parental injection is administered into the veins and the periphery of the body so arms hands or feet and set up into a central Vayner artery because of the regulations established by USP 797 many pharmacies contract out their tpn PPN orders to specialized compounding companies foreign intravenously via the subclavian vein in superior vena cava because of the higher concentration of nutrients patients must have a catheter surgically inserted in for this procedure p is administered via a peripheral vein either in the back of the hand or in another peripheral area in the upper extremity and therefore is a less complicated procedure regardless of how many milliliters run per hour the hyper alimentation must be changed at least every 24 hours to ensure the sterility of the solution a standard rate of infusion is 100 milliliter per hour therefore 2400 ml may be used over the course of one day most hyper elementation preparations are tailor-made for each patient so this figure 12.19 shows a total printer nutrition order form and they would look at the patient's Labs the doctor would and dose the medication out based on that all TPM preparations include dextrose and amino acids both ingredients help nourish the body the metabolism of dextrose provides calories and a quick energy source for the bodies whereas amino acids are the essential components the body uses to synthesize protein needed enzymes and other important molecules lipids commonly are added to give the body the fat needed for synthesis of important cell components such as cell membranes the rest of the additives are additional electrolytes these components can be determined daily if the patient is in a hospital other medications such as Ranitidine some medicine and famotidine which help patients with stomach problems also can be added to hyper elementation besides stomach medication insulin often is given in quantities up to 100 units per bag only regular insulin is added to hyper elementation preparations because it is the only insulin product that may be given intravenously so regular insulin the only insulin that can be given intravenously table 12.9 shows types of Parental additives so we have the abbreviation and the meaning so these are the electrolytes so calcium gluconate potassium acetate potassium chloride potassium phosphate magnesium sulfate sodium acetate sodium chloride and sodium phosphate that we have multiple Trace elements multivitamins insulin selenium and zinc we can add Tagamet Pepcid and this is the intact just so you guys know Zantac has been pulled from the market recently like the last two years or so so this would not be able to be added many different types of medications are prepared in a clean room some medications must be protected from light whereas others must be kept in bottles as previously discussed so 12.10 people 12.10 shows additional considerations for the preparation of drugs Amy odoron can only be mixed in D5W ciprofloxacin should be protected from light insulin normal saline or half saline must be placed in glass container Lorazepam should be protected from light stable longer in glass than in plastic and nitroglycerin should be in D5 and S or NS and must be placed in a glass container the final step in preparing parental medications is the application of the label first check the label against the medication and the physician's orders to ensure that the right medication is being given to the right patient although each Pharmacy prepares its own label all labels require the same minimum information all labels produced for Parental medications must be initialed by the technician who prepares them a registered pharmacist is responsible for the final label inspection if the medication is not used perhaps because of a discontinued order it is recycled for use with another patient once the technician has finished using the hood he or she should clean all unused materials and discard any unused products in February 2016 a proposed set of guidelines known as United States pharmacopoeia usp800 was added to deal with hazardous drugs and Health Care settings special considerations apply in the preparation of chemotherapeutic Agents both in preparation and administration two key changes from USP 797 were addressed HDs must have separate storage and preparation from non-hds usp800 requires the use of closed system transfer devices because the risks involved in handling chemotherapies technicians must be thoroughly trained in chemotherapeutic and mixture technique to reduce the chances of exposure to hazardous medications pharmacy technicians should always follow chemotherapy guidelines and should be trained in proper disposal of hazardous substances special chemotherapy gowns and gloves are worn to repel any substance that might spill or drip onto the technician during the compounding process double gloves are worn for Extra Protection face and eye Shields help the technician avoid contamination of the eyes masks are worn to prevent inhalation of any dangerous chemical when chemotherapeutic agents are compounded preparation and cleanup must be done slowly and carefully in the proper documentation should be completed so here's the BSC staging and the special chemo supplies and equipment if a spill occurs in the horizontal flow Hood it may be clean using a gauze pad and sterile 70 isopropyl alcohol the gauze can be discarded in a regular trash bin both Pharmacists and technicians must be able to show competency and compounding before compounding is permitted the pharmacist and technician must complete video Unwritten and practical instructions followed by a media field test in a written exam training and testing must be repeated annually for low and medium risk levels and semi-annually for the high risk level foreign media filters a microbial growth medium solution is substituted for the actual drug to simulate the egg mixture compounding technique after the TSB is injected into the compounded sterile product the final container is incubated at 20 degrees Celsius to 35 degrees Celsius for 14 days and then checked for turbidity a positive test result confirms the presence of microbial contaminants per the United States pharmacopoeia 797 regulations a media field test must be completed at the time of hire thereafter it must be performed at least yearly for low and medium risk compounding levels and twice a year for high risk compounding levels in addition there's a glove fingertip sample required and documentation of results as required by pharmacies to document the evaluation of the person compounding