Midterm Unit 2.1 (Compounding)

Chapter 797

The United States Pharmacopeia (USP) has published chapter — entitled "Pharmaceutical Compounding— Sterile Preparations"

It emphasizes the role of the pharmacist in the compounding of safe parenteral admixtures.

1. Sterile water

2. NSS

3. Dextrose

4. Ringer’s

5. Lactated Ringer’s

Examples of commonly seen compounding chemicals

Sterile water

It is water free of organisms, used for medications that is aseptic uses

• Isotonic

• Hypotonic

• Hypertonic

NSS normal saline:

• 0.9% chloride if —

• 0.45% if —

• 3% —

Dextrose

• It has glucose, and now sugar if metabolized.

• D means —, meaning it has sugar content.

• Usually 5%, 10%, 50% and is in a red bag. It is considered as HAM (High alert medications), because they are used for patients that need higher level of glucose

Ringer's Solution

It contains electrolytes, such as SoPoCa (NaCl, kCl, CaCl)

Dr. Ridney Ringer

Ringer's solution was formulated by:

Lactated ringer's

It contains lactate which serves as a buffer and metabolized to NaHCO3, so it contains SoPoCaSo

• Therapeutically and pharmaceutically appropriate for the patient

• Free from microbial and pyrogen contaminants

• Free from any level of particulate/toxic contaminants

• Correctly prepared

• Properly labeled, stored, and distributed

The department of pharmacy holds the responsibility to prepare PN admixtures that are:

True

True or false

• Asetic technique, aside from BLS, is very essential in hospital practice

• Encodes the order

• Generated compounding sheet is checked by another pharmacist

• Label printed is reviewed

• Preparation of materials, medications, fluids

• Compound

• Once done, notify station

• Check and dispense

• Administration

The pharmacist’s roles and responsibilities in compounding

• Anteroom

• Clean room

Special areas in compounding (see picture)

1. — Room to change into appropriate clothes before going into clean room; practicing aseptic technique

2. — Where compounding happens, now aseptic

24 hours

In every compounded product, there is a difference in expiration date

• TPN 

  • Reconstituted (meaning components are added) is good for — hours

48 hours

In every compounded product, there is a difference in expiration date

• TPN 

  • Non reconstituted (meaning no components are added) is good for — hours

IV Fluids

functions as a means for fluid replacement, electrolyte balance restoration and supplementary nutrition, and as vehicles for administration of other drug substances and in TPN

• Large volume parenterals (100-1000mL)

• Small volume parenterals (25-50mL)

What are the two types of IV fluids and their amount

• Colloid solutions

• Crystalloid solutions

What are two types of solutions

Colloid solutions

• contain large proteins or similarly sized molecules (macromolecules)

• increase intravascular volume (plasma expander)

• short term use, may dehydrate cell

• Plasma protein factor (for bleeding patient)

• Albumin

• Dextran

• Hetastarch

Examples of colloid solutions

Crystalloid solution

• contain electrolytes

• mainstay IV therapy

PNSS Plain normal saline solution

• isotonic

• 0.9% NaCl about 300mOsm/L

• to replace water & sodium

D5W Dextrose 5% in distilled water for injection

• isotonic about 300mOsm/L

• becomes hypotonic upon infusion due to the metabolism of glucose

• caloric agent

D5NSS Dextrose 5% in Normal Saline Solution

• hypertonic ; about 600mOsm/L

• becomes isotonic upon infusion, due to the metabolism of dextrose

• not very damaging to the cells

• caloric agent

True

True or false

• NSS, D52, and LR are all isotonic solutions

D2 500 45 NSS

• Isotonic to hypotonic

• Caloric agent

PRS Plain Ringers Solution

• hypotonic

• Na, K, Ca, Cl

• used to keep veins open for infusion

Plain Lactated Ringers Solution

• Ringer’s Solution + Na Lactate

• approximates extracellular fluid

• alkalinizing effect

• Lactate to Bicarbonate

• Commonly used for birthing moms, seen in birthing clinics to replenish electrolytes

Isotonic solutions

These solutions are used for patients with volume deficit (hypovolemia). Hypervolemia may occur with too much administration

• NSS

• D5W

• D5NSS

• D250045NSS

• PRS

• PLRS

What are the crystalloid solutions

intravenous (IV) fluids

When patients experience deficient fluid volume, these are often prescribed. They restore fluid to the intravascular compartment, and some are also used to facilitate the movement of fluid between compartments due to osmosis.

• Isotonic

• Hypertonic

• Hypotonic

Three types of intravenous (IV) fluids

Isotonic solutions

These are IV fluids that have a similar concentration of dissolved particles as blood.

Because the concentration of the IV fluid is similar to the blood, the fluid stays in the intravascular space and osmosis does not cause fluid movement between compartments

Hypotonic solutions

• They have a lower concentration of dissolved solutes than blood.

• They are used to treat cellular dehydration

Hypertonic solutions

• They have a higher concentration of dissolved particles than blood.

• When infused, these fluids cause an increased concentration of dissolved solutes in the intravascular space compared to the cells

hypervolemia

When administering hypertonic fluids, it is essential to monitor for signs of — such as breathing difficulties and elevated blood pressure.

IV Admixture

• when one or more sterile products are added to an IV fluid for administration

• it is prepared with aseptic technique or environment provided by laminar flowhood, in which the air is filtered through HEPA filter

True

True or false

• HEPA filters can be horizontal or vertical type

True

True or false

• In a laminar air flow hood, the air pressures can be horizontal or vertical (compounding). Positive and negative air pressure is for hospital in general

HOTO (horizontal air towards you)

Acronyms of Horizontal and Vertical LFH

Horizontal air flow

• For laminar flow hood

• air is going towards you

• for nontoxic or non chemotherapeutic drugs

Vertical airflow

• For laminar flow hood

• air is going away from you

• for dangerous and toxic drugs

Positive airflow

• for those patients that are immunocompromised to protect them from outside contaminants

• air should flow outside the room because of higher pressure inside room

PONI (Positive air flows outside, negative air flows inside)

Acronyms for positive and negative airflow

Negative airflow

• air flows in the room to contain the air inside

• air should flow inside because the pressure is lower

Total Parenteral Nutrition

IV administration of calories, nitrogen, and other nutrients in sufficient quantities to achieve tissue synthesis and anabolism

Total Parenteral Nutrition

is the practice of feeding a person intravenously , bypassing the usual process of eating and digestion . The person receives nutritional formulas containing salts glucose , amino acids lipids , , and added vitamins .

Total Parenteral Nutrition

• also referred to as Parenteral nutrition (PN)

• provided when the gastrointestinal tract is nonfunctional or absorptive capacity is impaired

• used for comatose patients

• Short term TPN

• Long term TPN

Two types of also referred to as Parenteral nutrition (PN) ➢provided when the gastrointestinal tract is nonfunctional or absorptive capacity is impaired ➢used for comatose patients

Short term TPN

This TPN may be used if a person's digestive system has shut down (for instance by Peritonitis )

Peritonitis

Usually in surgeries, it is brought by bacterial infections during these procedures.

Peritonitis

• inflammation membrane cavity of the peritoneum (the which lines part of the serous abdominal and some of the viscera it contains).

• often due to rupture of a hollow viscus (internal organ of the thorax or abdomen )

Long-term TPN

This TPN is occasionally used to treat people suffering the extended consequences of an accident or surgery.

infusion pump

• The preferred method of delivering TPN is with a medical — .

• A sterile bag of nutrient solution, between 500 mL and 4 L is provided. The pump infuses a small amount (0.1 to 10 mL/hr) continuously in order to keep the vein open.

infusion pump

infuses fluids, medication or nutrients into a patient’s circulatory system

Recall

Recall indications for PN

Parenteral nutrition

The primary goal of — is to provide patients with adequate calories and protein to prevent malnutrition and its associated complications

• bacterial infection

• The most common complication of TPN is —

  • usually due to the increased infection risk from having an indwelling venous catheter

  • Fungal infections can also occur

Liver failure

• This condition is due to the difficulty in processing food taken in directly into the bloodstream.

• Often related to fatty

• Bacterial infection

• Liver failure

• Venous thrombosis

• Priapism

• Metabolic acidosis

What are the complications of TPN

Venous thrombosis

Is a blood clot that forms within the vein

• Embolism

• Thromboembolism

• Since the veins return blood to the heart , if a piece of a blood clot formed in a vein breaks off it can be transported to the right side of the heart, and from there into the lungs .

  • A piece of thrombus that is transported in this way is an —

  • the process of forming a thrombus that becomes embolic is called a —

Pulmonary embolism PE

An embolism that lodges in the lungs is a —

True

True or false

• If a needle from the TPN is taken out, a clot can from

Priapism

It is a potentially harmful medical condition in which the erect return to its flaccid state

Rare complication

• Priapus

Priapism

• The name comes from the Greek god “— ”, referring to the myth that he was ironically punished by the other gods for attempting to rape a goddess, by being given a huge (but useless) set of wooden genitals.

• HCO3

• PaCO2

If metabolic, meanig anything about —

If respiratory, meaning anything about —

Metabolic acidosis

Other complications of TPN are related to the difficulties the body has processing TPN. One complication is non-anion gap —

Hyperventilation

What is the clinical manifestation of metabolic acidosis

Enteral

It means direct delivery of nutrients to the GI tract

• Nasogastric, nasoduodenal, nasojejunal, gastrostomy, jejunostomy

• PPN, TPN

What are the examples of enteral and parenteral

False

True or false

• PPN is used for long term TPN

Read

Answer read

• NGT patients usually has a functional GI Tract, but stroke patients cannot chew for themselves. Doctors would usually detect signs of stroke and then determine if NGT should be conducted when the patient has signs of aspiration (cough) when taking small amounts of water

• Nasogastric (NG Tube)

• Nasojejunal (NJ tube)

• Percutaneous endoscopic gastrostomy (PEG TUbe)

• Jejunostomy tube (J TUbe)

What are the types of feeding tubes

NG Tube

NJ Tube

Percutaneous endoscopic gastrostomy (PEG Tube)

Jejunostomy J Tube

• Protein (amino acids)

• Carbohydrates (dextrose)

• Fats (lipid emulsions)

• Water

• relectroyltes

• Vitamins

• Trace minerals