3. Topics3
Learning Objectives
Recognize the origins of small-volume parenteral
preparations—in particular, antibiotics.
Understand the USP Chapter <797> procedures that must be
performed prior to sterile compounding procedures.
Identify the critical sites of various small-volume parenteral
preparation supply items, and describe compounding situations
in which certain supply items should be used.
Discover the USP Chapter <797> procedures that must be
performed during small-volume parenteral preparation.
Demonstrate effective technique in the preparation of two
small-volume compounded sterile preparations.
2012 Paradigm Publishing
4. Topics4
Topics
Learning Objectives
Introduction
IVPBs
Compounding of IVPBs
Administration of IVPBs
Potential Complications of Parenteral Therapy
USP Chapter <797> Guidelines for SVPs
Understand the Resources and Supplies
Preview the Lab Procedure
Chapter Summary
2012 Paradigm Publishing
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5. Topics55
Introduction
Small-volume parenteral
(SVP) preparations—known
simply as SVPs—are sterile
solutions that typically have a
volume of 25 mL, 50 mL, 100
mL, 150 mL, or 250 mL
in general, these solutions are
neutral, isotonic, and isosmotic
2012 Paradigm Publishing
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IVPBs
The majority of SVPs prepared by sterile
compounding personnel are IV piggybacks, or IVPBs
an IVPB is comprised of a small volume of a base solution
and a medication
the standard IV base solution
may be a sterile fluid such as dextrose 5% in water (D5W),
normal saline (NS), half normal saline (½ NS), or sterile
water
2012 Paradigm Publishing
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IVPBs…/2
Unlike an LVP that is given for hydration or the
continuous infusion of medication, an IVPB is used
solely for the intermittent IV administration of
medication according to a dosing schedule specified
by a prescriber
this intermittent infusion is accomplished by piggybacking
the SVP through the tubing containing a patient’s primary
IV solution
2012 Paradigm Publishing
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IVPBs…/3
2012 Paradigm Publishing
A limited number of
IVPBs are supplied as
premixed, shelf-stable,
or frozen products
other types are available
in vial and bag systems
the majority of ordered
IVPBs must be
compounded by an IV
technician
9. Topics99
Compounding of IVPBs
A prescriber typically indicates the medication name,
dose, and dosing interval or schedule, without
specifying the base solution or volume
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Compounding of IVPBs…/2
The pharmacist considers several factors when
choosing the most appropriate IVPB base solution
and volume, including:
the compatibility of the medication with the base solution
the length of time over which the IVPB is to be
administered
the kidney function and hydration status of the patient
recipient
the minimum or maximum concentration required for safe
administration of the drug
2012 Paradigm Publishing
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Compounding of IVPBs…/3
Antibiotic Preparations
Antibiotics are antimicrobial medicines used to treat
a variety of infections caused by certain types of
microorganisms, such as fungi, protozoa, or bacteria
not effective in the treatment of viruses
The terms antibiotic drugs and antibacterial drugs
are sometimes used interchangeably
2012 Paradigm Publishing
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Compounding of IVPBs…/4
Antibiotic Preparations…continued
Most bacterial microorganisms are said to be either
gram-positive or gram-negative organisms
in essence, gram-positive bacteria have thicker cell walls
than gram-negative bacteria
patients requiring IVPB antibiotic therapy often undergo
blood testing (known as a culture and sensitivity test) to
determine which pathogenic organism is causing the
infection and—if the microorganism is a type of bacteria—
whether the organism is gram-positive or gram-negative
2012 Paradigm Publishing
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Administration of IVPBs
IVPBs are administered over a short period
Most IVPBs are administered by piggybacking them
through a patient’s primary IV line
occasionally, an IVPB medication is administered to a
patient who does not have a primary IV line
in this situation, the IVPB is administered through
secondary IV tubing, directly into the patient’s vein, via a
temporary injection port. This type of injection port—
called a heparin lock, saline lock, or, simply, a lock—is
attached to a flexible needle that is maintained in the
patient’s vein
2012 Paradigm Publishing
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Potential Complications of
Parenteral Therapy
All patients receiving parenteral therapy should be
monitored for the following complications:
nosocomial infection
allergic reaction (including anaphylaxis)
phlebitis
tissuing
embolism
extravasation
cellulitis
Stevens-Johnson syndrome
nephrotoxicity
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Potential Complications of
Parenteral Therapy…/2
For antibiotic SVPs, there is an
increased likelihood for allergic
reactions, including
anaphylaxis; Stevens-Johnson
syndrome; and nephrotoxicity
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Potential Complications of
Parenteral Therapy…/3
Incompatibility Issues
In addition to these risks, IVPBs, due to their
administration setup, have the potential for
incompatibility issues
for example, if two incompatible medications are
administered through the same IV tubing, a precipitate
could form, clogging the IV tubing and potentially causing
injury to the patient
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Potential Complications of
Parenteral Therapy…/4
Incompatibility Issues…continued
The primary IV tubing or the lock must be flushed
after the IVPB medication has been administered
if the patient is receiving a primary IV solution, the flush is
performed by lowering the empty IVPB bag with secondary
tubing attached to a height that allows gravity to force the
primary IV solution to back up into the secondary tubing
line
for patients without a primary IV solution, the lock is
usually flushed with a small volume of either NS solution,
or a heparinized saline solution
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Potential Complications of
Parenteral Therapy…/5
Antibiotic-Resistant Bacteria
IV technicians should be aware of a growing health
concern in the use of antibiotic therapy—the
development of antibiotic-resistant bacteria
known as superbugs
the evolution of superbugs has been influenced by two
factors: the widespread use of antimicrobial disinfectants
and the overuse of antibiotics
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Potential Complications of
Parenteral Therapy…/6
Antibiotic-Resistant Bacteria …continued
Antimicrobial Overuse
an antimicrobial is a substance or chemical compound
capable of killing or inhibiting the growth of
microorganisms
antimicrobial agents may be found in many hand soaps,
cleansers, and surface disinfectants, as well as some
medicines
the rise in the use of these products has helped to
strengthen various microbes
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Potential Complications of
Parenteral Therapy…/7
Antibiotic-Resistant Bacteria …continued
Antibiotic Overuse
often, prescribers yield to a patient’s demand for an
antibiotic for an illness that may be viral, not bacterial
another source of antibiotic overuse comes from the use
of antibiotics in the meat and dairy industries, whose
policies allow for the administration of prophylactic
antibiotic treatment to promote animal growth and to
prevent and treat illness in livestock
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Potential Complications of
Parenteral Therapy…/8
Superbugs as a Global Health Threat
Due to the widespread use of antimicrobials and
antibiotics, superbugs such as methicillin-resistant
Staphylococcus aureus (MRSA), carbapenem-
resistant Klebsiella pneumoniae (CRKP), and New
Delhi metallo-beta-lactamase (NDM-1) are on the
rise and considered by many scientists to pose a
serious threat to global health
2012 Paradigm Publishing
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Potential Complications of
Parenteral Therapy…/9
Superbugs as a Global Health Threat…continued
The World Health Organization (WHO) used World
Health Day (April 7, 2011) to issue an urgent plea:
The message on this World Health Day is loud and clear. The world is
on the brink of losing these miracle cures. The emergence and spread
of drug-resistant pathogens has accelerated. More and more essential
medicines are failing. The therapeutic arsenal is shrinking. The speed
with which these drugs are being lost far outpaces the development of
replacement drugs. In fact, the R&D pipeline for new antimicrobials
has practically run dry. The implications are equally clear. In the
absence of urgent corrective and protective actions, the world is
heading towards a post-antibiotic era, in which many common
infections will no longer have a cure and, once again, kill unabated.
2012 Paradigm Publishing
23. Topics23
Your Turn
2012 Paradigm Publishing
1) This is a substance or chemical compound capable of killing or
inhibiting the growth of microorganisms.
a. microbe
b. antibiotic
c. antimicrobial
d. saline
2) These are considered by many scientists to pose a serious threat to
global health.
a. colds
b. bacterial infections
c. superbugs
d. viruses
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24. Topics2424
USP Chapter <797> Guidelines for
SVPs
During the preparatory and compounding
procedures of SVPs, an IV technician must adhere to
the overarching principles set forth in USP Chapter
<797>
these guidelines are reinforced in each facility’s P&P
manual as well
in accordance with these guidelines, sterile compounding
personnel must pay strict attention to aseptic technique
protocols both in the anteroom and clean room
2012 Paradigm Publishing
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Understand the Resources and
Supplies
Essential Supplies
Most sterile compounding procedures require the
same essential supply items to be available for use in
both the anteroom and the clean room
2012 Paradigm Publishing
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Understand the Resources and
Supplies…/2
Procedure-Specific Supplies
IVPB Supplies – Vials
most IVPB compounding procedures require an IV
technician to reconstitute a powdered antibiotic
within a vial
to do so, the technician draws up diluent from a separate
vial and injects that fluid into the vial containing the
powdered antibiotic
there are several methods that may be used to complete
this procedure, including the use of the milking technique,
a vented needle, or a repeater pump
2012 Paradigm Publishing
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Understand the Resources and
Supplies…/3
Procedure-Specific Supplies
IVPB Supplies – Vials…continued
because positive pressure was created within the vial
when the diluent was injected, the milking technique can
be used to withdraw the dissolved powder from the vial
without injecting air
this method of reconstituting a powder within a vial is best
used when preparing a single CSP in which the entire
contents of a vial are injected into the IVPB to provide the
desired dose
2012 Paradigm Publishing
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Understand the Resources and
Supplies…/4
Procedure-Specific Supplies
IVPB Supplies – Vented
Needles
in addition to regular
needles, some IVPB sterile
compounding situations
require the use of a
vented needle
2012 Paradigm Publishing
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Understand the Resources and
Supplies…/5
Procedure-Specific Supplies
IVPB Supplies – Vented Needles…continued
a vented needle has a razor tip and is surrounded by a tiny
aluminum needle sheath
this unique design allows the injection of the diluent into
the vial while simultaneously venting air from the vial
this type of needle is used solely to reconstitute a
powdered medication within a vial
2012 Paradigm Publishing
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Understand the Resources and
Supplies…/6
Procedure-Specific Supplies
IVPB Supplies – IVPB Base Solutions
an IVPB base solution bag is very similar in design and
function to that of an LVP bag
the IVPB base solution bag is only available with a tail
injection port
when using an IVPB bag, the needle should be inserted
directly into the injection port without regard to the
position of the needle bevel, and without creating any
bend to the needle, as is done when inserting a needle
into a vial
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Understand the Resources and
Supplies…/7
Critical Sites of Essential Supplies and IVPB Supplies
Before beginning preparatory procedures in the
anteroom or clean room, the IV technician must
recall the critical sites of the supplies
After identifying the critical sites of all supply items,
care must be taken not to taint the critical site of any
supply item through touch contamination,
shadowing, or incorrect placement of the item within
the hood
2012 Paradigm Publishing
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Preview the Lab Procedure
Anteroom Preparatory
Procedures
verifying the CSP label against the
medication order
performing correct pharmacy
calculations to determine type, size,
and number of supply items needed
gathering and cleaning of supplies
performing aseptic garbing and hand
washing
donning a sterile gown
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Preview the Lab Procedure…/2
Clean Room Preparatory Procedures
cleansing hands with sterile, foamed 70% IPA
donning sterile gloves
cleaning the hood
Once the hood has been cleaned, you must transfer
the clean supplies from the transport vehicle or clean
countertop to certain areas of the hood
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Preview the Lab Procedure…/3
SVP Compounding Procedure, Scenario One:
Reconstitution Using the Milking Technique
2012 Paradigm Publishing
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Preview the Lab Procedure…/4
SVP Compounding Procedure, Scenario Two:
Reconstitution Using a Vented Needle
2012 Paradigm Publishing
36. Topics36
Your Turn
2012 Paradigm Publishing
3) This technique can be used to withdraw the dissolved powder from a
vial without injecting air.
a. shadowing
b. reconstitution
c. milking
d. filtering
4) This type of needle has a razor tip and is surrounded by a tiny
aluminum needle sheath.
a. regular
b. filter
c. vented
d. beveled
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