IV Room Don'ts

[btbucb]

So, I recently got a hospital position and I've been spending a lot of time in the iv room. Compounding for intravenous administration makes me nervous because it seems like almost anything goes.

You can dilute most things in either NS or D5W, you can dilute using a 50 mL bag or a 100 mL bag or 250 or 500, you can reconstitute a bottle of some drug (Vanco for example) using sterile water or NS. It just seems like there's a very short list of don'ts and that makes me nervous.

I thought it would be fun and nice to compile a list of don'ts. I'll start.

DON'T use a plastic bag that contains DEHP when making a bag of amiodarone

DON'T add more than 60 Meq of KCl to a liter bag of NS (at least that's the case at my hospital)

DON'T make a baby TPN with milliosmolarity greater than 950 if it's running through a peripheral line

Any more?

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[Monsterdaddy]

Vancomycin dissolves faster in sterile water vs. NS.

Don't shake up a vial of daptomycin you just added NS to unless you want to wait 3 hours for the bubbles to subside. LOL!
Do not puncture seals where the alcohol has not dried yet.
Calcium and phosphates, one is first add, the other is last add -- your choice.
Do not puncture a bag repeatedly to add medications, use a Port Saver/Q-site (I use for 3+ adds).
Air flush Port Savers/Q-sites to ensure all the medicine enters the bag (or rock and roll the last syringe to dilute the remaining fluid left in the Port Saver/Q-site plus needle).
And apparently, it is OK to ignore the MFG instructions on Levophed and add it to NS.

 

[Rockinacoustic]

Don't be the guy stuck in the IV room making the Ambisome

 

[type b pharmD]

Don't be the guy stuck in the IV room making the Ambisome

Rofl

 

[btbucb]

Those are some good tips. Thank you.

I'll have to ask about a PortSaver. Not sure if we have those.

And I was wondering if that was an issue with the alcohol. We spray alcohol on our minibags to make them slide on easier. That should be okay though.

 

[Monsterdaddy]

Wet alcohol does not sterilize. If the top of the vial is contaminated and you wet it with alcohol it is quite possible viable bacteria can enter the vial. If you first wipe all the vial tops and let it dry and then spray the tops just to wet it should be OK then. But in my experience, some people skip the wipe and dry step thinking the wet alcohol is enough, some thinking the wetter the better.

P.S. You do use sterile alcohol for wetting right?

 

[PharmNerdMatt]

DON'T add more than 60 Meq of KCl to a liter bag of NS (at least that's the case at my hospital)

DON'T make a baby TPN with milliosmolarity greater than 950 if it's running through a peripheral line

Just want to comment on this. We will run up to 80 mEq/L of KCl (into a central line). Also the osmolarity of TPNs in peripheral lines is debatable. Some will say 900 for infants, some 1000, we used to use 1100 (that's been a while). There also isn't a good reason to restrict this policy to just infants. You probably should be running anything more than ~1000mOsm/L in anyone's peripheral line.

My point is that there are definitely "IV room don'ts," but there are many more things that are hospital policy and will be debatable between institutions.

 

[sakigt]

There are too many to list, and more importantly memorize well.

ie: The amiodarone issues applies to the drip. The bolus can be placed in a normal bag for immediate use.

What I did is bust out the package insert for any "weird" drip I ran into. Eventually you memorize them.

Even as a Pharmacist I pull out the PI to make sure Im doing something I rarely do correctly.

No worries, just focus on getting your "routine" down.

 

[ExpressMaiL]

I like to keep my Sprite inside the laminar to keep it fresh.

 

[Sparda29]

Wet alcohol does not sterilize. If the top of the vial is contaminated and you wet it with alcohol it is quite possible viable bacteria can enter the vial. If you first wipe all the vial tops and let it dry and then spray the tops just to wet it should be OK then. But in my experience, some people skip the wipe and dry step thinking the wet alcohol is enough, some thinking the wetter the better.

P.S. You do use sterile alcohol for wetting right?

What's the science behind this? I thought the instant contact with alcohol kills the bacteria. And what's the deal with "sterile" alcohol? Isn't all alcohol sterile?

 

[fauxden]

What's the science behind this? I thought the instant contact with alcohol kills the bacteria. And what's the deal with "sterile" alcohol? Isn't all alcohol sterile?

i do believe the drying of the alcohol causes the plasma membrane of bacteria to rupture? Maybe. As far as sterile alcohol goes, I do not know.

 

[zelman]

What's the science behind this? I thought the instant contact with alcohol kills the bacteria. And what's the deal with "sterile" alcohol? Isn't all alcohol sterile?

There are bacteria that can grow in environments containing alcohol. Wine turns into vinegar when exposed to air because bacteria metabolize ethanol into acetic acid. So, no. Not all alcohol is sterile.

In terms of alcohol only being biocidal upon drying, I can't find any good references. Some random internet posts suggest that because the alcohol denatures proteins in the bacterial cell walls, they can survive with weakened walls in an aqueous environment, but cannot do so once in a dry one. Once the surrounding moisture is gone they lose structural integrity and spill their guts. Seems to me like the protein denaturation alone would kill those that are susceptible eventually, but maybe not?

edited to add:

Also, 100% ethanol doesn't kill bacteria at all. The water content is necessary for the biocidal action, so pure alcohol has no inherent sterility.

 

[Nguyen]

Let someone else make the heart meds

 

[zelman]

Let someone else make the heart meds

So, are you saying "Don't let someone else make the heart meds"? Or are you just throwing out a random insult to nobody in particular fishing for a flame war?

 

[Nguyen]

So, are you saying "Don't let someone else make the heart meds"? Or are you just throwing out a random insult to nobody in particular fishing for a flame war?

No, I meant let someone else make the heart meds due to the fact that it's just painful to make! (this might vary hospital to hospital though, idk) lol

 

[Monsterdaddy]

What's the science behind this? I thought the instant contact with alcohol kills the bacteria. And what's the deal with "sterile" alcohol? Isn't all alcohol sterile?

As someone mentioned above partially, it's a combination of rapid dehydration from the evaporation of alcohol causing proteins to denature. Water helps the denaturization process which is why 100% pure ethanol is not as effective.

Sterile alcohol has also been filtered for spores which can survive in alcohol. Definitely do not want to spray unsterile alcohol in a hood. Unfortunately, sterile alcohol costs quite a bit more.

I have to constantly remind new techs (and pharmacists). Plenty of folks think alcohol is a contact disinfectant so you are in good if mistaken company.

Also need to remind folks to wipe the tops. Drying alcohol may not disinfect say a large amount of contaminant on the surface of the vial. Wiping it off is pretty easy but sometimes people just spray and think that is enough. Sterile alcohol wipes do a pretty good job for such a simple thing.

 

[Monsterdaddy]

OK, I'll take a step back. I got curious and started researching myself and I am not finding any support either for the dehydrating part. I clearly recall one of my professors ferverently stating that bacteria won't be killed until all the alcohol has evaporated. I'll keep looking.

 

[pharmleague]

We are having a debate at my hospital, so I'd like to see what other hospitals do in this situation:

When making, for example, a phenylephrine drip with 40 mg of PE (4 of the 10 mg/mL vials), in 250 mL of NS, do you:

A). Inject the 4 mL of PE into the bag without removing 4 mL from the bag?
B). Remove 4 mL of NS from the bag prior to injecting the 4 mL of PE?
C). Remove overfill plus 4 mL of NS from the bag prior to injecting the 4 mL of PE?

A is going to cause the concentration to be off. (157 mcg/mL instead of 160 mcg/mL). Plus, there is overfill in the bag, so the concentration is really off. Now, 4 mL is not that much of a difference, but it can be a big difference when you start making double and quad strength drips.
B is a little better in terms of concentration, but there is still overfill in the bag that is making the concentration off. Also, you enter the bag twice which increases risk of contamination.
C would be the best in terms of making the concentration correct, but you have to know how much overfill is in the bag, and you have the entering the bag twice thing again.

So, which do you do?

 

[fauxden]

We are having a debate at my hospital, so I'd like to see what other hospitals do in this situation:

When making, for example, a phenylephrine drip with 40 mg of PE (4 of the 10 mg/mL vials), in 250 mL of NS, do you:

A). Inject the 4 mL of PE into the bag without removing 4 mL from the bag?
B). Remove 4 mL of NS from the bag prior to injecting the 4 mL of PE?
C). Remove overfill plus 4 mL of NS from the bag prior to injecting the 4 mL of PE?

A is going to cause the concentration to be off. (157 mcg/mL instead of 160 mcg/mL). Plus, there is overfill in the bag, so the concentration is really off. Now, 4 mL is not that much of a difference, but it can be a big difference when you start making double and quad strength drips.
B is a little better in terms of concentration, but there is still overfill in the bag that is making the concentration off. Also, you enter the bag twice which increases risk of contamination.
C would be the best in terms of making the concentration correct, but you have to know how much overfill is in the bag, and you have the entering the bag twice thing again.

So, which do you do?

I don't do too much with IVs aside from the occasionally antibiotics like vanco, invanz, and some doxycycline most recently. But does 4ml make that big of a difference? Concentration of 0.157 to .16? I'm genuinely curious.

 

[pharmleague]

No, 4 mL is not that big of a difference. But it can make a difference if you start making double or quad strength drips. Also, there are a few pharmacists that refuse to put their initials on something that says 160 mcg/mL on the label but is really not that concentration.

 

[zelman]

I don't do too much with IVs aside from the occasionally antibiotics like vanco, invanz, and some doxycycline most recently. But does 4ml make that big of a difference? Concentration of 0.157 to .16? I'm genuinely curious.

No. It doesn't. Different facilities will have a unique rule of thumb as to when overfill matters. I think it's usually 5% or 10% of original volume, so in this example it would be adding 25 mL or 12.5 mL.

 

[pharmleague]

That's the problem. Our facility doesn't have any rules of thumb regarding this. So we continue to debate what is the best way to handle it.

 

[zelman]

No, 4 mL is not that big of a difference. But it can make a difference if you start making double or quad strength drips. Also, there are a few pharmacists that refuse to put their initials on something that says 160 mcg/mL on the label but is really not that concentration.

They don't even know the actual product concentration. Manufacturers can be +/- more than the 1.9% change from the dilution in this example.

 

[ExpressMaiL]

No, 4 mL is not that big of a difference. But it can make a difference if you start making double or quad strength drips. Also, there are a few pharmacists that refuse to put their initials on something that says 160 mcg/mL on the label but is really not that concentration.

And they know before signing that the concentration is spot-on how?

 

[gwarm01]

Those are the type of pharmacists who make the rest of us look bad. They delay therapy over clinically insignificant issues that no one else on the team really cares about.

 

[mustang sally]

I don't think it matters which way you do it, but there should be a protocol for drips so that everyone does it the same way and the pharmacist can easily check it without debating about the concentration.

Whether you remove the 4 ml or not, there's no way to know exactly how much volume is in a bag anyway unless you measure it out into another bag (and who would do that when making an important drip?).

 

[pharmleague]

All of your arguments have been brought up during our pharmacy meetings, which is why we are having a debate.

So what do you do at your facility?

 

[confettiflyer]

Don't forget the extra risk that comes with extra manipulation of the bag, though that's not as big of a concern.

I think we have a 5% general rule with volume.

 

[fauxden]

geez... flip a coin and be done with it.

 

[Monsterdaddy]

For titrated medications, I think consistency is important but is that really the case in actual practice?

Think of it this way, if you remove the volume to start the drip and the next bag doesn't have the volume removed, will you cause the nurse to retitrate the drip? If yes, then I think a consistent method is important. If in actual practice you never see a re-titration then consistent practice is less important.

I just had this issue with Levophed bags but I don't have any nurse/doctors to contact to see if this is a real or imagined issue. @pharmleague, maybe you can get the nurse/doc input and please let us know. This makes the big assumption that re-titrating is something nurses don't want to do.

 

[confettiflyer]

There are so many other factors in play with ICU patients that variations that may occur while compounding shouldn't appreciably affect a patient.

In other words, stop being so anal and take care of the patient.

 

[OmiPharmD]

All of your arguments have been brought up during our pharmacy meetings, which is why we are having a debate.

So what do you do at your facility?

We follow the 10% rule. If the volume being added does not exceed 10% of the base solution then we add without removing. We have some exceptions (sodium bicarb, chemotherapy) but for the majority of IV meds this is what we do. (University affiliated teaching hospital)

 

[lapharmacienne]

10% is the general rule at my hospital. Some exceptions are amiodarone, alteplase, bicarb drips...

 

[pharmleague]

geez... flip a coin and be done with it.

I wish it were that simple. Part of the problem is that our computer system automatically puts in the following:

Phenylephrine 40 mg / 4 mL
NaCl 0.9% 250 mL
Total volume 250 mL

...which is not correct. We have to manually change the NS to 246 mL. Some pharmacists forget to do this (especially when the drip is needed stat), or they just don't change it because it's such a small difference, then the techs get confused on whether or not to pull out the volume.

Also, the other issue is that some of the critical care units have drip kits stocked on their units so they can make their own, and they are not pulling out the volume. Again, not really an issue if we are talking 4 mL, but definitely an issue when we are making a labetalol drip with 80 mL of labetalol.

Then, for electrolyte replacement, such as 40 mEq KCl (20 mL) in 250 mL, the nurse is going to run in the whole bag, so we don't bother taking out the 20 mL. Again, we have to manually manipulate the computer to show a total volume of 270 mL. It just gets crazy with us trying to fix and reprint labels and trying to tell the techs yes take the volume out of this one, but don't take it out on that one.

 

[ExpressMaiL]

I wish it were that simple. Part of the problem is that our computer system automatically puts in the following:

Phenylephrine 40 mg / 4 mL
NaCl 0.9% 250 mL
Total volume 250 mL

...which is not correct. We have to manually change the NS to 246 mL. Some pharmacists forget to do this (especially when the drip is needed stat), or they just don't change it because it's such a small difference, then the techs get confused on whether or not to pull out the volume.

Also, the other issue is that some of the critical care units have drip kits stocked on their units so they can make their own, and they are not pulling out the volume. Again, not really an issue if we are talking 4 mL, but definitely an issue when we are making a labetalol drip with 80 mL of labetalol.

Then, for electrolyte replacement, such as 40 mEq KCl (20 mL) in 250 mL, the nurse is going to run in the whole bag, so we don't bother taking out the 20 mL. Again, we have to manually manipulate the computer to show a total volume of 270 mL. It just gets crazy with us trying to fix and reprint labels and trying to tell the techs yes take the volume out of this one, but don't take it out on that one.

Do you so happen to work somewhere that's located on Bristol?

 

[pharmleague]

Do you so happen to work somewhere that's located on Bristol?

No, I don't. I guess they are having the same issue?

 

[confettiflyer]

I wish it were that simple. Part of the problem is that our computer system automatically puts in the following:

Phenylephrine 40 mg / 4 mL
NaCl 0.9% 250 mL
Total volume 250 mL

...which is not correct. We have to manually change the NS to 246 mL. Some pharmacists forget to do this (especially when the drip is needed stat), or they just don't change it because it's such a small difference, then the techs get confused on whether or not to pull out the volume.

Also, the other issue is that some of the critical care units have drip kits stocked on their units so they can make their own, and they are not pulling out the volume. Again, not really an issue if we are talking 4 mL, but definitely an issue when we are making a labetalol drip with 80 mL of labetalol.

Then, for electrolyte replacement, such as 40 mEq KCl (20 mL) in 250 mL, the nurse is going to run in the whole bag, so we don't bother taking out the 20 mL. Again, we have to manually manipulate the computer to show a total volume of 270 mL. It just gets crazy with us trying to fix and reprint labels and trying to tell the techs yes take the volume out of this one, but don't take it out on that one.

Can't you just build a "USE EXACT VOLUME" comment onto the drips that require an exact volume?

 

[confettiflyer]

This is cracking me up. I'm so glad my hospital isn't that jacked up.

Same here. Though I wonder if any inspecting body has ever raised a stink about this, most of the time they harp on sterility, BUD, and air quality.

 

[ExpressMaiL]

Same here. Though I wonder if any inspecting body has ever raised a stink about this, most of the time they harp on sterility, BUD, and air quality.

What they should do is require daily showers for people who want to work with csps.

 

[pharmleague]

Can't you just build a "USE EXACT VOLUME" comment onto the drips that require an exact volume?

So, when you say "USE EXACT VOLUME", are you saying to take out the overfill too?

We thought about adding "QS to 250 mL" to the label, but someone didn't like that idea. Plus, when the nurses make their own drip, they don't "QS".

Yes, I agree it is really jacked up. Would you believe we've been having this problem for two years. Someone raises a stink about it, so we start debating the best way to handle it. We don't reach a conclusion, so we just maintain status quo for awhile until someone raises a stink again.

I like the idea about the >10% thing. I may bring it up when the next stink is raised.

 

[gwarm01]

At my old hospital we would take out the overfill, and had a list of the approximate volume of overfill for each bag. I guess that only works if you stick with the same manufacturer and they don't alter the product any.

Currently we are operating under a policy of removing whatever you put in. That rule seems simple enough to remember and shouldn't confuse any of our techs. Our main goal is consistency, especially since some of our patients are premature infants. What could be a minute change in concentration for an adult might actually be significant for a baby that weighs less than 1 kg.

 

[confettiflyer]

So, when you say "USE EXACT VOLUME", are you saying to take out the overfill too?

We thought about adding "QS to 250 mL" to the label, but someone didn't like that idea. Plus, when the nurses make their own drip, they don't "QS".

Yes, I agree it is really jacked up. Would you believe we've been having this problem for two years. Someone raises a stink about it, so we start debating the best way to handle it. We don't reach a conclusion, so we just maintain status quo for awhile until someone raises a stink again.

I like the idea about the >10% thing. I may bring it up when the next stink is raised.

Yeah I see your point about "USE EXACT VOLUME" being ambiguous. Our current policy is 10% as well (not 5% like I mentioned earlier), so anything > 10% of volume needs to be removed and gets appended with "use exact volume" with overfill not being taken into account.

Like what @gwarm01 pointed out though, your institution's needs will vary (peds vs. adults), and using different manufacturers may influence your decision to deal with overfill. We have entirely different orders designated for our peds population that is a lot more strict with concentrations, volumes, overfill + vehicle for dispensing.

But really just as long as you keep it consistent, to me it's a no-brainer to not deal with excess volumes > 10% due to the theoretical risks of additional contamination + manipulation and technician/pharmacist time to check does not yield appreciable gains clinically.

 

[fauxden]

this could be a dumb question, What do you use (ie, reference or whatever) for conversion from oral to IV meds or the other way? Or is it just based on therapeutic doses?

 

[lapharmacienne]

this could be a dumb question, What do you use (ie, reference or whatever) for conversion from oral to IV meds or the other way? Or is it just based on therapeutic doses?

Lexicomp, clinical pharmacology, epocrates, micromedex....

 

[fauxden]

Tis

does that stand for something? or... what is it?

 

[El Trombopag]

I'm not sure, but tis a little annoying.

 

[type b pharmD]

I'm not sure, but tis a little annoying.

It's the board auto replacing words for Christmas

 

[fauxden]

hah. i see.... that was dumb i suppose.

 

[sakigt]

We use the 10% rule as well.

I rotated through a hospital that drew everything out and everytime I had to pull 1ml out of an insulin drip I muttered "this is stupid." I muttered quite often that month.

We also had a round of arguements over IV keppra getting thrown on minibags because of the slight overfill of the IV solution. Thank god it didnt go anywhere. Even that was more of a potential issue than the one being hammered out at your place. Its TITRATED.

The total volume issue is a real problem that needs fixing via IT. Weve had that problem before with other things and it can make a real difference. Im forgetting the actual scenario though....