1. 1 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Chapter 12 Aseptic Technique

2. 2 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. 1. Demonstrate the procedures in preparing the IV hood for use. 2. List the types of stock used within an intravenous room. 2a. List the sizes of syringes and needles used in the pharmacy setting and explain their anatomy. Supplies Used in an Intravenous Room Lesson 12.1

3. 3 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. 3. Describe five medication delivery systems. 4. Describe aseptic technique within a flow hood. 5. Explain the history of USP. Medication Delivery Systems, Aseptic Technique, and USP Lesson 12.2

4. 4 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. 6. List the main components of USP regulations. 7. Define the terms used under USP. 8. List the three risk levels of drug preparation determined by USP. Medication Delivery Systems, Aseptic Technique, and USP (cont’d) Lesson 12.2

5. 5 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. 9. Describe how to properly care for laminar flow hoods. 9a. Describe how often hoods must be inspected 10. Demonstrate how to manipulate a needle and syringe. 11. Describe how to properly dispose of needles, vials, and cytotoxic supplies Proper Care and Maintenance of the Flow Hood and Maintaining Aseptic Technique Lesson 12.3

6. 6 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. 12. Demonstrate the steps in reconstituting a parenteral powder. 13. Demonstrate the five steps of preparing medications from ampules. Preparation of Parenteral Medications and Nutrition Lesson 12.4

7. 7 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. 14. Explain the differences between total parenteral nutrition and peripheral parenteral nutrition. 15. List the medications that must be placed in glass containers. Preparation of Parenteral Medications and Nutrition (cont’d) Lesson 12.4

8. 8 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Introduction  Hospital technician crucial responsibility: proper preparation of parenteral products.  Contamination must be ______________ when preparing parenterals; only possible with proper manipulation of materials within the hood.

9. 9 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Introduction (cont’d)  Laminar flow hood:  Where all ________________ and ________________ are prepared  Various sizes and types available  All capable of keeping out ______ and unwanted particulates when proper aseptic technique is used

10. 10 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Introduction (cont’d)  Pharmacy technician prepares sterile products in:  Community pharmacy  ________ health service  Long-term care facilities  Hospital pharmacy

11. 11 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Terminology Used in Pharmacy  Written doctor’s orders contain _________ and abbreviations.  Understanding terminology is important.  For descriptions of pharmacy stock and terminology, see Box 12-1.  Attention must be paid to strength, form, dosage timing, route of administration.

12. 12 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Standard Precautions of a Healthcare Worker  Hospitals usually require an employee to receive both ____ testing and an annual flu shot.  Standard Precautions: ____ blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents.

13. 13 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Standard Precautions of a Healthcare Worker (cont’d)  Injectable drugs and other _______ products must be made in a “clean room” under laminar flow hoods.  Laminar flow hoods are recertified every ____ months by an independent contractor.  Routine cleaning of the hoods includes cleaning all work surfaces and prefilters.  All inspections are to be kept on file.

14. 14 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Supplies  Types of supplies:  ________ is determining factor  Automated pumps that automatically fill IV bags  Necessary to inventory these supplies and reorder stock on a _______ basis

15. 15 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Commonly Used Supplies for IV Room  ____% isopropyl alcohol  Alcohol pads  Amp breaker  Filter _______  Filter straws  Filters  Male/female adapter

16. 16 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved.  Syringe needles, syringe caps, syringes  Transfer needles  ____________ for pumps  Tubing transfer sets  Mini spike  Forceps Commonly Used Supplies for IV Room (cont’d)

17. 17 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Syringes  Eight basic sizes: 0.5, 1, 3, 5, 10, 20, 30, 60 ml  Two types of syringes:  Tension: 1 ml (for withdrawing ________ and other medications ≤ 1 ml)  Luer lock: hold needles in place by a lock mechanism

18. 18 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Two Types of Syringe Tips

19. 19 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Syringes (cont’d)  Made of _________  Disposed of after one use  _______ syringes rarely used, available for patients who have allergies to plastics; can be sterilized and reused  Tubex or Carpuject: can hold a variety of medications

20. 20 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Tubex Holder with Injection Cartridge Inserted

21. 21 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Needles  Aluminum or stainless steel  Different gauges (________) and lengths  Most are used by nurses to administer injections  Used to draw solutions into a syringe

22. 22 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Needles (cont’d)  Rule in sizing: gauge number of a needle is ____________ proportional to the needle’s bore size.  Bore size increases as gauge decreases.  25 G needle smaller ______ than 19 G.  Most common sizes: 19 G, 18 G, 16 G.

23. 23 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Needles (cont’d)  Length: can be __ to __ __ inches.  Coring increases as bore size increases.  Bevel up: avoids coring.  Filter needle used if coring occurs.  No part of the needle below the hub should be touched when preparing medications.

24. 24 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Parts of a Needle

25. 25 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Filters  Smallest: 0.____ microns; removes unwanted particles larger than 0.22 microns from solution.  Filter straw: is a straw-like needle used to remove any fine particles of glass from an ampule.  Some medications ______ ______ be filtered.

26. 26 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Stock Levels  IV room: stock kept at ___________ level at all times  IV technician: stocks IV room before and after each shift  Central supply: area of hospital where ___ supplies can be obtained

27. 27 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Stock Levels (cont’d)  Central supply: delivers by next ________  Off-site manufacturer takes 2 days to 1 week for delivery  IV antibiotics: available premade bulk packs; 12 to 24 ______; more expensive

28. 28 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Stock Levels (cont’d)  Technicians make extra ____ to be used all week; ____ can be frozen.  Large temperature-controlled refrigerators used to store ____ and recycle medications.  Multiple-dose vials stored in refrigerator for days.

29. 29 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Routes of Administration  Understanding the routes of administration is important as the solutions prepared differ in their __________ and/or concentrations.  The label must note the route of administration.

30. 30 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Medication Delivery Systems  Containers: many _____ are used to dispense medication.  They are stable and easy to use.  Medication: when _________, must be used within certain time or it expires and money is lost.

31. 31 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Piggyback Containers  Flexible ________ and _________ are the two main types of piggyback containers.  They are purchased prefilled with solutions or empty for use in preparing custom ___.  Sizes range from __ ml to ____ ml.  Insulin cannot be placed in viaflex bags; put in glass containers.

32. 32 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Piggyback Containers (cont’d)  Specialized containers: large- and small-_____ drips  Buretrol systems  Continuous __________ delivery systems  Patient-controlled analgesia syringe system  Patient-controlled analgesia cassette system

33. 33 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Large- and Small-Volume Drips  Large-volume—viaflex bags in four sizes: _____-mL, __-L, __-L, __-L  Deliver a variety of fluids, including parenteral nutrition  Parenteral nutrition: combination of essential nutrients administered over several ______

34. 34 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Buretrol Systems  This is a tubular drip chamber with its own flow regulator located ________ it.  Nurse administers -_______ amounts of medication over predetermined period.

35. 35 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Continuous Analgesic Delivery Systems  Analgesics required after _________ and hospice patients  Prepared in pharmacy  Nurses can prepare some from controlled substances ________ in unit  Morphine: prepared by pharmacy technician for patients who require it

36. 36 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Continuous Analgesic Delivery Systems (cont’d)  These pumps can be set for short or long durations to deliver medication, not to exceed a ___-hour period.  Are especially effective for those patients who require constant pain __________.

37. 37 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. PCA Syringe System  ____________-controlled analgesia device used to administer controlled substances  Regulated by a computerized device that automatically dispenses the medication  _________: preset amount of drug administered to patient when pain intensifies; prevents patient from overdosing  Used mainly in hospitals

38. 38 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. PCA Cassette System  PCA cassette system is system that can be used at ______.  Pumps are preset for dosage administration.  ___________ the line (tubing) is required after the cassette is filled.

39. 39 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Vials  Single- and multiple-dose vials  Volumes range from __ ml to ____ ml  Many types placed on piggyback solutions  Not mixed until right _______ administration

40. 40 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Vials (cont’d)  Technician attaches, nurse mixes  Advantage: avoidance of _________  Controlled-release infusion system (CRIS): vial is reconstituted but not added to piggyback

41. 41 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Aseptic Technique  Used to prepare all parenterals  Goes hand-in-hand with _______ precautions  Universal precautions used by all healthcare workers when dealing with fluids body.

42. 42 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Aseptic Technique (cont’d)  Aseptic technique is used to keep contamination from occurring by a _______ or to a _______.  Contaminated medication causes serious infection, death.  For aseptic techniques for technicians, see Box 12-2.  Aseptic technique ________ be stressed enough!

43. 43 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. USP  Gives guidelines for the preparation of parenteral and other sterile medications  Three major sections  Responsibilities of _______  Verification  Training

44. 44 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Risk Levels  USP has identified three risk levels; see Table 12-3.  Low: medications that are prepared from _________ products  Medium: bulk compounding  High: products susceptible to contamination due to the preparation of ___-sterile products and/or delayed sterilization

45. 45 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Education and Training  Training and testing must be repeated ___________ for low and medium risk levels and semiannually for high risk  Must be able to show competency in compounding Video/written and practical instruction _________-fill test Written exam

46. 46 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Requirements for Compounding  All personnel who prepare parenteral medications must be trained and monitored for ___________ with techniques.  Products must be stored according to manufacturer guidelines or other scientific findings.

47. 47 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. IV Environment  Having a laminar flow hood out in an open room is no safer than preparing products on a counter top.  Anteroom: is room adjacent to the __________ room.  Clean room: must meet stringent minimums pertaining to ____ particulates at all times.

48. 48 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Storage and Stability  The longer a compounded IV is exposed to room temperature, the greater the risk of _____________ growth.  Table 12-5 lists guidelines for both temperature ________ and expiration dates of compounded medications.

49. 49 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Hood Cleaning and Maintenance  Types of hoods:  Horizontal  Vertical  Depends on ______ of products being prepared  Horizontal: parenteral medication or sterile product mixtures

50. 50 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Hood Cleaning and Maintenance (cont’d)  Vertical: chemotherapeutic agents; can also be used for ____-chemotherapeutic agents  Chemotherapeutic agents: should ____ be prepared in horizontal flow hood  Hoods: inspected yearly by authorized inspector

51. 51 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Hood Cleaning and Maintenance (cont’d)  Horizontal hood: outside airflow into _____ of hood through an HEPA filter that traps all particles larger than 0.22 microns  Sides of hood and items in hood create ____________ in airflow

52. 52 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Hood Cleaning and Maintenance (cont’d)  Technician must work within __ inches from sides and front of hood.  Movement in hood: keep to minimum to decrease disruption of _____________.  For details on how to clean the horizontal hood, see Box 12-5.

53. 53 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Hood Cleaning and Maintenance (cont’d)  Vertical flow hood:  Air __________ be released back into the room.  Plexiglas shield to separate technician from inside work surface.  Air comes into _____ filter and then into workspace area.

54. 54 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Hood Cleaning and Maintenance (cont’d)  Vertical flow hood:  Grid at front of tabletop draws in air and filters once again through HEPA filter before release into open or to __________.  For details on how to clean the vertical hood, see Box 12-6.

55. 55 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Barrier Hoods  Totally enclosed and referred to as _____ box or barrier isolator  Reduces risk of contamination by using HEPA filter and additional __________ system

56. 56 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. The six-step process of aseptic technique in the hood: 1. Using _________, swipe the top of the vials and the ports on the IV bags from back to front (move ________ the vial and bag rather than over or behind).

57. 57 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. 2. Place the needle _____ side up and push it into the vial’s rubber stopper. Preload the syringe with the necessary amount of ____ to replace solution. The six-step process of aseptic technique in the hood (cont’d)

58. 58 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. 3. Invert the vial and syringe 180 degrees. Push in the ____ from the syringe and pull out the solution. The six-step process of aseptic technique in the hood (cont’d)

59. 59 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. The six-step process of aseptic technique in the hood (cont’d) 4. After removing the syringe from the vial, insert the needle into the ___ bag and inject the medication using a steady hand.

60. 60 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. 5. After injecting the IV bag with the medication, immediately flip the bag _____. ****This decreases the possibility of forgetting which bags have been injected and which ones have not. The six-step process of aseptic technique in the hood (cont’d)

61. 61 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. 6. Never _____ the used needles; instead, throw away each syringe in a sharps container along with the uncapped needle after use. Syringes cannot be _______ when changing from one drug to another. *********This decreases the chance of drug-to-drug contamination. The six-step process of aseptic technique in the hood (cont’d)

62. 62 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Hand Placement  Placement of hands is important aspect when preparing sterile medications.  Do not block the __________.  Do not overload the hood with drugs and ____________.

63. 63 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Disposal  All unused materials or used products should be discarded in designated ____________ after use of hood.  Last step: hood countertop must be _______ ___________.

64. 64 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Spills  If a spill occurs in a horizontal flow hood, it may be cleaned using a gauze pad and 70% isopropyl alcohol.  If a small spill occurs in a vertical flow hood, it should be cleaned up with sterile gauze and 70% isopropyl alcohol and disposed of inside a chemo protective bag.

65. 65 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Spills (cont’d)  If a small spill occurs in a ____, wipe up the spill with a disinfectant soaked paper towel, then clean the surface with ____% isopropyl alcohol.

66. 66 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Parenteral Antibiotics  Antibiotics: guidelines for dosing regimen  For examples of suggested dosing times, solutions, and appropriate volumes, see Table 12-8  Pharmacies: instructional chart as to amount of diluent needed, normal dosing time, expiration date, how to prepare, and how long powder takes to dissolve in diluent

67. 67 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Parenteral Antibiotics (cont’d)  When adding a diluent to a powder an equal amount of air must be removed from the vial or a _____________ pressure is created.  Never let go of a syringe.

68. 68 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Use of Ampules to Prepare Medications  Intravenous push or intramuscular (IM): prepared by nurse at nursing station or at patient’s bedside.  Pharmacies: prepare some __ push and __ medications.  Agents placed in syringe and sealed with syringe cap.

69. 69 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved.  There are ________ procedures to follow when preparing syringes from ampules.  Other injectables are premade from manufacturer, including Tubex ampules.  Remember to use a _________ needle when transferring drug from an ampule because small pieces may break off and fall into the solution. Use of Ampules to Prepare Medications (cont’d)

70. 70 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Hyperalimentation  Also known as “hyperals”  Large volumes of parenteral nutritional solutions made for persons who cannot take nutrition _________  Reasons: stomach or intestinal surgery, conditions that affect ___ system, coma

71. 71 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Hyperalimentation ( cont’d )  Two main types:  TPN: _______ parenteral nutrition  PPN: _________ parenteral nutrition  Home health clinics, hospitals: prepare week’s worth of hyperals  Electrolytes tested weekly instead of daily

72. 72 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Hyperalimentation (cont’d)  Preparation: different protocols  Large volumes come premixed; electrolytes and other medications added  TPN: __% dextrose, __% AA, __% fat  PPN: __% dextrose, __% AA, __% fat

73. 73 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Hyperalimentation (cont’d)  Hyperals are prepared for neonates, children, and adults.  Neonatal and pediatric additives _______ in concentration from adult formulas.

74. 74 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Hyperalimentation (cont’d)  TPNs: given __ via subclavian vein and superior vena cava (high concentration of nutrients)  PPNs: given via large peripheral vein  Typical volume: _ L to _ L

75. 75 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Hyperalimentation (cont’d)  Doctor determines rate of infusion over __ hours  Must be changed every 24 hours to ensure sterility of solution  Standard rate of infusion: _____ ml/hr  Tailor-made for each patient  See Figure 12-18

76. 76 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Electrolytes and Additives  All TPNs contain _______ and amino acids.  __________ commonly added.  Other medications: ranitidine, cimetidine, famotidine, insulin (regular).

77. 77 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Types of Parenteral Additives AbbreviationElectrolyte IonsConcentrationNotes KCLPotassium chloride2 mEq/ml KPO 4 Potassium phosphateK+ 2 mEq/ml,Always work phosphateout phosphate 3 mEq/mlfirst CaGluconateCalcium gluconate 0.465 mEq/ml MgSO 4 Magnesium sulfate1 mg/ml K AcPotassium acetate2 mEq/ml*Used to balance NaAcetateSodium acetate2 mEq/ml*Used to balance NaPO 4 Sodium phosphate2 mEq/ml NaCLSodium chloride2 mEq/ml*Used to balance

78. 78 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Miscellaneous Additives AbbreviationElectrolyte IonsConcentrationNotes ___MultivitaminComes in PEDI dosing ____Multiple trace elementsComes in PEDI dosing __Zinc __Selenium Regular insulinInsulinCan be added to TPNs and PPNs Types of Parenteral Additives (cont’d)

79. 79 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Other Nonsupplements Added to TPN or PPN Solutions GenericBrandConcentration RanitidineZantac40 mg/ml FamotidinePepcid20 mg/ml CimetidineTagamet150 mg/ml PEDI, Pediatrics; PPN, peripheral parenteral nutrition; TPN, total parenteral nutrition. *To balance means the pharmacist determines the amount to be added. Types of Parenteral Additives (cont’d)

80. 80 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Compatibility Considerations of Parenteral Medications  Different types of medications prepared in __ room  Some protected from _______  Some kept in bottles  Reference books available

81. 81 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Additional Considerations for the Preparation of Drugs MedicationSpecial Instructions InsulinNS or ½ NS AmiodaroneD5/NS NitroglycerinD5/NS or NS CiprofloxacinProtect from light LorazepamProtect from light; stable longer in glass than in plastic NS, Normal saline; D5/NS, 5% dextrose in normal saline.

82. 82 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Example of an Intravenous Medication Label

83. 83 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. Components of an IV Label  Final step is application of _______.  Label is checked against medication and doctor’s orders.  _________________ checks, along with vial used for preparation.  Delivery takes place.