IV ADMIXTURES

IV Admixture
When one or more sterile products are added to an IV fluid for administration, the
resulting combination is known as IV Admixture.

Purpose of centralize pharmacy IV Admixture Services

1. Saves nursing time for other professional nursing roles
2. Provides a system of screening physical, chemical incompatibilities and
dispensing of stable preparations
3. Minimizes pharmaceutical calculation errors
4. Reduces the risk of medication error by providing additional checks
5. Centralizes responsibility for preparation of parenteral admixtures
6. Label admixtures with rate of infusion as prescribed by physician and provides
a standard label format
7. Provides an aseptic environment for the preparation of admixtures
8. Conforms to the standard recommended by Joint Commission on Accreditation
of hospitals
9. Conforms to the guidelines established by the National Coordinating Committee
on large volume parenterals
10. Provide a mechanism for changing patients for IV therapy and creating revenue
11. Ensures more effective use of professional personnel in the hospital
12. Minimizes the potential for medico-legal liabilities
13. Provides for the preparation of solution which are not commercially available

Steps the in preparation of IV Admixture

Functions
Physicians Writes admixture order and includes IV fluids, additives and their
concentration, rate of flow, starting time and length of therapy
Pharmacist The order is checked for proper dosage, incompatibility, drug allergies
and stability
Checking whether the proper dosage has been given or requires a
knowledge of milliequivalent calculations.
Order is checked for compatibility
Admixtures are given the maximum expiration period if 24 hours
therapy (except ampicillin which require shorter expiration period)
Clerk Label and profile worksheet
The label should contain:
patients name room no.
date prepared expiration date
IV and additives with the amount
Time of infusion ( ml / hr or gtts / min)
Name of the nurse who administer
Label is affixed upside down in order that it can be read when hung.
Profile worksheet is prepared so that the pharmacist will be alerted
when the next bottle is due for preparation
Pharmacist Preparation of IV admixtures
aseptic technique should be used
Additive caps are affixed before delivered to the floor / wards
Supervising Checked the completed admixture
Pharmacists check the label with the original order
check for any color changes or particulate matter

Messenger Delivered to patient care area

STAT orders are picked up by Nursing staff
If the admixture is not to be infused immediately within an hour
store under refrigeration is required
If refrigerated, it must be used within 24 hours
Nurse Administer to the patient
checks for the correctness of the patients name, drugs and
concentration plus solution, expiration date, time started and
clarity

IV FLUIDS
-Large volume injections intended to be administered by IV infusion

Components of IV fluids
These are sterile solution of simple chemicals such as:
1. Sugars
2. Amino acids
3. Electrolytes

These are easily carried and assimilated by circulatory system. Prepared with
water for injection, USP and the solution is pyrogen free

Conditions where in IV Fluids is commonly used

1. Correction of disturbances in electrolyte balance
2. Correction of disturbance in body fluids (fluid replacement)
3. The means of providing basic nutrition
4. The basis for the practice of providing Total Parenteral Nutrition
5. Use as vehicle for other drug substances

IV Therapy Equipment
1. Infusion set
IV Injection or IV push or IV bolus
small amount of solution drug from the syringe
IV Continuous Infusion
Large volume over several hours at a constant slow rate
Intermittent IV infusion
small amount over a short period of time at specific interval
IV Piggy Back
 Uses y tubing
Additive Set infusion
With the use of infusion pumps
A device used to control the delivery of IV solutions at a selected rate
Used by ICU patients and pediatric patients
Heparin lock
Attach to IV catheter needle on one end that has a resealable rubber
diaphragm at the other end
After the drug is administered, the heparin lock is flushed with a small
volume of 0.9% sodium chloride injection or a diluted heparin
(anticoagulant) to prevent blood clotting.

2. Administration set- used to deliver fluids into your body

Spike
Port between the container and chamber
Drip Chamber
Regular or Macro drip 10 drops in 1 ml
Pediatric or Micro drip 60 drops in 1 ml
Volume Control chamber
A plastic container that has a measurement of volume along the side
It serves as a mini container from which the solution is allowed to flow
Ensure accurate measurement of the volume of fluid infused and safety
precaution to limit the volume of fluid that may be infused accidentally
Generally recommended for pediatric patients
Clamp
Regulate the rate of flow
Catheter
Where the liquid will pass through

3. Final Filters
IV admixtures sometimes contain very small particles that cannot be
seen by the naked eye and thus it will be very harmful to patients if they
become trapped and accumulate in the small capillaries of the lungs
Separate filter will be attached to be able to filter the solution before it
enters the body

Equipments to be used in Compounding IV admixtures

1. Computer
2. Laminar Flow Hood
Are designed to reduce the risk of airborne contamination during the
preparation of IV admixture by proving ultra clean environment
Most important part is the High-efficiency, bacteria-retentive filter (HEPA-
High Efficiency Particulate Air)
3. Needles
4. Syringes
 5. Solution Containers
o Plastic containers
o Plastic Bag
o Bottle containers
6. Filters

Factors affecting Compatibility and Stability

1. pH - if the pH of an admixture is unsuitable for one of the drug, that drug either
degrades or precipitates.
2. Complexation - combination of tetracycline and calcium drugs
3. Light- exposure to light may destroy or reduce potency of drugs
4. Time- most drug degrade in a relatively short time when placed in an IV
solution
5. IV Solutions- some drugs require a specific diluents for dilution
6. Temperature - heat increase the rate of chemical reaction; once it is
reconstituted it is stable for 24 hours at room temperature and 96 hours under
refrigeration but some drugs like mannitol should not be freeze because it
causes precipitation
7. Buffer capacity-it is the ability to resist a change in pH when either an acidic or
alkaline substance is added to it.
8. Order of mixing-Drugs that are in concentrated solutions may react to form a
precipitate, whereas both drugs in diluted solutions may combined
satisfactory
9. Plastics-The drug may adhere to the plastic bag especially PVC (Polyvinyl
chloride)
10. Filters- An in line filter can cause 86% to 94% reduction in the delivered
concentration
of nitrogen

Incompatibilities that should be observed in preparing IV Admixtures

1. Thoroughly review the literature provided by the manufacturer of the parenteral
solution
2. When possible, keep the number of additives to a minimum since the complex
interaction between numerous additives can result in either a visual, chemical
or therapeutic incompatibilities
3. Visually check appearance of completed admixture for evidence of
incompatibility
4. If a precipitate forms when a medication is added to an intravenous fluid, the
solution should be discarded unless the direction accompanying the medication
state otherwise
5. An administration set within a final filter should be used whenever possible to
trap detected precipitates
 6. The degree of solubility of an additives varies with the pH and most
incompatibilities are related to change in pH ( a chart listing the pH of certain
drugs and parenteral solutions can help predict potential incompatibilities)
7. Sodium bicarbonate and calcium salts should never be mixed since they form
an insoluble precipitate (calcium carbonate)
8. Valium should not be mixed with any parenteral solutions since a precipitate
may form. It is also incompatible with any other drug in syringe and solutions
9. It is best not to mix multiple vitamin complexes with potassium penicillin G
because the acidic ascorbic acid lowers the pH and can cause degradation of
the antibiotics
10. It is best not to mix heparin with antibiotics because heparin may affect the
stability of certain antibiotics
11. Hydrocortisone should not be mixed with tetracyclines, since a precipitate will
form
12. It is best not to administer sodium bicarbonate and epinephrine jointly because
sodium bicarbonate tends to neutralized epinephrine.

Complications of IV fluids administered locally and systemically

LOCAL COMPLICATIONS
1. Infiltration- it is characterized by the following:
Edema at the site of injection
Pain or discomfort in the area of infiltration
Significant decrease in the flow rate or a halt in flow when the filtration is
extensive
2. Hematoma- often result when inadequate time is spent applying pressure to
the venipuncture site after the IV device is removed
3. Phlebitis- is defined as inflammation of the vein and is evidenced by heat,
redness, swelling and discomfort adjacent to the venipuncture site.
4. Thrombophlebitis- denotes the presence of a thrombosis plus inflammation in
the vein

SYSTEMIC COMPLICATIONS- occurs when any part of IV administration apparatus

is or becomes contaminated
1. Pyrogenic reaction the presence of pyrogenic substance in either the
infusion solution or the administration setup can induce a febrile reaction
2. Air Embolism- is present in all IV infusions even though it does not occur
frequently.
3. Pulmonary Embolism- occurring when a substance, usually a blood clot,
becomes free-floating and is propelled by the venous circulation to the right
side of the heart and on into the pulmonary artery. This complications may
result from the unwise irrigation of an occluded cannula.
4. Speed Shock- occurs when a foreign substance usually a medication is rapidly
introduced into the circulation
5. Catheter Embolism- a piece of catheter breaks off and travels through the
vascular system
Sites of administration
1. Antecubital veins- the median cephalic and median basilica veins antecubital
fossa and are readily accessible for venipuncture because of their prominent
size.
-potential needle dislodgment
2. Hand Veins- use of dorsal veins for prolong parenteral therapy
3. Forearm veins- the cephalic vein is located along the radial border of the
forearm and is an excellent site of venipuncture
- can accommodate large needles, excellent route of transfusion
4. Scalp Veins -for pediatric IV therapy
-superficial veins located in the head
5. Veins of the lower extremity
- Danger in pulmonary embolism due to a thrombus extending from the
superficial veins into the deep veins