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28 | Rizaelle Pillejera2DPHPARENTERALSPart IVMAINTENANCE THERAPYgiven to patients entering or recovering from surgery and patients unconscious and unable to take fluids, electrolytes, and nutrition orally.If patient is receiving parenteral fluids for only a few days;Simple solutions providing adequate amounts of water, dextrose, and small amounts of sodium and potassium generally suffice.If patient is unable to take oral nutrition or fluids for longer periods (3-6 days);Solutions of higher caloric content may be usedIf oral feeding must be deferred for periods of weeks or longerTPN (Total Parenteral Nutrition) or TNAs (Total Nutritional Admixture) must be implemented. TNA include all substrates necessary for nutritional support --- carbohydrates, protein, fat, electrolytes, and trace elements --- mixed in a single plastic IV bag.Very useful for chemotherapy, gastrointestinal patients, and anorexic patients.Things the pharmacist must consider when using TNAs:Order of substrate mixingDifferentiate between various brands of substrate and their physicochemical propertiesDetermine the type of plastic bag system that is most appropriate. For example, plastic bags with DEHP (diethylhexylphthalate) may result in plasticizer leaching into the solution and injuring the patient.Determine how the product should be storedAssess any potential complicationsTNAs must be filtered with a 1.2m filter

FDA safety alert regarding hazards of precipitation associated with parenteral nutrition:Recommends that a filter be used when infusing either central or peripheral parenteral nutrition admixtures.A 0.22m filter containing both bacterial-retentive and air-eliminating filters has been recommended for use with lipid-free parenteral nutrient solutions.Lipid emulsions and three-in-one parenteral nutrient solutions can be safely filtered at a pore size of at least 1.2 m.A problem with the lipid emulsion in a three-in-one admixture is that it obscures any precipitate.

REPLACEMENT THERAPYfor patients who have suffered a heavy loss of water and electrolytes, such as severe diarrhea or vomiting.patients with Crohn disease, AIDS, burns, or trauma are candidates for replacement therapy.

WATER REQUIREMENTthe daily water requirement is the amount needed to replace normal and expected lossesNormal daily requirement of water for adults is about 25 to 40mL/kg of body weight, or an average of about 2L/m2 of body surface area.Water requirements correlate more closely with body surface area than with weight

Guideline to estimate normal daily requirement of water for children and small adults:10%) can be given peripherally.Solutions containing more than 10% dextrose should be given via the superior vena cava.A significant problem associated with the use of calcium (usually as calcium gluconate) and phosphate (usually as potassium or sodium phosphate), is the formation of calcium phosphate, an insoluble precipitate.

Nutrimix Macro TPN CompounderFour-station device; can pump four nutritional solutions simultaneously to compound nutritional admixtures by gravimetric means.

TPN Compounders are connected directly to a computer entry program, which automatically calculates the amount of each ingredient to be added and drives the compounder to deliver the required amount.PARENTERAL NUTRITIONBaxa CompounderHave a bar code reader that reads each bottle hung on the machine, reducing the chance of human error.Deliver ingredients in a specific order to avoid incompatibilities.PARENTERAL NUTRITION

Following abbreviations may be used in hospitals in describing the desired order for parenteral nutrition:CVTPN (central vein TPN)TPN (total parenteral nutrition)PPN (peripheral parenteral nutrition)ENTERAL NUTRITIONMay be administered orally, via nasogastric tube, via feeding gastrostomy, or via needle-catheter jejunostomy.Enteral feeding is preferable whenever unlike parenteral feeding, which is only appropriate for short-term use in hospital or long-term use care facility or when the GIT is unable to absorb nutrients.Just as effective as a source of nutrients, less expensive than parenteral feeding, and has a low potential to cause serious complications.Defined formula diets may be: Monomeric or oligomeric amino acids or short peptides and simple carbohydratesPolymeric complex protein and carbohydratesENTERAL NUTRITIONWhen formulas do not offer sufficient flexibility, modular supplements of protein (ProMod powder, Propac powder), carbohydrate (Moducal powder) or fat (Lipomul liquid) are used for individual supplementation.

ENTERAL NUTRITIONImportant considerations:Type of tubingLocation of the enteral tubeBulk-forming laxatives and cholestyramine resin should not be used because of the possibility of clogging the tubingEnteral feedings can alter the absorption of certain drugs; timing of administration is criticalINTRAVENOUS INFUSION DEVICESCost-efficient devices provide greater accuracy and reliability of drug delivery than the traditional gravity-flow infusion methods.Help reduce the fluid volume attributable to the medication infusion and decrease the need for monitoring fluid input, saving time.Multiple-drug dosages can be administered, and incompatible drugs can be administered separately.DisadvantagesInitial capital investmentExtensive in-service educationFactors that may alter the rate of drug delivery and the therapeutic response of the patient:Intrinsic FactorsOperating mechanismsFlow accuracyFlow continuityOcclusion detectionExtrinsic FactorBack pressurePump Classifications:Mechanism of OperationPeristalticPistonDiaphragmFrequency or Type of Drug DeliveryContinuous or intermittentBolus dosingSingle solutionMultiple SolutionTherapeutic ApplicationPCAINTRAVENOUS INFUSION DEVICESALARIS Medical Systems markets a variety of infusion systems. Medley Systems uses modularity, a common user interface.Guardrails Safety Software improve medication safety by using total quality management principles for administration at the point of care.Symbiq Infusion System with Hospira MedNet software requires users to select an entry form the drug library for all delivery programsWireless communication enables customers to gather infusion data remotely.Hospitals can track medication risk events and generate quality assurance reports.SELECTED INFUSION DEVICES USED IN LARGE VOLUME INFUSIONSPUMPMANUFACTURERFEATURESColleague CXBaxterBasic delivery programming, and ability to piggyback secondary medications.SymbiqHospiraDefine soft and hard limits for up to 400 medications. Track medication risks.Plum A+HospiraAutomated piggyback delivery, automated concurrent delivery etc.Outlook safety infusionB. BraunDoseScan technology; match the right drug to the right patient.Flo-gardBaxterFlow check occlusion alarm, automatic flow rate calculation.SPECIAL CONSIDERATIONS ASSOCIATED WITH PARENTERAL THERAPYSTANDARDIZATION OF INTRAVENOUS CONCENTRATIONSParenteral medications, including IV administration, account for twice as many errors as other methods of administration.Stakeholders including representatives from the ASHP, Infusion Nurses Society, the Joint Commission, National Patient Safety Foundation, Institute for Safe Medication Practices, and the USP met and called for standardization in IV use, especially with regard to infusion concentrations and dosage units by 2012.LOOK-ALIKE PRODUCTSTo prevent mix-ups in which one drug product is selected in error because of its similarity in appearance to another, storage shelves should be labeled to warn about this possibility.

A recent example of a serious medication error occurred when Lupron Depot-Ped 11.25mg, a 1-month gonadotropin-releasing analog used to treat central precocious puberty, was confused with Lupron Depot 3 Month.ADSORPTION OF DRUGSNumerous studies have demonstrated that some drugs are adsorbed to the inner lining of IV containers and tubing.Some of the drugs that have been implicated in this phenomenon include insulin and monoclonal antibodies.To obviate the adsorption phenomenon, human albumin is added.Plastic IV infusion sets have reportedly removed up to 80% of a dose, but 20% to 30% is more common.One method to minimize this is to administer infusions through short lengths of small-diameter tubing made of inert plastics.ADSORPTION OF DRUGSAbsorption (Sorption) of DrugsAbsorption of drugs into a plastic material has been shown to occur in IV containers, delivery sets, syringes, filters, and other plastic apparatus.Most drug-plastic container interactions result from drug absorption by the DEHP in flexible PVC bags and tubing.Examples of drugs lost from aqueous solutions during infusion through flexible PVC tubing include:Amiodarone HClChlorpromazine HClDiazepamLorazepamNitroglycerinPromazine HCl

Promethazine HClThiopental sodiumThioridazine HClTrifluoperazine HClWarfarin sodium

ADSORPTION OF DRUGSNitroglycerin should always be prepared in glass and/or plastic known to be compatible with it. It is adsorbed (40 to 80% of total dose) to PVC.Some manufacturers packaged NTG for IV use with special non-PVC tubing to avoid loss of the drug into the tubing during administration.Special high-density polyethylene administration sets are recommended for NTG IV administration. Hard solid plastics, such as polyethylene and polypropylene, generally do not adsorb NTG.The amount of NTG adsorption depends on such factors as concentration, flow rate, surface area of the tubing, and contact time with the tubing.HANDLING AND DISPOSAL OF CHEMOTHERAPEUTIC AGENTS FOR CANCERIn 1982, health care personnel became aware of environmental contamination from handling cytotoxic agents.In response, ASHP published its initial technical assistance bulletin on handling cytotoxic and hazardous drugs in 1985.In 2006, ASHP issued their Guidelines on Handling Hazardous Drugs; appendices include:Use of personal protective equipment, BCSs, and isolators.Reducing exposure to hazardous drugs during administration.Spill kits.Treatment of workers with direct skin or eye contact with hazardous drug.OTHER INJECTABLE PRODUCTS: PELLETS OR IMPLANTSOTHER INJECTABLE PRODUCTS: PELLETS OR IMPLANTSPellets or implants were sterile, small, usually cylindrical solid objects about 3.2mm in diameter and 8mm long.Prepared by compression and intended to be implanted subcutaneously.Pellets, implanted usually under the skin of the thigh or abdomen, are used for potent hormones.Implantation provides the patient with an economical means of obtaining long-lasting effects.Pellets were formulated with no binders, diluents, or excipients, to permit total dissolution and absorption.LEVONORGESTREL IMPLANTSRecently developed contraceptive system.Implanted capsules are intended to be removed surgically after an appropriate amount of time (up to 5 years), rather than be dissolved entirely.Set of six flexible closed capsules of a dimethylsiloxane-methyl vinyl Siloxane copolymer, each containing 36mg of the progestin.Appropriate insertion facilitates removal by the end of the fifth year.Provides long-term reversible contraception.

IRRIGATION AND DIALYSIS SOLUTIONSIRRIGATION AND DIALYSIS SOLUTIONSSubject to the same stringent standards as parenteral preparations. The difference is in use.Not injected into the vein but employed outside of the circulatory system.Generally used in large volumes, packaged in large containers of the screw-cap type, which permits rapid pouring.Dialysis solutions generally appear similar to IV bags, and irrigation solutions are screw-capped or bagged.IRRIGATION SOLUTIONSIrrigation solutions are intended to bathe or wash wounds, surgical incisions, or body tissues.Examples:Acetic acid irrigation, USPDuring urologic procedures, washes away blood, surgical debris while maintaining suitable conditions for tissue and permitting unobstructed view.Neomycin and Polymyxin B sulfates solution for irrigation, USPTopical antibacterial in continuous irrigation of bladder.Ringers irrigation, USPSterile and pyrogen free; must be labeled NOT FOR INJECTIONIRRIGATION SOLUTIONSSodium chloride irrigation, USPEmployed topically to wash wounds and body cavities where absorption into blood not likely; employed as enema; for simple evacuationSterile water for irrigation, USPLabel designation FOR IRRIGATION ONLY, NOT FOR INJECTION must appear prominently; must not contain any antimicrobial or other added agent.

DIALYSIS SOLUTIONSDialysis is separation of substances from one another in solution by taking advantage of their differing diffusibility through membrane.Peritoneal dialysis solutions, allowed to flow into the peritoneal cavity, are used to remove toxic substances normally excreted by the kidney.Solutions are made to be hypertonic to plasma to avoid absorption of water from the dialysis solution into the circulation.Uses the principles of osmosis and diffusion across the semipermeable peritoneal membrane and includes osmotic and chemical equilibration of the fluid within the peritoneal cavity with that of the extracellular compartment.DIALYSIS SOLUTIONSIntraperitoneal instillation of dialysis solutions allows for movement of water, toxic substances, and/or metabolites across the membrane in the direction of the concentrations gradient, removing these substances from the body following drainage of the solution from the peritoneal cavity.Hemodialysis is employed to remove toxins from the blood.The blood is shunted through a polyethylene catheter through an artificial dialyzing membrane bathed in an electrolyte solution.Following the dialysis, blood is returned to the body circulation through a vein.

DIALYSIS SOLUTIONSHemodialysis and peritoneal dialysis procedures have the capability to enhance the plasma clearance of a drug.Drugs which have been shown to be cleared from plasma by hemodialysis include:AcetaminophenCaptoprilCefaclorImipenemLithiumMetformin

DIALYSIS SOLUTIONS