3. Topics3
Learning Objectives
Gain an awareness of the historical roots of large-volume parenteral
preparations.
Understand the physiology of fluid balance and the chemical
properties of parenteral products.
Identify the risks associated with parenteral administration.
Describe the components and critical sites of various large-volume
parenteral preparation supply items.
Identify the USP Chapter <797> procedures that must be performed
prior to compounding large-volume parenteral preparations.
Demonstrate correct aseptic technique in preparing large-volume
parenteral products.
2012 Paradigm Publishing
4. Topics4
Topics
Learning Objectives
Introduction
Physiology of Fluid Balance
Properties of Parenteral Products
Potential Complications of Parenteral Therapy
LVP Preparations
USP Chapter <797> Guidelines for LVPs
Understand the Resources and Supplies
Preview the Lab Procedure
Chapter Summary
2012 Paradigm Publishing
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5. Topics55
Introduction
In hospital pharmacy settings, IV technicians are
largely responsible for preparing parenteral
solutions for patient administration
medications administered by any route other than through
the alimentary canal
maintain or correct the fluid status of patients whose
conditions disrupt their bodies’ innate fluid balance
2012 Paradigm Publishing
6. Topics66
Physiology of Fluid Balance
Water is a critical element of the human body,
composing approximately 70% of the body’s weight
primarily found within the cells of the body, or
intracellular spaces, but it also can be found in the spaces
between the cells, or interstitial spaces, and in the spaces
outside the cells, or extracellular spaces
also a component of blood vessels, where it is found in the
intravascular spaces
2012 Paradigm Publishing
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Physiology of Fluid Balance…/2
Maintaining the proper level of fluid and electrolytes
within the body, called homeostasis, is essential for
human life
fluid enters the body through the normal processes of
drinking and eating and exits the body through the
processes of perspiration, respiration, urination, and bowel
evacuation
2012 Paradigm Publishing
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Physiology of Fluid Balance…/4
When certain conditions affect normal fluid intake
and output patients may be at risk for dehydration
occurs when the amount of water entering the body is less
than the amount of water leaving the body
extreme loss of fluid may lead to kidney failure, cardiac
arrest, or death
the quickest method of rehydration is through the
injection of parenteral solutions into the blood supply
The vast majority of CSPs prepared by IV technicians
are large-volume parenteral products
2012 Paradigm Publishing
10. Topics1010
Properties of Parenteral Products
Because parenteral products are administered
directly into a patient’s blood supply, these solutions
must have certain chemical properties or
characteristics that render them safe for patient
administration
some characteristics include pH value, osmolarity,
osmolality, and tonicity, as well as the compatibility of CSP
additives
2012 Paradigm Publishing
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Properties of Parenteral
Products…/2
pH Value
The degree of alkalinity or acidity of a solution is
referred to as its pH value and is measured on a scale
from 0 to 14
any solution with a pH of less than 7.0 is considered to be
acidic
any solution with a pH greater than 7.0 is considered to be
alkaline
a solution with a pH of 7.0 is considered to be neutral
2012 Paradigm Publishing
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Properties of Parenteral
Products…/3
pH Value…continued
Human blood plasma has a pH of 7.4, which is
slightly alkaline
the pH of blood plasma must be maintained for optimal
health
Some facilities inject a buffer solution, such as sterile
sodium bicarbonate, into the CSP to neutralize the
pH and prevent patient discomfort
2012 Paradigm Publishing
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Properties of Parenteral
Products…/4
Osmolarity and Osmolality
Osmolarity is a measure of the number of
milliosmoles of solute per liter of solution (mOsm/L)
osmolarity refers to the osmotic pressure applied by a
solution across a cell wall
osmotic pressure is the pressure required to maintain
equilibrium within the cells
Osmolality is a measure of the number of
milliosmoles of solute per kilogram of solvent
osmolality refers to the number of ions or molecules in a
solution
2012 Paradigm Publishing
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Properties of Parenteral
Products…/5
Osmolarity and Osmolality…continued
Osmolarity and osmolality affect the flow of fluid into
and out of cells within the body
To maintain optimal health, the cells should be
maintained in a state of equilibrium
CSPs must be neither hyperosmotic nor hypoosmotic
this state of equilibrium is called isoosmotic, meaning that
the solution has relatively the same number of dissolved
particles and the same osmotic pressure as human blood
plasma
2012 Paradigm Publishing
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Properties of Parenteral
Products…/7
Tonicity…continued
A hypertonic solution contains a greater number of
dissolved particles than human blood plasma
A hypotonic solution contains fewer dissolved
particles than human blood plasma
An isotonic solution contains a number of dissolved
particles equivalent to human blood plasma
2012 Paradigm Publishing
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Properties of Parenteral
Products…/8
Tonicity…continued
Some conditions require treatment with a parenteral
solution that is either hypertonic or hypotonic
Total parenteral nutrition (TPN) and other hypertonic
solutions are generally administered into larger veins
such as the subclavian vein or the superior vena
cava
these larger veins have significantly more blood flowing
through them and can more easily accommodate the
hypertonic solution
2012 Paradigm Publishing
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Properties of Parenteral
Products…/9
Tonicity…continued
Unlike hypertonic solutions, hypotonic solutions, are
rarely administered to patients
occasionally, critical care patients who are experiencing
diuresis are treated with these solutions to replace the
high volume of fluid output without significantly increasing
plasma sodium concentration (PNa)
these patients must be monitored closely to ensure that
they do not develop a potentially life-threatening
electrolyte imbalance such as hyponatremia
2012 Paradigm Publishing
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Properties of Parenteral
Products…/10
Compatibility
Compatibility may be defined as the ability to
combine two or more base components or additives
within a solution, without creating a resultant
change in the physical or chemical properties of any
of the solution components or additives
a CSP comprised of one or more incompatible components
may result in a change to the physical or chemical
characteristics
this undesirable change is called an incompatibility and
may be dangerous to the patient recipient
2012 Paradigm Publishing
20. Topics20
Your Turn
2012 Paradigm Publishing
1) A solution with a pH of 7.0 is considered to be this.
a. acidic
b. alkaline
c. neutral
d. low
2) This type of solution contains a greater number of dissolved particles
than human blood plasma.
a. hypertonic
b. hypotonic
c. isotonic
d. isoosmotic
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21. Topics2121
Potential Complications of
Parenteral Therapy
Preparation Hazards
In fact, parenteral medications are considered to be
more dangerous than enteral products for several
reasons:
parenteral products are administered directly into a
patient’s blood supply, organs, or tissues
parenteral solutions injected into the bloodstream have
little or no chance of reversal if a medication error is made
parenteral administration introduces 100% of the drug into
the bloodstream
2012 Paradigm Publishing
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Potential Complications of
Parenteral Therapy…/2
Administration Hazards
All patients receiving parenteral fluids should be
monitored for nosocomial infection, extravasation,
tissuing, phlebitis, cellulitis, embolism, allergic
reaction (including anaphylaxis), Stevens-Johnson
syndrome, and nephrotoxicity
to manage these complications, healthcare practitioners
use various techniques, including the use of access points,
to administer LVPs
2012 Paradigm Publishing
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Potential Complications of
Parenteral Therapy…/3
Administration Hazards…continued
The most common access point is through a
peripheral vein, into which a nurse inserts a needle,
a catheter, or cannula, which is attached to IV tubing
this type of IV line is known as a peripheral IV line is most
often used for a patient who requires short-term
treatment
Patients who require long-term treatment may need
a PICC line
2012 Paradigm Publishing
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Potential Complications of
Parenteral Therapy…/4
Administration Hazards…continued
Other IV access points include the subclavian vein,
superior vena cava, or femoral vein
these access points are reached through the use of various
access devices such as the central line, Hickman line,
Broviac line, and various implantable ports
2012 Paradigm Publishing
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Potential Complications of
Parenteral Therapy…/5
Adherence to USP Chapter <797> Guidelines
In light of these potential complications,
IV technicians must adhere to strict aseptic
technique when preparing parenteral medications,
and healthcare personnel must be vigilant during
their administration to patients
2012 Paradigm Publishing
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LVP Preparations…/2
The most common LVPs are IV solutions
compounded from a standard solution or base
solution such as 0.9% sodium chloride (also known
as NS), dextrose 5% in water (D5W), dextrose 5% in
normal saline (D5NS), and LR solution
The most common volumes for LVPs are 250 mL,
500 mL, and 1000 mL
These IV solutions can be administered as either a
continuous infusion or a drip
2012 Paradigm Publishing
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LVP Preparations…/3
Continuous Infusion
A continuous infusion—also
called a maintenance
infusion, replacement
infusion, or hydration
infusion—typically consists of
a base solution with additives
2012 Paradigm Publishing
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LVP Preparations…/4
Continuous Infusion…continued
A continuous infusion is used to:
prevent or correct dehydration and restore electrolyte
balance in a patient whose condition impedes adequate
fluid consumption
replace fluids in a patient who has experienced significant
blood loss from trauma or a surgical procedure
provide easy vein access for blood draws and medication
administration in a patient during a hospital stay
2012 Paradigm Publishing
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LVP Preparations…/5
Drip
A second type of LVP solution is referred to as a drip
unlike continuous infusions, drip solutions are used to
continuously deliver an IV medication to treat a specific
medical condition
A physician may order an IV drip to be “titrated to
effect”
in this instance, a medication such as nitroglycerin is
administered at such a rate as to relieve the patient’s
chest pain
2012 Paradigm Publishing
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USP Chapter <797> Guidelines for
LVPs
During the preparatory and compounding
procedures of LVPs, the 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
As an IV technician, you bear primary responsibility
for the preparation and integrity of the CSPs
2012 Paradigm Publishing
32. Topics3232
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
For the anteroom, these include a standard
calculator, aseptic garb, presaturated aseptic
cleaning wipes, a waste container, and various other
compounding supplies
2012 Paradigm Publishing
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Understand the Resources and
Supplies…/2
Procedure-Specific Supplies
LVP Supplies – Vials
a vial is a sealed, sterile container that has a rubber top through
which an IV technician draws fluid
contains a medication either in a powdered form, which must
be dissolved with a liquid diluent, or in a liquid form
because a vial is a closed-system container, an IV technician
uses a milking technique to easily and safely release the
negative pressure within a vial
to perform this technique, the IV technician adds positive
pressure to the closed system
this technique prevents aspiration
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Understand the Resources and
Supplies…/3
Procedure-Specific Supplies
LVP Supplies – Vials
…continued
coring is an undesired
event that occurs when a
needle is inserted
incorrectly into the rubber
stopper atop a solution
vial, causing a small bit of
the stopper to tear off and
contaminate the solution
inside the vial
2012 Paradigm Publishing
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Understand the Resources and
Supplies…/4
Procedure-Specific Supplies
LVP Supplies – IV Base
Solutions
an IV base solution is
commonly provided by the
manufacturer in an IV bag
made of flexible plastic or
polyvinyl chloride (PVC)
2012 Paradigm Publishing
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Understand the Resources and
Supplies…/5
Procedure-Specific Supplies
LVP Supplies – IV Base Solutions…continued
the button or nipple injection port can be found at the
bottom of the IV bag’s face
the tail injection port, the most common type of IV
injection port, is located at the very bottom of the IV bag
2012 Paradigm Publishing
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Understand the Resources and
Supplies…/6
Critical Sites of Essential
Supplies and LVP Supplies
Before beginning, the IV
technician must recall the
critical sites of the supplies
care must be taken not to taint
the critical site of any of the
supply items through touch
contamination, shadowing, or
incorrect placement of the item
within the hood
2012 Paradigm Publishing
38. Topics3838
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
2012 Paradigm Publishing
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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
2012 Paradigm Publishing
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Preview the Lab Procedure…/3
LVP Compounding
Procedure
with the small supply
items arranged in the
outer six-inch zone
and the large supply
items placed in the
DCA, you are ready to
begin the LVP
compounding
procedure
2012 Paradigm Publishing
41. Topics41
Your Turn
2012 Paradigm Publishing
3) This is used to continuously deliver an IV medication to treat a specific
medical condition.
a. milking technique
b. continuous infusion
c. drip solution
d. aspiration
4) This is an undesired event that occurs when a needle is inserted
incorrectly into a vial’s rubber top.
a. tissuing
b. shadowing
c. coring
d. milking
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