Intravenous admixtures are sterile drug products added to IV fluids for medication purposes. They require strict aseptic technique during preparation to avoid contamination. Compatibility between drugs and solutions must also be considered to prevent precipitation or degradation. While IV admixtures provide benefits like convenience and accurate dosing, they carry higher risks than single drug infusions due to complexity and potential incompatibilities. Proper training and quality control processes are necessary for safe intravenous admixture preparation.

1. Intravenous
admixture

2. Content :
 Introduction.
 Definition.
 Preparation of IV admixtures.
 Incompatibility of IV admixture.
 Advantages and disadvantages of IV
admixture .
 Examples of intravenous admixture.
 References.

3. Introduction.
Intravenous admixture compounding is common practice in most
hospitals throughout the world, regardless of the country in
which one is practicing. Compounding intravenous medications
involves risk, as there is a high potential for error due to their
complexity in compounding and working in an aseptic
environment,
Numerous studies concerning the contamination rate in use
intravenous admixturehave been appeared,

4. so the intravenous admixture are prepared in laminer
Flowand there is no generate that the product will be
sterile .
The hospital pharmacist's professional responsibility is to
make sure that intravenous admixture he prepared for
adminstration to patients are of highest
quality, and one of paramters of this quality is sterility .

5. Definition :
 Intravenous admixtures are the preparations
consisting of sterile drug products added to an
IV fluid (s) for medication purposes.
 Intravenous admixture means a sterile parenteral
solution to which one or more additional drug products
have been added.

6. Preparation of IV Admixtures
1 Interpretation of the Order
Upon receipt, the pharmacist interprets the order, checks the dosage, and
checks =for incompatibility, instability, and contraindications by consulting
available reference sources.
If clarification of the order is needed, the pharmacist calls the physician, and
then notifies the nurse of the resultant clarification or change.
The pharmacist also checks the order against patient allergies and
diagnosis, addressographs the Profile Card with the patient's name and room
number, and records the name and dose of drugs added, and the name and
volume of IV solutions used. The intern or technician who prepares the
solution records the time of preparation and initials the IV Profile Card.

7. 2 Preparation of Labels
All IV admixtures prepared by the pharmacy are labeled according to
the
format illustrated in Figures 3 ,Sufficient labels are typed for a 24
hour period and paper clipped to the IV Profile Card. Continuous IV
Label Requirements :
1. Patient name. 2. Patient room number.
3. Additive strength and amount. 4. Primary IV solution.
5. Expiration date and time. 6. Prepared by.
7. Preparation time and date.
All labels are checked against the IV Profile Card before releasing to
the IV assembly area.

9. 3-Assembly and Preparation
The medication order and the IV Profile Card are attached to the completed
label. These are assembled with the needed IV stock solution, additives and
any transfer devices (syringes, nee dles, etc.) on a plastic tray prior to
preparation so that no additional items will be needed once the preparation
begins.
The prepared assembly tray is brought into the laminar hood and the IV ad
mixture is prepared. Work flow is from left to right in the hood. Only one
admixture is prepared at one time. Particu lar attention must be given to the
order in which drugs are added to the solution to prevent additive errors.
Attention must also be given to the additive list showing those additives that
(1) must be pro tected from light, (2) must be reconstituted with non-
preserved water, (3) must be buffered and (4) have limited stability.

10. All intravenous admixtures are pre pared in the laminar flow
hood using aseptic technique. All operations are car ried out in
such a way as to minimize the possibility of contamination of
the admixture.
All paper wrappings covering drugs or utensils should be
removed before setting down on the surface of the laminar flow
hood. Routinely, the laminar flow counter is swabbed with
alcohol, starting from the back and working forward.
4-Aseptic Technique

11. 5-Labelling and Check
The prepared label is stamped with the appropriate expiration date and at
fixed to the inverted IV bottle over the manufacturer's label so that the one
line identification of the IV solution label re mains visible.
Routinely, a 24-hour expiration date is stamped on the admixture label. How
ever, in the case of drugs which are stable for shorter periods (e.g.,
Ampicillin) the powdered form of the drug is dispensed in a plastic bag
attached to the solution to which it is to be added and dispensed with
directions for the nurse to reconstitute immediately prior to administering.

12. A registered pharmacist performs the checks:
1. The original order is checked against the label on the completed IV admixture for
accuracy and completeness. Particular attention is given to patient identity, identity of
drugs, amounts added, and solution used. The original order is checked against the label for
accuracy of volume of solution and accuracy of expiration date.
2. The original order is checked against the additive and amounts actually used by the
person preparing the admixture, as evidenced by the empty vials or ampules and the used
syringes.
3. Finally, the complete admixture is re checked against the candling unit and against a dark
background for particulate matter. Any evidence of foreign particles, coring or precipitated
material is cause for the admixture to be discarded.
If the pharmacist approves the admixture for use, he places his initials on the IV Profile Card
next to the initials of the person who prepared the admixture. The cards are then filed in the
IV Card Box in the Pharmacy.

13. Incompatibility of intravenous admixture .
I V admixture incompatibilities:-
Incompatibility may be between drugs, drugs and solutions,
drugs and container.
Types of incompatibility:
1-physical incompatibility:
it means incompatibility between drugs and i.v solution or
drugs with container and this lead to physical phenomena
as color change, precipitation,gas formation (effervescence)

14. 2-Therapeutic incompatibility: this is due to using of two
drugs have antagonist effect
e.g : metoclopramide, this drug increases GIt motility and drug
hyoscine, anticholinergic drug that decrease GIT motility
The previous two drugs shouldn't be mixed together in the
same syringe and the better is to wait half an hour between
them.
3- drug i.v container incompatibility
e.g : nitroglycerin, it's not better to put in back made polyvinyl
chloride to prevent the adsorption of nitroglycerin on the
surface of polyvinyl chloride and this lead to loss of doses
and concentration and therapeutic failure and should be made
from glass

15. 4- chemical incompatibility means that the drug is chemically
degraded, due to oxidation, reduction, hydrolysis, or
decomposition.
Chemical reactions can manifest themselves through
turbidity, precipitation and color changes
drugs and inappropriate IV solutions as diluent
two drugs (drug-drug incompatibility) when they are mixed
together, e.g. within the same infusion line(simultaneous
infusion) and/or IV container administered one after the other,
but within the same infusion line
drugs and adjuvants (preservative, buffer, stabilizer, solvent)

16. To reduce incompatibility
1- we should mix drugs and solutions as possible
and to minimise the number of drugs added
2-preparation should be freshly prepared
3- store it in relatively waterproof container
4-store it in place far from light

17. There are two forms of intravenous admixtures
A) large volume Parenterals : it is usually (500-1000 ml)
containers used for hydration or continous infusion of
medications.
B) small volume Parenterals : mini bags containing diluents
And has some advantages:
Wide availability of products-simple preparation-low cost-
availability to individualize doses .

18. Advantages of IV admixtures:
1- Lengthen expiration date
2- Time saving preparations
3- Provide nutritive fluids (glucose, electrolytes)
4- Quick onset
5- Supply large amount of nutrients to the body
6- Vomiting and unconscious patients could take
7- They provide effective, safe and high quality patient care
8- Poor absorption or instable in GIT drugs are suitable to be
taken through this preparation
9- Accurate and proper reconstituted drugs

19. Disadvantages IV admixture:
1-High risk of incompatibility
2-Need of skill and time
3-Requiring aseptic area, special equipment such as
refrigerator for storage
4-Requiring trained pharmacist
5-possibility of bacterial contamination

20. PH consideration
The effect of pH on solubility and stability is a critical factor in the
formulation of parenteral dosage forms and becomes more complicated in
intravenous admixtures since the additives and the vehicle may have
different pH values. This is especially important as a significant number of
parenteral medications require some compounding involving dissolution of
lyophilized powders, dilution of drug doses for infusion, mixing of dextrose,
amino acids, vitamins, and electrolytes for parenteral nutrition, etc. A change
in the acid-base environment of a drug involves both the solubility and
stability characteristics and can be critically related to pH as follows: (1) as a
solution goes away from the pH of maximum solubility, the drug can
precipitate out of solution, and (2) as the solution goes away from the pH of
maximum stability, the drug can degrade more rapidly and have a short
beyond-use date.

21. Examples of IV admixture
① Amphotericin B.
② Amphotericin B Cholesteryl Sulfate Complex
③ Ampicillin Sodium.
④ Epinephrine Hydrochloride.
⑤ Erythromycin Lactobionate.
⑥ Hetastarch.
⑦ Hydrocortisone Sodium.
⑧ Digoxin.
⑨ Dopamine Hydrochloride.

22.  Intropin (dopamine hydrochloride)
intravenous admixture
The stability of dopamine hydrochloride (intropin several large-
volume partentral solutions was studied.
Admixtures of dopamine were assayed by colormetric and
chromatographic procedures Admiras (800 og dopamine per in) as
the tollowing intravenous tuds i gass bottles a 6.115 or below were
found to be chemically and physically stable for at least 48 hours at
room temperature: detine 5%, dextrose 5% and sodium chloride
D5% 5% dextrosen 045% sodium chloride, dextrose 5% an lactated
Ringer's sudion, lactated Ringer's injection 0.9% sodium chloride, 15
molar sodium lactate and 20% mannel.

23. The admixture of dopamine in 5% dextrose was state for a
minimum of seven days at 5 C. & 3% dextrose-dopamine adute
polyvinylchonde bag was stable for at least 24 hours at room
temperature. The adriature of dopamine 5% sodium
bicarbonate solution produced an unstable solution of pH 520.
A chemical and physical change (development of a pink color)
was observed in this admixture .
It is recommended that dopamine not be added to 5% sudium
bicarbonate salution or any alkaline intravenous solution .

24. References
1) Bachman, S. 1 (1973). Intravenous Admixture Service Policy &
Procedure Manual Drug Intelligence de Clinical Pharmacy, 721, 84-
87.
2) Ausman, R. K. Holmes, C. J. Walter, C. W. & Kundsin, R. B.
(1980) The application of a freeze-microwave thaw technique to
central admixtime services. Drug intelligence d clinical pharmacy,
14(4), 284-287.
3) Buth, J. A. Coberly, RW.& Eckel, F. M. (1973). A practical method
of sterility monitoring of IV admistures and a method of
implementing a routine sterility monitoring program. Drug
Intelligence & Clinical Pharmacy, 7(6), 276-279. 4. Miller, W. A.,
Smith, G. L. & Latiolais, C. 1 (1971).

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you