PRODUCTS STERILE Applies to parenterals, ophthalmics, inhalants, ear washes, etc. Sterility- absence of life or the absolute freedom of living organisms. No growth of organisms, bacterial, fungal, viral, parasites, etc. Bactericide- destroys or kills only bacteria. Some agents are selective for gram + or gram Bacteriostatic- inhibits or stops bacterial growth. Disinfectant- Kills or causes the absence of life in an area. Applied to nonliving objects. Antiseptic- Inhibits or stops bacterial growth. Applied to nonliving objects. Asepsis- Freedom from infection. Sepsis- Infected with a microorganism. Pyrogen- Fever producing substance. Pyrogens are biologic degradation or waste products of organisms. Cell walls, nuclear material, and cytoplasmic contents are the main offenders. Other substances can cause fever also. Parenterals in hospitals are prepared in laminar flow hoods using a REP A filter to remove organisms from the air.
PARENTERAL ROUTES OF ADMINISTRATION (from book)
A. Intradermal (ID) Most painful 1. Injection area: Located just below the surface of the skin (at the interface between the epidermis and dermis). Generally on the anterior surface of the forearm. This route is most often used for skin tests in which systemicabsorption is undesirable and could be dangerous (e.g., serious allergic reactions). The needle is inserted horizontally into the skin with the bevel facing upward. The injection is made when the bevel just disappears into the corium. 2. Volumes: Limited to small quantities, usually 0.1 mL, but may be as small as 0.02 mL and as large as 0.5 mL. 3. Syringe sizes: 1-mL syringes, often labeled "tuberculin" because these syringes were used to administer tuberculin skin tests. Unlike other syringes, these are available with and without needles attached. If a syringe is sent to a nursing unit with a needle attached, be certain the needle cover is snapped in place. If it is not sent with a needle, the syringe should be filled with 0.1 mL excess for priming the new needle. The syringe should then be labeled with a statement to this effect: "This syringe contains 0.1 mL excess for priming." 4. Needle sizes: 25-28 gauge (23-26 according to Christensen), 3/8- to 5/8-inch length B. Subcutaneous (Se, SQ, Sub-Q, Hypo) 1. Injection area: Subcutaneous fat tissue located beneath the skin between the dermis and muscle. When administering a drug subcutaneously, the skin may be pinched up to avoid giving the drug into the muscle. This route is used for insulin, injectable pain medication, and others where specified. 2. Volumes: Limited to approximately 1.3 mL, painful at more than 2 mL 3. Syringe sizes: 1 to 3 mL 4. Needle sizes: Depends on use. Insulin syringes have ultrafine needles of 30 gauge (a 32-gauge needle is planned), 1/2 inch; "hypos" are often 25 gauge, 1/2- to 5/8-inch length. Usually 2426 gauge. Insulin syringes come with the needle attached. It is
left in place for administering the dose after withdrawing the drug from the product vial. For other drugs, the needle used for withdrawing the dose is usually removed; a Luer tip cap is applied; and the nurse or caregiver selects and attaches an appropriate needle at the time of injection. In this case, excess for priming the new needle should be included in the syringe and the syringe labeled to this effect. Sciatic nerve C. Intramuscular (IM) 1. Injection area: Muscle mass: deltoid (arm), gluteus maximus (buttocks), vastus lateralis (top of leg). Any nonirritating drug can be given by this route. 2. Volumes: The volume administered is limited by the mass of the injected muscle. For adults, up to 2 mL may be given in the deltoid muscle of the upper arm, and up to 5 mL into the gluteal medial muscle of the buttock (these upper limits may be painful). For children, the volumes are more restricted. See Table 32.3 for guidelines. For small children, the vastus lateralis muscle is the recommended muscle because it is the largest muscle mass in children under 3 years of age and it is free of major nerves and vessels. The gluteus maximus is not well developed until a child has walked for at least 1 year. It is also avoided because it has a major large nerve, the sciatic nerve, running through the middle. For children up to 3 years, the maximum volume is 1 mL. Keep this in mind when making IM. injections for children. 3. Syringe sizes: 1-5 mL 4. Needle sizes: 20-22 gauge, 1/2-1 1/2 inches in length Guidelines for Maximal Amounts of Solutions to Be Injected into Muscle Tissues (7) Birth to 1 years 3 to 6 6 to 15 15 years to Muscle group 1 to 3 years (cc) (cc) years (cc) years (cc) adulthood (cc) Not recommended unless Deltoid Not recommended 0.5 0.5 1 other sites are not available 0.5 Gluteus Not recommended unless Not recommended 1.5 1.5-2 2-2.5 maximus other sites are not available 1 Not recommended unless Ventrog1uteal Not recommended 1.5 1.5-2 2-2.5 other sites are not available 1 Vastus lateralis 0.5-1 1 1.5 1.5-2 2-2.5 D. Intravenous (IV) 1. Injection areas: Veins. This route is used for fluid, electrolyte, and nutrient replacement; for administration of any drug that needs to get into the circulation immediately; for irritating drugs; and for drugs that require carefully controlled blood levels. 2. Volumes: Obviously, volume is less of a limitation with IV therapy. There are fluid restrictions about 3 L a day for adults and less for children. Certain disease states further
restrict fluid load. The flow rate may also be restricted by the size of the vein chosen for administering the drug. 3. Syringe sizes: 1-60 mL 4. Needle sizes: 20-22 gauge, 1/2-1 1/2 inches in length NEEDLES Note: The size of a needle is designated using two numbers, the length in inches of the shaft and the gauge (the diameter of the needle bore). Long beveled needles: inner and outer portion sharpened so you can inject straight down. Short beveled needles: usually used to prepare IVs, only the outer edge is sharpened. It is easier to accidentally "bore" someone (tear through the tissue) so you should go in sideways then down if you must use this to inject someone. Gauge: gauges 12-18 are older, bigger, and independent gauges 19-20, 21-22, 22-23... 35-36 are considered the same even though we can now produce separate gauges. gauges 31 and above are considered pediatric. CATHETER Indwelling catheter: plastic flexible catheter requires surgical "cutdown" : very painful Catheter over needle: most common in which you remove the needle and leave the catheter Needle over catheter: not used as much, needle acts like a "tunnel" down which the catheter is fed
Y-joint IV-TUBING Note: Sometimes "catheter" is used to mean IV tubing Y-joint: Used to add a second drug once an IV has started. The two fluids don't mix because there is not enough pressure to overcome the osmotic force. Used in a "piggyback." Butterfly: Used to tape down a needle. AMPULE Prior to WWII all drugs were packaged this way, now it's mostly only epinephrine, because the manufacturers don't want to send it through the FDA again. Butterfly
LARGE VOLUME PARENTERALS (indications) Over 100 mL, large volume is more of total expense at a hospital than small volume, because of the sheer amount of large volumes given. 1. IV Maintenance Therapy (For fluid and electrolyte balance) biggest use of large volume IV (75%) Replace normal water and electrolyte losses (Na,K,CI,HCO3 possibly) in an uncomplicated surgical patient Lose water by urine 500-1500 ml per day insensitive water loss, ~800ml per day by sweat and respiration. lose about 25-40 ml/kg/24hrs for 70 kg person = 1750-2500 ml/24hrs Na requirements 100-200 mEq K requirements 50-150 mEq lost in kidneys (urine) 2. Replacement Therapy (for replacement of fluids and electrolytes) Replace like with like: added above what is required for maintenance for severe diarrhea (isotonic fluids), acute bleeding (replace with blood), sweat (hypotonic) (give hypotonic fluids)-not really very salty 3. Drug Vehicle Least common purpose for Large Volume Parenterals (5%) Dextrose 5 % inj. (D5W) or 0.9% Sodium Chloride (Normal Saline) Complications of Large Volume Parenterals Fluid 1. overload (too much too fast)- leads to CHF or Renal failure: over 3 L in 24 hours 2. Septicemia- infections due to non-sterile preparation. Compounding pharmacies are getting into trouble over this. 3. Induration- overuse of injection site causing swelling and hardening 4. Thrombosis: not common unless small particles get into the IV, immediately life threatening. SALINE SOLUTIONS pH 6.5-6.8 because CO2 (carbonic acid) in solutionSodium Chloride 0.9% Normal Saline (NS); nonbacterial static agent; one time use only; 154 mEq Na per Liter (isotonic with plasma); primary use is to replace extracellular fluid volume Sodium Chloride 0.45 % (Half strength Normal Saline or 1/2 NS); hypotonic and will lyse red blood cells (77 mEq/L); usually combined with D5W; if not check why it is being used; Replaces both intracellular and extracellular fluids; Used also as irrigating solution; life and death use Sodium Chloride 0.22% (1/4 strength Normal Saline); severely hypotonic must be used with D5W; used in irrigation of the bladder Sodium Chloride 1.8%, 3% and 5%; used to replace true sodium deficits; we rarely see this because normal saline works.
DEXTROSE SOLUTIONS Mainstay of IV therapy, often in 50 mL, but we call them large volume parenterals anyway. Dextrose (glucose) 5 % injection (D5W) isotonic with blood; Use as a water source and vehicle; not a good calorie source (need 2000 Kcal per day); dextrose anhydrous gives 3.4 Kcal/gm ~ 4 Kcal/g (50 x 4= 200 Kcal/L) or 170 Kcal/liter; pH = 4-5.0 and can irritate veins. Caused by the addition of HCI during manufacture so solution won't caramelize or turn brown. Dextrose 2.5% and 10% available (D2.5W, D10W) Dextrose 20%, 50%, and 70% for Total Parenteral Nutrition (TPN) a liter of 50 % dextrose provides 1700 Kcals SPECIALTY SOLUTIONS Potassium Chloride KCl cardiotoxic; 10 mEq/5ml, 20 mEq/10ml, 30mEq/15ml, and 40 mEq/20 ml (2 mEq/ml is 149mg/ml); 1.15% KCl is isotonic with blood (10 ml is diluted with 100 ml purified water for injection is isotonic); more dense than water and settles to bottom so have to shake well to mix up; infused at maximum rate of 10 mEq_r; 10mEq/100mI is irritating to veins. Sodium Bicarbonate NaHCO3 (Alkaline); 1 mEq/ml (50 ml syringe) or 5 % solution which is 500mIs; used to treat metabolic acidosis. Sodium Lactate (Alkaline); 1/6 M isotonic; used to treat acidosis also Acidic IV solutions (NH4Cl ammonium chloride 2.14% and HCI Hydrochloric acid 0.15N) admixture given via central line to inferior vena cava; Both are used to treat metabolic alkalosis AMINO ACID SOLUTIONS Concentration of Amino acids for Aminosyn II: 3.5%, 5%, 7%, 8.5%, 10% Other Brand Names: FreAmine Ill, Novamine, Travasol Common Volume sizes: 250ml, 500ml and 1000 ml. pH ranges between 5-6.5 3.5% solution is isotonic, others are hypertonic FAT EMULSIONS Most commonly soybean oil (Intralipid, nutrilipid, Liposyn III, Soyacal), but may also be half soybean and half safflower (Liposyn II); Common Volume sizes: 25 ml, 50 ml, 100 ml, 250 ml, and 500 ml 1.1-2.0 Kcal/mL (?) pH range from 6-8 osmolarity; 260-315 (approximately isotonic)
OSMOLARITY Iso-osmotic: Solution has equal osmolarity with the plasma Isotonic: Same meaning/definition as Iso-osmotic Hypertonic: The osmotic pressure is greater than plasma osmolarity Hypotonic: Osmotic pressure is less than plasma osmolarity (Both D5W and NaCl are Isotonic how they are prepared) Crenation: A shrinking of the cells, this occurs to RBC when exposed to a hypertonic solution Lysis: The bursting of RBC, this occurs when exposed to a hypotonic solutions (This can occur in less than a second of exposure to a hypotonic environment) pH: A major of acidity or basity, physiological pH is 7.4 mEq can be thought of as the moles of charge present Plasma osmolarity = 280 ~ 300 mOsm/L Osmolarity of normal saline 0.9 g x 10 dL x 1 mmol x 2 particles = 308 mOsm/L 100 mL L 58.5 mg note: really only 1.8 particles so osmolarity = 277 mOsm/L Osmolarity of Dextrose 5% in water (D5W) 5 g x 10 dL x 1 mmol x 1 particles = 278 mOsm/L 100 mL L 180 mg Extracellular Fluid (ECF) Sodium Potassium Protein Chloride Bicarbonate Phosphate/Sulfate Magnesium Calcium 142 mEq 4-5 mEq 15-25 mEq 100 mEq 25-30 mEq 2-5 mEq 2-3 mEq 5 mEq Intracellular Fluid (ICF) 10 mEq 140-150 mEq 40 mEq 2 mEq 8-10 mEq 150 mEq 35-40 mEq 3 mEq 2/3 total volume (30 L)
Water 1/3 total volume (15 L) NAMES OF INJECTIONS
(Drug) Injection: A drug packaged ready for injection with no solvents (insulin injection) Sterile (Drug): A drug which when mixed with a solvent will be ready for injection (sterile ampicillin) (Drug) for Injection: A drug with a buffer which when mixed with a solvent will be ready for injection (methicillin for injection) Sterile (Drug) Suspension: A suspension ready for injection- not IV (sterile cortisol suspension) Sterile (Drug) for Suspension: Dry solids which when mixed with a solvent will be read...