Parenteral Therapy

Chapter 15

Parenteral Drug Preparation and

Dispensing
Parenteral drugs are used for a variety of
diagnostic, therapeutic, and palliative indications
Requires prescription from physicians
Physicians orders require interpretation by a
pharmacist
Pharmacists should know the patients age,
weight, diagnoses, and allergies

 The medication order may not give the pharmacist

all the information needed to prepare doses.
e.g
Ampicillin IV 1 gram every 8 hours
Intermittently or continuously; What the diluent will be; What the
concentration of ampicillin in the diluent will be; What the hours of
administration will be; The time over which the dose should be
infused; How many doses to prepare

 The pharmacist must determine whether the dose is in

an appropriate range for the patient, whether
there might be an allergic reaction, and what
incompatibilities to anticipate with other drugs being
given by the same route
Pharmacists decisions: standardized or patient-specific
Parenteral routes of administration may be prescribed
for a variety of purposes
e.g fluid and electrolyte replacement, nutrition or as a vehicle for a
prescribed drug

 Packaging
ampuls, glass or plastic vials, prefilled syringes,
cartridges, glass or plastic bottles, plastic bags, etc
Most injections are aqueous solutions of a drug but
there are some injections in the forms of colloidal
dispersions, emulsions or suspensions

 Small volume parenteral (SVP) containers

may contain a single dose or multiple doses of a
drug in a volume no greater than 100 mL
- IV piggy-back container (e.g. minibags or minibottles in
50 mL or 100 mL sizes) that carry a diluent for the active
drug

Small Volume Parenterals in the 2 to 5 mL range

most commonly utilize a luer lock or luer slip fit
(vented luer) top geometry. Syringes can be
connected directly to the ampoules without a
needle, creating an inherently safer delivery
method.

Applications for Small Volume Parenterals include

local anesthetics, vaccines, and other traditional
injectable products. The 10 to 100 mL range is
typically designed for multi-dose applications.

 Large volume parenterals (LVPs) are

manufactured in bags or bottles up to 1000 mL
-common container sizes: 150 mL, 250 mL, 500 mL, and
1000 mL
-typically contain fluids (e.g., sodium chloride 0.9%),
nutrients (e.g., dextrose), and electrolytes (sodium or
potassium chloride) or plasma volume expanders (e.g.,
albumin)

Large Volume Parenterals are typically

injectable products designed for intravenous
delivery applications. The large volume
parenteral bottles are most often produced
from a resin that can be autoclaved, either at
106 C or 121 C.

Infusion therapies fall into several categories that include the

following and more:
Antineoplastic therapy (a.k.a cancer chemotherapy)
Biologic therapy (e.g., active and passive immunizations, allergen
extracts, monoclonal antibodies, etc)
Diagnostic agents (e.g., contrast media, skin tests)
Emergency treatments (e.g., autonomic drugs, antihypertensives)
Intravenous sedation
Parenteral solutions (e.g., fluids and electrolytes)
Parenteral drug therapy (e.g., antibiotics, hormones, etc.)
Parenteral nutrition (e.g., total parenteral nutrition)
Patient-controlled analgesia
Radiopharmaceuticals
Transfusions (i.e., blood and blood components)

Advantages of parenteral route

administration
An immediate physiological response can be achieved,
which is a prime consideration in emergent clinical
conditions such as cardiac arrest, or volemic shock
Parenterals are required for drugs that are not effective
orally or that are destroyed by digestive secretions,
such as vaccines, insulin or some antibiotics
Medications for nauseated or unconscious patients must
be administered parenterally

 When desirable, parenteral therapy gives the

health care provider control of the drug, since
the patient must return for continued treatment,
such as situations when patients cannot be
relied on to take oral medication
Parenteral administration can result in local
effects for drugs as when local anesthetics or
anti-inflammatory drugs are injected at the
affected site

 When prolonged drug action is needed

-long-acting steroids injected into joints
-long-acting penicillins given by deep intramuscular injection

Parenteral therapy provides a way of correcting serious

disturbances of fluid and electrolyte balances
When food cannot be taken by mouth or tube feeding,
TPN requirements can be supplied into large veins

Hazards of Parenteral Therapy

The dosage forms must be administered by trained
personnel, and typically require more nursing time than
those administered by other routes
Parenteral administration requires strict adherence to
aseptic procedures, and can cause some pain on
injection
Once a drug has been given parenterally, it becomes
more difficult to reverse the physiological effects

Hazards of Parenteral Therapy

Because of manufacturing and packaging requirements,
parenteral dosage forms are more expensive than
similar drugs given orally
Infusion of a parenteral product or compounded
preparation into a vein can lead to phlebitis
(inflammation of the vein) or thrombophlebitis
(inflammation and a clot in a vein)

Hazards of Parenteral Therapy

PHLEBITIS
Early sign: tenderness at the insertion site of the
intravenous (IV) needle or cannula. As phlebitis worsens,
the vein becomes red, warm and painful with edema and
stiffness
Latter stages: the vein appears palpable, tender red
cord
Duration and effect: infusion phlebitis can last for a
week or more, can induce fever, and predispose the

Hazards of Parenteral Therapy

Factors associated with infusion phlebitis
Type of needle used
Duration of drug therapy
Chemically irritating drugs
pH of the infusion
Osmolality of the liquid
Location of the IV site
Decreased blood flow
Possibly, the presence of particulate matter in the
infusion

Hazards of Parenteral Therapy

Infiltration, extravasation, or the accidental intra-arterial
injection of some drugs can cause necrosis resulting in
tissue damage, even loss of a limb. Caustic or vesicant
drugs (e.g., chemotherapy) or vasoconstricting drugs
are most often implicated in these injuries.
Particulate matter has been reported in a variety of
manufactured and compounded parenterals, including
large and small parenterals, dry-filled and lyophilized
drugs, TPN, and others

Hazards of Parenteral Therapy

The intravascular infusion of excessive particulate matter
may clog capillary beds, contribute to phlebitis, and cause
formation of granulomas or foreign body reactions
Because of the hazards of particulate matter in compounded
sterile preparations (CSPs), pharmacists checking CSPs
should view the finished preparation against light and dark
backgrounds to detect visible particles or cloudiness
0.22 micron, 0.45 micron or 5-micron filter
-0.22 and 0.45 micron have the disadvantages of slowing the rate of
IV administration and more frequent fliter blockage

Hazards of Parenteral Therapy

INFECTION
due to the presence growth of a pathologic
microorganism
Intravenous infections:
-infusate related
-catheter related
-administration delivery system related