Rachel Phillips

[Rachel Phillips]

more detailed picture is needed before attempting to fix electrolytes levels through PN. Adding right amount of electrolytes can only happen when you identify the causes. Here are some thoughts:

1. Hypomagnesemia: Drug induced i.e. Insulin, Diuretics? Is it hypomagnesemia induced by Hypokalemia? Extra Dextrose? The key is to reduce dextrose in PN and correct hypokalemia.

2. Hypokalemia: Is it due to Alkalosis induced by Diuretics? Extra dextrose/insulin? Excess GI losses? Try ranitidine 100mg in PN. Lower dextrose. Correct acid-base.

3. Hyponatremia: 90% of Hyponatremia is fluid overload. Check blood and urine Osmolarity and identify why Hyponatremia: R/O Hyperglycemia-induced Hyponatremia. Don’t add more than 155mmol/L.

Note: There is no limit on how much Mg and K can be added to PN assuming the patient has massive GI losses. If not, and if the the case is intracellular shift due to acid-base or drug-induced, then be more conservative.

The key to success with electrolytes correction is identifying the of etiologies.

[Rachel Phillips]

I was thinking about this topic a little bit more and I thought it might be helpful to share 2 other stories from my experience. To me they reinforce the importance of thoroughly cleaning the hoods and challenges with the current hood designs.

At one of the hospitals I worked at very early in my career I was told not to ever clean the metal grate that protects the HEPA filter. Initially, I just took the information and obeyed the command. After several months of working I started to notice all sorts of dried crud on the grate. I assume that it was from vials that were over pressured and then squirted their contents onto the grate. The stuff on the grate was there for months. Looking back on it now with our current understanding of bacterial or mold growth, if water can get on the grate then it’s possible for things to grow on the grate, therefore, it’s important to clean the grate. It’s also a very real concern that without careful cleaning, the HEPA filter can be damaged. Damaging the HEPA filter would be disastrous for your ability to maintain an ISO 5 environment in the hood, and potentially put your compounding operation at risk. I don’t actually see this as either you clean the grate and damage the HEPA filter or you leave the grate uncleaned and accept the risk of contamination growth. I believe you can train the people that will cleaning the hood to do so in a way that does not damage the HEPA filter.

Speaking about hood design, early on in my experience as a technician I noticed that there were parts of the hood that were not easy to access and thoroughly clean. On the vertical flow hoods that I worked with there is an air intake on the front of the hood to allow air to pass under the Direct Compounding Surface and recirculate the air. The problem was that the opening allowed for the collection of all sorts of dirt and unclean things. Because there was an area under the Direct Compounding Surface it wasn’t routinely looked at or cleaned. I can’t find the pictures right now, but I lifted up the Direct Compounding Surface and cleaned that space. It was disgusting. One could argue that the risk of contamination would be low since the air passing through that part of the hood still passes through a HEPA filter before it gets to the Direct Compounding Surface, but to me there are a lot of ways that the situation could be problematic. These experiences are why I’m much more in favor of designing a clean room without using hoods, but building the HEPA filters into the ceiling and using a more architectural solution to creating the clean room. All parts of the clean room are easy to see and easy to clean. To me, it’s a much more elegant design and solution.

[Rachel Phillips]

I understand the concern of deteriorating the HEPA filter. To me this all comes down to training the person who is going to clean the hood. In one of my previous hospitals the technician cleaning the hood used a spray bottle of alcohol to spray the metal grate. They didn’t realize that they were also spraying the the HEPA filter and they caused rapid deterioration of the HEPA filter and it needed to be replaced.

However, if the procedure is to wet a non-shedding cloth with water/sterile alcohol/germicidal detergent and then to wipe the grate there should be less likelihood of damage to the HEPA filter.

The key is to properly train the staff, and help explain why certain parts of the procedure are important.

[Rachel Phillips]

* Regarding the calculation and the infusion rate mentioned in “the 60 kg” example .
Being infused at 0.1ml/kg body weight/ hour for 10 minutes, means 6 ml/hr and the infusion time is 10 minutes = infusing 1ml over 10 minutes =setting the infusion pump into the following rate: 6 ml/hr and the infusion time is 10 minutes, and it doesn’t mean infusing the whole 6 mls over 10 minutes.

*The second issue, you can then increase gradually the infusion rate to the final infusion rate in order to avoid the side effects of the IgA which is usually responsible in the ADRs that happened with the infusion like the hypotension and allergy like reaction … so these reactions could happen “falsely ” if the products infused very fast and your will be denying the patient from getting the product.

In IgG infusion most of the ADRs are related to the infusion rate, so there should be a plan for the nurse what to do if she see these ADRs : headache, backache, myalgia, elevation in body temperature, chills abdominal pain, chest tightness, hypotension or hypertension, flushing, & N/V.
So, the safest way to handle this issue is to gradually double the rate after the first infusion q 15 for half an hour after that infuse the remaining over 60 minutes. Some patients could tolerate the product very well if infused very slowly.

*Third, it is always recommended to pre-medicate with acetaminophen and diphenhydramine . Also, don not infuse the product above 4 hrs as this a blood product, i.e. the minimum infusion time is 2 hrs and the maximum time 4 hrs.

*Fourth, Closely monitor the patient for the first 10 minutes and each time the rate is increased. The most of the infusion reactions occur is 30 to 60 minutes after the initiation and each time the rate is increased. Continue to monitor the patient as appropriate throughout the transfusion for changes in vital signs and symptoms of adverse reactions and for at least 20 minutes after the finish of the infusion.

* Finally… in general having printed infusion instructions ( or form) for IV immunoglobulin available to the nurse with instructions of what to do if she suspect an infusion reaction ; will contribute a lot to the safe infusion practice and will identify true allergy from just an infusion reaction that can be managed by decreasing the rate.

One more thing , when you want to select an IgG product to add it to the formulary always consider the IgA content of each product available in the market because this will relief you from a lot of infusion rate related problems.

[Rachel Phillips]

Infant or pediatric amino acids formula are recommended for the age under 18 months and strongly recommended for babies under the age of 6 months.
There are major differences between and infant or pediatric amino acids versus adults PN formula or we called standard amino acids and renal and hepatic amino acids formulas:
Infant or pediatric formula has the followings:
1-Low concentrations of methionine, phenylalanine, and glycine. Giving standard or adult amino formula what have very high concentrations of these amino acids and due to immature organ and enzymatic system, they lead to accumulation of these amino acids that have a potential harmful to the babies, like GI upset, affecting blood hemostasis, and possible brain damage.
2- It contains Taurine which plays a role in prevent cholestasis associated with PN and it is important for retinal development
3- It contains Cysteine which enhance the solubility of calcium and inorganic phosphate (if organic phosphate is not in use.

in case of a shortage, it was advised that the standard amino acids should NOT BE used for more than 3 days. There are many pediatric
formula options like Primine, Trophamine, Vaminolact, Aminoven infant in the market.
If PN is to be continued with adult amino acids, standard amino acids formula, you may continue with very low dose 0.5 gm/kg/day, even I Don’t like this approach.

[Rachel Phillips]

If you want the pharmacist to order PN or to offer clinical consults on PN then you require special competencies i.e. BCNSP, clinical PN internship, PGY-2, etc. If your system requires pharmacists to verify and process  orders and compounds PN then you require different types of clinical and technical competencies.

With above data, if you plan to prepare all Compounding Sterile Preparations in the Pharmacy, you should expect around 2.5 CSPs per bed day i.e. around 300 CSPs per day + 20 PN per day. The required space is around 50-60 meter square minimum.

Ideally each technician should be able to compound 100 CSPs per shift. You would require 2 FTEs for IV Pharmacists (operational) and 5-6 FTEs Pharmacy Technicians (depend on duty hours, vacation days, male:female ratio, etc.) to cover 24/7. If you plan to have a Clinical Pharmacist to round and order PN then this is an extra FTE.

[Rachel Phillips]

1. The key to success is the exposure to best practices… Workflows and technologies are very important. Consider to spend few days in hospitals with best practices.

2. Competencies-Competencies-Competencies: Are you willing to have a pharmacy-based compounding service or combined with pharmacy-based consulting/ordering PN service? If you develop the experts, your are 80% there!

3. What is your bed number, scope of practice (neonates, peds, adults, critical care, etc.), allocated space in pharmacy, number of pharmacy FTEs and your BUDGET, then we will guide you further on how to proceed! I strongly believe that Experienced Leaders can do MAGIC with any available resources.

4. I truly appreciate seeing such a consult. I have seen few hospitals who started PN services without solid knowledge and confidence, that had failed few months after starting the service. Main reason was lack of competencies and exposure to good practices.

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