Instructions on how to compound a sterile IV product in a hood while gowned and garbed appropriately:
- Assemble appropriate drug(s) and diluent; complete documentation of lot numbers, expiration dates & manufacturer name if not completed already. Affix auxillary labels as appropriate.
- Take the drug(s) & diluent to the appropriate hood to compound based on the information on the label.
- Hazardous drugs will be prepped within a class II, Type B2 Biological Safety Cabinet, in the ISO Class 7 negative pressure room.
- Non-hazadous drugs will be prepped in a laminar air flow hood in the ISO Class 7 positive pressure room.
- Assemble approriate syringe(s), needle(s), and alcohol swabs as required.
- For hazardous drugs requiring safe handling precaution, use the closed system transfer device (CSTD) on the vial and the syringe tip.
- Use P14 (blue cap) for vial size of
< 20 mL
- Use P50 (green cap) for vial size of
< 50 mL
- Inspect vials for particles and discoloration before removing vial caps; wipe rubber tops with alcohol swab.
- If drug requires reconstitution, obtain pharmacist precheck of the volume of diluent to be reconstituted with the drug.
- Draw up the amount of drug as directed according to the preparation label; eliminate air bubbles from the syringe.
- If the volume added to the bag is ≥ 10% of the volume of the diluent, then remove the same volume of diluent as the drug volume prior to adding the drug volume (e.g., if adding 30mL to a 250mL bag, then remove 30mL of diluent first).
- Overfill volume average per manufacturer:
- 50 mL = 5 mL
- 100 mL = 10 mL
- 250 mL = 30 mL
- 500 mL = 50 mL
- 1000 mL = 50 mL
- Place all items for checking in the pass through chamber.
- Pharmacist to perform quality review by verifying: all calculations are correct; ingredients are drawn up with correct volume and are free of particulates, cores, and discoloration; the selection of tubings, filter needle (if needed), base solution IV bags and auxillary labels are correct; and the expiration date is correct.
- After mixing, compounding technician will sign the bag product label indicating they compounded it.
- Place in amber bag if light protection required
- Dispose of waste in the appropriate waste container