Abstract Continuous technological enhancements in the quality

Abstract: Continuous technological enhancements in the quality of nutritional formulations and techniques for their parenteral administration have resulted in a significant improvement in patient care system. The capability to provide all essential nutrients by intravenous infusion, is called total parenteral nutrition (TPN), has sustained life and growth in patients who otherwise would not have been safed. Despite increasing improvements in total parenteral nutrition, a lot of slight deteriorations can occur to the patient which is a TPN-related incompatibility. drug-parenteral feed incompatibilities is due partly to the huge variability in composition of TPN solutions, and the range and concentration of drugs which may be administered simultaneously.Factors which affect drug and TPN stability and compatibility include:• composition of TPN regimen• contact time between drug and TPN solution:• brand and concentration of drug added• exposure of admixture to temperature and lightDrug compatibility is also critical in the supply of safe and effective drug therapy, multiple drugs may be administrated together to a critically ill patient and determining the compatibility of those agents is of great significance It’s estimated that over 30% of the commonly utilized drugs are incompatible when added or combined with other fluids or agents . The iv admixture incompatibilities include therapeutic incompatibility , physical incompatibility , chemical incompatibility , drug iv container incompatibility. While some general guidelines can be applied to the mixing of injection solutions, they are replete with exception and applicability varies with conditions. Mixing is best avoided. If conditions are so severe and it is urgent to mix any two or more solutions, there should be support from published compatibility data. A visual check examination for precipitation, turbidity or color change should be carried out before administering the mixture, but does not guarantee compatibility.Introduction: Calorie deficit compromises introducing of energy to our organism, which makes up a frequent and severe problem at I.C units. It is also accompanied with increase of complications , length of hospitalization and death rates. Parenteral nutrition (PN) is a vital therapeutic method for newborns, children and young adults under these conditions. A lot of indications use a variety of electrolytes and nutrients, which is a therapy that may supply calorie deficit and, therefore, assure fast and the best recovery. The ideal use of this complex therapy provides clinical benefits and reduces potential adverse effects .if a patient’s clinical status requires continous PN administration can drugs on the following list be administered through the same Y-tube with the PN (amino acid/dextrose) still running. Severe patients, in addition to PN, normally need a diversity of medications, solutions and blood transfusions. Co-administration of drugs with PN can be needed mainly in cases of limited venous nutrition. hence, chemical-physical incompatibility can occur between medications and PN. The role of clinical pharmacist is exactly to verify compatibility of injected drugs for infusion in parallel through the same venous access for PN. This verification must be done with extremely careful and comprise one of the last alternatives, because it would, whenever possible, avoid infusion due to risk of chemical-physical incompatibility. Keep away of formation of incompatible composition during infusion. Incompatibility can occur, for example, due to formation of precipitations that affect negatively and cause delay in recovery of inpatients.Parentral nutrition solutions are complex pharmaceuticals which provide nutrients, vitamins, trace elements and electrolytes. The similarities for physical and chemical incompatibilities between additives is high, and may be in the form of cracked PN or coalescence. Temperature, pH, concentration, order of mixing, light exposure and aeration are variables which require careful attention to ensure that interactions are minimized. Trace Elements Solution (TES, David Bull Labo- ratories) is routinely added to PN solutions to prevent deficiency states in patients undergoing prolonged parenteral hyperalimentation. It is reported that there is an incompatibility between aminophylline and elemental zinc injections during parenteral nutrition admixture. This interaction includes TES which contains zinc, copper, manganese and chromium which are transition metals and have the ability to form complexes. DRUG COMPATIBILY AND PARENTRAL NUITRITION The co-infusion of drugs and PN should be avoided. PN solutions are diverse in their composition and compatibilities with drugs can never be guaranteed. Drugs administered to patients receiving PN should be given through a separate IV site or catheter lumen. If a separate site is not available, the drug may be given through a separate line that has a Y-connection to the PN line as close to the patient as possible. The PN should not be running and the common tubing must be adequately flushed before and after drug administration. DRUDS ARE NOT COMPATIBLE WITH PARENTRAL NUTRITIEN: The following drugs are incompatible with PN and must not be run concurrently with PN solutions under any circumstances. These drugs may be administered through a Y-connection provided the PN solution is stopped, the line clamped immediately above the Y and the line adequately flushed.acetazolamide ,calcium ,doxorubicin ,phenytoin,acyclovir cefazolin etoposide , phosphate, amphotericin , ceftriaxone , furosemide , sodium bicarbonate , ampicillin cisplatin mannitol , ATG , deferoxamine , paraldehyde.Types of incompatibilities:1) chemical incompatibilities It is related to molecular rearrangement leading to chemical decomposition Which is caused by *Photolysis which can be prevented by using light proof containers *Oxidation reaction but we can prevent it by storing drugs in amber bottles 2) therapeutic incompatibility It is resulted from pharmacological effects of several drugs for one patient*example : heparin and antibiotics It is better to avoid mixing heparin with antibiotics in Iv administration as heparin can affect the stability of certain drugs 3)Physical incompatibility Which is resulted from solubility changes and container interactionsExample : physical precipitation of midazolam as result of unfavorable pHFactors cause IV incompatibility: *difference in pH*order of mixing*Temperature *Length of time in solutionHealth & financial consequences:Health consequences:• Toxic products that may be formed can cause some sort of tissue damage.• Separation and crystallization of some drug particles may form emboli .• PH changes may cause tissue irritation .• Failure of treatment may occur .Financial consequences:• Adverse effects may cause conditions that necessitate hospitalization with its added costs .• If respiratory complications resulted , additional healthcare is added .Preventive strategyI. Always check for compatibilityII. Standardize protocol for drug preparationIII. Check for alternative mode of administrationIV. Separation of drug doses by time and placeV. Usage of multi-lumen cathetersVI. Use in-line filterConclusion:The compatibility study of injectable drugs with parenteral nutrition and IV admixture has extremely importance, because it improve patient safety. incompatibility can occur by several mistakes, and most times has a harmful effect on the patient and may lead to death. so, this field should get a great interest and researchers should focus the light to this subject.and every pharmacist be careful to IV admixture and parentral nutrition.References:1. Templeton A, Schlegel M, Fleisch F, Rottenmund G, Schobi B, Hens S, Eich G, Multilumen Central Venous Catheters Increase Risk for Catheter-Related Bloodstream Infection: Prospective Surveillance Study. Infection 2008;36(4):322-272. Bergman H. Incompatibilities in Large Volume Parenterals. The Ann of Pharmacother 1977;11(6):345-60 3. Bertsche T, Mayer Y, Stahl R, Hoppe-Tichy T, Encke J, Haefeli WE, Prevention of Intravenous Drug Incompatibilities in an Intensive Care Unit. AJHP 2008;65(19):1834-40 4. Kanji S, Lam J, Goddard RD, Singh A, Goddard R, Fairbairn J, Lloyd T, Monsour D, Kakal J, Inappropriate Medication Administration Practices in Canadian Adult ICUs: A Multicenter, Cross-Sectional Observational Study. The Ann of pharmacother 2013;47(5):637-43 5. Westbrook JI, Rob MI, Woods A, Parry D. Errors in the Administration of Intravenous Medications in Hospital and the Role of Correct Procedures and Nurse Experience. BMJ quality & safety 2011;20(12):1027-34 6. Foinard A, Decaudin B, Barthelemy C, Debaene B, and Odou P, The Impact of Multilumen Infusion Devices on the Occurrence of Known Physical Drug Incompatibility: A Controlled In Vitro Study. Anesth & Analges 2013;116(1):101-06