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Regular Visitor
Posts: 3
Registered: ‎09-28-2017
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Best practice in IV room: tubing and reconstitution

Recently we had some management changes, which prompted our IV compounding procedures to be tweaked. These are changes I am not very comfortable with, so I was hoping for some feedback. The two changes I am uncomfortable with are reconstituting our chemos and mabs with fluid from the infusion bag instead of a separate vial, and using the fluid from the bag to prime the tubing. Historically, we reconstitute from a vial of appropriate diluent, and prime from a separate bag. By priming from a separate bag, we are keeping the volume of the bag true (tubing is roughly 20ml, the proposed change is to prime from bag and not account for this volume on the label or compounding instructions or final concentration). Please let me know if my concerns are valid, and what you think best practice is for mixing chemos and mabs. Thank you very much for your time!

Expert
Posts: 1,152
Registered: ‎02-23-2010
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Re: Best practice in IV room: tubing and reconstitution

I am trying to understand the different processes.  It is not uncommon to use a bulk of bag of sterile water to reconstitute medication vials. These bulk bags must be treated as a single-dose container (used for no more than 6 hours).  I, too am concerned that the priming the infusion tubing from this bag.  Usually, this is done from the final solution bag prior to adding the medication to the bag. Hope this helps.

Eric S. Kastango, MBA, RPh, FASHP

It's all about the patient.
Regular Visitor
Posts: 3
Registered: ‎09-28-2017
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Re: Best practice in IV room: tubing and reconstitution

Thank you so much for your reply! I'm not sure I was very clear in my original question...my apologies! Currently, we reconstitute from a 10ml or 50ml vial of appropriate diluent, and prime the tubing from a separate NS or D5 bag. There is a proposed change to take fluid from the infusion bag out, reconstitute the chemo with this fluid, then add it back in the bag. Priming would also come straight out of the infusion bag before any chemo is added. My concerns are that I've almost always seen reconstitution from a separate vial, not the infusion bag, and there is also about 20-25ml volume you are losing by priming directly from the infusion bag. In these cases, we aren't accounting for the lost volume, and I know some chemo is very concentration specific. I realize there is some overfill to the bags, however I am hesitant to agree with these changes because I've never seen it done this way. Hopefully that wasn't too confusing! Let me know if you have any thoughts, and I really appreciate your time!

Occasional Advisor
Posts: 13
Registered: ‎03-06-2017
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Re: Best practice in IV room: tubing and reconstitution

I found your question to be intriguing, so I wanted to tell you how this is done at my facility just as something to consider. I've been at my Oncology Infusion Pharmacy for about 10 years, and we've always done it this way: We have our sodium chloride or dextrose bag hanging (that will eventually be delivered to the patient), we attach the tubing to the bag, then we prime the tubing right from the bag. If the drug is all ready in liquid formulation, we draw up the drug and push it into the bag. The total volume on the bag we send over to the patient will be the bag size (i.e. 500ml) plus the overfill (i.e. 40ml) plus the drug (i.e. 20ml), to make a total volume of 560ml. If the drug needs to be reconstituted prior to being drawn up for the dose, we mix it with fluid from the bag, a vial of sterile water, or other vial that the PI states it needs to be mixed with. Sometimes that 540ml bag (including overfill) is more than 540ml or less than 540ml when it is ready to be sent to the patient. My point is, this has worked for us for years, much longer than I've been an employee here. Just have to make sure the total volume on the label states as closely to what is actually in the bag. I believe our nurses set their IV pumps to a larger volume than what our label state just in case there is a few extra ml's in the bag. We do not draw out the overfill simply because it's an extra time consuming step that isn't necessary for our practice. Hope this helps a little bit!

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Regular Visitor
Posts: 3
Registered: ‎09-28-2017
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Re: Best practice in IV room: tubing and reconstitution

Thank you so much for your input and time! This is very helpful, and I really appreciate it!

Frequent Visitor
Posts: 1
Registered: ‎11-14-2017
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Re: Best practice in IV room: tubing and reconstitution

Given your experience with this process, have you had any issues with deviations in infusion times for smaller volume bags (100 mL or less) contributed to the 15-20 mL used to prime the line?  Our department is currently expressing some concern with this (for study medications in particular) that do not allow much room for deviation in expected infusion times (drug in a 50mL bag + 7mL overfill + 8mL drug volume.  Removing 15mL from a bag this size to prime the line would create about a 26% difference between labeled volume and the volume actually in the bag.  Do you follow a different process for lower volume bags or follow the same process across the board?