Presentation on theme: "Aseptic Technique and USP 797 Definitions Asepsis is the state of being free from the presence of pathogenic microorganisms. Sepsis is the state of being."— Presentation transcript:
Aseptic Technique and USP 797 Definitions Asepsis is the state of being free from the presence of pathogenic microorganisms. Sepsis is the state of being contaminated by pathogenic microorganisms Septicemia is the presence of microorganisms in the blood Septic shock is the condition of overwhelming infection of the blood by septicemia. Aseptic technique is the procedure used to maintain an aseptic environment in which to compound sterile products CSPs Aseptic technique strives to maintain surgical asepsis. (meaning complete sterility and lack of endotoxin )
USP 797 rules United States Pharmacopeia 797 chapter on compounding of sterile products (CSP) was published in the 27 th revision to USP on January 1 st, 2004 USP 797 is applicable to all facilities where compounded sterile products (CSP) are made, stored and sent to the patient USP 797 applies to the aseptic technique used to make CSPs as well as the environment in which it is done (secondary engineering controls)
Microbial Risk Levels in USP 797 Low risk CSP Made under ISO5 conditions Involves aseptic transfer of manufacturer based sterile products using sterile equipment (i.e Needles and syringes) to compound IV admixtures. Does not involve open systems and no more than 3 components Medium Risk CSP Same as Low risk CSP but additionally More than three components are a part of the IV admixture (i.e TPNs) CSP dont contain antimicrobial preservative and product is given over more than 2 days Complex preparation involved High Risk CSP Same as Low risk CSP but additionally Compounding of manufactured ingredients that are non sterile and then performing terminal sterilization Performing compounding in condition outside ISO5
Risk Levels and Expiration Dating Low Risk CSP In the absence of sterility testing 48 hrs at room temperature 14 days under refrigeration 45 days frozen state Medium Risk CSP 30 hrs at room temperature 7 days at refrigeration 45 days at a frozen state High Risk CSP 24 hours at room temperature 72 hours refrigerated 45 days at a frozen state.
Hospital Compounding For the most part you may be preparing only low or medium risk CSPs Example of a low risk CSP Making a 50 ml SVP with 1 gram of vancomycin under ISO5 conditions Example of a medium risk CSP Compound a triple mix TPN with additional additives of insulin, multiple vitamin injections, and other electrolytes Example of high risk CSP Compounding a sterile ophthalmic solution from a manufactured product that is not sterile and passing solution through a 0.22 micron filter several times
Air Quality and Cleanness ISO stands for international organization for standardization ISO was formed in 1947 in Geneva Switzerland Provides different levels of air quality cleanness ISO 5 means no more than 100,000 particulates 0.1 micrometer or larger per cubic meter. By contrast, room air is classified as ISO9 which is no more than 1,000,000,000 particulates per cubic meter. (a ten thousand fold difference)
Anteroom Usually consists of a storage area, an area for records, computers and printers, an buffer area for gowning Has ISO class 8 standard (i.e 10X cleanner than normal room air) Has a sink equipped with surgical scrub soap (Chlorhexidine), and has handfree or pedal activated water systems Has the following characteristics: Smooth walls with panels locked and sealed Vinyl covered floor with seals heated together Joints and junctures between walls and ceilings must be chauked with no visible cracks.
Clean Room The room where the LAFW hoods are located Means same physical characteristics as anteroom No sinks and floor drains If facility only compounds low and/or medium risk CSPs the clean and ante rooms need not be separated. Area immediately next to LAFW hoods is called buffer area If all risk levels are compounded clean and ante rooms must be separated. Must be maintained as a positive room air pressure environment if separated.
Maintaining of ante and Cleanrooms Cleaning requirement BSC or LAFW = beginning of shift, before each preparation, 30 minutes into the procedure, when surface is visible contaminated Cleaning of all floor surfaces daily from the buffer area outwards, from the clean room out to anteroom. Countertops: daily Cleaning and disinfection of all shelving surfaces at least monthly Walls, Ceilings: monthly Documentation of such maintained Cleaning solvent required by USP for ISO5 and countertops: Isopropyl Alcohol USP 70%
Laminar Air Flow Hoods and Workbenchs LAFH and workbenchs are designed to blow parallel sheets of sterilized clean air over a work surface The hood is usually washed and disinfected with 70% isopropranol by a pharmacist at the beginning and end of the shift. Washing is from top to bottom of the hood and back to front in the direction of laminar flow. HEPA filters remove over 99% of particles, including microorganism 0.3 microns or larger. When cleaning the HEPA filter grill do not spray the filter always spray the sterile gauze pads and clean the surface of the grill If the HEPA Laminar flow hood is turn off for any reason then it must be turn on for at least 30 minutes before commencing any IV preparation. Horizontal Laminar Flow Hood: the HEPA filter is at the back of the hood and blows laminar air towards the operator Vertical Laminar Flow Hoods: the HEPA filter is on the top of the hood and laminar air flow sheets are blown to the work surface and not to the operator Also called a biological safety cabinet Must be recertified every 6 months
Biological Safety Cabinets Class I open system that draws air from the cleanroom Class II air is recirculated through vents in the front and back and passed though a HEPA filter on the top of the cabinet back down to the worksurfaces. Four types A, B1, B2, and B3 Type A is not vented to the outside Type B1,B2,B3 all provide some or all exhaust to the facilitys external vent system. Class III are completely enclosed system under negative pressure which are vented. Manipulation by the operator are with a gloved apparatus through the front of the cabinet
Preparing to make an IV product Enter the cleanroom with slow and deliberate movement. Remove jewelry and tie back loose hair. Put on shoe coverings (booties) and then proceed to anteroom. In anteroom, perform antiseptic washing of hands which includes washing hands and washing between fingers as well as using fingernail buffer pad to clean under the fingernails. Wash hands up to the elbows and rinse hands first allowing water to drip down to elbows. Don surgical gown, hair cap, beard cover (if needed) and surgical mask if working with a hood with no front panel. Gather syringes, needles, IV bags (with cover removed) Perform second antiseptic handwash. Donn powder free surgical latex gloves Enter Buffer zone Place all products into the laminar flow hood.
Remove all caps to vials. Swab each vial with alcohol swab from back to front once with swab. Swab medication port of the IV bag that you will use. All products should be 6 inches inside the hood. Arrange materials in such as way as to not block any of the laminar flow air currents. Once inside the hood, your hands should not leave the inside of the hood. If they do you will need to sanitize your gloves before returning to the hood area. Always remember not to touch critical areas
The following are critical areas which must not be touched. All parts of the needle. The hub of a luer lok syringe The ribs of the piston of the syringe. The injection port of the IV bag. The rubber entry port of the vial
Remember, touch is the number one cause of product contamination. Human skin harbors many organisms: Staphylococci, Streptococci, Actinobacter, Candida, Tricophyton Rubrum fungi, Pseudomonas, etc. Contaminated IV products can cause bacteremia and fungemia, septic shock and death. I will demonstrate aseptic technique in class with reference to drug manipulation.
The Finished products If you are a pharmacy technicians that will be performing IV admixtures. Always leave the following item for the RPH to check: All vials used in the process All syringes used in the process drawn back to the volume you used. All information recorded in the IV prep log book: Patients name, medical record number, drugs, concentrations, volumes used, lot number and manufacturers expiration. Assigned a pharmacy expiration date (usually 24 hours at room temperature)
IV products continued ALL Intravenous products must be clear to the eye. Cloudiness or discoloration could indicate a physical or chemical incompatibility. Cloudiness indicates a drug has come out or precipitated out of solution. One example of this is mixing phenytoin sodium (Dilantin®) in D5W solution. A cloudy haze forms in the IV bag on standing. A second example is in TPN, addition of calcium gluconate in a solution of high phosphate can cause calcium phosphate to come out of solution A third example is excessive shaking and agitation of a solution of mannitol. Mannitols needle like crystals can be seen after such agitation.
A great reference to use to determine drug-drug, drug-IV solution compatibilities is a book called, Trissels Handbook on Injectable Drugs® Common causes of physical and chemical incompatibilities are: Drugs mixed in low pH solutions, like D5W Drugs mixed in hypertonic solutions, like D5WNS Drugs mixed in incorrect IV mediums. Such drugs are not compatibility in the PVC container of an IV bags; these drug are mixed in glass IV containers. A class example is nitroglycerin which is used for patients with acute MI. Drugs mixed with other drugs that complex each other.
Routes of IV administration As mentioned before, the most common routes of IV administration are IV push, Primary IV infusion, and IV piggyback. In IV push, the luer lok of a syringe is attached directly to the patients intravenous access and slowly pushed in by pressing on the syringe barrel. It may also by given through a Y site on a primary IV line with a fluid running IV solution. Primary IV infusion, the drug admixture is a large volume parenteral IV bag that is run through a dedicated IV line. In IV piggyback, the drug admixture is a small volume parenteral that is infusion through a secondary line into a primary one through a Y site connection.
Other Parenteral routes Epidural routes are IV catheters that are tunneled into a patients back near the spinal cord of the patient. Meant to deliver opiates and other pain medications to post op patients and obstetric patients. Solutions made for epidural use must be made from preservative free drug products. Intrathecal injections are made into the spinal cord. The needle passes through the dura mater into the subarachnoid space. This method is used to administer spinal opiates at doses far below regular IV doses. It is also used to deliver chemotherapy with methothexate and in the delivery of a drug called baclofen to patients with severe cerebral palsy. Some drugs given this way can be fatal. An example is the drug Vincristine.