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Denise Burnham of Creative Compounding speaking

worked most of her career at OHSU mixing IV's as night pharmacist
did retail, hospital, transplant specialist pharm, ICU, etc etc
"saw too much medicine and not enough treating people"
started her own compounding store
customized meds for immediate needs
PCAP = accredited, fairly new accreditation, her lab has it
lots of SOP's, quality assurance, thermometers calibrated, etc
joint commission accreditation is what hospitals and nursing homes get

missed some stuff

*supersaturated solution can't really hold that much, must check for particulates
crystals want to precipitate out
calcium gluconate is notorious for precipitating, crystals around neck of vial

mixing stuff
careful with incompatibilities
don't add acid directly to base
calcium and sodium bicarb (used to buffer iv's)
inspect IV after each addition

careful of sterile areas: don't touch!
attachment end of needle, needle itself, threaded part of syringe, stem of plunger
has sterile room in compounding pharmacy, cleaned daily, plated monthly (they culture around in there)

other general tips
need uncluttered area, get routine or workflow to avoid mistakes
always check label, can kill patient with potassium chloride (hospital story, mistook KCl for heparin)
benzyl alcohol is bacteriostatic used in many waters, etc
preservative free may not be useable multi-dose
a few vials come with powder in them--to reconstitute, read pkg insert about how to mix
usu sterile water, and not the whole volume of the vial
use licensed facility, state license in state for where using, liability insurance won't save you
follow set rate of infusion, don't let pts push their own, don't push things too fast

she's going to talk about individual ingredients now
basic vitamin additives, she expects most of us to use these

thiamine B1
metab of carbs, complexes with atp, helps decarboxlyation, pentose pathyway
up to 500mg mb given c no SEs
200mg or more can precipitate herpes and eczema outbreaks
CI: hypersensitivity
unstable in neutral or alkaline, unstable other wise
2.5-4.5 ph
adverse rxns: warmth, etc long list, gi hemorrhage, etc etc
IM or IV
usu in complex, 100mg/ml in B complex 100

riboflavin
1-10mg/day
IV or IM
unstable over 10mg/ml, rarely given in high doses
unstable in acid
2mg/ml in complex, refrigerate and protect from light
400mg oral for migraine prevention, doesn't work IV
turns urine and breast milk yellow

niacinamide
nicotinamide in two forms
IV 100mg/day
CI in liver fail
compatible with most other additives at normal doses
SE: flushing
100mg/ml available alone, also in complex 100mg/ml
refrigerate

B5 pantothenic acid
up to 500mg/day
2mg/ml in complex
imp for stress
often ordered sep, 250mg/ml concentration made
can keep at room temp, is thick and syrupy, must be warmed to mix

B6 pyridoxine
50-100mg/day is common but occ up to 500mg/day sometimes given
usu given IV
acidic, is HCl salt, ph 2-4, incompatible with alkaline solutions and Fe salts
adverse: neuropathies if too much or too little
100mg/ml compounded, 2mg/ml in complex
stable at room temp but fridge if no preservative
avoid too much punctures of vial, use up quickly

3 kinds of B12
all hypoosmolar, red in color
osmolarities same as serum

cyanocobalamin
commercially available but on backorder
$10/bottle
.25-1mg/day usu given
breaks down to adenosyl and methyl cobalamin
can be given sq, im, iv
pH 3-7, fairly neutral, more toward 7
adverse: hives?
brick red (methyl and hydroxyl more purple in color), can tinge urine or tears pink
check carefully for precip
not compatible with strong acids or bases, weak ok
can be kept at room temp
powdered other forms usu in fridge, left out short term is no problem

hydroxylcobalamin
better for anemias
shorter t1/2
midwise on pricing, less than methylcobalamin, more than cyano

methyl cobalamin
can make 25mg/ml, dark color makes it hard to tell if precip, pts may injx self with precip and get site rxn
becoming popular as methyl donor esp for neuro probs, MS, autism, not 100% effective but does do good
10mg/day is high dose for neuro fx

folic acid
.2-1mg/day but intermittent up to 10mg/day
im, iv, sq ok
interferes with fx of b12
strange incompatibility: makes yellow jello, precips below 5.6
comes in 5 or 10mg/ml concentrations
se: skin rash, itching, erythma, bronchospasm

ascorbic acid
imp
high dose protocols
10mg-2g/day is normal dose
not stable alkaline or air exposed, turns dark brown like cream soda
ph 5.5-7, uses sodium hydroxide to make it tolerated and stable
if give too fast get hot flush, headache, fatigue, dvt
osmol from 5.8-8.2
refrigerate and protect from light
mb stable at room temp up to 4 years per 1 study

minerals
mb dangerous

magnesium
imp
mm relaxant, for pre-eclampsia 4-6g/2hrs then 1g/hour, vtach, vfib, tersades
usu no more than 1.5g/hr
levels 3-4.5
ci: renal impairment, heart block
incompatible with:
good for nasty pts, alcoholics, nurses like giving them mg shot in tush it hurts
se: flush, sweat, hypoten, depressed reflexes, circ and resp collapse
*always remember some formula she just said that I didn't get
do not refrigerate

potassium
very compatible salt, usu chloride
irritating to veins, must monitor pt for levels not more than 5, 3.5-5
some pts in renal failure can tolerate higher level dt slow rise
se: phlebitis, flaccid paralysis
max 10mEq/hr in 100ml fluid
osmol: 2mEq/ml ? always dilute for IV use

calcium
short on gluconate
chloride still spottily availabe
.5-2g infused at 50mg/min is ideal
se: local chem burns, sclerosis, coronary vasospasm
osmol is .72, not a very compatible salt, check for precipitates
carbonates and phosphates cause precip or may happen on its own

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