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1
Q

What is a hazard?

A

The potential to cause harm

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2
Q

what is a risk?

A

The likelihood of harm

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3
Q

How do hazards and risks differ?

A

Hazards often cannot be abolished, risks often can.

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4
Q

What types of hazard can exist in the workplace? [4]

A

Physical, Chemical, Biological, Psychological.

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5
Q

What criteria defines a hazardous drug?

A

If a drug is one or more of: carcinogenic, teratogenic, toxic to reproduction, toxic to organs at low doses, genotoxic.

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6
Q

What pieces of legislation are in place to deal with hazardous substances? [3]

A

Health and Safety at Work Act 1974.
Personal Protective Equipment at Work Regulations 2002.
COSHH: Control of Substances Hazardous to Health 2002.

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7
Q

What organisations are involved with hazardous substances and/or health and safety? [2]

A

NIOSH: National Institute For Occupational Safety and Health.
IARC: International Agency for Research on Cancer.

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8
Q

How can people be exposed to hazardous substances? [4]

A
  1. Ingestion of contaminated foods, drinks etc.
  2. Inhalation of drug aerosol or dust.
  3. Absorption through the skin
  4. Direct contact/injection.
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9
Q

What are the risks of cytotoxic drugs?

A

There is a latency period between exposure and disease development. It may take years before the carcinogenic link between compounds is discovered.

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10
Q

Where are the locations of highest surface contamination in a pharmacy?

A

Work surfaces and air-foil of biological safety cabinet and the floor in front of the cabinet.

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11
Q

Where are the locations of highest surface contamination in a hospital?

A

On the floor by the bed.

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12
Q

What is the hierarchy of control of risk?

A 
Assessment of risk. 
Elimination of risk.
Substitution of risk. 
Good Working Practice. 
Engineering Controls
Personal Protective Equipment.
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13
Q

How is it possible to eliminate contamination? [3]

A
  1. Removal of contaminants from general areas.
  2. Segregation of workflows.
  3. Purchase of ready-to-use liquids instead of powders which require reconstitution.
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14
Q

What are the 4 aspects of administrative controls that help control contamination?

A
  1. Education and training
  2. Availability of information e.g. data sheets.
  3. Presence of SOPs, policies, agreed work practices.
  4. Monitoring.
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15
Q

What agreed work practices should there be? [5]

A
  1. Minimum numbers of staff
  2. Adherence to recommended work protocols
  3. Standardised documentation.
  4. Clear, unambiguous, detailed written SOPs.
  5. Use of illustrations/diagrams.
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16
Q

How can training reduce contamination and risk?

A

If only properly trained and assessed staff are involved in handling the most hazardous substances then the risk that something will go wrong is minimised. Retraining and competency testing should be regular.

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17
Q

What does good supervision and monitoring ensure?

A

Good technique is adhered to and that procedures are undertaken accurately, correctly and safely. This will produce less waste and enhance operator and patient safety.

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18
Q

What has been shown to be a key factor influencing error rates?

A

A lack of appropriate supervision and monitoring.
Appropriate supervision and monitoring ensures that good technique is adhered to and that procedures are undertaken accurately, correctly and safely. This will produce less waste and enhance operator and patient safety.

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19
Q

What are BSCs?

A

Biological safety cabinets provide protection against hazardous drug exposure but are imperfect. Isolators are better but are not widely used.

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20
Q

What PPE is available to reduce risk?

A 
Garments: Gowns, sleeves, gloves, glasses, masks, undergarments. 
Matts, swabs. 
Shields, dispensing aids. 
Waste handling equipment. 
Luer-lock fittings.
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21
Q

How protective are gloves?

A

All gloves are permeable to some extent. This permeability increases with time so we should change regularly and immediately if they are damaged. Nitrile or neoprene gloves offer the best protection.

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22
Q

What waste disposal guidelines exist?

A

HTM 07-01 The Safe Management Of Healthcare Waste Memorandum.

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23
Q

What directive banned resheathing of needles in a healthcare setting?

A

EU Directive 2010/32/EU

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24
Q

Why is aseptic preparation of CIVAS products needed? [2]

A

They cannot be sterilised after preparation by autoclaving due to drug stability.
Some drugs are presented as freeze-dried powders which must be reconstituted and diluted.

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25
Why would we use a parenteral product? [7]
1. No other formulation available. 2. Nil by mouth patients. 3. Drug is broken down in the GI tract. 4. Non-functioning GI tract in patient. 5. Extensive 1st pass effect for drug 6. For local action. 7. Need fast onset or specific duration of action.
26
What are two CIVAS products used to treat bacterial infections?
Vancomycin and Ceftazidine.
27
What is a CIVAS product used to treat fungal infections?
Ambisome (liposomal amphotericin B).
28
How do CIVAS products typically present? [3]
1. Syringes. 2. Infusion bags. 3. Infusion devices etc.
29
What risks are associated with the administration of CIVAS products? [9]
1. Infection from a contaminated CIVAS preparation. 2. Thrombophlebitis 'inflammation of the wall of a vein with associated thrombosis' 3. Air embolism 4. Extravasation 'leakage of product from vein into underlying tissue' 5. Dose errors. 6. Incorrect drug. 7. Wrong site of administration. 8. Given at the wrong rate. 9. Incorrect formulation of a drug administered.
30
Why is the hospital pharmacy involved with the administration of CIVAS products?
Breckenridge report 1976. | Pharmacy should make all additions to infusion bags.
31
Why does the material the container is made from influence a CIVAS formulation?
Different rates of adsorption, leaching of plasticizer, oxygen permeability, moisture permeability, rate of admin.
32
How do we assign expiry dates to CIVAS formulations? [3]
SmPC from MHRA website. Trissel, handbook on injectable drugs. The Cytotoxics Handbook.
33
What information do we need to know regarding the reconstitution of CIVAS powders? [2]
1. Info on displacement values. | 2. Info on appropriate diluents, what effect will the diluent have?
34
What information regarding the use of filters do we need to know when preparing a CIVAS product? [2]
Will the filter size in use cause drug destruction or adsorption? What is the appropriate filter size to safely use?
35
What is the cause of most CIVAS product recalls?
Labelling errors.
36
What correct information should be found on a CIVAS product label? [10]
1. Pt name/identification number. 2. Drug name. 3. Total drug dose. 4. Total volume. 5. Diluent information. 6. Route of admin. 7. Storage instructions. 8. BN + Expiry. 9. Handling instructions. 10. Ward information.
37
What types of nuclear decay are utilised in radiopharmacy and why?
Alpha not used often as does not penetrate skin. Beta is used often. Gamma can be used for imaging in some cases.
38
What is nuclear medicine?
The isotopes are emitted from the patient and are used to show the function/lack of function of organs etc. They can show change as it happens in the body in real time.
39
What is an X - ray?
X-rays are passed through the patient to provide an image which shows structure only and can only show changes that have already occurred, not real-time.
40
What is a gamma camera?
Device which detects gamma radiation, can be used to image patients. Collimator absorbs scatter to give clearer image and sodium iodide crystals produce light pulses when impacted by gamma radiation.
41
What are the most common radionuclides in use?
99m Technetium, 123 Iodine.
42
Why is 99m Technetium used in radiopharmacy? [6]
1. Easily Manufactured 2. Readily available and short half-life. 3. Gamma emitter (Used in gamma camera imaging) 4. Low energy range 5. Decays to a stable isotope. 6. Can be combined with a wide range of targeted trackers/tracers.
43
What is the main difference between aseptic processing and radiopharmacy?
Operator safety comes first in radiopharmacy and processes are carried quicker to limit exposure.
44
Why are doses calculated differently for radiopharmacy?
1. Dose is in MBq 2. Calculated for the time of administration 3. 400MBq dose at 15:00hrs requires 800MBq at 9:00 if half life is 6 hours.
45
What is a MAG 3 scan?
Diagnostic/imaging scan that allows visualisation of tissue and can be used to investigate kidney function. Help surgeons pre- and post-surgery.
46
What is a DMSA scan?
Radionucleotide scan that uses dimercaptosuccinic acid to assess renal function. Used extensively in paediatric nephrology.
47
What compound is used in a DMSA scan?
Radionucleotide scan that uses dimercaptosuccinic acid to assess renal function. Used extensively in paediatric nephrology.
48
How is TcO4 (Pertechnetate) used in nuclear medicine?
Thyroid imagine, technetium has a similar size and shape to iodine.
49
For what is Kyrpton-81 gas used for in nuclear medicine?
Lung scan/VQ scan. Can diagnose pulmonary embolism.
50
How is organic phosphate complex used in nuclear medicine?
Can diagnose bone metastases. Tracer has homogenous distribution throughout the body. It is uptaken by hydroxyapatite crystals, dependent on bone turnover. Bone metastases lead to areas of increased uptake in the skeleton as bone becomes replaced by tumour cells.
51
How can organic phosphate complex be used to diagnose bone metastases?
Tracer has homogenous distribution throughout the body. It is uptaken by hydroxyapatite crystals, dependent on bone turnover. Bone metastases lead to areas of increased uptake in the skeleton as bone becomes replaced by tumour cells.
52
How are colloids used in nuclear medicine?
Bone marrow and lymphatic imaging. Standard lymphoscintigraphy. Sentinel node localisation.
53
What is a colloid solution?
Solution containing 1-1000 nanometer diameter particles with the ability to remain evenly distributed throughout.
54
What is defecating proctoscintigraphy?
``` Radioactive porridge. Ideal Pseudostool. Pooh in potty. Calculate pooh rate. Draw the pooh curve. ```
55
What patient groups typically require PN? [3]
1. Pre-term infants. 2. GI failure patients. 3. GI disease states, Crohns, obstruction.
56
What is the role of PN? [2]
1. provide adequate proteins + calories whilst maintaining the fluid balance. 2. Prevent malnutrition and associated complications.
57
What is PN made of? [8]
1. Protein (AA) 2. Carbohydrates (glucose) 3. Fat (as O/W emulsion) 4. Electrolytes (Na, K, Ca) 5. Trace elements (Zinc, Sodium) 6. Vitamins. 7. Water. 8. Occasionally drugs.
58
What different types of PN bag/preparations are available?
1. 2 in 1 bags, glucose and AAs. 2. 3 in 1 bags, all ingredients in one bag. 3. Triple chamber bags, glucose+AA+lipid 4. Etc.....
59
How can sunlight influence the stability of vitamin A?
Sunlight causes the breakdown of vitamin A.
60
Why does the presence of entrapped air in PN bags pose an issue? [3]
1. Lipid peroxides: form when sunlight+oxygen+lipid emulsion. Very chemically reactive and harmful. 2. Oxidation of amino acid contents: tyrosine, threonine, histidine, methionine + tryptophan. (Tryptophan degradation products might cause cholestasis and are possibly neurotoxic. 3. Vitamin C breaks down in presence of oxygen, sunlight and trace elements like Cu2+.
61
Why would we not want precipitation to form/occur in a PN bag?
Insoluble salts can block small capillaries in the lungs and other organs causing pulmonary emboli.
62
What is the most common cause or precipitation in PN bags?
The injection of strong concentrations of calcium, magnesium, phosphate etc. to PN without mixing between additions or without dilution.
63
What does the solubility of calcium phosphate depend upon? [4]
1. The salt used. Dibasic is much less soluble than the monobasic form. 2. Concentration 3. pH - 4. Other ingredients.
64
How does the compounding process influence the risk of precipitation?
Precipitation is more likely to occur as temperature rises. | Organic divalent components should be used in lieu of organic ones. Sodium glycerophosphate > calcium chloride etc.
65
``` In what order should the following be added to a PN bag? Macro Electrolytes. Amino acids. Glucose. Lipids. Vitamins. Trace elements. ```
1. Macroelectrolytes + Amino acids should be combined. 2. Then amino acids and glucose should be mixed together. 3. Then add lipids last. 4. Vitamins should have been added to the lipids. 5. Trace elements should have been added to glucose.
66
Why does glucose make the formulation of PN bags problematic? [3]
1. High concentrations destabilise fat emulsions by causing pH to drop. 2. High concentrations can cause hyperglycaemia in patients. 3. The pH of a glucose formulation with decrease with age.
67
How can destabilised lipids in PN cause harm?
1. Hepatic uptake 2. Uptake into heart, lung, liver. 3. Micro-emboli in lung
68
What type of lipid instability is irreversible?
Cracking. Aggregation and creaming are reversible upon agitation.
69
What factors influence lipid stability in PN formulations? [4]
1. Positive ion presence: electrostatic effect cause repulsion between lipid droplets. Al+++ >> Na+. 2. pH: ideal is pH 8. Below pH 6 cause precipitation. 3. Glucose concentration: ideally below 20%. 4. Lipid emulsion dilution: decreasing concentration decreases stability
70
How can amino acids affect the stability of TPN?
AA chelate with cations so i.e. chelated calcium is not free to form insoluble compounds. AA buffer TPN, stabilise constituents like lipid emulsions. Low pH may cause precipitation of AA though, tyrosine.
71
What bag material is gold standard and why for PN?
Multilayer. | PVC causes leaching of plasticizers. EVA is a poor barrier to oxygen.
72
What key points dictate safe use of PN in practice? [6]
1. All bags protected from sunlight (amber syringes and IV lines exist) 2. Removal of as much air as possible after compounding. 3. Copper and Vitamin C kept separate. (Add additional Vit C if needed) 4. Multilayer bags used. 5. Refrigerate between 2-8*C as soon as possible following compounding. 6. Allow PN bags to warm to room temp prior to admin (1 hour before)
73
What would occur following addition of addiphos to a PN feed followed by the addition of calcium gluconate?
A precipitate would form that is unable to be seen due to the all-in-one bag containing lipid (cloudy).
74
What is an EM2400 compounder?
Automatic robotic compounder that uses barcodes to confirm the ID of ingredients before following a fixed order of addition with automated volumes.
75
What quality testing occurs on all PN bags? [2]
1. Electrolyte tests: flame photometer, atomic absorption, chromatography, ICP-OES, inductively coupled optical emission spectroscopy. 2. Refractive index: confirms that correct sources of macroingredients such as glucose are present.
76
At what pH does precipitation of lipid emulsions occur?
Below pH 6. Ideal pH is 8, High concentrations of glucose cause lowering of pH.
77
Why is it important to allow PN feeds to warm up to room temperature before use?
Cold infusions cause cardiac arrest.
78
What legislation influences radiopharmacy? [3]
Health And Safety (Ionising Radiation Regulations) Radiation Protection 1999 Radioactive Substances Act 1993 The Radioactive Material (Road Transport) Regulations 2002.

Extemp (12 decks)

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