Precautions When Compounding Medications
Medications should be drawn up immediately before use, used for single patients only, and discarded after each case—never combine or multidose syringes or vials between patients. 1
Critical Sterility and Contamination Prevention
Immediate Preparation and Handling
- Draw up medications just before administration to minimize contamination risk and maintain sterility 1
- Discard any medication beyond use-by dates or showing visible contamination or breaches of sterile integrity 1
- The practice of combining medications, multidosing from a single syringe or vial, or using drawing-up bags between patients is unacceptable 1
Surface Decontamination
- Clean all ampule necks and rubber caps with 70% isopropanol (with or without chlorhexidine) and allow to dry completely before needle insertion 1
- Recognize that exterior surfaces of most injection vials are NOT sterile and require decontamination 1
- Disinfect access ports with alcohol wipes for 15-30 seconds using friction before each access 1
Syringe Tip Protection
- Any contact of syringe tips with fingers or surfaces dramatically increases contamination rates 1
- Always completely cover tips with sterile caps or blunt needles 1
- Use commercially available alcohol-impregnated cleaning caps for Luer-tip connectors to reduce contamination 1
High-Risk Medication: Propofol
Propofol requires special attention because it:
- Supports bacterial and fungal growth
- Promotes endotoxin production
- Maintains viral stability
- Increases contamination rates of syringes, IV lines, and stopcocks 1
Handle propofol with heightened sterility precautions and discard immediately after use.
Emergency Drug Preparation
When preparing emergency drugs for later use, label each syringe with:
- Medication name and concentration
- Date and time drawn up
- Name/initials of preparer (especially if used by someone else)
- Store per local guidelines in secured areas 1
Ideally, each person responsible for a shift should draw up their own emergency drugs to maintain accountability and freshness 1
Equipment and Environment
Workspace Hygiene
- Keep anaesthetic drug trays free of ampules, broken glass, pens, airway equipment, or dentures 1
- Thoroughly disinfect and dry reusable drug trays before and after each use 1
- Discard used syringes appropriately after use and certainly by case conclusion 1
Access Port Management
- Use closed injection ports or cover stopcocks with sterile caps when not in use 1
- Avoid open lumen devices—they are difficult to decontaminate and increase contamination with frequent access 1
- Flush access ports and lines clear of blood or residual medications after use 1
Regulatory and Safety Context
Compounded medications carry inherently higher risks than FDA-approved drugs because they:
- Are exempt from good manufacturing practice regulations (GMPs)
- Lack standardized quality, safety, and efficacy testing
- Have inconsistent product testing
- Show higher failure rates to meet specifications compared to FDA-approved drugs 2, 3
When to Compound
Only compound when FDA-approved medications cannot meet the patient's specific needs (different dose, route, or allergen avoidance) and when benefits clearly outweigh risks 2, 3
Common Pitfalls to Avoid
- Never reuse syringes or vials between patients—this is the most critical error leading to infection outbreaks 1
- Don't skip the drying step after alcohol disinfection—wet surfaces reduce antimicrobial efficacy 1
- Avoid touching syringe tips—even brief contact causes dramatic contamination increases 1
- Don't store medications in non-sterile trays with other equipment 1
- Never use compounded medications when commercial alternatives exist—the additional risk has no benefit 3
The evidence strongly emphasizes that contamination during compounding has led to multiple meningitis outbreaks and serious patient harm 3. Strict adherence to aseptic technique and single-use principles is non-negotiable for patient safety.