By Candy Finley, RN, IgCN and Joe DiStefano, RPh

Pooling is the process of transferring the total dose of drug plus overfill into an empty IV bag ("pooling bag"). Although NuFACTOR prefers administering IVIG by spiking vials one at a time sequentially or adding drug directly into a bag of diluent (e.g., infliximab/Remicade®), there are some times when pooling is appropriate. These include lyophilized powder IVIG requiring reconstitution (e.g., Gammagard® SD and Carimune®), HyQvia® (IG component only) and infliximab doses greater than 1000 mg. The process of pooling medications into a specially designed pooling bag is a relatively simple process. As simple a process it may be, several variables including nurse experience, the shortage of supplies and differences in manufacturing may lead to some confusion for the end-user, the nurse in the home. Another variable may be the individual practices typical to a given nursing agency or to one specialty pharmacy over another. In an effort to highlight considerations that are specific to NuFACTOR, we elaborate pooling nuances here in this blog.

Benefits of pooling versus using a syringe and adding through the bag's medication additive port include minimizing vial stopper coring and reducing the number of punctures into the final bag, theoretically decreasing the risk of contamination. A disadvantage of pooling versus sequentially spiking and administering one vial at a time is drug waste. If an adverse drug reaction or inability to re-gain lost IV access during an infusion occurs, the remaining amount of pooled drug needs to be discarded. If this happens with sequentially spiked vials, only the contents remaining in the vial need to be discarded.

Before opening packaging or piercing the rubber stoppers of drug vials for IV drugs, obtain IV access. Perform actions using sterile technique. Locate the pooling bag and gravity fill set tubing. The gravity fill set is the tubing with a vented spike at one end and a connection to attach to the pooling bag ("transfer port") at the other end. Depending on the manufacturer, the gravity fill set may have multiple spikes and be pre-attached to the pooling bag or packaged separately. Clamp the gravity fill set tubing. Attach to the pooling bag transfer port if not pre-attached. If required, reconstitute drug. Make sure the solution is clear and free of undissolved particles.

For IVIG or HyQvia® (IG component only), spike the drug vial, open the vent cap, invert the vial, unclamp the gravity fill set tubing and then allow the flow of drug into the pooling bag. Clamp the gravity fill set tubing before removing the vial. Repeat this process for each vial. Once the contents of all vials have been transferred into the pooling bag, clamp the bag transfer port, remove the gravity fill set tubing, attach the pooling bag cap and close the wings. The pooled drug is now ready for administration.

For pooled infliximab, 250ml of normal saline diluent is transferred using the gravity fill set tubing. The pooling bag is handled the same as for IVIG and HyQvia®. Lastly, reconstituted infliximab is added to the pooling bag through the medication additive port.

Due to an ongoing pooling bag manufacturer shortage, we are unable to provide pooling bags for drugs not listed above. Instead, drug may need to be administered by spiking vials one at a time sequentially. As supply chain tightens, traditionally pooled drugs may need to be administered by an alternate method. As pooling supplies become regularly available, we will return to our regular practices. Thank you for your understanding. If you have any questions, please contact us.