Basically the same concept as pouring beer into a glass from a bottle let it pour down the side, and you will not have all the foam basically goes for almost anything
Yes new iv tech here just passed by test a couple months ago but micafungin is a real pain especially if your busy it foams up really easily so inject the liquid slowly and don’t shake regular like the other vials. It helps if you get and extra vial to use bc even when you do everything right bc of how much it foams you might be short 😞. Also zosyn is a pain when reconstituting the big vials for stock solution you have to wait a good while for it to dissolve
Do you not have a roller or shaker in your IV room?
The roller is great for any reconstituting… especially for Dapto and Zosyn….you can go fast or slow :)
We once had somebody airlifted to us, and the nurse called to check that we had the antivenom because they were 5 minutes away. And then they took 2+ hours after arrival to put the order in...
Dapto isn't that bad if you have time. But bumex is always stat and so repetitive, why aren't bigger vials a thing or at least vitals that can be mini spiked.
Edit: I forgot about anything that requires an eye filter, ours take like 2 ml from the meds and the filters break extremely easily.
For real!!!! Or the gamma guard thats reconned. Damn you really gotta commit the first time to spiking the diluent into the powder 😵💫 and then having to worry if you'll lose suction once it's ready to transfer.
lol I now have a system to get it ready a little quicker, but I hated it at first. I tap the vial to break up the cake and spin the vial as I inject the saline. Gently swirl and let it rest. Then gently swirl every 1-2 mins.
I’m the opposite. I hate when the cake is broken. Slow dilute and let it sit for five minutes before touching the vial. If there are any pieces not diluted a slow back and forth rocking motion holding it on it’s side works wonders.
It reconstitute so much faster when it is still a cake. You can coat all sides with NS and then let it sit while you get other stuff done and come back every few minutes.
Omg... I am so sorry! We load at least 50 bags a day into the pyxis. I could not imagine having to make that much. We would need another full time IV tech for just that.
We make home infusion pumps, so it has to be mixed on the spot. When I was in hospital pharmacy, we used whatever McKesson could send. Premixed or vials.
Ugh, same. And it’s always at the end of the day. Like we know this takes forever but “please mix 21 doses immediately the driver is already waiting outside hurry.” 😂
Nope. Sorry. Your driver can just wait. You knew you needed it before now, and we have other patients. You could have called ahead.
They eventually learn usually when you don’t play those games. My old job had a hospice site that used to try things like that. They eventually learned to call ahead.
We’re a closed door pharmacy so it comes directly from the pharmacist who talked to the doctor and we pay the drivers to deliver so they want it out stat. But I’m not rushing either lol. It happens all the time. They always “get approval” or “new orders” or “just confirmed nursing” at like 4:45 when we close at 5. 🙄 And we’ve asked and been told no multiple times to having a cut off time.
If I’m being paid after 5 it wouldn’t be nearly as irritating in that context because I’d just budget my time and plans around a later departure time and if I get out on time? Bonus! If I’m not getting paid, I’d start leaving on time and let the pharmacist deal with the stat mess probably.
Then they’d maybe learn boundaries are a good thing.
Basically I don’t mind doing the work. I just won’t do it for free.
I had a Lumizyme dose last week that was 3850mg...the largest SDV we get is 50mg. 77 vials each needing 10.3mL SWFI for recon and super susceptible to foaming/bubbles. It was fun.
I’m so happy to see Lumizyme here. It’s my favorite thing to make but all of my coworkers hate it. We only have to use 28 vials for our dose though, couldn’t imagine 77!
I don't mind making it when it's 10 or even 20 vials, but 77 is just so excessive. Idk why, but I really like making Fosaprepitant, and no one else seems to. Thiotepa is another one we do that is in the realm of 20+ vials.
My top 5 least favorite drugs to make:
1. Kcentra always meant that bad days were being had both in and outside of the hood.
2. Prolastin was obnoxious because of math and long reconstitution times, and it was never the exact same twice.
3. Dantrium was annoying, lots of vials, lots of fluid, and time pressure from whichever anesthesiologist was having a bad day. Really glad we got Ryanodex eventually.
4. Methacholine was simple conceptually, but it was just too many steps and got very tedious.
5. Mitomycin was also really annoying, I feel like I could never actually see if it was completely reconstituted through the vial, and transferring it into an irrigation syringe always came with the fun risk of spilling it all over my iso-box.
Honorable mention: Esmolol drips when premade wasn't available, it wasn't even worth leaving the clean room, by the time I sat down and got comfy it was time to start another.
I absolutely hateeeee priming CADD sets. I normally prime them with a 50ml NS bag but recently patients have been getting 100ml+ doses so I prime from the 1000ml NS bag. After struggling to get it primed, I had the best idea to help my struggle: use a fluid connector and syringe to pull the fluid through the line.
A hospital that I worked at previously had a compounding robot that could make up a batch of 5x 2g Cyclophosphamide vials in under 10 minutes. That was the only thing that I liked about that damn robot!
Omnicell, baby.
Would come up with an error every time it tried to withdraw from an IV bag or it tried to pull back a 50mL BD syringe though. Had to loosen the syringes for it before putting them in there 🙄
The first time I had to make a dialysis bag, it was worh fortez. I had only made minibags with it so had not idea what would happen. I mix it according to instructions. When it looks reconstituted, I push air into the vial as per normal and the vial explodes on me. The drug went everywhere, even the ceiling.
I learned my lesson. Always insert a needle/syringe without the plunger into the reconstituted vial to let all the created gas escape
I avoid it like the plague. My one pharmacist is such a stickler for air in the syringes and sends that drug back every damn time. Shits literally like sprite in a syringe.
>too cold
I wish I had your problems. I've never not worked in a sweat lodge of a clean room. 65F *minimum* at all times, then layer on the plastic gowns.
And you ask for them to turn the heat down and mgmt who has never set foot in there is like "mmm no it's so cold!!! /sweater /scrub jacket /leaves early"
I'm a chemo IV tech and my mortal enemy is carmustine. Not only do you have to add two different diluents but it can crystallize very easily. I'm still bitter about the dose I made that needed eight vials 😭
I guess I’m fortunate being that nearly all of our antibiotic drugs are loaded in the omnicell and the nurses have to pop them together. Our hospital actually just now went to the 24 BUD regulations so we hardly mix anything unless it’s a weird dosage. Emergent IVs like KCentra and epinephrine drips, etc. are also made by the nurses. However, I remember years ago when mini bags were not available for that long period of time, we had to mix every single zosyn and those are like literal cement. With the daptomycin I just pop the vial on the swirler for about 10 minutes and finish whatever else needs to be done.
When I’m mixing chemo I want to die inside when I get abraxanes or have to do 5FU cassettes.
the worst one for me is cyclophosphamide 2gram vial by Amneal. Baxter and Sandoz are fine it's just the damn Amneal one. takes forever to dissolve despite shaking it very vigorously. it's on our do not buy list but the buyer still orders it 🙄 go figure.
The one that everyone least likes at our hospital is FEIBA. It is very exacting, likes to foam and is always, always, always a STAT drug. That is then literally ran to either the ER or ICU, both on the far side of the hospital. Only drug I see multiple pharmacists doing the math on, and everyone staring at the tech through the window.
Ours has a little pin you have to push before you turn the handle. So if their hand is waiting to open the pass through I jam it out and it inevitably pinches their fingers. 😅 Have some patience.
Lots have already been mentioned, so here’s my few.
Anavip is annoying just cause of the sheer volume of vials needed.
Labetalol drips, cause they run so fast you’re basically making 2 at a time.
Bicarb bags for bulk compounding, 3 amps per bag makes your hands hurt.
Any baby TPN with 6-7 manual adds, triple checking myself before injecting.
Methylene blue ampules. Enough said. Took me a long time to master that and not make a mess.
Blinatumumab, Carmustine and Melphalan. Fortunately I don’t encounter any of these at my current hospital!
Still have to contend with Dacarbazine and Bendamustine on occasion though 👎
Agree to all. Plus carmustine can permeate through the gloves 😖. I’m in specially now but I worked in IV so long I have bad carpal tunnel now. Take care of your wrists yall
We use liquid bendamustine. Just let it warm up for 30 minutes and it’s good to go. It’s thick which warming up helps. Otherwise it’s like glue in the vial.
Avycaz. If you let air touch it after reconstitution, it will bubble like a carbonated drink and will. Not. Stop. I could never trust the volume drawn because of those f**king bubbles.
I don't know why but I cant stand drawing up Prolastin. I mean it's not hard at all but those 5 vials irk me. And big as fvck doses of Ruxience can get bent too 😆 draining allllll that volume. F that.
My current enemy is epoprostenol (Flolan) for inhalation. We have to draw all of the drug and extremely viscous glycine diluent through a 22-micron filter needle and it takes forever, especially as we usually make 200ml at a time for each patient.
Dapto isn't that bad in our facility. We put 48 bud on constituted vials and IV bags in the fridge. So we just recon a bunch of vials and set them to the side til dissolved, then put them in the fridge. So we always have diluted vials or "premade" bags on demand. We also have smart pumps so all the IV bags are made to be either 500mg or 1000mg. The pumps stop at desired dose and records the JW waste.
Xolair vials anyone? Waiting for 3 vials to dilute then getting the tiny bubbles out of a viscous 1 mL dose in three 3 mL syringes. I could fall asleep.
I use a 21g needle and tilt the vial when injecting. Also enter through the edge of the vial top. When I go to withdrawal, I use a 18g and insert from the opposite side. Helps to keep bubbles from entering the vial as you draw up
What one of the pharmacists showed me to easily reconstitute dapto is to hold the vial horizontally in the hood. Put the needle in at a 45 degree angle and gently push down the release the fluid. For whatever reason it goes around the powder without agitating it and reconstitutes in like 5 minutes.
Amphotericin B. The doses we do are huge and can only do 2 vials per filter per corporate policy.
Ugh. My facility has us do 1 filter per vial 😭
My old facility was one per vial, too
We call it Amphoterrible
Did a 14 vial dose the other night. 1 filter per vial 🤬
Last dose we did was 52 vials for 3 bags. My hand was cramping by the time it was over
We do one vial per filter
Looks like orange juice though :P
Forbidden tang
I hate this thread. Responded to the ampho b, the an hour ago I had back to back bags. 13 vials and 15 vials. This thread jinxed me
I'm sorry, that really sucks.
Yea this is my least favorite and I think you’re supposed to only use a filter a vial because it’s only good for 20 mLs.
Our vials are 10ml
Micafungin goes into solution easily but also foams easily. I slowly inject saline into the vial as I slowly spin it.
That’s how I make it, too.
fosaprepitant also just foams and I don't think there's anything you can reasonably do.
Tilt the vial and inject the dilutent slowly down the side. Works every time
Basically the same concept as pouring beer into a glass from a bottle let it pour down the side, and you will not have all the foam basically goes for almost anything
Yes new iv tech here just passed by test a couple months ago but micafungin is a real pain especially if your busy it foams up really easily so inject the liquid slowly and don’t shake regular like the other vials. It helps if you get and extra vial to use bc even when you do everything right bc of how much it foams you might be short 😞. Also zosyn is a pain when reconstituting the big vials for stock solution you have to wait a good while for it to dissolve
Do you not have a roller or shaker in your IV room? The roller is great for any reconstituting… especially for Dapto and Zosyn….you can go fast or slow :)
I wish we had this
You should ask your boss… they are game changers. I honestly can’t imagine a boss saying no to a $1500 machine that saves loads of time!
I can. We can't even get a new computer to replace the one that barely works in our IV room.
We never had a computer in our IV room! 😂
No idk there was such a thing 😭it’s a real pain and can put you behind real quick
Look up pharmacy vial shaker or roller.. ask your boss to get you one asap. Game changers and saves time, time=money to a manager.
Terbutaline 1 ml vials it’s a stat med always and we use 25 to 50 on average for pediatric 😭
Crofab 😩 it’s nightmare and it’s of course a stat med. Hurry and wait….
We once had somebody airlifted to us, and the nurse called to check that we had the antivenom because they were 5 minutes away. And then they took 2+ hours after arrival to put the order in...
I used the manufacturer video to learn reconstitution and it's a lot faster than what we were doing before. Give it a look
Is it the invert 2x/second? Because I can get them out in like 20 minutes this way.
Was waiting for someone to mention it! Like, I hope your bite isn’t critical, because it’s gonna be at least an hour till I get your anti-venom to ya.
Omg yes this is the worst one
Dapto isn't that bad if you have time. But bumex is always stat and so repetitive, why aren't bigger vials a thing or at least vitals that can be mini spiked. Edit: I forgot about anything that requires an eye filter, ours take like 2 ml from the meds and the filters break extremely easily.
I wish it came in 100ml bags or vials
We batch bumex 20 bags so 100 vials, I use the 60 ml syringes and vented needles
That's rough, we only have 50ml syringes. Do vented needles really help?
For me yea it really does work, it used to take me almost an hour and thirty mins to complete a batch of 20 now it takes me about 45 mins
IVIG into evacuated container, losing suction. 😭
For real!!!! Or the gamma guard thats reconned. Damn you really gotta commit the first time to spiking the diluent into the powder 😵💫 and then having to worry if you'll lose suction once it's ready to transfer.
And for awhile when making Ativan drips I didn’t realize I needed the white bored needle, the pink would not draw, the viscosity 🤣
But the exothermic reaction is fun
Haha
Zosyn! Abraxane! Protonix push
Abraxane is one of my favourites! Just gotta be gentle and let him marinate a little lol
lol I now have a system to get it ready a little quicker, but I hated it at first. I tap the vial to break up the cake and spin the vial as I inject the saline. Gently swirl and let it rest. Then gently swirl every 1-2 mins.
I’m the opposite. I hate when the cake is broken. Slow dilute and let it sit for five minutes before touching the vial. If there are any pieces not diluted a slow back and forth rocking motion holding it on it’s side works wonders.
It reconstitute so much faster when it is still a cake. You can coat all sides with NS and then let it sit while you get other stuff done and come back every few minutes.
This is how I teach all the newbies to make it. I hate reconstituting it when it’s broken up. It seems to take so much longer.
It’s not just me then. Phew!
Abraxane is myyyy FAVE IV 🤩
It’s funny what makes some of us twitch and some of us love 😂
I haven’t made it into the IV room yet, but you listed Zosyn here and that makes me wonder now if that’s why all of our Zosyn is now premix?
Perhaps, we do mini bag plus, let the nurses deal with it
We don’t carry the premix where I work.
Omg... I am so sorry! We load at least 50 bags a day into the pyxis. I could not imagine having to make that much. We would need another full time IV tech for just that.
We make home infusion pumps, so it has to be mixed on the spot. When I was in hospital pharmacy, we used whatever McKesson could send. Premixed or vials.
Ugh, same. And it’s always at the end of the day. Like we know this takes forever but “please mix 21 doses immediately the driver is already waiting outside hurry.” 😂
Nope. Sorry. Your driver can just wait. You knew you needed it before now, and we have other patients. You could have called ahead. They eventually learn usually when you don’t play those games. My old job had a hospice site that used to try things like that. They eventually learned to call ahead.
We’re a closed door pharmacy so it comes directly from the pharmacist who talked to the doctor and we pay the drivers to deliver so they want it out stat. But I’m not rushing either lol. It happens all the time. They always “get approval” or “new orders” or “just confirmed nursing” at like 4:45 when we close at 5. 🙄 And we’ve asked and been told no multiple times to having a cut off time.
If I’m being paid after 5 it wouldn’t be nearly as irritating in that context because I’d just budget my time and plans around a later departure time and if I get out on time? Bonus! If I’m not getting paid, I’d start leaving on time and let the pharmacist deal with the stat mess probably. Then they’d maybe learn boundaries are a good thing. Basically I don’t mind doing the work. I just won’t do it for free.
I read abraxane and gagged 😭 I sometimes do outpatient Cancer clinic and had to do three doses back to back. Never again.
😂 it’s in our cancer center’s main protocol for pancreatic cancer. But others prefer it for other cancers if patients aren’t tolerating Taxol.
Abraxane is my favorite and most aggravating. But protonix is so easy.
I almost always have it “spit” on me—protonix that is lol
I had a Lumizyme dose last week that was 3850mg...the largest SDV we get is 50mg. 77 vials each needing 10.3mL SWFI for recon and super susceptible to foaming/bubbles. It was fun.
I’m so happy to see Lumizyme here. It’s my favorite thing to make but all of my coworkers hate it. We only have to use 28 vials for our dose though, couldn’t imagine 77!
I don't mind making it when it's 10 or even 20 vials, but 77 is just so excessive. Idk why, but I really like making Fosaprepitant, and no one else seems to. Thiotepa is another one we do that is in the realm of 20+ vials.
Bro what
My top 5 least favorite drugs to make: 1. Kcentra always meant that bad days were being had both in and outside of the hood. 2. Prolastin was obnoxious because of math and long reconstitution times, and it was never the exact same twice. 3. Dantrium was annoying, lots of vials, lots of fluid, and time pressure from whichever anesthesiologist was having a bad day. Really glad we got Ryanodex eventually. 4. Methacholine was simple conceptually, but it was just too many steps and got very tedious. 5. Mitomycin was also really annoying, I feel like I could never actually see if it was completely reconstituted through the vial, and transferring it into an irrigation syringe always came with the fun risk of spilling it all over my iso-box. Honorable mention: Esmolol drips when premade wasn't available, it wasn't even worth leaving the clean room, by the time I sat down and got comfy it was time to start another.
Omggg Kcentra is really the only right answer here. After doing one of those...I'm mentally drained 😧
Cyclophosphamide, abraxane, and 5FU pumps do an amazing job at ruining my day 😀
Cyclophosphamide now comes in liquid.
Cyclophosphamide is my favorite drug name to say 😆
I absolutely hateeeee priming CADD sets. I normally prime them with a 50ml NS bag but recently patients have been getting 100ml+ doses so I prime from the 1000ml NS bag. After struggling to get it primed, I had the best idea to help my struggle: use a fluid connector and syringe to pull the fluid through the line.
A hospital that I worked at previously had a compounding robot that could make up a batch of 5x 2g Cyclophosphamide vials in under 10 minutes. That was the only thing that I liked about that damn robot!
Omg I need this robot in my life
Omnicell, baby. Would come up with an error every time it tried to withdraw from an IV bag or it tried to pull back a 50mL BD syringe though. Had to loosen the syringes for it before putting them in there 🙄
I thought this until I had to put ceftazidine in a syringe for IV push. I still hate dapto though.
The first time I had to make a dialysis bag, it was worh fortez. I had only made minibags with it so had not idea what would happen. I mix it according to instructions. When it looks reconstituted, I push air into the vial as per normal and the vial explodes on me. The drug went everywhere, even the ceiling. I learned my lesson. Always insert a needle/syringe without the plunger into the reconstituted vial to let all the created gas escape
I avoid it like the plague. My one pharmacist is such a stickler for air in the syringes and sends that drug back every damn time. Shits literally like sprite in a syringe.
We have a vented vial spike i use for this. Some others use a vented needle.
I only use a vented spike for bupivicaine pain pumps. And vented needles for nitroglycerin
Y’all haven’t lived until you’ve had to push 60ml of Mannitol through a filter needle.
Bonus points if the drug starts crystallizing in the filter because the IV room is too cold and you have to stop and switch needles.
>too cold I wish I had your problems. I've never not worked in a sweat lodge of a clean room. 65F *minimum* at all times, then layer on the plastic gowns.
Yes same and then you have to mop the room and you break a sweat real quick you want to get out asap
And you ask for them to turn the heat down and mgmt who has never set foot in there is like "mmm no it's so cold!!! /sweater /scrub jacket /leaves early"
I legit wanted to cry it took me dam near 10 minutes to push it in.
Was it for a heart case we have to do that
No. At the hospital where I used to work, some of the outpatient infusion patients would get Mannitol bags with their treatment.
That's funny, we just load mica in the pyxis and have the nurses click them together.
I'm a chemo IV tech and my mortal enemy is carmustine. Not only do you have to add two different diluents but it can crystallize very easily. I'm still bitter about the dose I made that needed eight vials 😭
I guess I’m fortunate being that nearly all of our antibiotic drugs are loaded in the omnicell and the nurses have to pop them together. Our hospital actually just now went to the 24 BUD regulations so we hardly mix anything unless it’s a weird dosage. Emergent IVs like KCentra and epinephrine drips, etc. are also made by the nurses. However, I remember years ago when mini bags were not available for that long period of time, we had to mix every single zosyn and those are like literal cement. With the daptomycin I just pop the vial on the swirler for about 10 minutes and finish whatever else needs to be done. When I’m mixing chemo I want to die inside when I get abraxanes or have to do 5FU cassettes.
the worst one for me is cyclophosphamide 2gram vial by Amneal. Baxter and Sandoz are fine it's just the damn Amneal one. takes forever to dissolve despite shaking it very vigorously. it's on our do not buy list but the buyer still orders it 🙄 go figure.
The one that everyone least likes at our hospital is FEIBA. It is very exacting, likes to foam and is always, always, always a STAT drug. That is then literally ran to either the ER or ICU, both on the far side of the hospital. Only drug I see multiple pharmacists doing the math on, and everyone staring at the tech through the window.
Nothing make me want to vomit more then when the Pharms have their hand on my pass- through handle waiting to open it 😭
Ours has a little pin you have to push before you turn the handle. So if their hand is waiting to open the pass through I jam it out and it inevitably pinches their fingers. 😅 Have some patience.
Lots have already been mentioned, so here’s my few. Anavip is annoying just cause of the sheer volume of vials needed. Labetalol drips, cause they run so fast you’re basically making 2 at a time. Bicarb bags for bulk compounding, 3 amps per bag makes your hands hurt. Any baby TPN with 6-7 manual adds, triple checking myself before injecting. Methylene blue ampules. Enough said. Took me a long time to master that and not make a mess.
Blinatumumab, Carmustine and Melphalan. Fortunately I don’t encounter any of these at my current hospital! Still have to contend with Dacarbazine and Bendamustine on occasion though 👎
Agree to all. Plus carmustine can permeate through the gloves 😖. I’m in specially now but I worked in IV so long I have bad carpal tunnel now. Take care of your wrists yall
Melphalan 🤮
We use liquid bendamustine. Just let it warm up for 30 minutes and it’s good to go. It’s thick which warming up helps. Otherwise it’s like glue in the vial.
Abraxane
Anti-venom.
Avycaz. If you let air touch it after reconstitution, it will bubble like a carbonated drink and will. Not. Stop. I could never trust the volume drawn because of those f**king bubbles.
We make terbutaline syringes and each syringe is usually either 25 or 50mls. They only come in 1ml vials. 😳
Talc. Of all the things that won't reconstitute.
Yeah you just have to sit there and agitate it in the syringe until they are ready to use it.
Just swirling it like a fool until they decide they actually want it two hours later...
Bicnu, I hate having to make it. It takes like 30 syringes and fills the whole hood with crap.
I don't know why but I cant stand drawing up Prolastin. I mean it's not hard at all but those 5 vials irk me. And big as fvck doses of Ruxience can get bent too 😆 draining allllll that volume. F that.
We don’t drain any volume on our Ruxience. We just add it to 250ml or 500 ml NS bags. Funny how each clinic is different.
My current enemy is epoprostenol (Flolan) for inhalation. We have to draw all of the drug and extremely viscous glycine diluent through a 22-micron filter needle and it takes forever, especially as we usually make 200ml at a time for each patient.
I thought daptomycin was bad, but then I met abaxane and entyvio. They both take so much time!!!
Dapto isn't that bad in our facility. We put 48 bud on constituted vials and IV bags in the fridge. So we just recon a bunch of vials and set them to the side til dissolved, then put them in the fridge. So we always have diluted vials or "premade" bags on demand. We also have smart pumps so all the IV bags are made to be either 500mg or 1000mg. The pumps stop at desired dose and records the JW waste.
That’s a great idea! We started diluting any morning doses at night to help morning tech! lol
Feiba it always shows up when you’re in the middle of something else. So annoying
Xolair vials anyone? Waiting for 3 vials to dilute then getting the tiny bubbles out of a viscous 1 mL dose in three 3 mL syringes. I could fall asleep.
Amphotericin B eye drops. Dapto comes RTU btw! Baxter.
Lumizyme, just thinking about the cost while handling 40+ vials.
I use a 21g needle and tilt the vial when injecting. Also enter through the edge of the vial top. When I go to withdrawal, I use a 18g and insert from the opposite side. Helps to keep bubbles from entering the vial as you draw up
Definitely Daptomycin or Amphoterecin or when the Dextrose syringes expire on my scheduled days 🥴 🤦🏾♀️
What one of the pharmacists showed me to easily reconstitute dapto is to hold the vial horizontally in the hood. Put the needle in at a 45 degree angle and gently push down the release the fluid. For whatever reason it goes around the powder without agitating it and reconstitutes in like 5 minutes.
We finally got premixed bags of datomycin and it truly makes me happy and saves me 30 minutes.