In-line filtration reduces severe complications and length of stay on pediatric intensive care unit: a prospective, randomized, controlled trial

The potential for drug incompatibility and its drivers - A hospital wide retrospective descriptive study

OBJECTIVE

Drug incompatibility, a significant subset of medication errors, threaten patient safety during the medication administration phase. Despite the undeniably high prevalence of drug incompatibility, it is currently poorly understood because previous studies are focused predominantly on intensive care unit (ICU) settings. To enhance patient safety, it is crucial to expand our understanding of this issue from a comprehensive viewpoint. This study aims to investigate the prevalence and mechanism of drug incompatibility by analysing hospital-wide prescription and administration data.

METHODS

This retrospective cross-sectional study, conducted at a tertiary academic hospital, included data extracted from the clinical data warehouse of the study institution on patients admitted between January 1, 2021, and May 31, 2021. Potential contacts in drug pairs (PCs) were identified using the study site clinical workflow. Drug incompatibility for each PC was determined by using a commercial drug incompatibility database, the Trissel's™ 2 Clinical Pharmaceutics Database (Trissel's 2 database). Drivers of drug incompatibility were identified, based on a descriptive analysis, after which, multivariate logistic regression was conducted to assess the risk factors for experiencing one or more drug incompatibilities during admission.

RESULTS

Among 30,359 patients (representing 40,061 hospitalisations), 24,270 patients (32,912 hospitalisations) with 764,501 drug prescriptions (1,001,685 IV administrations) were analysed, after checking for eligibility. Based on the rule for determining PCs, 5,813,794 cases of PCs were identified. Among these, 25,108 (0.4 %) cases were incompatible PCs: 391 (1.6 %) PCs occurred during the prescription process and 24,717 (98.4 %) PCs during the administration process. By classifying these results, we identified the following drivers contributing to drug incompatibility: incorrect order factor; incorrect administration factor; and lack of related research. In multivariate analysis, the risk of encountering incompatible PCs was higher for patients who were male, older, with longer lengths of stay, with higher comorbidity, and admitted to medical ICUs.

CONCLUSIONS

We comprehensively described the current state of drug incompatibility by analysing hospital-wide drug prescription and administration data. The results showed that drug incompatibility frequently occurs in clinical settings.

Effect of in-line filtration in newborns: study protocol of the Intravenous Neonatal Central Access Safety (INCAS) randomized controlled trial

BACKGROUND

Particulate contamination due to infusion therapy (administration of parenteral nutrition and medications) carries a potential health risk for infants in neonatal intensive care units (NICUs). This particulate consists of metals, drug crystals, glass fragments, or cotton fibers and can be generated by drug packaging, incomplete reconstitution, and chemical incompatibilities. In-line filters have been shown to remove micro-organisms, endotoxin, air, and particles in critically ill adults and older infants, but its benefits in newborn remain to be demonstrated. Moreover, 50% of inflammatory episodes in the setting of NICUs are blood culture-negative. These episodes could be partly related to the presence of particles in the infusion lines.

METHODS

A multicenter randomized single-blind controlled trial was designed. All infants admitted to NICUs for which prolonged infusion therapy is expected will be enrolled in the study and randomized to the Filter or Control arm. All patients will be monitored until discharge, and data will be analyzed according to a "full analysis set." The primary outcome is the frequency of patients with at least one sepsis-like event, defined by any association of suspected sepsis symptoms with a level of c-reactive protein (CRP) > 5 mg/L in a negative-culture contest. The frequency of sepsis, phlebitis, luminal obstruction, and the duration of mechanical ventilation and of catheter days will be evaluated as secondary outcomes. The sample size was calculated at 368 patients per arm.

DISCUSSION

This is the first multicenter randomized control trial that compares in-line filtration of parenteral nutrition and other intravenous drugs to infusion without filters. Sepsis-like events are commonly diagnosed in clinical practice and are more frequent than sepsis in a positive culture contest. The risk of these episodes in the target population is estimated at 30-35%, but this data is not confirmed in the literature. If the use of in-line filters results in a significant decrease in sepsis-like events and/or in any other complications, the use of in-line filters in all intravenous administration systems may be recommended in NICUs.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05537389, registered on 12 September 2022 ( https://classic.

CLINICALTRIALS

gov/ct2/show/results/NCT05537389?view=results ).

Visible particles in parenteral drug products: A review of current safety assessment practice

Parenteral drug products (PDPs) are administered extensively to treat various diseases. Product quality plays a critical role in ensuring patient safety and product efficacy. One important quality challenge is the contamination of particles in PDPs. Particle presence in PDPs represents potential safety risk to patients. Differential guidance and practice have been in place for visible (VPs) and subvisible particles (SVPs) in PDPs. For SVPs, the amount limits have been harmonized in multiple Pharmacopeias. The pharmaceutical industry follows the guided limits for regulatory and quality compliance. However, for VPs, no such acceptable limit has been set. This results in not only quality but also safety challenges for manufacturers and drug developers in managing and evaluating VPs. It is important to understand the potential safety risk of VPs so these can be weighed against the benefit of the PDPs. To evaluate their potential risk(s), it is necessary to understand their nature, origin, frequency of their occurrence, safety risk, the risk mitigation measures, and the method to evaluate their safety. The current paper reviews the critical literature on these aspects and provides insight into considerations when performing safety assessment and managing the risk(s) for VPs in PDPs.

Spallation and particles infusion into the extracorporeal circuit during CRRT: a preventable phenomenon

Patients in intensive care are exposed to the risk of microparticle infusion via extracorporeal lines and the resulting complications. A possible source of microparticle release could be the extracorporeal circuit used in blood purification techniques, such as continuous renal replacement therapy (CRRT). Disposable components of CRRT circuits, such as replacement bags and circuit tubing, might release microparticles such as salt crystals produced by precipitation in replacement bags and plastic microparticles produced by spallation. In-line filtration has proven effective in retaining microparticles both in in-vitro and in-vivo studies. In our study, we performed an in-vitro model of CRRT-treatment with the aim of detecting the microparticles produced and released into the circuit by means of a qualitative and quantitative analysis, after sampling the replacement and patient lines straddling a series of in-line filters. Working pressures and flows were monitored during the experiment. This study showed that microparticles are indeed produced and released into the CRRT circuit. The inclusion of in-line filters in the replacement lines allows to reduce the burden of microparticles infused into the bloodstream during extracorporeal treatments, reducing the concentration of microparticles from 14 mg/mL pre in-line filter to 11 mg/mL post in-line filter. Particle infusion and related damage must be counted among the pathophysiological mechanisms supporting iatrogenic damage due to artificial cross-talk between organs during CRRT applied to critically ill patients. This damage can be reduced by using in-line filters in the extracorporeal circuit.

The quality of drugs and drug products - Always guaranteed?

To ensure the efficacy, safety, and quality of drugs, several national and international guidelines and regulatory requirements exist. The most important international regulatory framework for quality is the collection of the guidelines ICH Q1-Q14 (International Council for Harmonization of Technical Requirements for Pharmaceuticals for Human Use), which form the basis for the development and approval of medicinal products. Additionally, international and national pharmacopoeias and national regulatory authorities like Food and Drug Administration (FDA) and European Directory for the Quality of Medicines and HealthCare (EDQM) have to be considered during the lifecycle of a drug. Further, regular updates and optimization of processes and methods together with periodic audits and inspections of the manufacturing plants help to ensure compliance with the complex regulatory requirements for medicinal products. Although the pharmaceutical world seems to be very well regulated and controlled, several drug recalls per year have to be announced and conducted to remove defect products from the market and protect the patient from any potential health risk. This review article provides an overview of the most common reasons for such recalls presenting several historical and current cases with a detailed discussion of root causes. A specific focus lies on quality issues like drug degradation, impurity and nitrosamine contamination, lack of drug stability, occurrence and transformation of polymorphs, contamination with particulates and foreign matters, amongst others. The role of APIs, excipients and packaging will be discussed as well as the analytical challenges to detect, control and mitigate such quality issues. A final chapter will discuss the current situation and an outlook on emerging topics and future challenges for drug quality.

Evaluation of particle size distribution of sub-visible particles in powder injections with different packaging forms - small-sized sub-visible particles should not be ignored

OBJECTIVES

Sub-visible particle, or particulate matter, is an important indicator in the safety assessment of clinical infusions. The present study aims to evaluate the effect of the packaging formats of antibiotic on the distribution of sub-visible particles in the small particle size range (<10 μm), to provide evidence for explanation to clinical adverse reactions and guidelines for rational drug use.

METHODS

The conventional light blockage and the single particle optical sensing (SPOS) technology were applied to determine the size distribution of the sub-visible particles in the redissolved injections in different packages (dual-chamber bag and vial) from different manufacturers. In order to verify our hypothesis, the influences of active pharmaceutical ingredient (API) and solvent were controlled. Further, scanning electron microscopy (SEM) was utilized to observe the morphological characteristics of sub-visible particles from different package injections.

RESULTS

After redissolving, the small-sized sub-visible particles (<10 μm) in the solution of injectable powder packaged in the dual-chamber bag were significantly lower than that of the conventional injectable powder packaged in the vial, and the difference remained significant after controlling for API. The results observed by SEM also supported the differences in the amount of particulate matter between the two packaging formats, showing a higher number of sub-visible particles from sodium chloride dissolved preparations packed in vails, with irregular shapes.

CONCLUSION

In our study, the differences in the distribution of sub-visible particles were mainly attributed to the packaging formats. The dual-chamber bag injection might be an effective alternative to reduce the adverse reactions caused by sub-visible particles.

Evaluation of Strategies for Reducing Vancomycin-Piperacillin/Tazobactam Incompatibility

BACKGROUND

Drug incompatibility is defined as a physical-chemical reaction between two or more injectable drugs and that results mainly in precipitation or insolubility. Several strategies for reducing incompatibilities have been implemented empirically in intensive care units. However, these strategies have never been compared directly (and particularly in terms of the particulate load and drug mass flow rate) under standardized conditions. The objective of the present in vitro study was to evaluate the impact of various strategies for preventing incompatibility between simultaneously infused vancomycin and piperacillin/tazobactam.

METHODS

An in-line filter, a dilute vancomycin solution (5 mg/mL), and an alternative saline administration line were evaluated separately. The infusion line outlet was connected to a dynamic particle counter. The antibiotic concentration was measured in an HPLC-UV assay.

RESULT

The use of an in-line filter and an alternative saline administration route did not significantly reduce the particulate load caused by vancomycin-piperacillin/tazobactam incompatibility. Dilution of the vancomycin solution was associated with a significantly lower particulate load and maintenance of the vancomycin mass flow rate.

DISCUSSION

It is important to systematically compare the efficacy of strategies for preventing drug incompatibility. The use of diluted vancomycin solution gave the best results in the case of vancomycin-piperacillin/tazobactam incompatibility.

Negative Outcomes Associated with Medication in Neonates on Parenteral Nutrition Therapy

OBJECTIVE

In Ecuador, studies on clinical daily practice problems focused on parenteral nutrition in neonates are scarce. Therefore, this research aimed to identify negative results associated with medications (NRAM) in neonates with parenteral nutrition (PN) in a third-level hospital in Ecuador.

MATERIAL AND METHODS

An observational, prospective, descriptive study was designed in the neonatology area of a tertiary-level public hospital, where, for over four months, the medical records, PN prescriptions, and pharmacy-managed databases of 78 patients were analyzed. Drug-related problems (DRPs) as possible causes of NRAM were classified through administrative, physicochemical, and clinical validation.

RESULTS

DRPs classified as follows were found: 78.81% by physicochemical, 17.62% by clinical, and 3.57% by administrative validation. The NRAM were 72% quantitatively uncertain, 16% needed, and 11% quantitatively ineffective.

CONCLUSION

The NRAM associated with DRPs were statistically related to prematurity condition, APGAR score, PN time, and the number of medications administered, which suggests the need to create a nutritional therapy committee at the health facility.

Exploring a case of incompatibility in a complex regimen containing Plasma-Lyte 148 in the pediatric intensive care

BACKGROUND

In the local pediatric intensive care unit, precipitation was observed in the intravenous catheter upon co-administration of four drugs together with the buffered electrolyte solution (Plasma-Lyte 148, Baxter). Co-infusion of incompatible combinations represents a safety concern.

AIMS

To reproduce the clinical case of precipitation. To further explore and understand the risk of precipitation, different combinations of the components as well as the corresponding electrolyte solution with 5% glucose (Plasma-Lyte 148 with 5% glucose) should be investigated.

METHODS

Physical compatibility of fentanyl, ketamine, midazolam, and potassium chloride was tested in combination with the buffered electrolyte solutions. The concentrations and infusion rates representative of children 10-40 kg were used to estimate mixing ratios. Analyses detecting visual particles (Tyndall beam) and sub-visual particles (light obscuration technology) were undertaken. Measured turbidity and pH in mixed samples were compared with unmixed controls.

RESULTS

Both midazolam and ketamine showed formation of visual and sub-visual particles upon mixing with Plasma-Lyte 148, respectively. Particle formation was confirmed by increased turbidity and a distinct Tyndall effect. pH in mixed samples mirrored the pH of the buffered electrolyte, suggesting that the solubility limits of midazolam, and in some ratios also ketamine, were exceeded. Midazolam also precipitated in combination with the glucose-containing product that held a lower pH, more favorable for keeping midazolam dissolved.

CONCLUSIONS

Replication of the case revealed that both midazolam and ketamine contributed to the precipitation. Midazolam and ketamine were both evaluated as incompatible with the buffered electrolyte solution and midazolam also with the buffered electrolyte-glucose solution and should not be co-administered in the same i.v.-catheter line. Fentanyl and potassium chloride were interpreted as compatible with both buffered electrolytes.

Metrology in health: challenges and solutions in infusion therapy and diagnostics

The significance of Metrology in infusion therapy and diagnostics, both critical in health care safety and quality, is discussed in this article. Although infusion therapy is the most used form of drug administration, infusion errors are often made with reported dramatic effects in different applications, especially in neonatology. Adverse incidents, morbidity, and mortality have often been traced back to poor or inaccurate dosing. For critical infusion applications to vulnerable patients, well-controlled medication administration might be accomplished by improved dosing accuracy, traceable measurement of volume, flow, and pressure in existing drug delivery devices and in-line sensors operating at very low flow rates. To this end, the contribution of recently upgraded metrological infrastructures in European Metrology Institutes to a safer infusion therapy in health care is described in detail. Diagnostics, on the other hand is a sector characterized by rapid developments further triggered recently by the necessity for the management and prevention of infectious diseases like COVID-19. In this context, the impact of metrology in future large-scale commercialization of next generation diagnostics (e.g., point-of-care) is highlighted. Moreover, the latest contributions of Metrology in the development of traceable testing methods and protocols to ensure the sensitivity and accuracy of these devices are described.

[Drug-drug interactions and physicochemical incompatibilities during acute phase after allo-SCT: Guidelines from the SFGM-TC]

Since patients require multiple intravenous drugs, drug incompatibilities and drug interactions are frequent during the acute phase following hematopoietic cell transplantation. The risk of drug-drug interactions is increased in patients with several comorbidities. The goal of this workshop was to learn how to mitigate the risks of drug incompatibilities and interactions when their usage is therapeutically warranted. Our focus was on proton pump inhibitors and antiemetic drugs as they are routinely used in hematopoietic transplants and frequently lead to incompatibilities and interactions with other drugs such as immunosuppressives and antimicrobials. Routine procedures in transplantation such as the choice of vascular access devices, the setting of infusion lines, the scheduling of administration of drugs and their dilution volumes can be effective armaments to mitigate the risks of drug incompatibilities and interactions. In addition, a multidisciplinary concertation between clinicians, pharmacists and nurses is a key point in the success of patient's care.

Simultaneous infusion of two incompatible antibiotics: Impact of the choice of infusion device and concomitant simulated fluid volume support on the particulate load and the drug mass flow rates

Vancomycin and piperacillin/tazobactam are known to be incompatible. The objectives of the present study were to evaluate the impact of their simultaneous infusion on mass flow rates and particulate load and identify preventive strategies. We assessed both static conditions and a reproduction of an infusion line used in a hospital's critical care unit. A high-performance liquid chromatography/UV diode array system and static and dynamic laser diffraction particle counters were used. The mass flow rates were primarily influenced by the choice of the infusion device and the presence of simulated fluid volume support. Drug incompatibility also appeared to affect vancomycin's mass flow rate, and the dynamic particulate load increased during flow rate changes - especially in the infusion set with a large common volume line and no concomitant simulated fluid volume support. Only discontinuation of the piperacillin/tazobactam infusion was associated with a higher particulate load in the infusion set with a large common volume line and no concomitant simulated fluid volume support. A low common volume line and the use of simulated fluid volume support were associated with smaller fluctuations in the mass flow rate. The clinical risk associated with a higher particulate load must now be assessed.

A large amount of microscopic precipitates are inevitably injected during infusion therapy without an in-line filter

Infusion route problems can have a significant impact on hemodynamics in children with severe heart failure. Here, we report the case of a 13-year-old girl with dilated cardiomyopathy. Her condition fluctuated due to frequent occlusion of the central venous catheter (CVC) route. However, a quick check revealed no apparent abnormalities in the CVC, infusion route, in-line filter or infusion pump. Scanning electron microscopy revealed that dobutamine and heparin had crystallized and that the in-line filter membrane was occluded. This case emphasizes the importance of proper infusion route management in pediatric patients with severe heart failure. Even drugs that are used daily may form microscopic crystals at several concentrations and administration rates. Without an in-line filter, microscopic particles are injected into the body, and there is no evidence that the injected crystals do not cause permanent damage.

Assessing the Utility of In-Line Intravenous Infusion Filters

The use of in-line filters to remove fibrous material in the administration of intravenous fluids dates to the early 1830's. Following advancements in therapeutic interventions, high volume fluid support and parenterally administered drugs and biologic preparations, some observers are calling for a routine use of bedside filtration. Unfortunately, the assessment of filter components, their interaction and compatibility with the drug product, and the impact of use on clinical outcomes cannot be conducted by a single entity. Recommendations for use are often predicated upon fragmented and incomplete information. The current challenges in evaluating the benefit/risk profile for the use of in-line filters should not be ignored. While there are select instances showing well-defined therapeutic settings where in-line filtration of intravenous infusions would likely provide an additional safety margin and hence, net benefit, the majority of observational studies to date fail to provide sufficient scientific support for broad-based routine use. While infusion set filters are appropriate where expert opinion is well corroborated by scientific evidence, the general and routine use of filters used during parenteral administration cannot be supported by substantive studies and should not be routinely utilized. Ultimately, the determination falls to a healthcare provider with the information available at-hand.

Strategies to prevent drug incompatibility during simultaneous multi-drug infusion in intensive care units: a literature review

PURPOSE

Drug protocols in intensive care units may require the concomitant administration of many drugs as patients' venous accesses are often limited. A major challenge for clinicians is to limit the risk of simultaneously infusing incompatible drugs. Incompatibilities can lead to the formation of particles and inactivation of drugs, whose consequences on the body have already been indicated. Our objective was to assess current strategies to counter the risk of incompatible infusions and control the resulting clinical consequences.

METHODS

This review was independently conducted by three investigators in respect of the PRISMA statement. Three online databases were consulted. Full-text articles, notes, or letters written in English or French, published or in press between the 1990s and the end of February 2020, with clinical study design, were eligible. Parameters of interest were mainly number and size of particles, and a number of observed/avoided incompatibilities.

RESULTS

All in all, 382 articles were screened, 17 meeting all the acceptance criteria. The strategies outlined and assessed were filtration, the use of multi-lumen devices, the purging of infusion lines, incompatibility tables and databases, and the use of standard operating procedures.

CONCLUSION

Although many strategies have been developed in recent years to address drug incompatibility risks, clinical data is still lacking. All studies with in vitro design were excluded although some current innovative strategies, like niosomes, should be considered and studied by means of clinical data in the future.

Challenges in reducing the risk of infection when accessing vascular catheters

Injection safety is essential to reduce the risk of healthcare-associated infections (HAIs) when accessing vascular catheters. This general review evaluates the contamination of vascular catheter access ports and associated HAIs in acute care settings, focusing on open lumen stopcocks (OLSs) and disinfectable needleless closed connectors (DNCCs). PubMed was searched from January 2000 to February 2021. OLS intraluminal surfaces are frequently contaminated during patient care, increasing the risk of HAIs, and neither an isopropyl alcohol (IPA) pad nor a port-scrub device can reduce contamination effectively. In contrast, DNCCs can be disinfected, with most studies indicating less intraluminal contamination than OLSs and some studies showing decreased HAIs. While the optimal DNCC design to reduce HAIs needs to be determined, DNCCs alone or stopcocks with a DNCC bonded to the injection port should replace routine use of OLSs, with OLSs restricted to use in sterile fields. Compliance with disinfection is essential immediately before use of a DNCC as use of a non-disinfected DNCC can have equivalent or greater risk of HAIs compared with use of an OLS. The recommendations for access port disinfection in selected national and international guidelines vary. When comparing in-vitro studies, clinical studies and published guidelines, consensus is lacking; therefore, additional studies are needed, including large randomized controlled trials. IPA caps disinfect DNCCs passively, eliminate scrubbing and provide a contamination barrier; however, their use in neonates has been questioned. Further study is needed to determine whether IPA caps are more efficacious than scrubbing with disinfectant to decrease HAIs related to use of central venous, peripheral venous and arterial catheters.

Optimising an Infusion Protocol Containing Cefepime to Limit Particulate Load to Newborns in a Neonatal Intensive Care Unit

Background: In neonatal intensive care units (NICUs), the simultaneous administration of drugs requires complex infusion methods. Such practices can increase the risk of drug incompatibilities resulting in the formation of a particulate load with possible clinical consequences. Methods: This paper evaluates strategies to reduce the particulate load of a protocol commonly used in NICUs with a potential medical incompatibility (vancomycin/cefepime combination). The protocol was reproduced in the laboratory and the infusion line directly connected to a dynamic particle counter to evaluate the particulate matter administered during infusion. A spectrophotometry UV assay of cefepime evaluated the impact of filters on the concentration of cefepime administered. Results: A significant difference was observed between the two infusion line configurations used in the NICU, with higher particulate load for cefepime infused via the emergency route. There was no change in particulate load in the absence of vancomycin. A filter on the emergency route significantly reduced this load without decreasing the cefepime concentration infused. Preparation of cefepime seemed to be a critical issue in the protocol as the solution initially contained a high level of particles. Conclusion: This study demonstrated the impact of a reconstitution method, drug dilution and choice of infusion line configuration on particulate load.

Clinical evaluation of an interoperable clinical decision-support system for the detection of systemic inflammatory response syndrome in critically ill children

Background

Systemic inflammatory response syndrome (SIRS) is defined as a non-specific inflammatory process in the absence of infection. SIRS increases susceptibility for organ dysfunction, and frequently affects the clinical outcome of affected patients. We evaluated a knowledge-based, interoperable clinical decision-support system (CDSS) for SIRS detection on a pediatric intensive care unit (PICU).

Methods

The CDSS developed retrieves routine data, previously transformed into an interoperable format, by using model-based queries and guideline- and knowledge-based rules. We evaluated the CDSS in a prospective diagnostic study from 08/2018–03/2019. 168 patients from a pediatric intensive care unit of a tertiary university hospital, aged 0 to 18 years, were assessed for SIRS by the CDSS and by physicians during clinical routine. Sensitivity and specificity (when compared to the reference standard) with 95% Wald confidence intervals (CI) were estimated on the level of patients and patient-days.

Results

Sensitivity and specificity was 91.7% (95% CI 85.5–95.4%) and 54.1% (95% CI 45.4–62.5%) on patient level, and 97.5% (95% CI 95.1–98.7%) and 91.5% (95% CI 89.3–93.3%) on the level of patient-days. Physicians’ SIRS recognition during clinical routine was considerably less accurate (sensitivity of 62.0% (95% CI 56.8–66.9%)/specificity of 83.3% (95% CI 80.4–85.9%)) when measurd on the level of patient-days. Evaluation revealed valuable insights for the general design of the CDSS as well as specific rule modifications. Despite a lower than expected specificity, diagnostic accuracy was higher than the one in daily routine ratings, thus, demonstrating high potentials of using our CDSS to help to detect SIRS in clinical routine.

Conclusions

We successfully evaluated an interoperable CDSS for SIRS detection in PICU. Our study demonstrated the general feasibility and potentials of the implemented algorithms but also some limitations. In the next step, the CDSS will be optimized to overcome these limitations and will be evaluated in a multi-center study.

Trial registration: NCT03661450 (ClinicalTrials.gov); registered September 7, 2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01428-7.

WoCoVA consensus on the clinical use of in-line filtration during intravenous infusions: Current evidence and recommendations for future research

The need for filtering intravenous infusions has long been recognized in the field of venous access, though hard scientific evidence about the actual indications for in-line filters has been scarce. In the last few years, several papers and a few clinical studies have raised again this issue, suggesting that the time has come for a proper definition of the type of filtration, of its potential benefit, and of its proper indications in clinical practice. The WoCoVA Foundation, whose goal is to increase the global awareness on the risk of intravenous access and on patients' safety, developed the project of a consensus on intravenous filtration. A panel of experts in different aspects of intravenous infusion was chosen to express the current state of knowledge about filtration and to indicate the direction of future research in this field. The present document reports the final conclusions of the panel.

Incidence and Causes of Infusion Alarms in a Neonatal and Pediatric Intensive Care Unit: A Prospective Pilot Study

OBJECTIVES

To evaluate the incidence and causes of infusion alarms in a NICU/PICU setting.

METHODS

We conducted a 90-day prospective analysis of event logs downloaded daily from infusion pumps (syringe and volumetric pumps). The details about conditions surrounding alarm events were described daily by bedside nurses on a standardized form. The occlusion pressure alarm was set at 300 mm Hg on each device.

RESULTS

Forty-one pediatric patients including 12 neonates, mean weight 11.0 ± 11.3 kg (minimum-maximum, 0.48-50), were included for a total infusion time of 2164 hours. Eight hundred forty-three infusion alarms were documented (220 [26.1%] occlusion; 273 [32.4%] infusion completed; 324 [38.4%] door open/syringe disengagement; 26 [3.1%] air-in-line) resulting in an incidence of 4.7 infusion (1.2 occlusion) alarms per patient per day.Detailed conditions surrounding occlusion alarm events were documented in only 22.7% (50/220) of the cases. Of these, 36% (18/50) were related to closed or clamped lines, 4% (2/50) to syringe change, 16% (8/50) to drug injection, and 8% (4/50) to patient-related factors. The remaining 36% (18/50) occurred without any apparent external cause during ongoing infusion, among these drug incompatibilities were a potential cause for 12 events.

CONCLUSION

Alarms from infusion pumps were frequent in the NICU/PICU setting, a quarter of them resulting from line occlusion. Other than well-known triggers (mechanical and patient factors), drug incompatibilities were identified as a potential cause for occlusion alarms in this pilot study.

Intravenous Drug Incompatibilities in the Intensive Care Unit of a Tertiary Care Hospital in India: Are they Preventable?

Objective:

The main aim of the study was to identify the physical and chemical incompatibilities among the drugs administered intravenously to patients admitted to the Intensive Care Unit (ICU) of a 1000 bedded hospital. The study also envisaged establishing pharmaceutical guidelines for the administration of incompatible medications.

Methods:

This prospective cross-sectional study was conducted from January to July 2018 in the ICU after getting approval from the Hospital Ethics Committee. A total of 104 medication charts were collected, and their data were analyzed. Compatibility of the selected drug with a second drug, when given together, was then analyzed using the Micromedex health-care series, Trissel's handbook of injectable drugs, and Manufacturer's product information. The pharmaceutical intervention was performed by preparing. The drug compatibility chart of selected drugs and the same was reported to the study department.

Findings:

Of 104 medication charts reviewed, 66 charts had incompatibility, accounting for 90 incompatibilities. Incompatibility between two intravenous (IV) bolus drugs constituted 68.8% with pantoprazole and ondansetron (85.4%) being the most frequent combination. Incompatibility between infusion-bolus was found to be 26.6%. Meropenem (infusion) and pantoprazole (bolus) constituted 16.6%. Incompatibility between two infusions in the same IV line was found to be 4.4%. A drug compatibility chart containing 19 selected drugs was prepared and submitted to the study department for their perusal.

Conclusion:

The current study showed that a significant number of drug incompatibilities occur in hospitalized critically ill patients in our tertiary care hospital. These incompatibilities could generally be prevented by adhering to proper medication administration techniques like flushing the line using compatible fluid or through a multi-lumen catheter or multiple IV access.

Nanomedicine: a new paradigm to overcome drug incompatibilities

OBJECTIVES

Drug incompatibilities may compromise the safety and effectiveness of combined drugs and result in mild-to-serious clinical complications, such as catheter obstruction, loss of drug efficacy, formation of toxic derivatives and embolism. Various preventive strategies have been implemented to overcome drug incompatibilities with limited success. This review presents an innovative approach to prevent drug incompatibilities via isolating the incompatible drugs into nanostructures.

KEY FINDINGS

Several examples of incompatible drugs may be loaded separately into nanostructures of various types. Physicochemical characteristics and biocompatibility of the nanomaterials that are being utilized to prevent physicochemical incompatibilities should be carefully considered.

CONCLUSIONS

There is a new era of exploiting nanomaterials in overcoming various types of physicochemical incompatibilities, with additional benefits of further improvements in pharmacokinetic profiles and pharmacological actions of the administered drugs.

In-line filtration in very preterm neonates: a randomized controlled trial

In-line filtration is increasingly used in critically-ill infants but its benefits, by preventing micro-particle infusion in very preterm neonates, remain to be demonstrated. We conducted a randomized controlled trial among very preterm infants allocated to receive either in-line filtration of all the intra-venous lines or standard care without filters. The primary outcome was differences greater than 20% in the median changes in pro-inflammatory cytokine serum concentrations measured at day 3 and day 8 (+/-1) using a Luminex multianalytic profiling technique. Major neonatal complications were analyzed as secondary predefined outcomes. We randomized 146 infants, assigned to filter (n = 73) or control (n = 73) group. Difference over 20% in pro-inflammatory cytokine concentration between day 3 and day 8 was not found statistically different between the two groups, both in intent-to-treat (with imputation) and per protocol (without imputation) analyses. The incidences of most of neonatal complications were found to be similar. Hence, this trial did not evidence a beneficial effect of in-line filtration in very preterm infants on the inflammatory response syndrome and neonatal morbidities. These data should be interpreted according to local standards in infusion preparation and central line management.

In-line filtration of intravenous infusion may reduce organ dysfunction of adult critical patients

BACKGROUND

The potential harmful effects of particle-contaminated infusions for critically ill adult patients are yet unclear. So far, only significant improved outcome in critically ill children and new-borns was demonstrated when using in-line filters, but for adult patients, evidence is still missing.

METHODS

This single-centre, retrospective controlled cohort study assessed the effect of in-line filtration of intravenous fluids with finer 0.2 or 1.2 μm vs 5.0 μm filters in critically ill adult patients. From a total of n = 3215 adult patients, n = 3012 patients were selected by propensity score matching (adjusting for sex, age, and surgery group) and assigned to either a fine filter cohort (with 0.2/1.2 μm filters, n = 1506, time period from February 2013 to January 2014) or a control filter cohort (with 5.0 μm filters, n = 1506, time period from April 2014 to March 2015). The cohorts were compared regarding the occurrence of severe vasoplegia, organ dysfunctions (lung, kidney, and brain), inflammation, in-hospital complications (myocardial infarction, ischemic stroke, pneumonia, and sepsis), in-hospital mortality, and length of ICU and hospital stay.

RESULTS

Comparing fine filter vs control filter cohort, respiratory dysfunction (Horowitz index 206 (119-290) vs 191 (104.75-280); P = 0.04), pneumonia (11.4% vs 14.4%; P = 0.02), sepsis (9.6% vs 12.2%; P = 0.03), interleukin-6 (471.5 (258.8-1062.8) ng/l vs 540.5 (284.5-1147.5) ng/l; P = 0.01), and length of ICU (1.2 (0.6-4.9) vs 1.7 (0.8-6.9) days; P <  0.01) and hospital stay (14.0 (9.2-22.2) vs 14.8 (10.0-26.8) days; P = 0.01) were reduced. Rate of severe vasoplegia (21.0% vs 19.6%; P > 0.20) and acute kidney injury (11.8% vs 13.7%; P = 0.11) was not significantly different between the cohorts.

CONCLUSIONS

In-line filtration with finer 0.2 and 1.2 μm filters may be associated with less organ dysfunction and less inflammation in critically ill adult patients.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov (number: NCT02281604).

Evaluation of Incompatible Coadministration of Continuous Intravenous Infusions in a Pediatric/Neonatal Intensive Care Unit

OBJECTIVES We aimed to evaluate and quantify incompatible coadministrations of continuous intravenous medication in the daily clinical practice of a PICU/NICU.

METHODS We conducted a retrospective, observational study in the setting of an 18-bed PICU/NICU. All concurrently administered continuous infusions, including blood products and parenteral nutrition, were analyzed for 2 months. Raw electronic data were retrieved and subjected to quality controls. Infusion combinations were classified as compatible, incompatible, no data, or variable according to the internal hospital charts, Trissel's database, and the Swiss summary of product characteristics. For situations with incompatible coadministrations, we assessed alternative distributions of infusions among the currently available lumen.

RESULTS Data for 100 patients were analyzed. Patients were exposed to a mean of 6.9 ± 3.6 individual continuous infusions administered through 3.8 ± 1.8 lumina. Among the 1447 coadministered continuous infusions, we detected 146 incompatible combinations (10%), resulting in 105 individually relevant incompatible situations. Furthermore, 185 combinations (13%) were not covered by internal compatibility charts, and for 207 combinations (15%) no data on compatibility were available. We found that 58% of the incompatible situations could have been avoided by a redistribution of the infusions among the available lumina.

CONCLUSIONS Most infusion combinations in the studied PICU/NICU were compatible and covered by the internal compatibility charts. However, we also identified concurrent administrations of incompatible infusions or for which compatibility data are not available. A significant reduction of coadministrations of incompatible infusions could be achieved through optimal use of available lumina.

Emulsion Stability of Different Intravenous Propofol Formulations in Simulated Co-Administration with Remifentanil Hydrochloride

Background

Propofol and remifentanil often need to be co-administered via the same intravenous catheter line, which predisposes to potential compatibility issues. Our aim was to determine and compare the emulsion stability of three propofol formulations, two with medium chain triglycerides and one with long chain triglycerides, when administered together with remifentanil hydrochloride.

Methods

Remifentanil hydrochloride (Ultiva ® ) 50 µg/mL was mixed with two concentrations (10 and 20 mg/mL) of each propofol formulation in mixing ratios 10+1, 20+1, 1+1 and 1+20. Emulsion stability was assessed immediately after mixing and 4 hours later by measurements of pH, mean droplet diameter, polydispersity index, and calculating percentage of fat residing in globules>5 µm (PFAT5).

Results

High PFAT5 values were observed in certain mixing ratios. The correlation between elevated PFAT5 and high propofol concentration (20 mg/mL), when remifentanil was in abundance and for long contact time indicated that these factors influenced the stability of the propofol emulsions.

Conclusions

Stability differences between the propofol formulations were identified under extreme test conditions. Co-administration of remifentanil and propofol in the same i.v. line is safe when propofol is in abundance. Caution is advised when remifentanil is present in equal parts or in abundance when co-administered with propofol 20 mg/mL.

Paediatric parenteral nutrition: current issues

Parenteral nutrition transformed the prognosis for infants and children with intestinal failure. Soon after its introduction into clinical care 50 years ago, parenteral nutrition was also rapidly adopted for use in the preterm infant, where immaturity of gastrointestinal motor function precluded enteral feeding. Preterm infants subsequently became the single largest group of patients to be fed in this way. Although the development of scientific knowledge and the lessons of clinical experience have reduced the risk of complications, some of the problems and difficulties associated with this form of nutritional support remain challenging. These include central venous catheter-related sepsis, thrombosis, liver disease, bone disease and metabolic disturbance. In an initiative to promote best practice, guidelines on parenteral nutrition were first published by the European Society for Paediatric Gastroenterology, Hepatology and Nutrition and collaborating organisations in 2005. These were constructed following a thorough review of the scientific literature, allowing a series of evidence-based recommendations to be made. The exercise was repeated just over 10 years later and updated guidelines published in 2018. This review summarises key elements from the new guideline, with a focus on what has changed since 2005.

CADDIE2-evaluation of a clinical decision-support system for early detection of systemic inflammatory response syndrome in paediatric intensive care: study protocol for a diagnostic study

INTRODUCTION

Systemic inflammatory response syndrome (SIRS) is one of the most critical indicators determining the clinical outcome of paediatric intensive care patients. Clinical decision support systems (CDSS) can be designed to support clinicians in detection and treatment. However, the use of such systems is highly discussed as they are often associated with accuracy problems and 'alert fatigue'. We designed a CDSS for detection of paediatric SIRS and hypothesise that a high diagnostic accuracy together with an adequate alerting will accelerate the use. Our study will (1) determine the diagnostic accuracy of the CDSS compared with gold standard decisions created by two blinded, experienced paediatricians, and (2) compare the system's diagnostic accuracy with that of routine clinical care decisions compared with the same gold standard.

METHODS AND ANALYSIS

CADDIE2 is a prospective diagnostic accuracy study taking place at the Department of Pediatric Cardiology and Intensive Care Medicine at the Hannover Medical School; it represents the second step towards our vision of cross-institutional and data-driven decision-support for intensive care environments (CADDIE). The study comprises (1) recruitment of up to 300 patients (start date 1 August 2018), (2) creation of gold standard decisions (start date 1 May 2019), (3) routine SIRS assessments by physicians (starts with recruitment), (4) SIRS assessments by a CDSS (start date 1 May 2019), and (5) statistical analysis with a modified approach for determining sensitivity and specificity and comparing the accuracy results of the different diagnostic approaches (planned start date 1 July 2019).

ETHICS AND DISSEMINATION

Ethics approval was obtained at the study centre (Ethics Committee of Hannover Medical School). Results of the main study will be communicated via publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT03661450; Pre-results.

Effect of multi-lumen perfusion line on catheter-related bacteremia in premature infants: study protocol for a cluster-randomized crossover trial

Background

Catheter-related bacteremia (CRB) is the most frequent nosocomial infection in neonatal intensive care unit (NICU) patients, especially in very low-birth-weight infants. Administration of injectable drugs in premature newborn infants has many particularities and several types of infusion incidents have been reported. The Edelvaiss® Multiline NEO device is a novel multi-lumen access infusion device adapted to the specificities of infusion in neonatology. This multicenter, randomized, controlled study was therefore designed to determine whether or not Edelvaiss® Multiline NEO reduces the risk of CRB in preterm newborn infants in an NICU.

Methods/design

This is a multicenter, randomized, controlled trial, using a cluster-randomized crossover design. Four investigator centers (four clusters) will participate in the study and will be randomized into two groups, corresponding to two different sequences (either the Edelvaiss® Multiline NEO or standard infusion system sequence, then vice versa). A total of 280 patients will be recruited. Infants will be enrolled in the study at the time of placing a single-lumen central venous catheter. Three visits recording specific data are planned in the study protocol. The primary outcome measure is the incidence density (ID) of CRB. For each patient, the total number of catheters and CRB incidents as well as the duration of stay in the NICU will be computed and considered for analysis.

Discussion

The study will provide high-quality evidence to determine whether the Multiline NEO device reduces the risk of CRB in preterm newborns in NICUs or not.

Trial registration

ClinicalTrials.gov, NCT02633124. Registered on 7 December 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3218-6) contains supplementary material, which is available to authorized users.

Drug incompatibilities in intravenous therapy: evaluation and proposition of preventive tools in intensive care and hematology units

PURPOSE

Physicochemical incompatibility (PCI) between drugs infused together is frequent, but under-recognized. PCI can lead to drug inactivity, catheter occlusion, embolism or inflammatory reactions. The aims of this work were to identify most frequent and relevant drug incompatibilities and to review and develop strategies for their prevention.

METHOD

This was an observational prospective survey conducted between January and March 2015 in an intensive care unit (ICU) and in September 2014 in a hematology sterile unit (HSU). Drugs administered to patients were recorded and their compatibility assessed based on published compatibility data.

RESULTS

Drug incompatibilities accounted for 12% (23/189) and 17% (116/686) of drug pairs infused in the ICU and the HSU, respectively. Pantoprazole was the most frequent drug implied in PCI. Regarding drug classes, anti-infective agents and gastrointestinal drugs were the most frequently implied. Among the incompatible pairs, 78% and 61% implicated a drug with extreme pH in the ICU and HSU, respectively. The tools proposed to reduce the frequency of PCI included: compatibility cross-tables, labeling of drugs with extreme pH and optimized administration schedules.

CONCLUSIONS

Given the frequency and the potential for severe consequences of PCI, pharmacists have a role to play in raising awareness of nurses and practitioners, and proposing adequate tools and solutions to reduce their incidence.

Analysis of particulate exposure during continuous drug infusion in critically ill adult patients: a preliminary proof-of-concept in vitro study

BACKGROUND

In critically ill patients, drug incompatibilities frequently occur because of the number of drugs to be administered through a limited number of infusion lines. These are among the main causes of particulate contamination. However, little data is available to quantify particle exposure during simultaneous IV-drug infusion. The objective of this study was to evaluate the particulate matter potentially administered to critically ill patients.

METHODS

The particulate matter (between 1 μm and 30 mm) of infused therapies used in ICUs for patients suffering from either septic shock or acute respiratory distress syndrome was measured in vitro over 6 h using a dynamic image analysis device, so that both overall particulate contamination and particle sizes could be determined. Data is presented according to the recommendations of the European Pharmacopoeia (≥ 10 and 25 μm).

RESULTS

For the six experimental procedures (continuous infusion of norepinephrine, midazolam, sufentanil, heparin, 5% glucose, binary parenteral nutrition and discontinuous administrations of omeprazole, piperacillin/tazobactam and fluconazole), the overall number of particles over the 6-h infusion period was 8256 [5013; 15,044]. The collected values for the number of particles ≥ 10 and 25 μm were 281 [118; 526] and 19 [7; 96] respectively. Our results showed that discontinuous administrations of drugs led to disturbances in particulate contamination.

CONCLUSIONS

This work indicates the amount of particulate matter potentially administered to critically ill adult patients. Particulate contamination appears lower than previous measurements performed during multidrug IV therapies in children.

Effectiveness of in-Line Filters to Completely Remove Particulate Contamination During a Pediatric Multidrug Infusion Protocol

The large number of drugs administered simultaneously to neonates and children in hospital results in the formation of particles that are potentially infused. We have investigated the ability of IV in-line filters to eliminate particulate matter from multidrug infusion lines and so prevent contamination. The impact on particle occurrence of the internal volume of the IV line below the in-line filter was then evaluated. The multidrug therapy given to children was reproduced with and without in-line filtration. Three combinations with a filter were tested to vary the internal volume (V) between the filter and the catheter egress. The catheter was then connected to a dynamic particle count to evaluate the particulate matter potentially administered to children during infusion. The introduction of in-line filters led to a significant reduction in overall particulate matter, from 416,974 [208,479-880,229] to 7,551 [1,985-11,287] particles (p < 0.001). Larger particles of ≥10 and 25 µm were also significantly reduced. Adding an extension set to the egress of the in-line filter (V = 1.7 mL) caused a significant increase in particulate contamination for both. This study showed that in-line filtration is an effective tool in preventing particle administration to patients. Their position in the infusion in-line is therefore important because of its impact on internal volume and drug particle formation.

An interoperable clinical decision-support system for early detection of SIRS in pediatric intensive care using openEHR

BACKGROUND

Clinical decision-support systems (CDSS) are designed to solve knowledge-intensive tasks for supporting decision-making processes. Although many approaches for designing CDSS have been proposed, due to high implementation costs, as well as the lack of interoperability features, current solutions are not well-established across different institutions. Recently, the use of standardized formalisms for knowledge representation as terminologies as well as the integration of semantically enriched clinical information models, as openEHR Archetypes, and their reuse within CDSS are theoretically considered as key factors for reusable CDSS.

OBJECTIVE

We aim at developing and evaluating an openEHR based approach to achieve interoperability in CDSS by designing and implementing an exemplary system for automated systemic inflammatory response syndrome (SIRS) detection in pediatric intensive care.

METHODS

We designed an interoperable concept, which enables an easy integration of the CDSS across different institutions, by using openEHR Archetypes, terminology bindings and the Archetype Query Language (AQL). The practicability of the approach was tested by (1) implementing a prototype, which is based on an openEHR based data repository of the Hannover Medical School (HaMSTR), and (2) conducting a first pilot study.

RESULTS

We successfully designed and implemented a CDSS with interoperable knowledge bases and interfaces by reusing internationally agreed-upon Archetypes, incorporating LOINC terminology and creating AQL queries, which allowed retrieving dynamic facts in a standardized and unambiguous form. The technical capabilities of the system were evaluated by testing the prototype on 16 randomly selected patients with 129 days of stay, and comparing the results with the assessment of clinical experts (leading to a sensitivity of 1.00, a specificity of 0.94 and a Cohen's kappa of 0.92).

CONCLUSIONS

We found the use of openEHR Archetypes and AQL a feasible approach to bridge the interoperability gap between local infrastructures and CDSS. The designed concept was successfully transferred into a clinically evaluated openEHR based CDSS. To the authors' knowledge, this is the first openEHR based CDSS, which is technically reliable and capable in a real context, and facilitates clinical decision-support for a complex task. Further activities will comprise enrichments of the knowledge base, the reasoning processes and cross-institutional evaluations.

Development and validation of a diagnostic model for early differentiation of sepsis and non-infectious SIRS in critically ill children - a data-driven approach using machine-learning algorithms

BACKGROUND

Since early antimicrobial therapy is mandatory in septic patients, immediate diagnosis and distinction from non-infectious SIRS is essential but hampered by the similarity of symptoms between both entities. We aimed to develop a diagnostic model for differentiation of sepsis and non-infectious SIRS in critically ill children based on routinely available parameters (baseline characteristics, clinical/laboratory parameters, technical/medical support).

METHODS

This is a secondary analysis of a randomized controlled trial conducted at a German tertiary-care pediatric intensive care unit (PICU). Two hundred thirty-eight cases of non-infectious SIRS and 58 cases of sepsis (as defined by IPSCC criteria) were included. We applied a Random Forest approach to identify the best set of predictors out of 44 variables measured at the day of onset of the disease. The developed diagnostic model was validated in a temporal split-sample approach.

RESULTS

A model including four clinical (length of PICU stay until onset of non-infectious SIRS/sepsis, central line, core temperature, number of non-infectious SIRS/sepsis episodes prior to diagnosis) and four laboratory parameters (interleukin-6, platelet count, procalcitonin, CRP) was identified in the training dataset. Validation in the test dataset revealed an AUC of 0.78 (95% CI: 0.70-0.87). Our model was superior to previously proposed biomarkers such as CRP, interleukin-6, procalcitonin or a combination of CRP and procalcitonin (maximum AUC = 0.63; 95% CI: 0.52-0.74). When aiming at a complete identification of sepsis cases (100%; 95% CI: 87-100%), 28% (95% CI: 20-38%) of non-infectious SIRS cases were assorted correctly.

CONCLUSIONS

Our approach allows early recognition of sepsis with an accuracy superior to previously described biomarkers, and could potentially reduce antibiotic use by 30% in non-infectious SIRS cases. External validation studies are necessary to confirm the generalizability of our approach across populations and treatment practices.

TRIAL REGISTRATION

ClinicalTrials.gov number: NCT00209768; registration date: September 21, 2005.

Avoid Drug Incompatibilities: Clinical Context in Neonatal Intensive Care Unit (NICU)

The administration of several intravenous products on the same catheter is a very common situation in neonatology, where the stakes are high and the dangers sometimes unknown to clinicians. A large number of factors are involved in this administration, directly related to the installation of the infusion line. Moreover, the therapeutics used are often limited, and excluding classic “Marketing Authorization”. Some of these products may prove to be incompatible and thus lose their effectiveness, or even generate particles that are likely to be administered to the patient. We must be aware of these risks in order to optimize the prescription and administration of these intravenous products, especially as we treat fragile and immature patients. The aim of this work is to review the literature on the subject for the prescribers of neonatology units.

Dynamic Image Analysis To Evaluate Subvisible Particles During Continuous Drug Infusion In a Neonatal Intensive Care Unit

Studies have shown that infused particles lead to numerous complications such as inflammation or organ dysfunctions in critically ill children. Nevertheless, there is very little data available to evaluate the amount of particulate matter potentially administered to patients, and none with regard to infants. We have investigated the quantity received by these patients during multidrug IV therapies. Two different protocols commonly used in our neonatal intensive care unit (NICU) to manage excessively preterm infants were reproduced in the laboratory and directly connected to a dynamic particle analyser. The particulate matter of infused therapies was measured over 24 h, so that both overall particulate contamination and particle sizes could be determined. No visible particles were observed during drug infusions. Particulate analyses showed a significant number of particles that can reach 85,000 per day, with peaks during discontinuous drug infusions. Moreover, we showed that very large particles of about 60 µm were infused to infants. This study showed that despite very low infusion flow rates, infants may receive a large number of particles during drug infusion, especially in NICUs. Particulate contamination of IV fluids is not without consequences for fragile infants. Preventive solutions could be effective, such as the use of in-line filters.

The Fragility Index in a Cohort of Pediatric Randomized Controlled Trials

Data suggest inadequacy of common statistical techniques for reporting outcomes in clinical trials. The Fragility Index can measure how many events the statistical significance hinges on, and may facilitate better interpretation of trial results. This study aimed to assess the Fragility Index in pediatric randomized controlled trials (RCTs) with statistically significant findings published in high-quality medical journals. A Fragility Index was calculated on included trials with dichotomous positive outcomes. Analysis of the relationship between trial characteristics and the Fragility Index was performed. Of the 429 abstracts screened, 17 met the inclusion criteria and underwent analysis. The median Fragility Index was 7 with an interquartile range of 2-11. In 41% of the studies, the number of patients lost to follow-up or withdrawn prior to analysis was equal to or greater than the Fragility Index. There was no correlation between the RCT sample size and the Fragility Index (r = 0.249, p = 0.335) nor the event group size and the Fragility Index (r = 0.250, p = 0.334). There was a strong negative correlation between the original p-value and the Fragility Index (r = -0.700, p = 0.002). The Fragility Index is a calculated metric that may assist in applying clinical relevance to statistically significant outcomes in pediatric randomized controlled trials with dichotomous outcomes.

Incompatible intravenous drug combinations and respective physician and nurse knowledge: a study in routine paediatric intensive care

Objectives

To identify incompatible intravenous drug combinations in routine paediatric intensive care and evaluate physician and nurse knowledge.

Methods

In a university paediatric intensive care unit, intravenous drug incompatibilities were analysed using a database and physician and nurse knowledge of incompatibilities was assessed using a questionnaire.

Results

We analysed 665 prescriptions in 87 patients. Incompatible drug administration was identified in 9 (10%) of the 87 patients with a median of 3 different incompatibilities per patient (Q25/Q75: 1/3). We found 26 incompatible combinations. The most frequently involved drugs were cefotaxime, pantoprazole and vancomycin. A median of 10 of the 15 drug combinations were correctly assessed as compatible or incompatible (Q25/Q75: 8/11). Pantoprazole had a low number (20%) of correct answers.

Conclusions

One in 10 patients in paediatric intensive care was affected by drug incompatibility, with knowledge deficits seen in a third of assessed combinations. This indicates quality improvement strategies should be urgently implemented by pharmacists.

Compatibility of Ceftazidime-Avibactam, Ceftolozane-Tazobactam, and Piperacillin-Tazobactam with Vancomycin in Dextrose 5% in Water

Objectives: The compatibility of vancomycin with existing and novel β-lactam/β-lactamase inhibitors at clinically relevant concentrations in 5% dextrose in water has not been fully explored to date. Methods: Vancomycin concentrations tested ranged from 5 to 20 mg/mL. Ceftazidime-avibactam was tested at 8, 20, and 40 mg/mL, ceftolozane-tazobactam at 15 mg/mL, and piperacillin-tazobactam at 28 mg/mL. Compatibility of drug admixtures were tested via both simulated and actual y-site infusion. For the simulated y-site compatibility assessment, 1:1 mixtures of each respective drug were analyzed over 24 hours. Actual y-site infusion followed a 4-hour extended-infusion protocol, with aliquots tested hourly for 4 hours. At all time points, the compatibility of each admixture was determined using 6 different methods: visual, microscopic, Tyndall beam, nephelometric, pH, and microbiologic bioassay assessment. If any admixture failed any one of these 6 assays, it was considered incompatible. Any combination deemed incompatible was filtered through a 0.22 μm filter and reanalyzed to assess impact of particle size. Results: There were no differences in compatibility categorizations between simulated and actual y-site infusion. There were no changes in compatibility over the time course of any experiment. Ceftazidime-avibactam at 8 mg/mL was incompatible with vancomycin at 5 mg/mL. The maximum compatible vancomycin concentrations were 5 mg/mL and 10 mg/mL with 20 and 40 mg/mL of ceftazidime-avibactam, respectively. Ceftolozane-tazobactam 15 mg/mL was compatible with vancomycin concentrations up to 10 mg/mL. The maximum compatible vancomycin concentration with piperacillin-tazobactam 28 mg/mL was 5 mg/mL. None of the β-lactam/β-lactamase inhibitors tested were compatible with 15 or 20 mg/mL of vancomycin. None of the admixtures considered incompatible by other methods displayed any decrease in antimicrobial activity as assessed by bioassay. After filtration, all admixtures originally deemed incompatible maintained their visual turbidity and microscopic particulate matter. Conclusions: Ceftazidime-avibactam prepared at the lowest concentration recommended in the package insert is incompatible with vancomycin. Ceftolozane-tazobactam did not display incompatibility until vancomycin concentrations above 10 mg/mL were tested. Piperacillin-tazobactam at a typical extended-infusion concentration is compatible with vancomycin in D5W. To our knowledge, this is the first study to assess compatibility of antibiotic admixtures via direct measurement of antimicrobial activity. The lack of any decrement in antibacterial activity of any apparently incompatible admixture and maintenance of incompatibility after passage through a 0.22 μm filter may suggest a lack of clinically relevant adverse effects when co-administered. Future compatibility studies should incorporate appropriate methods to accurately assess both efficacy and safety of co-administered drug products.