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Henkel ED, Haller CN, Diaz LZ, Ricles V, Wong Grossman AV, Nemergut ME, Krakowski AC. Optimizing pediatric periprocedural pain management part II-Adjunct therapies to support the use of infiltrative anesthetics. Pediatr Dermatol 2024; 41:588-598. [PMID: 38965874 DOI: 10.1111/pde.15677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 06/01/2024] [Indexed: 07/06/2024]
Abstract
Pediatric procedure-related pain management is often incompletely understood, inadequately addressed, and critical in influencing a child's lifelong relationship with the larger healthcare community. We present a comprehensive review of infiltrative anesthetics, including a comparison of their mechanisms of action and relative safety and efficacy data to help guide clinical selection. We also describe the multimodal utilization of adjunct therapies-in series and in parallel-to support the optimization of pediatric periprocedural pain management, enhance the patient experience, and provide alternatives to sedation medication and general anesthesia.
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Affiliation(s)
- Emily D Henkel
- Division of Dermatology, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Courtney N Haller
- Division of Dermatology, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Lucia Z Diaz
- Division of Dermatology, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
- Dell Children's Medical Center, Austin, Texas, USA
- Department of Pediatrics, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | | | | | | | - Andrew C Krakowski
- Department of Dermatology, St. Luke's University Health Network, Easton, Pennsylvania, USA
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2
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Chittora M, Rao D, Panwar S, Samaddar K, Remi RV. A comparative evaluation of the efficiency of warm local anesthetic solution delivered on precooled injection sites with the conventional local anesthetic technique in 7-9-year-old children: A randomized split-mouth cross-over trial. J Indian Soc Pedod Prev Dent 2024; 42:126-133. [PMID: 38957910 DOI: 10.4103/jisppd.jisppd_52_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 04/12/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Both precooling the site and injecting a warm anesthetic solution have proven to be efficient in reducing pain individually. However, there is insufficient data on evaluating the efficiency of precooling the site of injection along with the simultaneous administration of a warm local anesthetic solution on the same site in a single patient. AIM The aim of this study was to evaluate and compare the efficacy, pain perception, hemodynamic changes, and adverse effects of a warm local anesthetic solution injected on precooled injection sites using 2% lignocaine with the conventional local anesthetic technique during inferior alveolar nerve block in 7-9-year-old children. METHODS A split-mouth, double-blinded, randomized clinical trial was conducted on 70 children who received 2% lignocaine with either technique A or B during the first or second appointment of the treatment procedure. The pain perception, anesthetic efficacy, pulse rate, oxygen saturation levels, and adverse events were evaluated. RESULTS Pain during injection and treatment after administration of the warm local anesthesia (LA) technique was less as compared to the conventional block technique. Anesthetic success was observed with a faster onset of action (212.57 ± 32.51 s) and shorter duration of LA (165.16 ± 33.09 min) in the warm local technique as compared to the conventional technique. No significant differences were found with regard to heart rate and oxygen saturation levels between the two techniques. Administrating warm LA solutions at precooled injection sites revealed fewer adverse events. CONCLUSION Injecting warm LA solution on precooled injection sites causes less discomfort and anxiety in children, which makes it more suitable for the child as well as the pediatric dentist.
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Affiliation(s)
- Megha Chittora
- Department of Paediatric Dentistry, Pacific Dental College and Hospital, Udaipur, Rajasthan, India
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Sobuwa S, Singh T, Kalicharan K. Emergency care drugs' chemical stability after eight weeks' deployment in the prehospital setting. Afr J Emerg Med 2024; 14:7-10. [PMID: 38173689 PMCID: PMC10761352 DOI: 10.1016/j.afjem.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/30/2023] [Accepted: 11/28/2023] [Indexed: 01/05/2024] Open
Abstract
Temperature conditions vary in emergency service vehicles, which may pose a risk to the integrity of the drugs on board, possibly rendering them ineffective and increasing morbidity and mortality in patients. Aim This study assessed the stability of four emergency care drugs (adrenaline, etomidate, ketamine, and rocuronium) after eight weeks of deployment in the prehospital context. Methods The study adopted a longitudinal quantitative design to evaluate the chemical stability of emergency care drugs. The study was conducted at four emergency medical service bases in Ballito, Durban and Pietermaritzburg, South Africa. The primary outcome was the relative reduction in drug concentration from the labelled concentration after four and eight weeks. High-performance liquid chromatography-mass spectrometry (HPLC-MS) analysed samples to determine the concentration of active ingredients in the drug samples. Results HPLC analysis was done on 176 samples. The ambient temperature ranged from 18.7 to 44 °C in the first four weeks, averaging 26.8 °C ± 3.0. At 4 and 8 weeks, Adrenaline decreased 24.93 % and 22.73 %, respectively. Etomidate's control had 3.06 mg/ml, not the 2 mg/ml on the bottle. After 4 and 8 weeks, the samples had 3.10 and 3.15 mg/ml active components, respectively. Ketamine degraded over 30 % after four weeks but not beyond that. The Ketamine package states 10 mg/ml. However, we found 17.46 mg/ml. Rocuronium was 6.45 mg/ml in the control, although the manufacturer specified 10 mg/ml. At four weeks, the concentration was 6.70 mg/ml; at eight weeks, 6.56. Conclusion This study suggests that adrenaline and ketamine degrade by more than 20 % within four weeks of deployment in the prehospital field, whereas etomidate and rocuronium remain stable after eight weeks.
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Affiliation(s)
- Simpiwe Sobuwa
- Faculty of Health & Wellness Sciences, Department of Emergency Medical Sciences, Cape Peninsula University of Technology, Cape Town, South Africa
| | - Thishana Singh
- School of Chemistry and Physics, College of Agriculture, Engineering and Science, University of KwaZulu-Natal, Durban, South Africa
| | - Kerusha Kalicharan
- School of Chemistry and Physics, College of Agriculture, Engineering and Science, University of KwaZulu-Natal, Durban, South Africa
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An Evaluation of the Drone Delivery of Adrenaline Auto-Injectors for Anaphylaxis: Pharmacists’ Perceptions, Acceptance, and Concerns. DRONES 2020. [DOI: 10.3390/drones4040066] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Anaphylaxis is a life-threatening condition where delays in medical treatment can be fatal. Such situations would benefit from the drone delivery of an adrenaline auto-injector such as EpiPen®. This study evaluates the potential risk, reward, and impact of drone transportation on the stability of adrenaline during episodes of anaphylaxis. Further, this study examines pharmacists’ perceptions on drone delivery—pharmacists approved the use of drones to deliver EpiPen® during emergencies but had concerns with drone safety and supply chain security. Laboratory simulated onboard drone conditions reflected typical missions. In these experiments, in vitro model and pharmaceutical equivalent formulations were subjected independently to 30 min vibrations at 5, 8.43, and 13.33 Hz, and temperature storage at 4, 25, 40, and 65 °C for 0, 0.5, 3, and 24 h. The chiral composition (an indicator of chemical purity that relates to molecular structure) and concentration of these adrenaline formulations were determined using ultraviolet (UV) and circular dichroism spectroscopy (CD). Adrenaline intrinsic stability was also explored by edge-of-failure experimentation to signpost the uppermost limits for safe transportation. During drone flight with EpiPen®, the temperature and vibration g-force were 10.7 °C and 1.8 g, respectively. No adverse impact on adrenaline was observed during drone flight and laboratory-simulated conditions shown by conformation to the British Pharmacopeia standards (p > 0.05 for CD and UV). This study showed that drone delivery of EpiPen® is feasible. There are more than 15,000 community pharmacies and ≈9000 GP surgeries spanning the UK, which are likely to provide achievable ranges and distances for the direct drone delivery of EpiPen®. The authors recommend that when designing future missions, in addition to medicine stability testing that models the stresses imposed by drone flight, one must conduct a perceptions survey on the relevant group of medical professionals, because their insights, acceptance, and concerns are extremely valuable for the design and evaluation of the mission.
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Crea F, De Stefano C, Irto A, Lando G, Materazzi S, Milea D, Pettignano A, Sammartano S. Understanding the Solution Behavior of Epinephrine in the Presence of Toxic Cations: A Thermodynamic Investigation in Different Experimental Conditions. Molecules 2020; 25:E511. [PMID: 31991662 PMCID: PMC7037007 DOI: 10.3390/molecules25030511] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 01/16/2020] [Accepted: 01/21/2020] [Indexed: 11/16/2022] Open
Abstract
The interactions of epinephrine ((R)-(-)-3,4-dihydroxy-α-(methylaminomethyl)benzyl alcohol; Eph-) with different toxic cations (methylmercury(II): CH3Hg+; dimethyltin(IV): (CH3)2Sn2+; dioxouranium(VI): UO22+) were studied in NaClaq at different ionic strengths and at T = 298.15 K (T = 310.15 K for (CH3)2Sn2+). The enthalpy changes for the protonation of epinephrine and its complex formation with UO22+ were also determined using isoperibolic titration calorimetry: HHL = -39 ± 1 kJ mol-1, HH2L = -67 ± 1 kJ mol-1 (overall reaction), HML = -26 ± 4 kJ mol-1, and HM2L2(OH)2 = 39 ± 2 kJ mol-1. The results were that UO22+ complexation by Eph- was an entropy-driven process. The dependence on the ionic strength of protonation and the complex formation constants was modeled using the extended Debye-Hückel, specific ion interaction theory (SIT), and Pitzer approaches. The sequestering ability of adrenaline toward the investigated cations was evaluated using the calculation of pL0.5 parameters. The sequestering ability trend resulted in the following: UO22+ >> (CH3)2Sn2+ > CH3Hg+. For example, at I = 0.15 mol dm-3 and pH = 7.4 (pH = 9.5 for CH3Hg+), pL0.5 = 7.68, 5.64, and 2.40 for UO22+, (CH3)2Sn2+, and CH3Hg+, respectively. Here, the pH is with respect to ionic strength in terms of sequestration.
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Affiliation(s)
- Francesco Crea
- Dipartimento di Scienze Chimiche, Biologiche, Farmaceutiche ed Ambientali, Università degli Studi di Messina, V.le F. Stagno d’Alcontres, 31, I-98166 Messina, Italy; (C.D.S.); (A.I.); (G.L.); (D.M.); (S.S.)
| | - Concetta De Stefano
- Dipartimento di Scienze Chimiche, Biologiche, Farmaceutiche ed Ambientali, Università degli Studi di Messina, V.le F. Stagno d’Alcontres, 31, I-98166 Messina, Italy; (C.D.S.); (A.I.); (G.L.); (D.M.); (S.S.)
| | - Anna Irto
- Dipartimento di Scienze Chimiche, Biologiche, Farmaceutiche ed Ambientali, Università degli Studi di Messina, V.le F. Stagno d’Alcontres, 31, I-98166 Messina, Italy; (C.D.S.); (A.I.); (G.L.); (D.M.); (S.S.)
| | - Gabriele Lando
- Dipartimento di Scienze Chimiche, Biologiche, Farmaceutiche ed Ambientali, Università degli Studi di Messina, V.le F. Stagno d’Alcontres, 31, I-98166 Messina, Italy; (C.D.S.); (A.I.); (G.L.); (D.M.); (S.S.)
| | - Stefano Materazzi
- Dipartimento di Chimica, Università “La Sapienza” di Roma, Piazzale A. Moro 5, I-00185 Rome, Italy;
| | - Demetrio Milea
- Dipartimento di Scienze Chimiche, Biologiche, Farmaceutiche ed Ambientali, Università degli Studi di Messina, V.le F. Stagno d’Alcontres, 31, I-98166 Messina, Italy; (C.D.S.); (A.I.); (G.L.); (D.M.); (S.S.)
| | - Alberto Pettignano
- Dipartimento di Fisica e Chimica, Università degli Studi di Palermo, V.le delle Scienze, ed. 17, I-90128 Palermo, Italy;
| | - Silvio Sammartano
- Dipartimento di Scienze Chimiche, Biologiche, Farmaceutiche ed Ambientali, Università degli Studi di Messina, V.le F. Stagno d’Alcontres, 31, I-98166 Messina, Italy; (C.D.S.); (A.I.); (G.L.); (D.M.); (S.S.)
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Aravena PC, Barrientos C, Troncoso C, Coronado C, Sotelo-Hitschfeld P. Effect of warming anesthetic on pain perception during dental injection: a split-mouth randomized clinical trial. Local Reg Anesth 2018; 11:9-13. [PMID: 29503582 PMCID: PMC5826251 DOI: 10.2147/lra.s147288] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The purpose of this study is to determine the effectiveness of warming anesthesia on the control of the pain produced during the administration of dental anesthesia injection and to analyze the role of Transient Receptor Potential Vanilloid-1 nociceptor channels in this effect. PATIENTS AND METHODS A double-blind, split-mouth randomized clinical trial was designed. Seventy-two volunteer students (22.1±2.45 years old; 51 men) from the School of Dentistry at the Universidad Austral de Chile (Valdivia, Chile) participated. They were each administered 0.9 mL of lidocaine HCl 2% with epinephrine 1:100,000 (Alphacaine®) using two injections in the buccal vestibule at the level of the upper lateral incisor teeth. Anesthesia was administered in a hemiarch at 42°C (107.6°F) and after 1 week, anesthesia was administered by randomized sequence on the contralateral side at room temperature (21°C-69.8°F) at a standardized speed. The intensity of pain perceived during the injection was compared using a 100 mm visual analog scale (VAS; Wilcoxon test p<0.05). RESULTS The use of anesthesia at room temperature produced an average VAS for pain of 35.3±16.71 mm and anesthesia at 42°C produced VAS for pain of 15±14.67 mm (p<0.001). CONCLUSION The use of anesthesia at 42°C significantly reduced the pain during the injection of anesthesia compared to its use at room temperature during maxillary injections. The physiological mechanism of the temperature on pain reduction could be due to a synergic action on the permeabilization of the Transient Receptor Potential Vanilloid-1 channels, allowing the passage of anesthetic inside the nociceptors.
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Affiliation(s)
- Pedro Christian Aravena
- Department of Dentistry, Universidad Austral de Chile, Valdivia, Chile
- Department of Dental Implant Surgery, São Leopoldo Mandic School and Dental Institute, Campinas, SP, Brazil
| | - Camila Barrientos
- Department of Dentistry, Universidad Austral de Chile, Valdivia, Chile
| | - Catalina Troncoso
- Department of Dentistry, Universidad Austral de Chile, Valdivia, Chile
| | - Cesar Coronado
- Faculty of Health Science, School of Medicine, Universidad Autónoma de Chile, Santiago, Chile
| | - Pamela Sotelo-Hitschfeld
- Department of Center for Interdisciplinary Studies on Nervous System (CISNe), Universidad Austral de Chile, Valdivia, Chile
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Weir WB, Fred LY, Pike M, Rubakhin SS, Ludwig TJ, Shar AM, Zhu L, Frederick A, Uzoaru I, Wang L, Sweedler JV. Expired Epinephrine Maintains Chemical Concentration and Sterility. PREHOSP EMERG CARE 2018; 22:414-418. [PMID: 29373043 DOI: 10.1080/10903127.2017.1402109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Epinephrine shortages affect nearly all American emergency medical services (EMS) systems. Utilization of expired epinephrine could mitigate this situation in daily EMS operations. Concerns about using expired medications include sterility, potency, and potential harmful chemical decay byproducts. There are no cross-platform analyses of sterility and chemical purity of multiple samples of expired parenteral epinephrine. We hypothesized that epinephrine injections will remain sterile and will retain their active ingredient's content for more than 30 months past expiration. METHODS Six parenteral epinephrine prefilled syringes, 1 mg/10 mL, with an expiration date of January 1, 2012 had been stored in the climate controlled setting of a hospital inpatient pharmacy where they remained until they were taken for chemical or microbial analysis 30 months after expiration. An unexpired parenteral epinephrine prefilled syringe content was used as a control. Contents of three separate syringes with expired content from the same lot and one control underwent ultra-high pressure liquid chromatography-mass spectrometry (UHPLC-MS) and nuclear magnetic resonance (NMR) to determine epinephrine content and stability. In parallel, contents of another three expired epinephrine syringes were analyzed for sterility by plating on aerobic, anaerobic, and fungal media in a hospital microbiology laboratory. The aerobic plates were checked for growth in 3 days, the anaerobic in 5 days, and the fungal in 28 days. RESULTS UHPLC-MS and NMR showed that content of epinephrine present in the original sample remained unchanged compared to the control. There was no statistical difference in the UHPLC-MS and NMR signal amplitudes between the control and the expired samples. No chemical degradation byproducts were detected using NMR. There was no growth of any bacteria or fungus. CONCLUSION Recurrent epinephrine shortages impact EMS and hospital operations in the United States. Individual administrators may be hesitant to authorize use of expired pharmaceuticals due to perceived potential complications or fear of litigation. This study shows that the original parenteral epinephrine remains sterile and detectably pure more than 2.5 years after expiration. Further study of the sterility and chemical integrity of expired medications that had been subjected to the conditions of EMS vehicles may be a future research endeavor based on the aforementioned paradigm.
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Affiliation(s)
- F Lee Cantrell
- From California Poison Control System, San Diego, California
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Allegra J, Brennan J, Fields L, Grabiner F, Kiss G, Lavery R, Prusik T. Monitoring the Storage Temperature of Ambulance Medications with Time-Temperature Indicators. Hosp Pharm 2017. [DOI: 10.1177/001857870003500315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The US Pharmacopeia gives recommendations for the storage of pharmaceuticals in terms of mean kinetic temperature (MKT). This study's goal was to determine if color-changing time–temperature indicator (TTI) labels can reliably monitor the MKTs of medications used in ambulances. TTI labels and miniature electronic temperature recorders were placed into the drug storage boxes in five advanced life support units over 12 summer weeks in 1995 and in three advanced life support units over 4 weeks the following winter. The electronic temperature recorders measured temperatures several times per hour, and the color changes of the TTI labels were analyzed periodically. The MKTs calculated from the TTI labels differed from those calculated from the electronic temperature recorders in all cases by less than 1° C. The authors concluded that TTIs can accurately measure the MKTs of medications used in ambulances. A TTI label on each medication container may help insure that drugs are not damaged by temperture conditions.
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Affiliation(s)
- John Allegra
- Attending Physician, Morristown Memorial Hospital, Morristown, NJ
| | - John Brennan
- Emergency Physician, Children's Hospital, Newark Beth Israel Hospital Center, Newark, NJ
| | | | | | - George Kiss
- Emergency Medicine Resident, Morristown Memorial Hospital, Morristown, NJ
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10
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Horak J, Haberleitner A, Schauberger G. How to transport veterinary drugs in insulated boxes to avoid thermal damage by heating or freezing. BMC Vet Res 2017; 13:140. [PMID: 28545450 PMCID: PMC5445343 DOI: 10.1186/s12917-017-1058-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 05/15/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The transport of veterinary drugs must comply with the general standards for drug storage. Although many vehicles are equipped with active heating and/or cooling devices assuring recommended storage conditions, simple insulated transport boxes are also often used. In this study, measurements for typical transport boxes were performed under laboratory conditions by the use of a climate chamber for a temperature of -20 °C and 45 °C to investigate the impact of box size, insulation material, liquid vs. dry filling products, filling degree and other parameters on the thermal performance of insulated boxes. Model calculations and instructions are presented to predict the retention time of recommended drug storage temperatures. RESULTS The measurements and the model calculations showed that the loading of the transport boxes with additional water bottles to increase the heat capacity is appropriate to prolong the retention time of the recommended temperature range of the drugs. Insulated transport boxes are not suitable to store drugs over a period of more than approximately 12 h. For practical use a recipe is presented to measure the thermal properties of a transport box and the related retention time for which the recommended storage temperatures can be assured. CONCLUSIONS The following principles for drug transportation in vehicles are recommended: (1) Before transfer into boxes, drugs should always be thermally preconditioned (2) Increase the filling degree of the boxes with thermally preconditioned water bottles or re-usable thermal packs will increase the heat capacity. Do not deep-freeze the bottles or packs below 0 °C to avoid drug freezing due to contact. (3) Open the lid of the boxes only to uncase drugs that are immediately needed. (4) The bigger the box and the higher the filling degree, the longer the retention time of the transport box. (5) Wherever possible, place the drug box at a cool site inside the vehicle. (6) The monitoring of the inside temperature of the transport boxes is recommended. By the proper use of such transport boxes the recommended temperatures can be maintained over one working day.
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Affiliation(s)
- Johannes Horak
- WG Environmental Health, Division for Physiology and Biophysics, Department for Biomedical Sciences, University of Veterinary Medicine Vienna, Veterinärplatz 1, A 1210 Vienna, Austria
- Institute of Atmospheric and Cryospheric Sciences, University of Innsbruck, Innrain 52f, A-6020 Innsbruck, Austria
| | - Astrid Haberleitner
- Institute of Pharmacology and Toxicology, Department for Biomedical Sciences, University of Veterinary Medicine Vienna, Veterinärplatz 1, A 1210 Vienna, Austria
| | - Günther Schauberger
- WG Environmental Health, Division for Physiology and Biophysics, Department for Biomedical Sciences, University of Veterinary Medicine Vienna, Veterinärplatz 1, A 1210 Vienna, Austria
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Parish HG, Bowser CS, Morton JR, Brown JC. A systematic review of epinephrine degradation with exposure to excessive heat or cold. Ann Allergy Asthma Immunol 2016; 117:79-87. [PMID: 27221065 DOI: 10.1016/j.anai.2016.04.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 04/01/2016] [Accepted: 04/08/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Epinephrine is a lifesaving drug in the treatment of anaphylaxis and cardiac resuscitation. Current US storage recommendations are for controlled room temperature (20°C-25°C), with excursions permitted from 15°C to 30°C. Maintaining epinephrine within this required range is challenging, particularly for patients carrying autoinjectors and during storage in emergency vehicles. OBJECTIVE To study epinephrine degradation with extreme temperature exposure for epinephrine concentrations used in anaphylaxis and cardiac resuscitation. METHODS We searched the literature for all studies of epinephrine in sealed syringes, vials, or ampules in concentrations between 1:1,000 and 1:10,000, that measured epinephrine in samples exposed to temperatures above and/or below the recommended storage temperature compared with control samples. RESULTS Nine studies were included. Heat exposure resulted in epinephrine degradation but only with prolonged exposure. Constant heat resulted in more degradation. None of the studies that evaluated epinephrine exposure to extreme cold found significant degradation. None of the studies evaluating the effects of real-world temperature fluctuations detected significant degradation. Only 2 small studies (1 evaluating heat and 1 freezing) involved autoinjectors, and all 40 devices tested fired correctly. CONCLUSION Temperature excursions in real-world conditions may be less detrimental than previously suggested. Freezing and limited heat excursions did not result in epinephrine degradation. Refrigeration of epinephrine appears to reduce degradation. However, the effect of extreme temperatures, particularly freezing, on autoinjectors is not sufficiently well established. More research in needed at clinically relevant high temperatures, with limited exposure to heat, and involving autoinjector devices.
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Affiliation(s)
| | | | | | - Julie C Brown
- Seattle Children's Hospital, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington.
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12
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Bretti C, Cigala RM, Crea F, De Stefano C, Vianelli G. Solubility and modeling acid–base properties of adrenaline in NaCl aqueous solutions at different ionic strengths and temperatures. Eur J Pharm Sci 2015; 78:37-46. [DOI: 10.1016/j.ejps.2015.06.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 06/22/2015] [Accepted: 06/26/2015] [Indexed: 10/23/2022]
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Beasley H, Ng P, Wheeler A, Smith WR, McIntosh SE. The Impact of Freeze-Thaw Cycles on Epinephrine. Wilderness Environ Med 2015; 26:514-9. [PMID: 26001487 DOI: 10.1016/j.wem.2015.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Revised: 03/13/2015] [Accepted: 04/07/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Epinephrine is the first-line medical treatment for anaphylaxis, a life-threatening allergic syndrome. To treat anaphylaxis, backcountry recreationalists and guides commonly carry epinephrine autoinjectors. Epinephrine may be exposed to cold temperatures and freezing during expeditions. An epinephrine solution must contain 90% to 115% of the labeled epinephrine amount to meet United States Pharmacopeia standards. The purpose of this study was to determine whether freeze-thaw cycles alter epinephrine concentrations in autoinjectors labeled to contain 1.0 mg/mL epinephrine. A further objective was to determine whether samples continued to meet United States Pharmacopeia concentration standards after freeze-thaw cycles. METHODS Epinephrine from 6 autoinjectors was extracted and divided into experimental and control samples. The experimental samples underwent 7 consecutive 12-hour freeze cycles followed by 7 12-hour thaw cycles. The control samples remained at an average temperature of 23.1°C for the duration of the study. After the seventh thaw cycle, epinephrine concentrations were measured using a high-performance liquid chromatography assay with mass spectrometry detection. RESULTS The mean epinephrine concentration of the freeze-thaw samples demonstrated a statistically significant increase compared with the control samples: 1.07 mg/mL (SD ± 8.78; 95% CI, 1.04 to 1.11) versus 0.96 mg/mL (SD ± 6.81; 95% CI, 0.94 to 0.99), respectively. The maximal mean epinephrine concentration in the experimental freeze-thaw group was 1.12 mg/mL, which still fell within the range of United States Pharmacopeia standards for injectables (0.90 to 1.15 mg/mL). CONCLUSIONS Although every attempt should be made to prevent freezing of autoinjectors, this preliminary study demonstrates that epinephrine concentrations remain within 90% to 115% of 1.0 mg/mL after multiple freeze-thaw cycles.
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Affiliation(s)
- Heather Beasley
- University of Utah School of Medicine (Ms Beasley), Salt Lake City, UT.
| | - Pearlly Ng
- Division of Emergency Medicine (Drs Ng and McIntosh), University of Utah Health Care, Salt Lake City, UT
| | - Albert Wheeler
- St. John's Medical Center (Drs Wheeler and Smith), Jackson, WY
| | - William R Smith
- St. John's Medical Center (Drs Wheeler and Smith), Jackson, WY; WWAMI Clinical Faculty (Dr Smith), University of Washington School of Medicine, Seattle, WA
| | - Scott E McIntosh
- Division of Emergency Medicine (Drs Ng and McIntosh), University of Utah Health Care, Salt Lake City, UT
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14
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Rachid O, Simons FER, Rawas-Qalaji M, Lewis S, Simons KJ. Epinephrine doses delivered from auto-injectors stored at excessively high temperatures. Drug Dev Ind Pharm 2015; 42:131-135. [DOI: 10.3109/03639045.2015.1035283] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Ousama Rachid
- College of Pharmacy, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada,
| | - F. Estelle R. Simons
- Department of Pediatrics & Child Health and Department of Immunology, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada, and
| | - Mutasem Rawas-Qalaji
- Health Professions Division, College of Pharmacy, Nova Southeastern University, FL, USA
| | - Stephen Lewis
- College of Pharmacy, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada,
| | - Keith J. Simons
- College of Pharmacy, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada,
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Epinephrine doses contained in outdated epinephrine auto-injectors collected in a Florida allergy practice. Ann Allergy Asthma Immunol 2015; 114:354-356.e1. [PMID: 25707326 DOI: 10.1016/j.anai.2015.01.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 01/23/2015] [Accepted: 01/27/2015] [Indexed: 11/20/2022]
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Rachid O, Simons FER, Rawas-Qalaji M, Lewis S, Simons KJ. Epinephrine autoinjectors: does freezing or refrigeration affect epinephrine dose delivery and enantiomeric purity? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:294-6. [PMID: 25609348 DOI: 10.1016/j.jaip.2014.11.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 11/21/2014] [Accepted: 11/24/2014] [Indexed: 11/24/2022]
Affiliation(s)
- Ousama Rachid
- College of Pharmacy, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - F Estelle R Simons
- Department of Pediatrics and Child Health and Department of Immunology, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Stephen Lewis
- College of Pharmacy, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Keith J Simons
- College of Pharmacy, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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Dynamic Temperature and Humidity Environmental Profiles: Impact for Future Emergency and Disaster Preparedness and Response. Prehosp Disaster Med 2014; 29:4-12. [DOI: 10.1017/s1049023x13009199] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractIntroductionDuring disasters and complex emergencies, environmental conditions can adversely affect the performance of point-of-care (POC) testing. Knowledge of these conditions can help device developers and operators understand the significance of temperature and humidity limits necessary for use of POC devices. First responders will benefit from improved performance for on-site decision making.ObjectiveTo create dynamic temperature and humidity profiles that can be used to assess the environmental robustness of POC devices, reagents, and other resources (eg, drugs), and thereby, to improve preparedness.MethodsSurface temperature and humidity data from the National Climatic Data Center (Asheville, North Carolina USA) was obtained, median hourly temperature and humidity were calculated, and then mathematically stretched profiles were created to include extreme highs and lows. Profiles were created for: (1) Banda Aceh, Indonesia at the time of the 2004 Tsunami; (2) New Orleans, Louisiana USA just before and after Hurricane Katrina made landfall in 2005; (3) Springfield, Massachusetts USA for an ambulance call during the month of January 2009; (4) Port-au-Prince, Haiti following the 2010 earthquake; (5) Sendai, Japan for the March 2011 earthquake and tsunami with comparison to the colder month of January 2011; (6) New York, New York USA after Hurricane Sandy made landfall in 2012; and (7) a 24-hour rescue from Hawaii USA to the Marshall Islands. Profiles were validated by randomly selecting 10 days and determining if (1) temperature and humidity points fell inside and (2) daily variations were encompassed. Mean kinetic temperatures (MKT) were also assessed for each profile.ResultsProfiles accurately modeled conditions during emergency and disaster events and enclosed 100% of maximum and minimum temperature and humidity points. Daily variations also were represented well with 88.6% (62/70) of temperature readings and 71.1% (54/70) of relative humidity readings falling within diurnal patterns. Days not represented well primarily had continuously high humidity. Mean kinetic temperature was useful for severity ranking.ConclusionsSimulating temperature and humidity conditions clearly reveals operational challenges encountered during disasters and emergencies. Understanding of environmental stresses and MKT leads to insights regarding operational robustness necessary for safe and accurate use of POC devices and reagents. Rescue personnel should understand these principles before performing POC testing in adverse environments.FergusonWJ, LouieRF, TangCS, Paw UKT, KostGJ. Dynamic temperature and humidity environmental profiles: impact for future emergency and disaster preparedness and response. Prehosp Disaster Med. 2014;29(1):1-8.
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Nakamura T, Yamaji T, Takayama K. [Effect of heat transfer in the packages on the stability of thiamine nitrate under uncontrolled temperature conditions]. YAKUGAKU ZASSHI 2013; 133:1411-5. [PMID: 24292190 DOI: 10.1248/yakushi.13-00199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
To accurately predict the stability of thiamine nitrate as a model drug in pharmaceutical products under uncontrolled temperature conditions, the average reaction rate constant was determined, taking into account the heat transfer from the atmosphere to the product. The stability tests of thiamine nitrate in the three packages with different heat transfers were performed under non-isothermal conditions. The stability data observed were compared with the predictions based on a newly developed method, showing that the stability was well predicted by the method involving the heat transfer. By contrast, there were some deviations observed from the predicted data, without considering heat transfer in the packages with low heat transfer. The above-mentioned result clearly shows that heat transfer should be considered to ensure accurate prediction of the stability of commercial pharmaceutical products under non-isothermal atmospheres.
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De Winter S, Vanbrabant P, Vi NT, Deng X, Spriet I, Van Schepdael A, Gillet JB. Impact of Temperature Exposure on Stability of Drugs in a Real-World Out-of-Hospital Setting. Ann Emerg Med 2013; 62:380-387.e1. [DOI: 10.1016/j.annemergmed.2013.04.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Revised: 04/08/2013] [Accepted: 04/22/2013] [Indexed: 11/15/2022]
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20
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Nakamura T, Yamaji T, Takayama K. Effects of packaging and heat transfer kinetics on drug-product stability during storage under uncontrolled temperature conditions. J Pharm Sci 2013; 102:1495-503. [PMID: 23450624 DOI: 10.1002/jps.23486] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 01/31/2013] [Accepted: 02/04/2013] [Indexed: 11/11/2022]
Abstract
To predict the stability of pharmaceutical preparations under uncontrolled temperature conditions accurately, a method to compute the average reaction rate constant taking into account the heat transfer from the atmosphere to the product was developed. The average reaction rate constants computed with taken into consideration heat transfer (κ(re) ) were then compared with those computed without taking heat transfer into consideration (κ(in) ). The apparent thermal diffusivity (κ(a) ) exerted some influence on the average reaction rate constant ratio (R, R = κ(re) /κ(in) ). In the regions where the κ(a) was large (above 1 h(-1) ) or very small, the value of R was close to 1. On the contrary, in the middle region (0.001-1 h(-1) ), the value of R was less than 1.The κ(a) of the central part of a large-size container and that of the central part of a paper case of 10 bottles of liquid medicine (100 mL) fell within this middle region. On the basis of the above-mentioned considerations, heat transfer may need to be taken into consideration to enable a more accurate prediction of the stability of actual pharmaceutical preparations under nonisothermal atmospheres.
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Affiliation(s)
- Toru Nakamura
- Department of Pharmaceutics, Hoshi University, Shinagawa-ku, Tokyo 142-8501, Japan
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21
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Hoellein L, Holzgrabe U. Ficts and facts of epinephrine and norepinephrine stability in injectable solutions. Int J Pharm 2012; 434:468-80. [DOI: 10.1016/j.ijpharm.2012.05.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Revised: 05/10/2012] [Accepted: 05/11/2012] [Indexed: 12/22/2022]
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22
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Hogan ME, vanderVaart S, Perampaladas K, Machado M, Einarson TR, Taddio A. Systematic review and meta-analysis of the effect of warming local anesthetics on injection pain. Ann Emerg Med 2011; 58:86-98.e1. [PMID: 21316812 DOI: 10.1016/j.annemergmed.2010.12.001] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Revised: 11/23/2010] [Accepted: 12/01/2010] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE Local anesthetics are the main class of analgesics used for pain management during laceration repair and other minor surgeries; however, they are administered by injection, which is painful. Warming local anesthetics has been proposed as a cost-free intervention that reduces injection pain. A systematic review of the effectiveness of this technique has not yet been undertaken. We determine the effectiveness of warming local anesthetics to reduce pain in adults and children undergoing local anesthetic infiltration into intradermal or subcutaneous tissue. METHODS We used published articles from MEDLINE (1950 to June 2010), EMBASE (1980 to June 2010), CINAHL (1982 to June 2010), the Cochrane Library (second quarter 2010), International Pharmaceutical Abstracts (1970 to June 2010), and ProQuest Dissertations and Theses database (1938 to June 2010). We included studies with randomized or pseudorandomized designs and healthy subjects or patients receiving subcutaneous or intradermal injection of local anesthetics that were warmed (body temperature) or not (room temperature). Studies of regional anesthesia and intraarticular, spinal, or periorbital administration of local anesthetics were excluded. Data were extracted onto predesigned forms and verified by 2 reviewers. Quality was assessed with the Cochrane risk of bias tool. The primary outcome was self-reported pain as assessed by a visual analog or numeric rating scale. Data were combined with mean differences with 95% confidence intervals (CIs) by using a random-effects model. RESULTS Twenty-nine studies were retrieved for close examination and 19 studies met inclusion criteria. A total of 18 studies with 831 patients could be included in a meta-analysis. Seventeen studies had an unclear risk of bias and 1 had a high risk of bias. A mean difference of -11 mm (95% CI -14 to -7 mm) on a 100-mm scale was found in favor of warming local anesthetics. Subgroup analysis of 8 studies investigating the effect of warming on buffered local anesthetics yielded similar results: -7 mm (95% CI -12 to -3 mm). CONCLUSION Warming local anesthetics leads to less pain during injection and therefore should be done before administration.
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Affiliation(s)
- Mary-Ellen Hogan
- Graduate Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
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Brown LH, Krumperman K, Fullagar CJ. OUT-OF-HOSPITAL MEDICATIONSTORAGETEMPERATURES: A REVIEWOF THE LITERATUREAND DIRECTIONSFOR THE FUTURE. PREHOSP EMERG CARE 2009. [DOI: 10.1080/312703004362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Gammon DL, Su S, Jordan J, Patterson R, Finley PJ, Lowe C, Huckfeldt R. Alteration in prehospital drug concentration after thermal exposure. Am J Emerg Med 2008; 26:566-73. [PMID: 18534286 DOI: 10.1016/j.ajem.2007.09.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2007] [Revised: 09/08/2007] [Accepted: 09/09/2007] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The aim of the study was to determine the remaining concentration of 23 commonly carried emergency medical services medications used in the United States after they have experienced thermal extremes that have been documented in the prehospital environment for a period of 1 month. METHODS Pharmaceuticals were thermally cycled (-6 degrees C and 54 degrees C) every 12 hours and then assayed by high-performance liquid chromatography. RESULTS Eight (35%) of 23 prehospital pharmaceuticals revealed ending concentrations of less than 90% with strong correlation to thermal exposure time. These included lidocaine, diltiazem, dopamine, nitroglycerin, ipratropium, succinylcholine, haloperidol, and naloxone. CONCLUSION A decrease in concentration was found to be statistically significant in 8 (35%) of 23 commonly carried emergency medical services pharmaceuticals. These results provide new information and perspective regarding stability of emergency drugs in the prehospital environment by evaluating a broad range of pharmaceuticals as well as by using thermal exposure points that have been documented in the United States.
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Affiliation(s)
- Dustin L Gammon
- St. John's Emergency Medical Services, Springfield, MO 65804, USA.
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Brown LH, Wojcik SM, Bailey LC, Tran CD. Can stock rotation effectively mitigate EMS medication exposure to excessive heat and cold? Am J Emerg Med 2006; 24:14-8. [PMID: 16338503 DOI: 10.1016/j.ajem.2005.05.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2005] [Indexed: 11/21/2022] Open
Abstract
The United States Pharmacopeia recently published a general chapter specifically addressing on-ambulance storage of medications, including a suggestion for stock rotation. This study describes the effectiveness of a simple stock rotation strategy in mitigating EMS medication exposure to excessive heat and cold. Previously collected on-ambulance temperature data from 5 US cities were randomly resampled to generate model exposures of 2 days to 6 months duration. The temperature measurements for every other 24-hour period were then set at 20 degrees C to model the rotation of medications into a controlled environment. For each model, we then determined consistency with the official United States Pharmacopeia definition of controlled room temperature. Without stock rotation, excessive heat occurred in 39.9% of the model exposures. With stock rotation, exposures to excessive heat occurred in less than 1% of northern city models and in 2.9% of the central US models. Stock rotation did not reduce heat exposures in the models for southern cities.
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Affiliation(s)
- Lawrence H Brown
- Department of Emergency Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, USA.
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Küpper TEAH, Schraut B, Rieke B, Hemmerling AV, Schöffl V, Steffgen J. Drugs and drug administration in extreme environments. J Travel Med 2006; 13:35-47. [PMID: 16412107 DOI: 10.1111/j.1708-8305.2006.00007.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Emergency medicine must often cope with harsh climates far below freezing point or high temperatures, and sometimes, an alternative to the normal route of drug administration is necessary. Most of this information is not yet published. Therefore, we summarized the information about these topics for most drugs used in medical emergencies by combining literature research with extensive personal communications with the heads of the drug safety departments of the companies producing these drugs. Most drugs can be used after temperature stress of limited duration. Nevertheless, we recommend replacing them at least once per year or after extreme heat. Knowledge about drugs used in extreme environments will be of increasing importance for medical personnel because in an increasingly mobile society, more and more people, and especially elderly -often with individual medical risks-travel to extreme regions such as tropical or arctic regions or to high altitude, and some of them need medical care during these activities. Because of this increasing need to use drugs in harsh climates (tourism, expeditions, peace corps, military, etc) the actual International Congress of Harmonization recommendations should be added with stability tests at +50 degrees C, freezing and oscillating temperatures, and UV exposure to simulate the storage of the drugs at "outdoor conditions."
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Affiliation(s)
- Thomas E A H Küpper
- Institute of Aerospace Medicine, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
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Helm M, Castner T, Lampl L. Environmental temperature stress on drugs in prehospital emergency medical service. Acta Anaesthesiol Scand 2003; 47:425-9. [PMID: 12694141 DOI: 10.1034/j.1399-6576.2003.00062.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Drugs used in prehospital emergency medical service (EMS) in principle are subject to the same storage restrictions as hospital-based medications. The prehospital emergency environment however, often exceeds these storage recommendations. Main stress factors are sunlight, vibration and extreme temperature, which may lead to alteration in chemical and physical stability of stored pharmaceuticals, as well as microbiological contamination and concentration enhancement of pharmacological inserts. METHODS The purpose of this study was to determine the environmental temperature stress upon drugs used in the prehospital EMS under real mission conditions within different types of rescue vehicles (rescue helicopter [HEMS], ambulance [AMB] and emergency physician transport vehicle [EPTV]) during a 'summer' and 'winter' monitoring period (2 months duration each/location: southern Germany). RESULTS Recorded temperatures varied from -13.2 degrees C to +50.6 degrees C. The recommended maximum storage temperature (+25 degrees C) was exceeded in all rescue vehicles (33-45% of total exposure time), whereas the recommended minimum storage temperature (0 degrees C) only fell short in the EPTV (19% of total exposure time). The daily maximum temperature variations ranged from 19.0 degrees C (winter) to 32.9 degrees C (summer). CONCLUSIONS These results show that even in a moderate climatic zone, drugs used in prehospital EMS are significantly influenced by temperature stress; furthermore, these results recommend the usage of temperature-controlled drug boxes.
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Affiliation(s)
- M Helm
- Department of Anaesthesiology and Intensive Care Medicine, Federal Armed Forces Medical Center Ulm, Ulm, Germany.
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Simons FE, Gu X, Simons KJ. Outdated EpiPen and EpiPen Jr autoinjectors: past their prime? J Allergy Clin Immunol 2000; 105:1025-30. [PMID: 10808186 DOI: 10.1067/mai.2000.106042] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND EpiPen and EpiPen Jr autoinjectors are often recommended for prehospital treatment of anaphylaxis. When these units become outdated, there may be a delay in replacing them. OBJECTIVES Our purpose was to evaluate unused, outdated EpiPen and EpiPen Jr autoinjectors, obtained from patients at risk for anaphylaxis, for epinephrine bioavailability and epinephrine content. METHODS We conducted a prospective, randomized, cross-over study of epinephrine bioavailability after injection from outdated autoinjectors in rabbits; controls included EpiPen and EpiPen Jr autoinjectors that had not expired ("in-date" autoinjectors) and intramuscular injection of 0.9% saline solution. In addition, the epinephrine content of the outdated EpiPen and EpiPen Jr autoinjectors was measured by a spectrophotometric method and an HPLC-UV method. RESULTS Twenty-eight EpiPen and 6EpiPen Jr autoinjectors were studied 1 to 90 months after the stated expiration date. Most were not discolored and did not contain precipitates. Epinephrine bioavailability from the outdated EpiPen autoinjectors was significantly reduced (P <.05) compared with epinephrine bioavailability from the in-date autoinjectors. The inverse correlation between the decreased epinephrine content of the outdated autoinjectors, assessed with an HPLC-UV method, and the number of months past the expiration date was 0.63. CONCLUSIONS For prehospital treatment of anaphylaxis, we recommend the use of EpiPen and EpiPen Jr autoinjectors that are not outdated. If, however, the only autoinjector available is an outdated one, it could be used as long as no discoloration or precipitates are apparent because the potential benefit of using it is greater than the potential risk of a suboptimal epinephrine dose or of no epinephrine treatment at all.
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Affiliation(s)
- F E Simons
- Section of Allergy and Clinical Immunology, Department of Pediatrics and Child Health, Faculty of Medicine, University of Manitoba, Winnipeg, Canada
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Szucs P, Allegra JR, Fields LA, Grabiner FR, Lavery R, Prusik T, Tortella B. Storage temperatures of medications on an air medical helicopter. Air Med J 2000; 19:19-21. [PMID: 11067232 DOI: 10.1016/s1067-991x(00)90087-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The safety and efficacy of medications stored on air medical helicopters may be adversely affected by extreme temperatures. The purpose of this study was to determine whether temperatures inside an air medical helicopter drug box were within the U.S. Pharmacopeia recommendations for controlled room temperature. This is defined as a temperature between 15 degrees and 30 degrees C (59 degrees and 86 degrees F) with a mean kinetic temperature of less than 25 degrees C (77 degrees F). An additional goal was to determine whether time/temperature indicator labels can reliably monitor mean kinetic temperatures. METHODS Temperatures were monitored with miniature electronic temperature recorders and color-changing time/temperature indicator labels. RESULTS The mean kinetic temperatures for the summer and winter periods were 25.1 degrees C (77.2 degrees F) and 12.7 degrees C (54.8 degrees F), respectively. In the summer, the electronic recorders logged temperatures exceeding 25 degrees C (59 degrees F) 37% of the time and more than 30 degrees C (86 degrees F) 6% of the time. In the winter, temperatures less than 15 degrees C (59 degrees F) were recorded 83% of the time. The mean kinetic temperatures obtained from the electronic recorder and the time/temperature indicator labels differed by less than 0.7 degree C (1.3 degrees F). The results show that medications on an air medical helicopter are subject to temperatures out of the recommended range and that time/temperature indicator labels can reliably monitor mean kinetic temperatures.
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Affiliation(s)
- P Szucs
- Morristown Memorial Hospital Residency in Emergency Medicine, Morristown, N.J., USA
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Allegra JR, Brennan J, Lanier V, Lavery R, MacKenzie B. Storage temperatures of out-of-hospital medications. Acad Emerg Med 1999; 6:1098-103. [PMID: 10569380 DOI: 10.1111/j.1553-2712.1999.tb00110.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine whether temperatures inside drug boxes used in the out-of-hospital setting are within the U.S. Pharmacopeia recommendations for "controlled room temperature," which is defined as a temperature maintained between 15 degrees C and 30 degrees C with a mean kinetic temperature less than 25 degrees C, and to determine whether time-temperature indicator labels can reliably monitor mean kinetic temperatures. METHODS Two methods were used to monitor temperatures: miniature electronic temperature recorders and color-changing time-temperature indicator labels. These were placed in drug storage boxes of advanced life support units over three summer months and two winter months. RESULTS In summer, the electronic recorders logged temperatures exceeding 30 degrees C in all drug storage boxes, ranging from 3% to 29% of the total time. The mean kinetic temperatures by location for the whole period ranged from 21 degrees C to 30 degrees C. In the winter, the electronic recorders logged temperatures exceeding 30 degrees C at one location 2% of the total time. There were significant temperature excursions below 15 degrees C at all locations, ranging from 16% to 90% of the total time. At one location, there were temperature readings below 0 degrees C for 9% of the total time. The mean kinetic temperatures obtained from the electronic recorders and the indicator labels differed by less than 1 degrees C. CONCLUSIONS This study demonstrates that out-of-hospital medications are subject to temperatures both above and below recommended storage temperatures. Time-temperature indicator labels can reliably monitor exposure to elevated temperatures.
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Affiliation(s)
- J R Allegra
- Morristown Memorial Hospital, NJ 07962, USA.
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Abstract
The degradation of epinephrine in USP injectable cartridges was investigated under different heating conditions. Epinephrine (EPI) and EPI sulfonic acid (EPI-SA) levels in 1:10,000 (0.1 mg/mL) EPI injectable solutions subjected to either cyclical (65 degrees C for 8 hr/d for 4 to 12 weeks) or constant (65 degrees C for 7 days) heating were determined using high-pressure liquid chromatography with diode array and electrochemical detection. Constant (169 total hours of heat exposure) heating resulted in complete degradation of both compounds and dark brown discoloration of the solution. Cyclical heating (672 total hours of heat exposure) resulted in a 31% reduction in EPI concentration and a 225% increase in EPI-SA concentration with no discoloration of the solution. In laboratory-prepared solutions, the degradation of EPI and the formation of EPI-SA was found to be dependent on sodium metabisulfite concentration and the duration of cyclical heating. These results indicate that the thermal stability of EPI and the formation of EPI-SA depends on the method of heat exposure and the amount of bisulfite present in the solution.
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Affiliation(s)
- W H Church
- Department of Chemistry, East Carolina University, Greenville, NC 27858
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