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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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Foertsch MJ, McMullan JT, Harger NJ, Rodriquez D, Salvator A, PharmD EWM, Droege CA. Ketamine Stability over Six Months of Exposure to Moderate and High Temperature Environments. PREHOSP EMERG CARE 2021; 26:422-427. [PMID: 34028315 DOI: 10.1080/10903127.2021.1934203] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
Background: All medications should be stored within temperature ranges defined by manufacturers, but logistical and operational challenges of prehospital and military settings complicate adherence to these recommendations. Lorazepam and succinylcholine experience clinically relevant heat-related degradation, whereas midazolam does not. Because ketamine's stability when stored outside manufacturer recommendations is unknown, we evaluated the heat-related degradation of ketamine exposed to several temperature ranges. Methods: One hundred twenty vials of ketamine (50 mg/mL labeled concentration) from the same manufacturer lot were equally distributed and stored for six months in five environments: an active EMS unit in southwest Ohio (May-October 2019); heat chamber at constant 120 °F (C1); heat chamber fluctuating over 24 hours from 86 °F-120 °F (C2); heat chamber fluctuating over 24 hours from 40 °F-120 °F (C3); heat chamber kept at constant 70 °F (manufacturer recommended room temperature, C4). Four ketamine vials were removed every 30 days from each environment and sent to an FDA-accredited commercial lab for high performance liquid chromatography testing. Data loggers and thermistors allowed temperature recording every minute for all environments. Cumulative heat exposure was quantified by mean kinetic temperature (MKT), which accounts for additional heat-stress over time caused by temperature fluctuations and is a superior measure than simple ambient temperature. MKT was calculated for each environment at the time of ketamine removal. Descriptive statistics were used to describe the concentration changes at each time point. Results: The MKT ranged from 73.6 °F-80.7 °F in the active EMS unit and stayed constant for each chamber (C1 MKT: 120 °F, C2 MKT: 107.3 °F, C3 MKT: 96.5 °F, C4 MKT: 70 °F). No significant absolute ketamine degradation, or trends in degradation, occurred in any environment at any time point. The lowest median concentration occurred in the EMS-stored samples removed after 6 months [48.2 mg/mL (47.75, 48.35)], or 96.4% relative strength to labeled concentration. Conclusion: Ketamine samples exhibited limited degradation after 6 months of exposure to real world and simulated extreme high temperature environments exceeding manufacturer recommendations. Future studies are necessary to evaluate ketamine stability beyond 6 months.
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Cheng T, Farah J, Aldridge N, Tamir S, Donofrio‐Odmann JJ. Pediatric respiratory distress: California out-of-hospital protocols and evidence-based recommendations. J Am Coll Emerg Physicians Open 2020; 1:955-964. [PMID: 33145546 PMCID: PMC7593477 DOI: 10.1002/emp2.12103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 04/22/2020] [Accepted: 04/28/2020] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES Prehospital protocols vary across local emergency medical service (EMS) agencies in California. We sought to develop evidence-based recommendations for the out-of-hospital evaluation and treatment of pediatric respiratory distress, and we evaluated the protocols for pediatric respiratory distress used by the 33 California local EMS agencies. METHODS Evidence-based recommendations were developed through an extensive literature review of the current evidence regarding out-of-hospital treatment of pediatric patients with respiratory distress. The authors compared the pediatric respiratory distress protocols of each of the 33 California local EMS agencies with the evidence-based recommendations. Our focus was on the treatment of 3 main pediatric respiratory complaints by presentation: stridor (croup), wheezing < 24 months (bronchiolitis), and wheezing > 24 months (asthma). RESULTS Protocols across the 33 California local EMS agencies varied widely. Stridor (croup) had the highest protocol variability of the 3 presentations we evaluated, with no treatment having uniform use among all agencies. Only 3 (9.1%) of the local EMS agencies differentiated wheezing in children < 24 months of age, referencing this as possible bronchiolitis. All local EMS agencies included albuterol and epinephrine (intravenous/intramuscular) in their pediatric wheezing (asthma) treatment protocols. The least common treatments for wheezing (asthma) included nebulized epinephrine (3/33) and magnesium (2/33). No agencies included steroids in their treatment protocols (0/33). CONCLUSION Protocols for pediatric respiratory distress vary widely across the state of California, especially among those for stridor (croup) and wheezing in < 24 months (bronchiolitis). The evidence-based recommendations that we present for the prehospital treatment of these conditions may be useful for EMS medical directors tasked with creating and revising these protocols.
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Affiliation(s)
- Tabitha Cheng
- Department of Emergency MedicineUniversity of California San Diego (UCSD)San DiegoCaliforniaUSA
| | - Jennifer Farah
- Department of Emergency MedicineUniversity of California San Diego (UCSD)San DiegoCaliforniaUSA
| | - Nicholas Aldridge
- Department of Emergency MedicineUniversity of California San Diego (UCSD)San DiegoCaliforniaUSA
| | - Sharon Tamir
- Department of PediatricsUCSDSan DiegoCaliforniaUSA
- Rady Children's Hospital of San DiegoSan DiegoCaliforniaUSA
| | - J. Joelle Donofrio‐Odmann
- Department of Emergency MedicineUniversity of California San Diego (UCSD)San DiegoCaliforniaUSA
- Department of PediatricsUCSDSan DiegoCaliforniaUSA
- Rady Children's Hospital of San DiegoSan DiegoCaliforniaUSA
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The Effect of High Storage Temperature on the Stability and Efficacy of Lyophilized Tenecteplase. Prehosp Disaster Med 2020; 35:501-507. [PMID: 32686630 DOI: 10.1017/s1049023x20000928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Tenecteplase is a thrombolytic protein drug used by paramedics, emergency responders, and critical care medical personnel for the prehospital treatment of blood clotting diseases. Minimizing the time between symptom onset and the initiation of thrombolytic treatment is important for reducing mortality and improving patient outcomes. However, the structure of protein drug molecules makes them susceptible to physical and chemical degradation that could potentially result in considerable adverse effects. In locations that experience extreme temperatures, lyophilized tenecteplase transported in emergency service vehicles (ESVs) may be subjected to conditions that exceed the manufacturer's recommendations, particularly when access to the ambulance station is limited. STUDY OBJECTIVE This study evaluated the impact of heat exposure (based on temperatures experienced in an emergency vehicle during summer in a regional Australian city) on the stability and efficacy of lyophilized tenecteplase. METHODS Vials containing 50mg lyophilized tenecteplase were stored at 4.0°C (39.2°F), 35.5°C (95.9°F), or 44.9°C (112.8°F) for a continuous period of eight hours prior to reconstitution. Stability and efficacy were determined through assessment of: optical clarity and pH; analyte concentration using UV spectrometry; percent protein monomer and single chain protein using size-exclusion chromatography; and in vitro bioactivity using whole blood clot weight and fibrin degradation product (D-dimer) development. RESULTS Heat treatment, particularly at 44.9°C, was found to have the greatest impact on tenecteplase solubility; the amount of protein monomer and single chain protein lost (suggesting structural vulnerability); and the capacity for clot lysis in the form of decreased D-dimer production. Meanwhile, storage at 4.0°C preserved tenecteplase stability and in vitro bioactivity. CONCLUSION The findings indicate that, in its lyophilized form, even relatively short exposure to high temperature can negatively affect tenecteplase stability and pharmacological efficacy. It is therefore important that measures are implemented to ensure the storage temperature is kept below 30.0°C (86.0°F), as recommended by manufacturers, and that repeated refrigeration-heat cycling is avoided. This will ensure drug administration provides more replicable thrombolysis upon reaching critical care facilities.
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Carter AJ, Hall EJ, Connolly SL, Russell ZF, Mitchell K. Drugs, dogs, and driving: the potential for year-round thermal stress in UK vehicles. Open Vet J 2020; 10:216-225. [PMID: 32821666 PMCID: PMC7419075 DOI: 10.4314/ovj.v10i2.11] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 05/27/2020] [Indexed: 12/02/2022] Open
Abstract
Background: Dogs are regularly transported or housed in vehicles, with guidelines for housing dogs suggesting that the ambient temperature should be maintained between 15°C and 24°C. Veterinary drugs are routinely stored and carried in vehicles providing ambulatory veterinary care. Non-refrigerated medications typically require storage between 8°C and 25°C. Aim: This study aims to investigate the potential for thermal stress associated with vehicular storage and transportation of drugs and dogs in a temperate climate, such as the United Kingdom. Methods: The study used data loggers to continuously record internal temperatures of four vehicles at 15-minute intervals over a two-year period, to investigate the effect of seasonality and time of day on the internal car temperature. Results: The internal car temperature ranged from −7.4°C to 54.5°C during the study period. Temperatures fell below 8°C every month, except June and July. The internal car temperature exceeded typical drug storage recommendations (>25°C) during every month, and exceeded the canine thermoneutral zone (>35°C) from April to September. Peak temperatures occurred between 14:00 and 17:00 hours. Conclusion: The results demonstrate the year-round potential for thermal stress of both dogs and drugs left in cars. Public awareness campaigns highlighting the risks of leaving dogs in hot cars are typically launched in late spring, but should consider launching earlier in light of these findings. Veterinary surgeons transporting drugs should take measures to ensure that drugs are stored within the manufacturer’s temperature range year-round. This will limit the potential for drug degradation and decreased efficacy.
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Affiliation(s)
- Anne J Carter
- School of Animal, Rural and Environmental Sciences, Nottingham Trent University, Nottingham, UK
| | - Emily J Hall
- School of Animal, Rural and Environmental Sciences, Nottingham Trent University, Nottingham, UK
| | - Sophie L Connolly
- School of Animal, Rural and Environmental Sciences, Nottingham Trent University, Nottingham, UK
| | | | - Kirsty Mitchell
- School of Animal, Rural and Environmental Sciences, Nottingham Trent University, Nottingham, UK
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Wallace T. Transportation of Temperature-sensitive Medications in an Air Medical Setting. Air Med J 2019; 38:165-167. [PMID: 31122580 DOI: 10.1016/j.amj.2019.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 01/21/2019] [Indexed: 11/17/2022]
Abstract
INTRODUCTION This article describes an effective system for the transportation of temperature-sensitive medications within acceptable temperature ranges in the air medical setting. METHOD A temperature audit using data logging thermometers of drug bags used to transport temperature-sensitive medications revealed that temperature excursions above the accepted maximums (8°C) occurred frequently. An experimental methodology was developed using a commercially available shipping container that was subject to a rapid conditioning regimen. Through a series of experimental trials, it was determined that with the devised conditioning regimen the system would maintain a consistent 2°C to 8°C. This system was implemented, and data were collected over a series of air medical missions (5) over a 90-day period. RESULTS The average mission duration was 10 hours with temperature-sensitive medications spending an average of 15.3 hours out of the pharmacy fridge. Temperature data showed temperature-sensitive medications remained within the 2°C to 8°C range for the duration of all missions in which the shipping container was prepared appropriately. CONCLUSION This proof of concept study showed a system that can maintain acceptable storage conditions for temperature-sensitive medications.
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Affiliation(s)
- Timothy Wallace
- CareFlight Northern Operations, Eaton, Northern Territory, Australia.
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7
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Lai D, Pham AT, Nekkar Rao PP, Beazely MA. The effects of heat and freeze-thaw cycling on naloxone stability. Harm Reduct J 2019; 16:17. [PMID: 30813917 PMCID: PMC6391798 DOI: 10.1186/s12954-019-0288-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 02/13/2019] [Indexed: 11/10/2022] Open
Abstract
Purpose The availability of take home naloxone (THN) was increased for Canadians in 2016, including access to kits via pharmacies. Unlike typical over-the-counter (OTC) and prescription drugs, THN kits may be stored in non-standard conditions, including in vehicles, backpacks, and out of doors. To evaluate whether these non-standard storage conditions affect stability, we investigated the impact of heat and freeze-thaw cycling on naloxone hydrochloride stability. Methods To assess the effect of heat, naloxone hydrochloride ampoules were exposed to 80 °C in a temperature-controlled oven for 8 h followed by 16 h at room temperature. To assess the effect of freeze-thaw cycles, naloxone hydrochloride ampoules were exposed to − 20 °C for 16 h followed by 8 h at 4 °C. The impact of these conditions on naloxone hydrochloride stability was evaluated each day for 1 week and after 2 and 4 weeks. The concentration of remaining naloxone hydrochloride was quantified using high-performance liquid chromatography (HPLC). Naloxone hydrochloride ampoules stored at room temperature served as the experimental control. Results Naloxone hydrochloride ampoules exhibit no changes in drug concentration following exposure to heat or freeze-thaw cycles for up to 28 days compared to ampoules maintained at room temperature (as indicated in the product monograph). Conclusions Naloxone hydrochloride remains chemically stable following exposure to heat or freeze-thaw cycles after 28 days. If THN kits are stored in non-standard conditions (for up to 28 days) the active naloxone is likely to remain stable. Despite this, pharmacists should continue to emphasize the importance of appropriate storage of THN kits to ensure optimal efficacy should naloxone administration be required in an emergency situation. Electronic supplementary material The online version of this article (10.1186/s12954-019-0288-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dulcie Lai
- School of Pharmacy, Faculty of Science, University of Waterloo, 10 Victoria Street South, Kitchener, Ontario, N2G 1C5, Canada
| | - Amy Trinh Pham
- School of Pharmacy, Faculty of Science, University of Waterloo, 10 Victoria Street South, Kitchener, Ontario, N2G 1C5, Canada
| | - Praveen P Nekkar Rao
- School of Pharmacy, Faculty of Science, University of Waterloo, 10 Victoria Street South, Kitchener, Ontario, N2G 1C5, Canada
| | - Michael A Beazely
- School of Pharmacy, Faculty of Science, University of Waterloo, 10 Victoria Street South, Kitchener, Ontario, N2G 1C5, Canada.
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Browne E, Peeters F, Priston M, Marquis PT. Expired Drugs in the Remote Environment. Wilderness Environ Med 2019; 30:28-34. [PMID: 30718138 DOI: 10.1016/j.wem.2018.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 10/23/2018] [Accepted: 11/05/2018] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The British Antarctic Survey Medical Unit works in a very remote area of the world, with several Antarctic bases receiving only a single annual resupply of consumable goods. Pharmaceuticals supplied in this manner will often be approaching or past the end of their nominal shelf life before the following year's resupply. Drugs are transported from the UK via ship; the hold is not temperature controlled, and the ship crosses through the tropics (air temperature 25-30°C for approximately 3 wk). The drugs then must be transported from the ship to the base, often in temperatures substantially below freezing. This study assessed the stability of 5 expired drugs (atropine, nifedipine, flucloxacillin, naproxen, and bendroflumethiazide) returned from Antarctic bases. METHODS Drugs were opportunistically obtained and tested using stability-indicating assays. RESULTS All tested drugs were stable. CONCLUSIONS The results suggest that the studied drugs may be stable beyond expiry, even when not maintained in strictly temperature-controlled conditions.
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Affiliation(s)
- Emma Browne
- British Antarctic Survey Medical Unit, Plymouth, UK.
| | - Frank Peeters
- Centre for Life Sciences (LIFE), Royal Military Academy, Brussels, Belgium
| | - Melanie Priston
- Pharmacy Research Laboratory, Derriford Hospital, Plymouth, UK
| | - P T Marquis
- British Antarctic Survey Medical Unit, Plymouth, UK
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Donnelly RF. Stability of Procainamide Injection in Clear Glass Vials and Polyvinyl Chloride Bags. Hosp Pharm 2017; 52:704-708. [PMID: 29276243 DOI: 10.1177/0018578717724896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives The objective of this study was to evaluate the chemical stability of procainamide hydrochloride, 100 mg/mL, when repackaged in clear glass vials or diluted to 3 mg/mL with normal saline and packaged in polyvinyl chloride (PVC) bags when stored at either 23°C and exposed to light (ETL) or 5°C and protected from light (PFL). Methods Solutions were assayed using a stability-indicating high-performance liquid chromatography method. Samples (5 mL) were collected from triplicate containers on days 0, 7, 14, 21, 28, 56, 91, and 193. Color/clarity and pH changes were also monitored at each time interval. Results During the study, all samples remained clear and there was only a slight pH change. The color of the solutions stored at 23°C intensified but did not correlate with a significant decrease in concentration, while solutions stored at 5°C remained unchanged. Solutions repackaged in glass vials were stable for 193 days when stored at 23ºC and ETL or 5ºC and PFL. When further diluted to 3 mg/mL with normal saline and packaged in PVC bags, procainamide was also stable for 193 days at either 23ºC and ETL or 5°C and PFL. Conclusions The stability of procainamide, 100 mg/mL, repackaged in clear glass vials was 193 days when stored at either 23ºC and ETL or 5ºC or PFL. If diluted further to 3 mg/mL with normal saline and packaged in PVC bags, the drug was also stable for 193 days at either 23ºC and ETL or 5°C and PFL.
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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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Froid et suxaméthonium : une recommandation non fondée. ANNALES FRANCAISES DE MEDECINE D URGENCE 2016. [DOI: 10.1007/s13341-015-0600-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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13
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Ondrak JD, Jones ML, Fajt VR. Temperatures of storage areas in large animal veterinary practice vehicles in the summer and comparison with drug manufacturers' storage recommendations. BMC Vet Res 2015; 11:248. [PMID: 26429552 PMCID: PMC4590276 DOI: 10.1186/s12917-015-0561-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 09/25/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Large animal veterinarians carry drugs in their practice vehicles in storage areas that are not typically refrigerated. The most common upper limits of manufacturers' storage temperatures for United States (U.S.)-approved non-refrigerated drugs are 25 or 30 °C. Because ambient temperatures in many locations in the U.S. exceed these temperatures during the summer, we measured storage area temperatures over 4 months in the summer of 2013 to evaluate the extent to which labeled storage temperatures are exceeded. METHODS A convenience sample of 12 vehicles from 5 central Texas practices and 12 vehicles from 4 south central Nebraska practices was used. Temperatures were recorded in one drug storage compartment in each vehicle from May 15 - September 16, 2013, at 15-minute intervals using a self-contained, battery operated temperature recording device. RESULTS The highest temperatures recorded in a storage unit were 54.4 and 47.7 °C in Texas and Nebraska, respectively. The mean temperature recorded across all 24 storage units was 29.1 °C, with a mean of 26.9 °C in Nebraska and 31.4 °C in Texas. In Nebraska, at least one temperature over 25 °C was recorded on a mean of 111/124 days and a mean of 63 % of total logger readings. In Texas, temperatures over 25 °C were recorded on a mean of 123/124 days and a mean of 95 % of total logger readings. CONCLUSIONS Temperatures in storage units in participating veterinary practice vehicles exceeded labeled drug storage temperatures a significant portion of the summer of 2013. More research is needed to determine whether these excursions above the manufacturers' recommended storage temperatures alter efficacy of stored drugs.
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Affiliation(s)
- Jeff D Ondrak
- Great Plains Veterinary Educational Center, University of Nebraska-Lincoln, Clay Center, NE, USA.
| | - Meredyth L Jones
- Large Animal Clinical Sciences, Texas A&M University College of Veterinary Medicine and Biomedical Sciences, College Station, TX, USA.
| | - Virginia R Fajt
- Veterinary Physiology and Pharmacology, Texas A&M University College of Veterinary Medicine and Biomedical Sciences, College Station, TX, USA.
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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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Lefort H, Mendibil A, Margerin S, Cuquel AC, Jost D, Tazarourte K, Domanski L, Tourtier JP. [Storing succinylcholine in prehospital settings following the recommendations of the French National Agency for the safety of medicines]. ACTA ACUST UNITED AC 2014; 33:395-9. [PMID: 24930762 DOI: 10.1016/j.annfar.2014.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 05/14/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The French National Pharmaceuticals Agency (ANSM) has recommanded in July 2012 not to break the cold chain before using succinylcholine (Celocurine®). RESEARCH OBJECTIVE to understand the pre-clinical evolution of the conservation modes of this curare. RESEARCH TYPE Descriptive study before (year 2011) and after (year 2012). PATIENTS AND METHOD Online survey to French Samu/Smur. DATA COLLECTED SMUR location, conservation method at clinical base, in the mobile unit (UMH) and at the patient. Principal decision criteria: evolution of the conservation modes before and after the recommendation (qualitatives variables compared with a Fisher test). RESULTS Out of 101 SAMU/SMUR, 62 answered. Conservation modes of succinylcholine vials were significantly different (P<0.001). Proper conservation was observed in 26 % of the cases before and 43 % after. Mobile units (UMH) equipped with a fridge increased from one out of two to 77 %. The lack of conservation modes passive or active on UMH went from 31 % to 3.4 % with isotherms bags with ice when a fridge was not available. The destruction of capsules at current temperature in a 24-hour period increased: 22 % before, 47 % after (P=0.04). CONCLUSION After recommendations from ANSM, conservation modes and destruction of succinylcholine in a prehospital environment were significantly impacted.
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Affiliation(s)
- H Lefort
- Service médical d'urgence, brigade de sapeurs-pompiers de Paris, 3, rue Darmesteter, 75013 Paris, France.
| | - A Mendibil
- Service médical d'urgence, brigade de sapeurs-pompiers de Paris, 3, rue Darmesteter, 75013 Paris, France
| | - S Margerin
- Service médical d'urgence, brigade de sapeurs-pompiers de Paris, 3, rue Darmesteter, 75013 Paris, France
| | - A-C Cuquel
- Pharmacie centrale, hôpital d'Instruction des Armées du Val-de-Grâce, 74, boulevard de Port-Royal, 75005 Paris, France
| | - D Jost
- Service médical d'urgence, brigade de sapeurs-pompiers de Paris, 3, rue Darmesteter, 75013 Paris, France
| | - K Tazarourte
- Samu Smur de Melun, rue Fréteau-de-Pény, 77011 Melun, France
| | - L Domanski
- Service médical d'urgence, brigade de sapeurs-pompiers de Paris, 3, rue Darmesteter, 75013 Paris, France
| | - J-P Tourtier
- Service médical d'urgence, brigade de sapeurs-pompiers de Paris, 3, rue Darmesteter, 75013 Paris, France
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Mertes PM, Debaene B. [Cold and medical safety: from guidelines to practice]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2014; 33:387-388. [PMID: 25038979 DOI: 10.1016/j.annfar.2014.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- P M Mertes
- Service d'anesthésie-réanimation chirurgicale, hôpitaux universitaires de Strasbourg, Nouvel Hôpital Civil, 1, place de l'Hôpital, BP 426, 67091 Strasbourg cedex, France.
| | - B Debaene
- Département d'anesthésie-réanimation, CHU de Poitiers, 2, rue de la Milétrie, BP 577, 86021 Poitiers cedex, France
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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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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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Kupas DF, Shayhorn MA, Green P, Payton TF. Structured Inspection of Medications Carried and Stored by Emergency Medical Services Agencies Identifies Practices That May Lead to Medication Errors. PREHOSP EMERG CARE 2012; 16:67-75. [DOI: 10.3109/10903127.2011.621046] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Merlin MA, Marques-Baptista A, Yang H, Ohman-Strickland P, Aquina C, Buckley B. Evaluating degradation with fragment formation of prehospital succinylcholine by mass spectrometry. Acad Emerg Med 2010; 17:631-7. [PMID: 20624143 DOI: 10.1111/j.1553-2712.2010.00766.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Pharmaceutical manufacturers recommend refrigerating succinylcholine at a temperature range of 2-8 degrees C. With widespread use of prehospital succinylcholine on ambulances without refrigeration, it is important to understand the stability of this drug. Using mass spectrometry, this study investigated the degradation of the succinylcholine compound before and after its exposure to ambulance cabin temperatures, while removing light exposure. A 10% degradation threshold was set as not appropriate for human use, in accordance with U.S. Food and Drug Administration guidelines. METHODS The study used 17 vials of succinylcholine sealed with duct tape in light-resistant bags. The bags were placed in climate controlled compartments in two ambulances: one stationed in a garage and the other stationed outdoors. Mass spectrometry analysis was used to examine drug degradation at Time 0, the 14th day of the first month, and monthly from Time 0 to 7 months. RESULTS The degradation products of succinyl monocholine (SMC) and choline are already present at Day 0. Ten percent degradation was achieved at approximately 90 days into the experiment. Temperature in the ambulance climate controlled compartment was 70 degrees F, with a range from 56 to 89 degrees F during the 6-month time period. CONCLUSIONS Identifiable breakdown fragments of succinylcholine have been identified using mass spectrometry with fresh drug upon receipt from the manufacturer. Ten percent degradation was not observed until approximately 90 days after being placed on ambulances. Temperature variations did not significantly contribute to degradation of succinylcholine, and it is safe for injection until approximately 90 days in similar climates.
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Affiliation(s)
- Mark A Merlin
- Department of Emergency Medicine, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
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