Impact of Temperature Exposure on Stability of Drugs in a Real-World Out-of-Hospital Setting

Emergency care drugs' chemical stability after eight weeks' deployment in the prehospital setting

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.

Photonic Crystal Sensor Evaluating the Effectiveness of Medical Products under Different Storage Conditions

The effectiveness of time- and temperature-sensitive medical products (TTSMPs) (vaccines, medicines, and biological agents) is generally evaluated by sporadically checking the storage conditions recorded in electronic thermometers. However, electronic thermometers do not achieve all-time and all-regional record, resulting in the wrong evaluation of a single TTSMP and seriously endangering public health. Herein, we report a photonic crystal sensor for evaluating the effectiveness of a single TTSMP processing storage environment. The photonic crystal sensor assembled by colloidal microspheres (WO3-x nanospheres were added into the microsphere gap) generates a fascinating composite color of angle-dependent structural color (maximum reflectivity = 45%) and durative color (WO3-x coloration). Effectiveness evaluation principle reveals that the pattern on the sensor, which was printed by the composite color, fades sensitively to time and temperature, thus having different visible periods (0-21 days affected by temperature). The visible periods of the patterns can be used to evaluate a single TTSMP's effectiveness stored under different temperatures. Furthermore, the photonic crystal sensor shows outstanding flexibility and slight adhesion, offering a promising application toward the effectiveness evaluation of TTSMPs throughout storage, transportation, and sales processes.

Rational Design of Topical Semi-Solid Dosage Forms-How Far Are We?

Specific aspects of semi-solid dosage forms for topical application include the nature of the barrier to be overcome, aspects of susceptibility to physical and chemical instability, and a greater influence of sensory perception. Advances in understanding the driving forces of skin penetration as well as the design principles and inner structure of formulations, provide a good basis for the more rational design of such dosage forms, which still often follow more traditional design approaches. This review analyses the opportunities and constraints of rational formulation design approaches in the industrial development of new topical drugs. As the selection of drug candidates with favorable physicochemical properties increases the speed and probability of success, models for drug selection based on theoretical and experimental approaches are discussed. This paper reviews how progress in the scientific understanding of mechanisms and vehicle-influence of skin penetration can be used for rational formulation design. The characterization of semi-solid formulations is discussed with a special focus on modern rheological approaches and analytical methods for investigating and optimizing the chemical stability of active ingredients in consideration of applicable guidelines. In conclusion, the combination of a good understanding of scientific principles combined with early consideration of regulatory requirements for product quality are enablers for the successful development of innovative and robust semi-solid formulations for topical application.

Deep Eutectic Solvents for Efficient Drug Solvation: Optimizing Composition and Ratio for Solubility of β-Cyclodextrin

Deep eutectic solvents (DESs) show promise in pharmaceutical applications, most prominently as excellent solubilizers. Yet, because DES are complex multi-component mixtures, it is challenging to dissect the contribution of each component to solvation. Moreover, deviations from the eutectic concentration lead to phase separation of the DES, making it impractical to vary the ratios of components to potentially improve solvation. Water addition alleviates this limitation as it significantly decreases the melting temperature and stabilizes the DES single-phase region. Here, we follow the solubility of β-cyclodextrin (β-CD) in DES formed by the eutectic 2:1 mole ratio of urea and choline chloride (CC). Upon water addition to DES, we find that at almost all hydration levels, the highest β-CD solubility is achieved at DES compositions that are shifted from the 2:1 ratio. At higher urea to CC ratios, due to the limited solubility of urea, the optimum composition allowing the highest β-CD solubility is reached at the DES solubility limit. For mixtures with higher CC concentration, the composition allowing optimal solvation varies with hydration. For example, β-CD solubility at 40 wt% water is enhanced by a factor of 1.5 for a 1:2 urea to CC mole ratio compared with the 2:1 eutectic ratio. We further develop a methodology allowing us to link the preferential accumulation of urea and CC in the vicinity of β-CD to its increased solubility. The methodology we present here allows a dissection of solute interactions with DES components that is crucial for rationally developing improved drug and excipient formulations.

Optimizing systems to manage postpartum hemorrhage

Systems to optimize the management of postpartum hemorrhage must ensure timely diagnosis, rapid hemodynamic and hemostatic resuscitation, and prompt interventions to control the source of bleeding. None of these objectives can be effectively completed by a single clinician, and the management of postpartum hemorrhage requires a carefully coordinated interprofessional team. This article reviews systems designed to standardize hemorrhage diagnosis and response.

Stability of Drugs Stored in Helicopters for Use by Emergency Medical Services: A Prospective Observational Study

STUDY OBJECTIVE

Drugs stored in rescue helicopters may be subject to extreme environmental conditions. The aim of this study was to measure whether drugs stored under the real-life conditions of a Swiss helicopter emergency medical service (HEMS) would retain their potency over the course of 1 year.

METHODS

A prospective, longitudinal study measuring the temperature exposure and concentration of drugs stored on 2 rescue helicopters in Switzerland over 1 year. The study drugs included epinephrine, norepinephrine, amiodarone, midazolam, fentanyl, naloxone, rocuronium, etomidate, and ketamine. Temperatures were measured inside the medication storage bags and the crew cabins at 10-minute intervals. Drug stability was measured on a monthly basis over the course of 12 months using high-performance liquid chromatography. The medications were considered stable at a minimum remaining drug concentration of 90% of the label claim.

RESULTS

Temperatures ranged from -1.2 °C to 38.1 °C (29.84 °F to 100.58 °F) inside the drug storage bags. Of all the temperature measurements inside the drug storage bags, 37% lay outside the recommended storage conditions. All drugs maintained a concentration above 90% of the label claim. The observation periods for rocuronium and etomidate were shortened to 7 months because of a supply shortage of reference samples.

CONCLUSION

Drugs stored under the real-life conditions of Swiss HEMS are subjected to temperatures outside the manufacturer's approved storage requirements. Despite this, all drugs stored under these conditions remained stable throughout our study. Real-life stability testing could be a way to extend drug exchange intervals.

Nanostructured Temperature Indicator for Cold Chain Logistics

Food, chemicals, agricultural products, drugs, and vaccines should be transported and stored within an appropriate low-temperature range, following cold chain logistics. Violations of the required temperature regime are generally reported by time-temperature indicators; however, current sensors do not cover a sufficiently broad low-temperature range and may lack thermal and photostability. Here, we report a nanostructured solvatochromic temperature indicator formed from cellulose nanocrystals decorated with carbon dots (C-dots). The indicator utilizes a strong nonlinear dependence of photoluminescence of C-dots on the composition of water/dimethyl sulfoxide (DMSO) solvent and a composition-dependent variation of the melting temperature of the water/DMSO mixture. Exceeding the temperature of the frozen mixed solvent above a designated threshold value results in solvent melting, flow, and impregnation of the nanostructured film, thus causing an irreversible change in the intensity and wavelength of photoluminescence emission of the film, which is reported both qualitatively and quantitatively. The indicator covers a temperature range from -68 to +19 °C and is cost-efficient, portable and photo- and thermostable.

Impact of Ambient Temperature on 5 Emergency Drugs Aboard an Emergency Medical Car Over a 1-Year Period

STUDY OBJECTIVE

Drugs in emergency medical service (EMS) cars are often exposed to temperature variations that could affect the stability of these drugs. We aimed to study the influence of real-life temperature exposure on the stability of 5 drugs onboard an EMS vehicle.

METHODS

Concentrations of active principles of 5 emergency drugs (amiodarone, rocuronium, fentanyl, succinylcholine, and epinephrine) aboard an EMS vehicle were analyzed every 3 months up to 1 year. The samples were compared to the same drugs stored for 1 year either at room temperature or in a refrigerator in the pharmacy. Succinylcholine was additionally analyzed once a week for 4 weeks after being taken out of the refrigerator. The dosage of the active principle was measured using high-pressure liquid chromatography coupled with ultraviolet detection.

RESULTS

After the 12-month period, all drugs from the EMS car, except succinylcholine, presented concentrations still above 90% of the concentrations measured at the start of the project. Concentrations ranged from 96.3% to 103%. For succinylcholine at 12 months, the remaining concentration was 89%. Temperatures in the EMS car ranged from 13.9 °C to 33.9 °C (median, 22.8 °C [interquartile range, 20.5 °C to 25.8 °C]).

CONCLUSION

In real-life conditions, amiodarone, rocuronium, fentanyl, succinylcholine, and epinephrine onboard an EMS vehicle did not suffer pharmacologically relevant degradation from temperature variations. All concentrations measured remained in the specification intervals given by the manufacturers.

Influence of Storage Conditions on the Stability of Gum Arabic and Tragacanth

Storage conditions should be chosen so that they do not affect the action and stability of the active pharmaceutical substance (API), and excipients used in pharmacy. UV irradiation, increased temperature, and relative humidity can decompose storage substances by photolysis, thermolysis, and hydrolysis process, respectively. The effect of physical factors may be the decomposition of pharmaceutical substances or their inappropriate action, including pharmacological effects. Polymers of natural origin are increasingly used in the pharmaceutical industry. With this in mind, we evaluated the effect of storage conditions on the stability of gum arabic (GA) and tragacanth (GT). The influence of higher temperature, UV irradiation, and relative humidity on GA and GT was tested. Thermogravimetry (TG, c-DTA), colorimetric analysis, UV-Vis spectrophotometry, and optical microscopy were used as research methods. The TGA and c-DTA examination indicated that decomposition of GA starts at a higher temperature compared to GT. This indicate that gum arabic is more resistant to higher temperatures compared to tragacanth. However, the conducted analysis showed that gum arabic is more sensitive to the tested storage conditions. Among the tested physical conditions, both polymers were most sensitive to conditions of increased relative humidity in the environment.

Medication Handling and Storage among Pilgrims during the Hajj Mass Gathering

We aimed to investigate the knowledge and practices of Hajj pilgrims regarding medication storage and handling during the Hajj mass gathering. In this cross-sectional study, adult pilgrims from 30 countries were interviewed using a structured questionnaire during the 2019 Hajj. The study enrolled 1221 participants with a mean age of 50.8 years (SD = 12.5, range = 18-98) and male:female ratio of 1.7:1. Most pilgrims were literate, 50.4% had a university or higher education, and 38% reported at least one underlying health condition. Most pilgrims reported receiving education regarding the proper way to store their medication during Hajj, mainly from physicians (73.7%) and pharmacists (39.4%). Although 68.2% of pilgrims had good knowledge regarding medication storage and the potential effect of inappropriate storage conditions on medications and health, inadequate knowledge and poor practice were identified among some. Level of education, having an underlying health condition and receiving health education on mediation storage were independently associated with good knowledge. Most pilgrims took their medications with them during Hajj, although storage and handling of their medication also varied depending on the stages of their Hajj pilgrimage journey. Improving Hajj pilgrims' awareness and knowledge about appropriate storage and handling of their medications are beneficial in reducing the risk of associated adverse health outcomes, both during Hajj and beyond the mass gathering.

The Effect of High Storage Temperature on the Stability and Efficacy of Lyophilized Tenecteplase

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.

Drugs, dogs, and driving: the potential for year-round thermal stress in UK vehicles

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.

Emergency Department Design in Low- and Middle-Income Settings: Lessons from a University Hospital in Haiti

Background:

Studies from high-income settings have demonstrated that emergency department (ED) design is closely related to operational success; however, no standards exist for ED design in low- and middle-income countries (LMICs).

Objective:

We present ED design recommendations for LMICs based on our experience designing and operating the ED at Hôpital Universitaire de Mirebalais (HUM), an academic hospital in central Haiti. We also propose an ideal prototype for similar settings based on these recommendations.

Methods:

As part of a quality improvement project to redesign the HUM ED, we collected feedback on the current design from key stakeholders to identify design features impacting quality and efficiency of care. Feedback was reviewed by the clinical and design teams and consensus reached on key lessons learned, from which the prototype was designed.

Findings and conclusions:

ED design in LMICs must balance construction costs, sustainability in the local context, and the impact of physical infrastructure on care delivery. From our analysis, we propose seven key recommendations: 1) Design the “front end” of the ED with waiting areas that meet the needs of LMICs and dedicated space for triage to strengthen care delivery and patient safety. 2) Determine ED size and bed capacity with an understanding of the local health system and disease burden, and ensure line-of-sight visibility for ill patients, given limited monitoring equipment. 3) Accommodate for limited supply chains by building storage spaces that can manage large volumes of supplies. 4) Prioritize a maintainable system that can provide reliable oxygen. 5) Ensure infection prevention and control, including isolation rooms, by utilizing simple and affordable ventilation systems. 6) Give consideration to security, privacy, and well-being of patients, families, and staff. 7) Site the ED strategically within the hospital. Our prototype incorporates these features and may serve as a model for other EDs in LMICs.

Ergometrine stability in postpartum haemorrhage kits: Does temperature and light matter?

BACKGROUND

Postpartum haemorrhage (PPH) kits containing uterotonics are used on obstetric units for the timely management of PPH. Visible discolouration of ergometrine and ergometrine-oxytocin injections was observed in PPH kits stored in medical refrigerators on the obstetric unit at our hospital.

AIM

To investigate the stability of ergometrine and ergometrine-oxytocin injections in PPH kits under simulated clinical storage conditions and to determine the potency of ampoules quarantined from PPH kits on our obstetric unit.

MATERIAL AND METHODS

Ergometrine and ergometrine-oxytocin injection ampoules were stored exposed to and protected from light at 4°C and room temperature (25°C) for up to three months, and assayed by high-performance liquid chromatography. Stability was based on the time for the ergometrine or oxytocin concentration to fall to 90% of the original concentration (t₉₀ ). The potency of quarantined discoloured ampoules also was determined.

RESULTS

Ergometrine was stable at both temperatures for >6 months, when stored protected from light in simulated clinical conditions. When exposed to light, ergometrine was stable for approximately 4 days at 25°C and 10 days at 4°C. Discoloured ergometrine and ergometrine-oxytocin injection ampoules were found to be <90% of the nominal concentration.

CONCLUSION

Stability of ergometrine in PPH kits is largely unaffected by temperature fluctuations (at 4°C and 25°C) over 6 months when protected from light. Ergometrine and ergometrine-oxytocin ampoules should be inspected prior to use and any discoloured ampoules discarded.

Practical Management of Epileptic Seizures and Status Epilepticus in Adult Palliative Care Patients

In terminally ill patients, paroxysmal or episodic changes of consciousness, movements and behavior are frequent. Due to ambiguous appearance, the correct diagnosis of epileptic seizures (ES) and non-epileptic events (NEE) is often difficult. Treatment is frequently complicated by the underlying condition, and an approach indicated in healthier patients may not always be appropriate in the palliative care setting. This article provides recommendations for diagnosis of ES and NEE and treatment options for ES in adult palliative care patients, including aspects of alternative administration routes for antiepileptic drugs such as intranasal, subcutaneous, or rectal application.

How to transport veterinary drugs in insulated boxes to avoid thermal damage by heating or freezing

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.

Hot and Cold Drugs: National Park Service Medication Stability at the Extremes of Temperature

STUDY OBJECTIVE

National Park Service (NPS) Parkmedics provide medical care in austere environments. The objective of this study was to evaluate the stability of specific medications used by Parkmedics at extremes of temperatures likely to be faced in the field.

METHODS

This is a bench research study conducted in the laboratory setting over a 4-week period. Parenteral medications were separated into 4 temperature exposure groups: A) 45°C (hot); B) -20°C (cold); C) hot then cold temperatures alternating weekly; and D) cold then hot temperatures alternating weekly. At study start and the end of each week, three aliquots from each group were sampled to determine the remaining drug concentration through liquid chromatography-quadrupole time-of-flight mass spectrometry (Agilent LC 1260- QTOF/MS 6550). Quantitative analysis was done using Agilent MassHunter Quantitative Analysis software. The mean drug concentration from triplicate aliquots was expressed as percentage of its baseline concentration to monitor the drug's stability during storage.

RESULTS

Eight medications were analyzed (atropine, diphenhydramine, fentanyl, hydromorphone, midazolam, morphine, naloxone, ondansetron). Hydromorphone, morphine, and ondansetron showed the greatest stability, at above 90% of original concentration in all study arms. Diphenhydramine, fentanyl and midazolam showed heat independent degradation, degrading the same way regardless of heat exposure. By the end of the study period, 51-56% midazolam remained in all groups. Atropine and naloxone showed heat dependent degradation, degrading more when exposed to heat. Atropine had the most degradation, being undetectable after 4 weeks of heat exposure.

CONCLUSIONS

We recommend that EMS providers replace atropine, naloxone, diphenhydramine, fentanyl, and midazolam frequently if they are practicing in low call volume or high-temperature environments. Further studies will be needed to determine if re-dosing midazolam, naloxone, and atropine is the appropriate clinical strategy in this setting if adequate clinical effect is not reached with a single dose.

Prehospital Endotracheal Intubation in Warm Climates: Caution is Required

BACKGROUND

Out-of-hospital endotracheal intubation is a frequent procedure for trauma care. Nevertheless, in warm climates, sunlight and heat can interfere with the flow of the usual procedure. They can affect the equipment and hinder the operator. There are few data on this issue. The presentation of this case highlights three common complications that may occur when intubating under a hot and bright sun.

CASE REPORT

A 23-year-old man had a car accident in Djibouti, at 11:00 a.m., in broad sunlight. The heat was scorching. Due to a severe head trauma, with a Glasgow Coma Scale score of 8, it was decided to perform an endotracheal intubation. The operator faced three problems: the difficulty of seeing inside the mouth in the bright sunlight, the softening of the tube under the influence of the heat, and the inefficiency of colorimetric CO2 detectors in the warm atmosphere in confirming the proper endotracheal tube placement. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Solutions are simple, but must be known and planned ahead, prior to beginning the procedure: Putting a jacket over his head while doing the laryngoscopy would solve the problem of dazzle; adjuncts like a stylet or gum elastic bougie have to be used at the outset to fix the softening problem; alternative methods to exhaled CO2 detection, such as the syringe aspiration technique, to confirm the proper tube placement, should be available.

Stability of Drugs Used in Helicopter Air Medical Emergency Services: An Exploratory Study

OBJECTIVE

Transportation by air exposes drugs used in emergency medical services to vibrations. The aim of the study was to determine whether or not vibrations caused by a helicopter induce the degradation of 5 drugs used in this setting.

METHODS

A longitudinal study in an operating medical helicopter along with a worst case was conducted. The studied drugs were 3 drugs labeled for refrigeration (cisatracurium, lorazepam, and succinylcholine) and 2 albumin solutions (human albumin 4% and 20%). These drugs were stored for 4 months according to the following conditions: inside a helicopter, worst case with exposure to extreme vibrations, at room temperature, and according to manufacturers' recommendations. Samples were analyzed with validated high-performance liquid chromatography assay methods. A drug was considered stable if the remaining drug content was above 90% of the label claim. Except for the albumin solutions, visual inspection was used to determine instability by the formation of aggregates.

RESULTS

Only the samples stored at room temperature became unstable after 4 months. No difference in extreme foaming was observed in the albumin solutions.

CONCLUSIONS

These data suggest that the effect of degradation of drugs caused by vibrations is negligible. Temperature was observed as the main cause of drug degradation.

A systematic review of epinephrine degradation with exposure to excessive heat or cold

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.

Special Considerations in Medical Screening for Participants in Remote Endurance Events

As participation at remote endurance events increases, so does the need to screen participants for potentially problematic medical conditions, but this process has been ill-defined to date. This article aims to outline a general approach to screening and discusses common or important medical conditions that may need consideration in the screening process. Medical conditions that are considered low risk may translate to high-risk conditions in the setting of a remote and austere location. Medical directors of remote endurance events should have a familiarity with assessing risks and applying informed consent principles to participation. While there are no specific standards on medical disqualification from an event based on medical history alone, several systematic considerations should be made that allow for an assessment of risk to an individual for a specific event. The medical director and event director, in discussion with the athlete and treating clinician when appropriate, should come to a consensus on participation when high-risk medical conditions become apparent during the screening process. Both modifications and accommodations to participation may be used to mitigate both clinical and medicolegal risk and allow for participation.

Treatment of Convulsive Status Epilepticus

OPINION STATEMENT

Convulsive status epilepticus (CSE) is a medical emergency with an associated high mortality and morbidity. It is defined as a convulsive seizure lasting more than 5 min or consecutive seizures without recovery of consciousness. Successful management of CSE depends on rapid administration of adequate doses of anti-epileptic drugs (AEDs). The exact choice of AED is less important than rapid treatment and early consideration of reversible etiologies. Current guidelines recommend the use of benzodiazepines (BNZ) as first-line treatment in CSE. Midazolam is effective and safe in the pre-hospital or home setting when administered intramuscularly (best evidence), buccally, or nasally (the latter two possibly faster acting than intramuscular (IM) but with lower levels of evidence). Regular use of home rescue medications such as nasal/buccal midazolam by patients and caregivers for prolonged seizures and seizure clusters may prevent SE, prevent emergency room visits, improve quality of life, and lower health care costs. Traditionally, phenytoin is the preferred second-line agent in treating CSE, but it is limited by hypotension, potential arrhythmias, allergies, drug interactions, and problems from extravasation. Intravenous valproate is an effective and safe alternative to phenytoin. Valproate is loaded intravenously rapidly and more safely than phenytoin, has broad-spectrum efficacy, and fewer acute side effects. Levetiracetam and lacosamide are well tolerated intravenous (IV) AEDs with fewer interactions, allergies, and contraindications, making them potentially attractive as second- or third-line agents in treating CSE. However, data are limited on their efficacy in CSE. Ketamine is probably effective in treating refractory CSE (RCSE), and may warrant earlier use; this requires further study. CSE should be treated aggressively and quickly, with confirmation of treatment success with epileptiform electroencephalographic (EEG), as a transition to non-convulsive status epilepticus is common. If the patient is not fully awake, EEG should be continued for at least 24 h. How aggressively to treat refractory non-convulsive SE (NCSE) or intermittent non-convulsive seizures is less clear and requires additional study. Refractory SE (RSE) usually requires anesthetic doses of anti-seizure medications. If an auto-immune or paraneoplastic etiology is suspected or no etiology can be identified (as with cryptogenic new onset refractory status epilepticus, known as NORSE), early treatment with immuno-modulatory agents is now recommended by many experts.

Temperatures of storage areas in large animal veterinary practice vehicles in the summer and comparison with drug manufacturers' storage recommendations

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.

[Storing succinylcholine in prehospital settings following the recommendations of the French National Agency for the safety of medicines]

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.