Ficts and facts of epinephrine and norepinephrine stability in injectable solutions

Assessment of the extent and monetary loss in the selected public hospitals in Jimma Zone, Ethiopia: expired medicine perspectives

Introduction

Medicine plays a crucial role in the field of healthcare as a therapeutically significant pharmaceutical product. By effectively preventing diseases, medicine has the power to save countless lives and improve the quality of life for people worldwide. However, despite hospitals' efforts to provide medical care to patients, a significant issue arises from the substantial amount of drugs that go unused due to expiration dates. This problem is particularly prevalent in resource-limited countries like Ethiopia, where the pharmaceutical supply system fails to adequately address the issue of expired drugs in public hospitals, leading to an unsatisfactory situation. Hence, the objective of this study was to assess the economic impact and volume of expired medicines in the selected public hospitals in Jimma Zone, Southwestern Ethiopia.

Methods

A hospital-based cross-sectional study design was conducted to assess the economic impact and volume of expired medicines available in the public hospitals in Jimma Zone. All available hospitals that fulfilled the EFDA guidelines were included. The medication expiration rate was calculated by dividing the total monetary value of expired medicines in a year by the total value of medicines received in the same year multiplied by 100. Then, the collected data was cleared, filtered, coded, and quantitatively analyzed using the Microsoft Excel 2010 version.

Results

The average medicine waste rate was 4.87% in the fiscal year of 2019/2020 and 2020/2021 in Jimma Zone public hospitals worth 32,453.3 US$. Additionally, the facility wasted an estimated of 2711.44 US$ on the disposal of expired medicines. The expiration of medicines has been linked to several issues, including near-expiry, irrational prescribing practices, and weak participation of clinicians in medicine selection and quantification of the facility. Additionally, only two hospitals had relatively good storage and handling practices.

Conclusion

Overall, the expiration rate of medicines in the public hospitals in Jimma Zone was greater than the allowed level of 2%. In order to optimize the allocation of healthcare funds and ensure the appropriate use of pharmacologically significant medications it is vital to conduct a comprehensive examination at the national level within a regional hospitals.

Extended Stability of Isoproterenol Hydrochloride Injection in Polyvinyl Chloride Bags Stored in Amber Ultraviolet Light Blocking Bags

Purpose:Evaluate the stability of isoproterenol hydrochloride injection in 0.9% sodium chloride in polyvinyl chloride bags for up to 90 days. Methods: Dilutions of isoproterenol hydrochloride injection to a concentration of 4 μg/mL were performed under aseptic conditions. The bags were stored in amber ultraviolet light blocking bags at room temperature (23°C-25°C) or under refrigeration (3°C-5°C). Three samples of each preparation and storage environment were analyzed on days 0, 2, 14, 30, 45, 60, and 90. Physical stability was performed by visual examination. The pH was assessed at baseline, each analysis day, and upon final degradation evaluation. Sterility of the samples was not assessed. Chemical stability of isoproterenol hydrochloride was evaluated using liquid chromatography with tandem mass spectrometry. Samples were considered stable if there was <10% degradation of the initial concentration. Results: Isoproterenol hydrochloride diluted to 4 μg/mL with 0.9% sodium chloride injection was physically stable throughout the study. No precipitation was observed. At days 2, 14, 30, 45, 60, and 90 all bags diluted to 4 μg/mL had <10% degradation when stored under refrigeration (3°C-5°C) or stored at room temperature (23°C-25°C). Conclusion: Isoproterenol hydrochloride diluted to a concentration of 4 μg/mL with 0.9% sodium chloride for injection in ultraviolet light blocking bags was stable for 90 days at room temperature and under refrigeration.

Unmasking lower gastrointestinal bleeding under administration of norepinephrine

BACKGROUND

Bleeding in the gastrointestinal tract is common and transarterial embolization enables the clinician to control gastrointestinal bleeding. Contrast extravasation is a prerequisite for successful embolization. Provocative angiography is helpful in the detection of elusive bleeding.

AIM

We performed a retrospective analysis of angiographic treatment in patients with lower gastrointestinal hemorrhage and initially negative angiographies, as well as the role of norepinephrine (NE) in unmasking bleeding.

METHODS

We analyzed 41 patients with lower gastrointestinal bleeding after angiography who had undergone treatment over a period of 10 years. All patients had a positive shock index and needed intensive care.

RESULTS

In three of four patients, angiography disclosed the site of bleeding when NE was used during the procedure for hemodynamic stabilization.

CONCLUSION

We suggest that angiography performed after the administration of NE in unstable patients with gastrointestinal bleeding and an initially negative angiography has the potential to unmask bleeding sites for successful embolization. However, this statement must be confirmed in prospective studies.

Long-term stability of ready-to-use epinephrine 0.02 mg/mL injection solution in 50 mL glass vials

Objectives

In adult intensive care patients, epinephrine is mostly administered by continuous injection with syringe pumps. The objective of this study was to investigate the physicochemical stability of pharmacy prepared ready-to-use epinephrine (E) 0.02 mg/mL injection solutions (total volume 50 mL) for assigning shelf-life.

Methods

E 0.02 mg/mL injection solution in 50 mL amber type l glass vials was produced batch-wise in the pharmacy department. Stability of the refrigerated (2–8 °C) product was investigated in real time over a period of 36 months by analyzing E concentrations, osmolality, pH, and sub-visible particles at predefined time-points. For E concentration measurements a stability-indicating, validated reversed-phase HPLC-PDA assay was used.

Results

The autoclaving process of E 0.02 mg/mL injection solution in 50 mL amber type I glass vials caused 5% loss of the active substance. The finished product remained stable over the study period of 36 months when stored refrigerated.

Conclusions

Batch-wise production of ready-to-use E injection solution 0.02 mg/mL in 50 mL amber glass vials was successfully implemented in our pharmacy department. According to the stability tests, a shelf-life of 36 months can be assigned to the finished product stored refrigerated. Studies concerning stability at room temperature would be useful.

Influence of the Dispersion Medium and Cryoprotectants on the Physico-Chemical Features of Gliadin- and Zein-Based Nanoparticles

The evaluation of the physico-chemical features of nanocarriers is fundamental because the modulation of these parameters can influence their biological and in vivo fate. This work investigated the feasibility of saline, 5% w/v glucose and phosphate-buffered saline solution, as polar media for the development of nanoparticles made up of two vegetal proteins, zein from corn and gliadin from wheat, respectively. The physico-chemical features of the various systems were evaluated using dynamic and multiple light scattering techniques, and the results demonstrate that the 5% w/v glucose solution is a feasible medium to be used for their development. Moreover, the best formulations were characterized by the aforementioned techniques following the freeze-drying procedure. The aggregation of the zein nanoparticles prepared in water or glucose solution was prevented by using various cryoprotectants. Mannose confirmed its crucial role in the cryopreservation of the gliadin nanosystems prepared in both water and glucose solution. Sucrose and glucose emerged as additional useful excipients when they were added to gliadin nanoparticles prepared in a 5% glucose solution. Specifically, their protective effect was in the following order: mannose > sucrose > glucose. The results obtained when using specific aqueous media and cryoprotectants permitted us to develop stable zein or gliadin nanoparticles as suspension or freeze-dried formulations.

An Evaluation of the Drone Delivery of Adrenaline Auto-Injectors for Anaphylaxis: Pharmacists’ Perceptions, Acceptance, and Concerns

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.

Survey of the Preparation of Cardiovascular Emergency Medications for Adult Cardiovascular Anesthesia

OBJECTIVES

To describe current practices and safety concerns regarding cardiac emergency medications in cardiac anesthesia.

DESIGN

An anonymous survey with multiple-choice questions.

SETTINGS

Online survey using Opinio platform.

PARTICIPANTS

Cardiac anesthesiologists from United States and Canada.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Response rate was 12% (n = 320), with 78% of respondents from the United States and 22% from Canada. The majority of the respondents were experienced (66%), academic (60%), and worked in large cardiac institutions (81%). Most cardiac emergency medications were prepared in the operating room (53.4%), followed by the pharmacy (34%) and industry (8.2%). American respondents had more medications prepared by a pharmacy (53%) versus Canadian (10%, p < 0.001). The majority (85%) considered expiration time of cardiac medications prepared in the operating room to be more than 12 hours. Familiarity with the American Society of Anesthesiologists guidelines on labeling was 58%, other medication safety guidelines 25%, and 34% were not familiar with any guidelines. The majority used color-coded labeling (95%), and a minority (11%) used bar-code systems. Most respondents (69%) agreed that lack of availability of preprepared medications could compromise patient safety. Having to prepare medications by themselves was a concern for respondents based on distractions (66%), lack of availability for emergencies (53%), labeling errors (41%), incorrect concentration (36%), sterility (33%), and stability (30%).

CONCLUSION

This survey found that cardiac emergency medications commonly are prepared in the operating room. The authors identified gaps in familiarity with parenteral medications safety guidelines. Most safety concerns could be addressed with the application of current medication safety guidelines.

Prefilled Cyclic Olefin Sterilized Syringes of Norepinephrine Injection Solution Do Not Need to Be Stabilized by Antioxidants

Norepinephrine is a potent α-sympathomimetic drug which plays an important role in the acute treatment of hypotension and shock. Commercially available norepinephrine solutions contain sodium metabisulfite (Na2S2O5) as an antioxidant. However, prefilled cyclic olefin polymer syringes are not compatible with sodium metabisulfite. The aim of this study was to develop a new formulation of 0.1-mg/mL norepinephrine solution without sodium metabisulfite which is chemically stable and sterile and can be stored in prefilled polymer syringes. Formulation studies were performed with 0.1-mg/mL norepinephrine solution with 0, 0.05, or 0.1% ascorbic acid added as antioxidant. The syringes were filled under nitrogen gassing, stored at 20 ± 5°C, and protected from daylight. Based on the formulation test results, the final formulation was defined and stability testing at 20 ± 5°C was performed measuring norepinephrine concentration, pH, clarity, color of the solution, subvisible particles, and sterility at time intervals up to 12 months. The norepinephrine concentrations at t = 22 weeks were 100.4%, 95.4%, and 92.2% for the formulations with no ascorbic acid and with 0.05% and 0.10% ascorbic acid, respectively. Three batches for the stability study were produced containing norepinephrine, sodium edetate, sodium chloride, and water for injections filled under nitrogen gassing and stored at 20 ± 5°C. Norepinephrine concentrations were respectively 98.8%, 98.6%, and 99.3% for batches 1, 2, and 3 at t = 12 months. It can be concluded that norepinephrine (0.1 mg/mL) solution without metabisulfite is stable for at least 12 months at room temperature when protected from daylight.

Forced degradation studies of norepinephrine and epinephrine from dental anesthetics: Development of stability-indicating HPLC method and in silico toxicity evaluation

Injectable solutions containing epinephrine (EPI) and norepinephrine (NE) are not stable, and their degradation is favored mainly by the oxidation of catechol moiety. As studies of these drugs under forced degradation conditions are scarce, herein, we report the identification of their degradation products (DP) in anesthetic formulations by the development of stability-indicating HPLC method. Finally, the risk assessment of the major degradation products was evaluated using in silico toxicity approach. HPLC method was developed to obtain a higher selectivity allowing adequate elution for both drugs and their DPs. The optimized conditions were developed using a C18 HPLC column, sodium 1-octanesulfonate, and methanol (80:20, v/v) as mobile phase, with a flow rate of 1.5 mL/min, UV detection at 199 nm. The analysis of standard solutions with these modifications resulted in greater retention time for EPI and NE, which allow the separation of these drugs from their respective DPs. Then, five DPs were identified and analyzed by in silico studies. Most of the DPs showed important alerts as hepatotoxicity and mutagenicity. To the best of our acknowledgment, this is the first report of a stability-indicating HPLC method that can be used with formulations containing catecholamines.

Long-term stability of ready-to-use norepinephrine solution at 0.2 and 0.5 mg/mL

Objectives

Norepinephrine is a vasopressor frequently administered after dilution to treat hypotension and shocks in intensive care units. The stability of norepinephrine is known to be highly sensitive to storage conditions. Moreover, medication errors linked to the dilution step are frequent and may be deleterious for critically-ill patients, especially in intensive care units. This study aimed to evaluate the stability of ready-to-use diluted norepinephrine solutions prepared at two target concentrations (0.2 and 0.5 mg/mL), according to the summary of product characteristics, and stored for 365 days in two containers: AT-closed cyclic olefin copolymer vials, and polypropylene syringes.

Methods

A fast reversed-phase liquid chromatography method coupled with an ultra-violet detector was developed to assess the chemical stability of norepinephrine solutions. Validation was conducted according to the linearity of the calibration ranges, selectivity, sensitivity, accuracy and precision. Dosage, sub-visible particle contamination, pH monitoring and sterility assays were performed. Chemical stability was maintained if the measured concentration respected the lower limit of 90% of the initial concentration. Containers were stored at -20±5°C, +5±3°C and +25±2°C with 60±5% relative humidity in a dark closed enclosure.

Results

Stability was successfully maintained for every concentration and container tested when stored at -20±5°C and +5±3°C. In these storage conditions, particle contamination, pH monitoring and sterility assay respected the required criteria. Chemical degradation and colouring of solutions appeared before the end of the 1 year study period for most norepinephrine solutions stored at room temperature.

Conclusions

Ready-to-use solutions containing 0.2 and 0.5 mg/mL norepinephrine in polypropylene syringes or cyclic olefin copolymer vials must be stored at refrigerated or frozen temperatures to obtain acceptable 1 year shelf-stability. Exposure to higher temperatures significantly decreases shelf-stability. Our study protocol for compounding polypropylene syringes and cyclic olefin copolymer vials containing norepinephrine is adapted to implementation in centralised intravenous additive services.

Understanding the Solution Behavior of Epinephrine in the Presence of Toxic Cations: A Thermodynamic Investigation in Different Experimental Conditions

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.

Effect of Formulation Factors and Oxygen Levels on the Stability of Aqueous Injectable Solution Containing Pemetrexed

The aim of this study was to investigate the effects of various parameters at each control strategy in drug product degradation on the stability of pemetrexed in injectable aqueous solution. A forced degradation study confirmed that oxidation is the main mechanism responsible for the degradation of pemetrexed in aqueous solutions. As control strategies, the antioxidant levels, drug concentration, pH of the control formulation, dissolved oxygen (DO) levels in the control process, and headspace oxygen levels in the control packaging were varied, and their effects on the stability of pemetrexed were evaluated. Sodium sulfite was found to be particularly effective in preventing the color change, and N-acetylcysteine (NAC) had a significant effect in preventing chemical degradation. The sulfite and NAC were found to stabilize pemetrexed in the aqueous solution by acting as sacrificial reductants. A pH below 6 caused significant degradation. The stability of pemetrexed in the solution increased as the concentration of the drug increased from 12.5 to 50 mg/mL. In addition, the DO levels in the solution were controlled by nitrogen purging, and the oxygen levels in headspace were controlled by nitrogen headspace, which also had significant positive effects in improving the stability of the pemetrexed solution; thus, it was confirmed that molecular oxygen is involved in the rate-limiting oxidation step. Based on these results obtained by observing the effects of various control strategies, the optimal formulation of an injectable solution of pemetrexed is suggested as follows: sodium sulfite at 0.06 mg/mL, as an antioxidant for prevention of color change; NAC at 1.63 mg/mL, as an antioxidant for prevention of chemical degradation; pH range 7-8; DO levels below 1 ppm; and headspace oxygen levels below 1%. In conclusion, it can be suggested that this study, which includes well-designed control strategies, can lead to a better understanding of the complex degradation mechanism of pemetrexed; thus, it can lead to the development of an injectable solution formulation of pemetrexed, with improved stability.

A systematic review of the stability of finished pharmaceutical products and drug substances beyond their labeled expiry dates

In recent years, there has been a very active debate about the stability of drug products especially after exceeding the expiry dates. The regulatory authorities require comprehensive stability data for market approval. The shelf-life obtained determines the expiry date, which is typically between 1 and 5 years and commonly set in a conservative manner. Conducting stability studies is a resource- and time-consuming matter for the pharmaceutical manufacturer. Short shelf-lives of drug products are also a challenge for managers of hospitals, nursing homes, and strategic national stockpile agencies which have to dispose of large quantities of outdated medicines every year. This conflict raises the question whether shelf-lives are often longer than the labeled one. In the past years, the FDA has launched several programs for shelf-life extension in order to defer replacement costs and to prevent drug shortages due to supply disruption. The aim of this review was to bring together the available literature of expired drug products as well as historical pharmaceutical relicts with an age of more than 80 years and to discuss the actual shelf-life with regard to the respective dosage form and the affiliation of the drug class. It seems to be reasonable for a large portion of drugs to extend the expiry dates far beyond five years.

Expired Epinephrine Maintains Chemical Concentration and Sterility

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.

Extended Stability of Epinephrine Hydrochloride Injection in Polyvinyl Chloride Bags Stored in Amber Ultraviolet Light-Blocking Bags

Objective: The objective of this study was to evaluate the stability of epinephrine hydrochloride in 0.9% sodium chloride in polyvinyl chloride bags for up to 60 days. Methods: Dilutions of epinephrine hydrochloride to concentrations of 16 and 64 µg/mL were performed under aseptic conditions. The bags were then placed into ultraviolet light-blocking bags and stored at room temperature (23°C-25°C) or under refrigeration (3°C-5°C). Three samples of each preparation and storage environment were analyzed on days 0, 30, 45, and 60. Physical stability was performed by visual examination. The pH was assessed at baseline and upon final degradation evaluation. Sterility of the samples was not assessed. Chemical stability of epinephrine hydrochloride was evaluated using high-performance liquid chromatography. To determine the stability-indicating nature of the assay, degradation 12 months following preparation was evaluated. Samples were considered stable if there was less than 10% degradation of the initial concentration. Results: Epinephrine hydrochloride diluted to 16 and 64 µg/mL with 0.9% sodium chloride injection and stored in amber ultraviolet light-blocking bags was physically stable throughout the study. No precipitation was observed. At days 30 and 45, all bags had less than 10% degradation. At day 60, all refrigerated bags had less than 10% degradation. Overall, the mean concentration of all measurements demonstrated less than 10% degradation at 60 days at room temperature and under refrigeration. Conclusion: Epinephrine hydrochloride diluted to 16 and 64 µg/mL with 0.9% sodium chloride injection in polyvinyl chloride bags stored in amber ultraviolet light-blocking bags was stable up to 45 days at room temperature and up to 60 days under refrigeration.

Stability of Ready-to-Administer and Ready-to-Use Epinephrine and Norepinephrine Injection Solutions

Background

In the University Medical Centre Mainz, standard concentrations are defined for medicinal products to be administered by continuous injection with syringe pumps in adult intensive care patients. The objective of this study was to evaluate the physicochemical stability of ready-to-use and ready-to-administer preparations containing Epinephrine (E) and Norepinephrine (NE) in standardized concentrations and prepared batch wise in the pharmacy department as basis for assigning shelf-lives.

Methods

E 20 µg/mL and NE 10 µg/mL in disposable syringes and NE 40, 100, 200, 400 µg/ml in 50 ml amber type I glass vials were prepared batch wise and the concentrations were analyzed by stability-indicating, validated reversed-phase HPLC-PDA assays. Test solutions for long-term stability studies were stored under refrigeration (2–8 °C) for 6–12 months or at elevated temperatures (21–27 °C) light protected for up to 6 months or without light protection for up to one month. Osmolality and pH were measured on predefined intervals.

Results

The concentrations of E in 50 mL syringes and NE in 10 mL syringes remained unchanged over a period of 6 months when stored at 2–8 °C. NE preparations of different concentrations prepared in amber glass vials remained stable over a study period of 12 months. At RT the shelf-life decreased to about 6 months and the exposure to mixed daylight at RT caused loss of stability in only few days.

Conclusions

Batch wise preparation of ready-to-administer (RTA) preparations containing 20 µg/mL E or 10 µg/mL NE in disposable syringes as well as ready-to-use (RTU) preparations containing 40, 100, 200 and 400 µg/mL NE was successfully implemented in a pharmacy department. Storage of the preparations at refrigerated temperatures is required to obtain acceptable shelf-lives of 6–12 months. Elevated temperatures and especially exposure to mixed daylight significantly decreased the shelf life.

Temperature-sensitive Medications in Interfacility Transport: The Ice Pack Myth

INTRODUCTION

Critical Care Transport teams use various strategies to maintain temperature sensitive drugs and equipment at optimal temperature. The purpose of this study was to examine the effectiveness of current passive refrigeration of temperature sensitive transport medications/equipment.

METHODS

Initially, we performed a retrospective review of transport durations. Subsequently, an experimental paradigm was created using a temperature probe inside of the transport cooler packs utilizing various configurations and initial starting temperatures with high and low "in range" temperature margins of 8°C (max) and 2°C (min).

RESULTS

The mean round-trip transport time was 2.5 hours and over 15% of transports last longer than 4 hours. At a starting temperature of -3.9°C, the cooler and ice pack maintained "in range" temperatures for 3 hours. When the ice pack starting temperature was -12.9°C, high temperatures excursions weren't experienced until 6 hours 55 minutes, but initially low excursions fell below for up to 3 hours. iSTAT^® cartridges remained within range between 1-4 hours at cooler and ice pack starting temperature of -3.9°C.

CONCLUSION

The current system of passive refrigeration does not appear to be sufficient for safely storing medications or point-of-care testing equipment for our transport services. This might reveal a flaw in the existing practices around medication refrigeration in transport.

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.

Stability of Adrenaline in Irrigating Solution for Intraocular Surgery

Intraocular irrigating solution containing 1 µg/mL adrenaline is widely used during cataract surgery to maintain pupil dilation. Prepared intraocular irrigating solutions are recommended for use within 6 h. After the irrigating solution is admistered for dilution, the adrenaline may become oxidized, and this may result in a decrease in its biological activity. However, the stability of adrenaline in intraocular irrigating solution is not fully understood. The aim of this study was to evaluate the stability of adrenaline in clinically used irrigating solutions of varying pH. Six hours after mixing, the adrenaline percentages remaining were 90.6%±3.7 (pH 7.2), 91.1%±2.2 (pH 7.5), and 65.2%±2.8 (pH 8.0) of the initial concentration. One hour after mixing, the percentages remaining were 97.6%±2.0 (pH 7.2), 97.4%±2.7 (pH 7.5), and 95.6%±3.3 (pH 8.0). The degradation was especially remarkable and time dependent in the solution at pH 8.0. These results indicate that the concentration of adrenaline is decreased after preparation. Moreover, we investigated the influence of sodium bisulfite on adrenaline stability in irrigating solution. The percentage adrenaline remaining at 6 h after mixing in irrigating solution (pH 8.0) containing sodium bisulfite at 0.5 µg/mL (concentration in irrigating solution) or at 500 µg/mL (concentration in the undiluted adrenaline preparation) were 57.5 and 97.3%, respectively. Therefore, the low concentration of sodium bisulfite in the irrigating solution may be a cause of the adrenaline loss. In conclusion, intraocular irrigation solution with adrenaline should be prepared just prior to its use in surgery.

The Impact of Freeze-Thaw Cycles on Epinephrine

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.

Synthesis, characterization and kinetics of formation of silver nanoparticles by reduction with adrenaline in the micellar media

The present paper describes about the easy, simple and convenient procedure for the synthesis of silver nanoparticles (Ag-NPs) in aqueous solutions by the reduction of silver nitrate with adrenaline. The surfactant molecules of cetyltrimethylammonium bromide (CTABr) and sodium dodecyl ate (SDS) behaved differently during the reduction of Ag(+) ions by adrenaline. The obtained data suggest that the variation of [CTABr] gave a maxima-like curve for rate constant versus [CTABr], while, the values of rate constant decreased with the increase in [SDS]. The addition of surfactant molecules stabilized the Ag-NPs. The UV-Visible spectra were analyzed to deduce the particle size. The calculated sizes of the nanoparticles were further compared by the TEM images. The XRD spectrum confirmed the crystalline nature of silver nanoparticles having the face-centered cubic crystal structure. The edge length of unit cell was found 4.076 Å. The kinetics of formation of Ag-NPs was performed at different concentrations of adrenaline, AgNO3, NaOH and [surfactant]. The values of rate constant were independent on [adrenaline] and [AgNO3]. The increase in [NaOH] increased the rate of agglomeration of silver particles to form Ag-NPs. A linear relationship was obtained for the plot of rate constant versus [NaOH].

Spectrophotometric investigation on the kinetics of oxidation of adrenaline by dioxygen of μ-dioxytetrakis(histidinato)-dicobalt(II) complex

The cobalt(II)histidine complex binds molecular oxygen reversibly to form an oxygen adduct complex, μ-dioxytetrakis-(histidinato)dicobalt(II). The molecular oxygen can be released from the oxygenated complex by heating it or by passing N2, He or Ar gas through its solution. μ-Dioxytetrakis-(histidinato)dicobalt(II) complex oxidizes adrenaline into leucoadrenochrome at 25°C while at higher temperature (>40°C) adrenochrome with λmax at 490nm is formed. The rate of formation of leucoadrenochrome was found to be independent of [bis(histidinato)cobalt(II)]. The rate of reaction for the formation of leucoadrenochrome and adrenochrome increased with the increase in [adrenaline] at its lower concentration but become independent at higher concentration. Similarly, the rate of formation of both leucoadrenochrome and adrenochrome was linearly dependent upon [NaOH]. The values of activation parameters i.e. ΔEa, ΔH(‡) and ΔS(‡) for the formation of leucoadrenochrome are reported.

Delay and stability of central venous administration of norepinephrine in children: a bench study

In children, because of the dead volume of the central venous catheter (CVC) and the low flow rate of norepinephrine (NE) infusion, the delay between start-up and effective administration can be adversely long. A theoretical calculation enables to estimate the delay and variations of effective administration. However, numerous factors can hinder this theoretical approach. Herein, we measured via bench testing the actual delay and stability of NE administration kinetics. Using an assembly reproducing our currently-implemented catecholamine administration protocol, diluted NE (200 μg ml(-1)) was infused at an initial rate of 2 ml h(-1) (theoretically 6.67 μg min(-1)) for a period of 24 h. An assay measuring the amount of NE (μg) exiting the CVC was conducted by high-pressure liquid chromatography with colorimetric detection. The theoretical calculation of the delay in administered NE, taking into account a CVC dead volume of 0.3 ml, was 9 min. The measured percentage of the administered dose as a function of time in minutes (M) was M0-M3 (0 %), M3-M6 (0 %), M6-M9 (13 %), M9-M12 (28 %), M12-M15 (70 %), and M15-M18 (100 %) The amount of NE (μg) at fixed rate (2 ml h(-1)) was established at 6.9 ± 0.4 μg min(-1) during the 24 h.

CONCLUSION

Continuous NE infusion via a CVC at low rate is stable. In children, because of CVC dead volume and low flow rate infusion, the delay in achieving intended dose delivery is significantly longer than that estimated by theoretical calculation. New modalities of initiation of catecholamine infusion adapted to the child are warranted.