Intralipid medication errors in the neonatal intensive care unit

Use of Intravenous Lipid Emulsions With Parenteral Nutrition: Practical Handling Aspects

A number of topics important to the handling of intravenous lipid emulsions (ILEs) were discussed at the international summit. ILE handling includes the preparation and the administration steps in the typical use of parenteral nutrition (PN). The discussion and consensus statements addressed several issues, including standardization of the PN process, use of commercially available multi-chamber PN or compounded PN bags, the supervision by a pharmacist with expertise, limiting ILE repackaging, and infusion duration.

Summary of Proceedings and Expert Consensus Statements From the International Summit "Lipids in Parenteral Nutrition"

BACKGROUND

The 2018 Lipids in Parenteral Nutrition summit involved a panel of experts in clinical nutrition, lipid metabolism, and pharmacology, to assess the current state of knowledge and develop expert consensus statements regarding the use of intravenous lipid emulsions in various patient populations and clinical settings. The main purpose of the consensus statements is to assist healthcare professionals by providing practical guidance on common clinical questions related to the provision of lipid emulsions as part of parenteral nutrition (PN).

METHODS

The summit was designed to allow interactive discussion and consensus development. The resulting consensus statements represent the collective opinion of the members of the expert panel, which was informed and supported by scientific evidence and clinical experience.

RESULTS

The current article summarizes the key discussion topics from the summit and provides a set of consensus statements designed to complement existing evidence-based guidelines. Lipid emulsions are a major component of PN, serving as a condensed source of energy and essential fatty acids. In addition, lipids modulate a variety of biologic functions, including inflammatory and immune responses, coagulation, and cell signaling. A growing body of evidence suggests that lipid emulsions containing ω-3 fatty acids from fish oil confer important clinical benefits via suppression of inflammatory mediators and activation of pathways involved in the resolution of inflammation.

CONCLUSIONS

This article provides a set of expert consensus statements to complement formal PN guideline recommendations.

A Review of Regional Anesthesia in Infants

Regional anesthesia provides effective anesthesia and pain relief in infants with age-specific data attesting to safety and efficacy. Regional anesthesia decreases exposure to opioids and general anesthetic agents and associated adverse drug effects, suppresses the stress response, and provides better hemodynamic stability compared to general anesthesia. Regional anesthesia can prevent long-term behavioral responses to pain. As a result, the overall number and variety of nerve blocks being used in infants is increasing. While neuraxial blocks are the most common blocks performed in infants, the introduction of ultrasound imaging and a better safety profile has advanced the use of peripheral nerve blocks. Infant-specific pharmacokinetic and pharmacodynamic data of local anesthetic medications are reviewed including risk factors for the accumulation of high serum levels of unbound, pharmacologically active drug. Bupivacaine accumulates with continuous infusion and 2-chloroprocaine can be used as an alternative. Local anesthetic systemic toxicity has the highest incidence in infants less than 6 months of age and is associated with bolus dosing and penile nerve blocks. Local anesthetic toxicity is treated by securing the airway, suppression of seizure activity and implementation of cardiopulmonary resuscitation. Administration of intralipid (intravenous lipid emulsion) is initiated at the first sign of toxicity. A high level of expertise in regional anesthesia is needed when treating infants due to their unique development.

Intravenous Lipid Emulsion Overdose in Infancy: A Case Report and Overview of Opportunities, Challenges and Prevention

Medication errors remain among the major problems seen in hospitals. Such errors can relate to the prescription, dispensation, or administration of drugs. Human factors account for most of these mistakes, but other factors such as infusion pump programming defects should always be considered. Worldwide, medication errors have been reported to affect 2-30% of patients, depending on the institution. Intravenous lipid emulsion (ILE) infusion is frequently used as part of total parenteral nutrition in patients of all ages with feeding and gastrointestinal issues. ILE overdose has been previously reported, with variable clinical outcomes. We report a case of accidental ILE (Intralipid) overdose in a 3-month-old male infant who fully recovered after single-volume blood exchange transfusion. We also review reported cases and summarize potential solutions for ILE overdose. Our review indicates that ILE infusion is a high-risk medication, and opportunities for errors remain even in the best hospital set-ups. Attention should be directed towards proper prescription, dosing, dispensation, and administration. Most of the cases indicate the safety breach was at the nursing drug-administration level, with improper pump use or programming, together with other fluid infusion rate switching, being the main possible defects. Strategies targeting the areas of weakness in the drug-delivery pathway are needed. Special attention should be paid towards nursing duties and working hours. In addition, nursing staff should receive frequent education sessions and should be required to pass competency modules regularly. An error-prevention plan should be established and implemented. This plan needs full collaboration between physicians, pharmacists, and nursing staff.

Successful exchange transfusion in extremely preterm infant after symptomatic lipid overdose

BACKGROUND

Complications of intravenous lipid administration are relatively uncommon. However, inadvertent rapid infusion of intravenous fat emulsion (IVFE) is an inherent risk when fats are infused separately from the dextrose-amino acid solution.

CASE REPORT

Extremely preterm infant, born at 25 weeks and 6 days of gestational age weighing 920 g, who inadvertently received a massive overdose of IVFE due to a device failure. He developed lethargy, apnea, metabolic acidosis and hemodynamic instability requiring mechanical ventilation and inotropic support. Despite discontinuation of IVFE and supportive care, clinical course and metabolic acidosis worsened, so a double-volume exchange transfusion was performed. The procedure was well tolerated, without complications. Serum triglyceride concentration as well as other laboratory data normalized immediately after the exchange transfusion. The patient was extubated to continuous positive airway pressure and inotropic support was discontinued 24 hours after the procedure. He was discharged home at 40 weeks of corrected age with normal magnetic resonance imaging and neurological examination.

CONCLUSION

In cases of profound, symptomatic hypertriglyceridemia due to lipid overdose, double-volume exchange transfusion should be considered, even in extremely preterm infants.

A.S.P.E.N. clinical guidelines: parenteral nutrition ordering, order review, compounding, labeling, and dispensing

BACKGROUND

Parenteral nutrition (PN) is a high-alert medication available for patient care within a complex clinical process. Beyond application of best practice recommendations to guide safe use and optimize clinical outcome, several issues are better addressed through evidence-based policies, procedures, and practices. This document provides evidence-based guidance for clinical practices involving PN prescribing, order review, and preparation.

METHOD

A systematic review of the best available evidence was used by an expert work group to answer a series of questions about PN prescribing, order review, compounding, labeling, and dispensing. Concepts from the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) format were applied as appropriate. The specific clinical guideline recommendations were developed using consensus prior to review and approval by the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. The following questions were addressed: (1) Does education of prescribers improve PN ordering? (2) What is the maximum safe osmolarity of PN admixtures intended for peripheral vein administration? (3) What are the appropriate calcium intake and calcium-phosphate ratios in PN for optimal neonatal bone mineralization? (4) What are the clinical advantages or disadvantages of commercially available premade ("premixed") multichambered PN formulations compared with traditional/customized PN formulations? (5) What are the clinical (infection, catheter occlusion) advantages or disadvantages of 2-in-1 compared with 3-in-1 PN admixtures? (6) What macronutrient dosing limits are expected to provide for the most stable 3-in-1 admixtures? (7) What are the most appropriate recommendations for optimizing calcium (gluconate) and (Na- or K-) phosphate compatibility in PN admixtures? (8) What micronutrient contamination is present in parenteral stock solutions currently used to compound PN admixtures? (9) Is it safe to use the PN admixture as a vehicle for non-nutrient medication delivery? (10) Should heparin be included in the PN admixture to reduce the risk of central vein thrombosis? (11) What methods of repackaging intravenous fat emulsion (IVFE) into smaller patient-specific volumes are safe? (12) What beyond-use date should be used for (a) IVFE dispensed for separate infusion in the original container and (b) repackaged IVFE?

Rapid infusion of fish oil-based emulsion in infants does not appear to be associated with fat overload syndrome

BACKGROUND

Inadvertent rapid infusion of parenteral lipid emulsion is an inherent risk when fats are infused separately from the dextrose-amino acid solution. Patients may experience hypertriglyceridemia that resolves upon discontinuation of the infusion; in other cases, complications such as fat overload syndrome can occur. Since 2004, fish oil-based emulsions have been used investigationally for the treatment of parenteral nutrition-associated liver disease. Anecdotal reports suggest that patients who receive rapid infusions of this emulsion do not develop symptoms consistent with fat overload syndrome. The aim of this investigation was to determine whether infants receiving a rapid infusion of a fish oil lipid emulsion exhibited symptoms consistent with fat overload syndrome.

METHODS

The medical records of patients treated at Children's Hospital Boston with a fish oil emulsion from September 2004 to August 2008 were reviewed for cases of rapid infusion.

RESULTS

Six of 99 patients (6%) received a dose of fish oil emulsion at an infusion rate that exceeded 0.17 g/kg/h. Infusion rates as high as 5 g/kg/h were accidentally administered (range, 0.2-5 g/kg/h) without evidence of fat overload syndrome. Transient elevations in serum triglyceride levels were observed but promptly returned to acceptable levels.

CONCLUSIONS

Rapid infusion of a fish oil-based emulsion in 6 infants were well tolerated. No patients developed signs or symptoms of fat overload syndrome.

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit

OBJECTIVE

To identify a risk profile for harmful medication errors in the neonatal intensive care unit (NICU).

STUDY DESIGN

A retrospective cross-sectional study on NICU medication error reports submitted to MEDMARX between 1 January 1999, and 31 December 2005. The Rao-Scott modified chi(2) test was used for analysis.

RESULT

6749 NICU medication error reports were submitted by 163 health-care facilities. Administering errors accounted for approximately one half of errors, and human factors were the most frequently cited cause of error. Patient age was not associated with an increased likelihood of an error being harmful (P=0.11). Error reports involving Institute for Safe Medication Practices (ISMP) High-Alert Medications, occurring in the prescribing phase of medication processing, or involving equipment/delivery device failures were more likely to be harmful (P< or =0.05).

CONCLUSION

Risk factors for harmful medication error reports include use of ISMP High-Alert Medications, the prescribing phase of the medication use process, and failure of equipment/delivery devices.

Pediatric aspects of inpatient health information technology systems

US adoption of health information technology as a path to improved quality of patient care (effectiveness, safety, timeliness, patient-centeredness, efficiency, and equity) has been promoted by the medical community. Children and infants (especially those with special health care needs) are at higher risk than are adults for medical errors and their consequences (particularly in environments in which children are not the primary patient population). However, development and adoption of health information technology tools and practices that promote pediatric quality and patient safety are lagging. Two inpatient clinical processes-medication delivery and patient care transitions-are discussed in terms of health information technology applications that support them and functions that are important to pediatric quality and safety. Pediatricians and their partners (pediatric nurses, pharmacists, etc) must develop awareness of technical and adaptive issues in adopting these tools and collaborate with organizational leaders and developers as advocates for the best interests and safety of pediatric patients. Pediatric health information technology adoption cannot be considered in terms of applications (such as electronic health records or computerized physician order entry) alone but must be considered globally in terms of technical (health information technology applications), organizational (structures and workflows of care), and cultural (stakeholders) aspects of what is best.

Medication errors in neonates

Prevention of harm from medication errors has become a national priority. Medication errors in the neonatal intensive care unit are common, and most can be avoided. This article reviews the prevalence and types of medication errors affecting the care of the neonate and summarizes approaches that have been used to reduce these errors. Safety initiatives applicable to minimizing medication errors also are discussed.

Computer-related medication errors in neonatal intensive care units

Iatrogenic medication errors in the neonatal ICU (NICU) are reported to occur up to 2.6 times per 100 NICU days. It has been learned during the last decade that well-intended but faulty implementations of technology can increase the frequency of errors and also can give rise to new types. This article compares and discusses iatrogenic medication errors in the NICU that are related to computer entry and computerized physician order entry systems. The authors also propose a possible approach for evaluating technology that is intended to prevent iatrogenic mediation errors in the NICU.