Hazards of parenteral treatment: do particles count?

Physical compatibility of insulin aspart, lidocaine, alprostadil and vancomycin with individualised two-in-one parenteral nutrition used in the neonatal intensive care unit

OBJECTIVES

Critically ill newborn infants often require simultaneous administration of multiple intravenous (IV) solutions through the same catheter lumen, making compatibility of these solutions crucial in neonatal intensive care units (NICUs). This study aimed to investigate the physical compatibility of insulin aspart, lidocaine, alprostadil and vancomycin with individualised two-in-one parenteral nutrition (PN).

METHODS

The study was conducted at the hospital pharmacy's drug compounding facility of the University Medical Centre Utrecht. Two PN formulations were prepared with different electrolyte concentrations (PN1 with high electrolytes and PN2 with low electrolytes), each with either 0% or 30% w/v glucose, resulting in four solutions for testing. Each solution was then mixed with the selected IV drugs in a 1:1 ratio. Compatibility was assessed through visible particle testing, pH measurements and subvisible particle testing at multiple time points (T=0, T=1, T=4 hours).

RESULTS

No visible particles were detected in any combinations. However, insulin and lidocaine combinations exceeded the subvisible particle threshold of 6000 particles ≥10 µm per container volume at T=0 hours, with insulin also exceeding the threshold in a specific PN combination at T=4 hours. pH measurements indicated minimal shifts in the PN solutions, suggesting significant buffering capacity.

CONCLUSION

Alprostadil and vancomycin IV solutions are physically compatible with two individualised neonatal PN solutions, with high as well as low glucose concentrations. Combinations of PN with lidocaine or insulin form subvisible particles, which could have clinical implications if administered in large volumes over extended periods of time. In clinical scenarios where there is no other option but to administer lidocaine or insulin through the same catheter lumen as PN using a Y-site connector, the use of an in-line filter is advised. Our study adds important compatibility data that can guide clinical practice in NICU settings. However, the broader application of these results requires careful consideration of the unique characteristics of each neonatal PN solution and drug combination.

Is intravenous infusion an unrecognized route for internal microplastic human exposure? A general assessment

As newly recognized environmental pollutants, microplastics (MPs, ≤5 mm in length) have been reported in various human tissues and fluids, including the spleen, liver, heart, blood and blood clots, raising global concerns about their impact on human health. This study investigated the characteristics of MPs in intravenous infusion and the removal of MPs from infusion products by infusion sets fitted with different filters using micro-Fourier Transform Infrared Spectroscopy. MPs were detected in infusion products, with an average abundance of 1.24 ± 1.44 items/unit (2.91 ± 3.91 items/L). The primary types of MPs identified were fragmented particles of polyethene and polypropylene, ranging in size from 15-100 µm. Internal filters in infusion sets played a crucial role in removing MPs, particularly fibrous ones, resulting in a reduction in both abundance and particle size of MPs in the human body. Moreover, this study conducted a general assessment of intravenous microplastic exposure among hospital patients and estimated the global per-person input of MPs via intravenous administration. It is an opportunity for us to gain a deeper understanding of MPs in intravenous infusion and provides guides selecting infusion devices, increasing awareness of associated health risks.

Physical compatibility of medications with concentrated neonatal and pediatric parenteral nutrition: A simulated Y-site drug compatibility study

BACKGROUND

The physical intravenous Y-site compatibility of 15 different medications with highly concentrated neonatal and pediatric parenteral nutrition (PN) compounds is described, using existing and novel methods.

METHODS

PN formulations were developed based on common prescribing practices in a 400+-bed freestanding children's hospital. Medications at commonly used pediatric concentrations were mixed in a 1:1 ratio with both pediatric and neonatal PN formulations and incubated at room temperature for 4 h to simulate Y-site administration. Samples were then analyzed using the light obscuration (LO) technique, as recommended by United States Pharmacopeia (USP) chapter <788>, in addition to novel flow imaging (FI) microscopy and backgrounded membrane imaging (BMI). Physical compatibility was determined using USP <788> particle count limits for all techniques.

RESULTS

Most combinations were found to be compatible per USP <788> thresholds. Pediatric PN was incompatible by at least two methods with cisatracurium 2 mg/ml, sildenafil 0.8 mg/ml, furosemide 10 mg/ml, and ketamine 10 mg/ml. Neonatal PN was incompatible by at least two methods with cisatracurium 2 mg/ml and furosemide 10 mg/ml. Overall, results for 20 of the 30 combinations (66%) agreed across all three methods. FI and BMI results agreed for 22 of 30 combinations. LO agreed with FI in 25 of 30 combinations, and BMI and LO results agreed in 23 of 30 combinations.

CONCLUSION

Most combinations tested were found to be compatible across all methods. Novel methods of FI and BMI seem useful to further evaluate LO findings and improve accuracy of particle counts when assessing PN-medication combinations.

Exploring a case of incompatibility in a complex regimen containing Plasma-Lyte 148 in the pediatric intensive care

BACKGROUND

In the local pediatric intensive care unit, precipitation was observed in the intravenous catheter upon co-administration of four drugs together with the buffered electrolyte solution (Plasma-Lyte 148, Baxter). Co-infusion of incompatible combinations represents a safety concern.

AIMS

To reproduce the clinical case of precipitation. To further explore and understand the risk of precipitation, different combinations of the components as well as the corresponding electrolyte solution with 5% glucose (Plasma-Lyte 148 with 5% glucose) should be investigated.

METHODS

Physical compatibility of fentanyl, ketamine, midazolam, and potassium chloride was tested in combination with the buffered electrolyte solutions. The concentrations and infusion rates representative of children 10-40 kg were used to estimate mixing ratios. Analyses detecting visual particles (Tyndall beam) and sub-visual particles (light obscuration technology) were undertaken. Measured turbidity and pH in mixed samples were compared with unmixed controls.

RESULTS

Both midazolam and ketamine showed formation of visual and sub-visual particles upon mixing with Plasma-Lyte 148, respectively. Particle formation was confirmed by increased turbidity and a distinct Tyndall effect. pH in mixed samples mirrored the pH of the buffered electrolyte, suggesting that the solubility limits of midazolam, and in some ratios also ketamine, were exceeded. Midazolam also precipitated in combination with the glucose-containing product that held a lower pH, more favorable for keeping midazolam dissolved.

CONCLUSIONS

Replication of the case revealed that both midazolam and ketamine contributed to the precipitation. Midazolam and ketamine were both evaluated as incompatible with the buffered electrolyte solution and midazolam also with the buffered electrolyte-glucose solution and should not be co-administered in the same i.v.-catheter line. Fentanyl and potassium chloride were interpreted as compatible with both buffered electrolytes.

Physical Compatibility of Y-site Pediatric Drug Administration: A Call for Question of US Pharmacopeia Standards

OBJECTIVE

To evaluate the physical intravenous Y-site compatibility of 29 combinations of medications at commonly used pediatric concentrations using both existing and novel techniques.

METHODS

Medication combinations included were selected by a varied group of pediatric inpatient pharmacists, and then assessed by 3 independent reviewers for existing literature. For each combination, 2 different medications were mixed together in a 1:1 ratio and incubated at room temperature for 4 hours to simulate Y-site administration. Each sample was then analyzed using the US Pharmacopeia (USP) <788> recommended analytical technique of light obscuration (LO) in addition to novel flow imaging (FI) microscopy and backgrounded membrane imaging (BMI). Physical compatibility was determined using USP chapter <788> large volume particle count limits for all techniques.

RESULTS

A total of 29 different medication combinations were studied. Five combinations met criteria for compatibility by all 3 techniques. The remaining 24 combinations reached the threshold to be considered incompatible by at least 1 of the 3 techniques. Light obscuration, BMI, and FI identified 14%, 59%, and 76% of combinations as incompatible, respectively. All samples deemed incompatible by LO were also incompatible by at least 1 of the other 2 techniques. Flow imaging and BMI results agreed in 69% of samples tested.

CONCLUSIONS

Most combinations tested were found to be incompatible by at least 1 of the 3 instruments used. Light obscuration appears to have reduced accuracy for identifying particulate resulting in physical medication incompatibility when compared with the novel techniques of FI and BMI.

Impact of mechanical stress on flexible tubing used for biomedical applications: Characterization of the damages and impact on the patient's health

Flexible tubing is a key part of a lot of medical devices used in hospital, but may be subjected to a lot of various mechanical stresses that can led to the failure or to complications for the patients. The nature and causes of these mechanical stresses were listed for peristaltic pump tubing, infusion set tubing and catheters. Their consequences in term of tubing damages and particular contamination were reported. The impact of the chemical nature of the tubing, of its size and also the impact of various parameters of the clinical acts were reviewed. Last the consequences for the patient's health were discussed.

Effect of Central Venous Nutrition Infusion, Intravenous Fat Emulsion, and Therapeutic Agents on the Particle Size of Fat Emulsion for Simultaneous Administration of Three Drugs

BACKGROUND

In Japan, therapeutic agents are often administered through the side tube of a central venous line or mixed with a total parenteral nutrition (TPN) infusion. This is expected to result in the mixture of three drugs in the infusion line: the infusion product for TPN, the fat emulsion, and the therapeutic agent. Therefore, we investigated whether various therapeutic agents affect the particle size of the fat emulsion.

METHODS

In model of administration A, the TPN infusion formulation was administered through the main tube, and the fat emulsion and therapeutic agents were simultaneously administered through the side tube; 21 therapeutic agents were used. In model of administration B, the TPN infusion formulation mixed with therapeutic agents was administered through the main tube, and the fat emulsion was simultaneously administered through the side tube; 20 therapeutic agents were used. The number of fine particles for each particle size range in the mixed solution was measured over time using a light-shielding automatic fine-particle measuring device.

RESULTS

In model A, the number of fine particles in the fat emulsion changed rapidly for five therapeutic agents and slowly for two therapeutic agents. In model B, this change occurred drastically for five therapeutic agents and slowly for one therapeutic agent.

CONCLUSIONS

Some therapeutic agents may contribute to fat particle aggregation. Therefore, these therapeutic agents should not be concurrently administered with fat emulsions.

X-ray imaging: A potential enabler of automated particulate detection and cake-structure analysis in lyophilized products?

The presence of particulate matter in parenteral products is a major concern since it affects the patients' safety and is one of the main reasons for product recalls. Conventional quality control is based on a visual inspection, which is a labour-intensive task. Limited to clear solutions and the surface of lyophilised products, it cannot be applied to opaque containers. This study assesses the application of X-ray imaging for detecting the particulate matter in a pharmaceutical lyophilized product. The most common types of particulates (i.e., steel, glass, lyo stopper, polymers and organics in different size classes) were intentionally spiked in vials. After optimizing all relevant parameters of the X-ray set-up, all classes of particulates were detected. At the same time, due to contrast enhancement, the inherent structures of lyophilized cake became obvious. This work addresses the potential and limits of X-ray technology in that regard, paving the way for automated image-based particulate matter detection. Moreover, this paper discusses using this approach to predict critical quality attributes (CQAs) of the drug product based on the cake structure attributes.

Safety concerns with glass particle contamination: improving the standard guidelines for preparing medication injections

Background

Glass ampoules are widely used to contain injection medications because of their properties. However, the existing literature reports that glass particle contamination is found in opening glass ampoules. To date, nursing practice standards on this issue have not gained attention in terms of the manual breaking methods generally used for opening ampoules in a clinical setting that can minimize the risk of glass particle contamination and, therefore, increase patient safety.

Objective

This study aimed to compare manual breaking methods commonly used to open ampoules in clinical practice that affected the number of glass particles and to identify the factors influencing glass particle contamination.

Methods

We used a comparative research design to evaluate the manual breaking methods for opening medication ampoules among 56 registered nurses from diverse clinical areas in a university hospital. Each participant broke 12 ampoules in two sizes using six methods, each method combined with wrapping material and one breaking direction. We measured the number of glass particles in five sizes for each method and the factors influencing glass particle contamination.

Results

In total, 449 of 672 ampoules were contaminated with glass particles. Breaking the ampoule with a cotton ball (partial ampoule neck wrapping) from an outward direction resulted in the fewest glass particles, while breaking the ampoule with a gauze pad (entire ampoule neck wrapping) from an inward direction resulted in the most glass particles. Breaking method, ampoule size and clinical experience significantly influence glass particle contamination (P < 0.05).

Conclusions

The method (wrapping technique and breaking direction) that nurses use to break ampoules affects the number of glass particles. Therefore, improving the standard guidelines for preparing medication injections and training in breaking methods for opening ampoules is essential.

WoCoVA consensus on the clinical use of in-line filtration during intravenous infusions: Current evidence and recommendations for future research

The need for filtering intravenous infusions has long been recognized in the field of venous access, though hard scientific evidence about the actual indications for in-line filters has been scarce. In the last few years, several papers and a few clinical studies have raised again this issue, suggesting that the time has come for a proper definition of the type of filtration, of its potential benefit, and of its proper indications in clinical practice. The WoCoVA Foundation, whose goal is to increase the global awareness on the risk of intravenous access and on patients' safety, developed the project of a consensus on intravenous filtration. A panel of experts in different aspects of intravenous infusion was chosen to express the current state of knowledge about filtration and to indicate the direction of future research in this field. The present document reports the final conclusions of the panel.

Supporting the use of sildenafil infusions in paediatric and neonatal intensive care - A compatibility study

OBJECTIVE

Intravenous (IV) sildenafil, a phosphodiesterase type 5 inhibitor, is increasingly being used for the treatment of pulmonary hypertension (PH) in the paediatric population. Sildenafil (Revatio®) is approved for the treatment of pH in adults where it is administered as a bolus injection. However, in paediatrics it is used off-label and administered by continuous IV infusion. In the critically unwell child, limited IV access necessitates the administration of multiple IV infusions through a single IV lumen. The absence of compatibility data between sildenafil and other IV medications commonly used in this context necessitates the use of a dedicated IV line for sildenafil. The overall aim of this study was to establish the physical and chemical compatibility of sildenafil with commonly administered infusions in the paediatric and neonatal intensive care setting.

DESIGN

This study evaluated the chemical and physical compatibility of binary and multiple combinations (n = 42) of sildenafil with adrenaline, noradrenaline, milrinone, vasopressin and heparin. These were tested using three diluents (NaCl 0.9%w/v, Glucose 5%w/v, and Glucose 10%w/v) and two environmental conditions (room temperature and 37 °C) frequently encountered in paediatric or neonatal intensive care units. Prior to drug combination analysis, HPLC methods were developed and optimised to allow for the quantification of drugs in accordance with current pharmaceutical guidance. Binary and multiple drug mixtures of sildenafil were examined for physical and chemical compatibility to establish compatibility.

MEASUREMENTS AND MAIN RESULTS

Of the drug combinations not containing heparin, all were deemed compatible with the exception of the five drug mix of Sildenafil 800 μg/mL, Milrinone 200 μg/mL, Vasopressin 0.4Units/mL, Noradrenaline 60 μg/mL, Adrenaline 60 μg/mL at 37 °C, in 10%w/v glucose. All binary or multi drug combinations containing heparin were deemed incompatible.

CONCLUSIONS

This research provides support and information to clinicians looking to co-administer sildenafil with other IV medicines thus removing the requirement to subject their patients to multiple intravenous cannula insertion points where IV access is restricted.

ARTICLE TWEET

New evidence to support administration of sildenafil infusions in #PedsICU and #nicu- collaboration between @RCSIPharBioMol@FionaSOBrien1 and @OLCHCrumlin @RCSI_Irl @MoninneHowlett #CHI.

In-line filtration in very preterm neonates: a randomized controlled trial

In-line filtration is increasingly used in critically-ill infants but its benefits, by preventing micro-particle infusion in very preterm neonates, remain to be demonstrated. We conducted a randomized controlled trial among very preterm infants allocated to receive either in-line filtration of all the intra-venous lines or standard care without filters. The primary outcome was differences greater than 20% in the median changes in pro-inflammatory cytokine serum concentrations measured at day 3 and day 8 (+/-1) using a Luminex multianalytic profiling technique. Major neonatal complications were analyzed as secondary predefined outcomes. We randomized 146 infants, assigned to filter (n = 73) or control (n = 73) group. Difference over 20% in pro-inflammatory cytokine concentration between day 3 and day 8 was not found statistically different between the two groups, both in intent-to-treat (with imputation) and per protocol (without imputation) analyses. The incidences of most of neonatal complications were found to be similar. Hence, this trial did not evidence a beneficial effect of in-line filtration in very preterm infants on the inflammatory response syndrome and neonatal morbidities. These data should be interpreted according to local standards in infusion preparation and central line management.

Overcoming stability challenges during continuous intravenous administration of high-dose amoxicillin using portable elastomeric pumps

While treatment of serious infectious diseases may require high-dose amoxicillin, continuous infusion may be limited by lack of knowledge regarding the chemical stability of the drug. Therefore, we have performed a comprehensive study so as to determine the chemical stability of high-dose amoxicillin solutions conducive to safe and effective continuous intravenous administration using portable elastomeric pumps. First, amoxicillin solubility in water was assessed within the range of 25 to 300 mg/mL. Then, amoxicillin solutions were prepared at different concentrations (25, 50, 125, 250 mg/mL) and stored in different conditions (5±2°C, 25±1°C, 30±1°C and 37±1°C) to investigate the influence of concentration and temperature on the chemical stability of amoxicillin. Finally, its stability was assessed under optimized conditions using a fully validated HPLC-UV stability-indicating method. Degradation products of amoxicillin were investigated by accurate mass determination using high-resolution mass spectrometry. Amoxicillin displayed limited water solubility requiring reconstitution at concentrations below or equal to 150 mg/mL. Amoxicillin degradation were time, temperature as well as concentration-dependent, resulting in short-term stability, in particular at high concentrations. Four degradation products of amoxicillin have been identified. Among them, amoxicilloic acid and diketopiperazine amoxicillin are at risk of allergic reaction and may accumulate in the patient. Optimized conditions allowing for continuous infusion of high-dose amoxicillin has been determined: amoxicillin should be reconstituted at 25 mg/mL and stored up to 12 hours at room temperature (22 ± 4°C) or up to 24 hours between 4 and 8°C.

Clinical implications of intravenous drug incompatibilities in critically ill patients

OBJECTIVE

The aim of this review is to analyse the clinical consequences of intravenous drug incompatibilities in critically ill patients, especially the incidence of organ dysfunctions and mortality.

METHODS

A review of literature was conducted according to the PRISMA statement in June 2017, using Medline, ISI Web of Science and Clinicaltrials.gov.

DATA EXTRACTION

Eligible studies were case reports and randomised controlled trials (RCTs) that assessed the effects of drug incompatibilities in critically ill patients on morbidity or mortality as primary or secondary outcomes, or adverse events. Two investigators independently reviewed the eligibility of the study from abstracts or manuscript data.

DATA SYNTHESIS

Twelve articles met the selection criteria. The six articles reporting RCTs concern only four RCTs. RCTs were single-centre studies comparing infusion with or without filter. One of them included adult patients. The others included paediatric and neonatal intensive care unit patients. Primary endpoints were SIRS, organ failure, overall complication rate, bacteraemia, sepsis, phlebitis and length of stay. The results are mixed with one RCT reporting a reduction in SIRS, organ failure and overall complication rate, two studies in disagreement over the occurrence of sepsis and one study reporting no impact on length of hospital stay. The six articles on case reports show different drug incompatibility situations. They report pulmonary toxicity.

CONCLUSION

Little data is available on this topic. Infused particles may induce organ failure, in particular pulmonary toxicity and SIRS. Further studies are needed to establish a link between the level of exposure to drug incompatibilities and clinical implication.

What are we injecting with our drugs?

In preparation for a case, an anaesthetist opened a 20 ml glass vial of propofol and aspirated the propofol into a syringe via a blunt drawing-up needle. Increased resistance was felt with aspiration. On inspection, a shard of glass was found at the tip of the drawing-up needle. The shard was presumed to be from the propofol ampoule, and to have fallen into the solution upon snapping open its glass tip. This illustrative case raises the issue of contamination of drugs by particles introduced during the drawing-up process. It also highlights the possibility that during the drawing-up process, intravenous drugs may become contaminated not just with particles, but with microorganisms on the surface of the particles. In this article, we discuss relevant recent research of the implications of this type of drug contamination. We draw attention to the need for meticulous care in drawing up and administering intravenous drugs during anaesthesia, particularly propofol.

Avoid Drug Incompatibilities: Clinical Context in Neonatal Intensive Care Unit (NICU)

The administration of several intravenous products on the same catheter is a very common situation in neonatology, where the stakes are high and the dangers sometimes unknown to clinicians. A large number of factors are involved in this administration, directly related to the installation of the infusion line. Moreover, the therapeutics used are often limited, and excluding classic “Marketing Authorization”. Some of these products may prove to be incompatible and thus lose their effectiveness, or even generate particles that are likely to be administered to the patient. We must be aware of these risks in order to optimize the prescription and administration of these intravenous products, especially as we treat fragile and immature patients. The aim of this work is to review the literature on the subject for the prescribers of neonatology units.

Dynamic Image Analysis To Evaluate Subvisible Particles During Continuous Drug Infusion In a Neonatal Intensive Care Unit

Studies have shown that infused particles lead to numerous complications such as inflammation or organ dysfunctions in critically ill children. Nevertheless, there is very little data available to evaluate the amount of particulate matter potentially administered to patients, and none with regard to infants. We have investigated the quantity received by these patients during multidrug IV therapies. Two different protocols commonly used in our neonatal intensive care unit (NICU) to manage excessively preterm infants were reproduced in the laboratory and directly connected to a dynamic particle analyser. The particulate matter of infused therapies was measured over 24 h, so that both overall particulate contamination and particle sizes could be determined. No visible particles were observed during drug infusions. Particulate analyses showed a significant number of particles that can reach 85,000 per day, with peaks during discontinuous drug infusions. Moreover, we showed that very large particles of about 60 µm were infused to infants. This study showed that despite very low infusion flow rates, infants may receive a large number of particles during drug infusion, especially in NICUs. Particulate contamination of IV fluids is not without consequences for fragile infants. Preventive solutions could be effective, such as the use of in-line filters.

Characterization of the surface physico-chemistry of plasticized PVC used in blood bag and infusion tubing

Commercial infusion tubing and blood storage devices (tubing, blood and platelets bags) made of plasticized PVC were analyzed by spectroscopic, chromatographic and microscopic techniques in order to identify and quantify the additives added to the polymer (lubricants, thermal stabilizers, plasticizers) and to put into evidence their blooming onto the surface of the devices. For all the samples, deposits were observed on the surface but with different kinds of morphologies. Ethylene bis amide lubricant and metallic stearate stabilizers were implicated in the formation of these layers. In contact with aqueous media, these insoluble deposits were damaged, suggesting a possible particulate contamination of the infused solutions.

Particulate Matter in Injectable Drugs: Evaluation of Risks to Patients

One of the fundamental principles guiding the pharmaceutical quality of parenteral products is to prevent injecting contaminants from microbiological, chemical or physical sources. It is just as difficult to ensure the absence of chemical and particulate contaminants in injectable products as it is to weigh up the microbiological risk. The problem of particulate matter is mainly related to the preparing and administrating of injectable drugs rather than through the contamination of marketed products. Particulate contamination also arises

Influence of in-line microfilters on systemic inflammation in adult critically ill patients: a prospective, randomized, controlled open-label trial

Background

In critically ill children, in-line microfilters may reduce the incidence of the systemic inflammatory response syndrome (SIRS), the overall complication and organ dysfunction rate. No data on the use of in-line microfilters exist in critically ill adults.

Methods

In this prospective, randomized, controlled open-label study, we evaluated the influence of in-line microfilters on systemic immune activation in 504 critically ill adults with a central venous catheter in place and an expected length of stay in the intensive care unit >24 h. Patients were randomized to have in-line microfilters placed into all intravenous lines (intervention group) or usual care (control group). The primary endpoint was the number of intensive care unit days with SIRS. Secondary endpoints were the incidence of SIRS, SIRS criteria per day, duration of invasive mechanical ventilation, intensive care unit length of stay, the incidence of acute lung injury, maximum C-reactive protein, maximum white blood cell count, incidence of new candida and/or central-line-associated bloodstream infections, incidence of new thromboembolic complications, cumulative insulin requirements and presence of hyper- or hypoglycemia.

Results

The study groups did not differ in any baseline variable. There was no difference in the number of days in the intensive care unit with SIRS between microfilter and control patients [2 (0.8–4.7) vs. 1.8 (0.7–4.4), p = 0.62]. Except for a higher incidence of SIRS in microfilter patients (99.6 vs. 96.8 %, p = 0.04), no difference between the groups was observed in any secondary outcome parameter. Results did not change when only patients with an intensive care unit length of stay of greater than 7 days were included in the analysis. The rate of adverse events was comparable between microfilter and control patients. In two patients allocated to the microfilter group, the study intervention was discontinued for technical reasons. Use of in-line microfilters was associated with additional costs.

Conclusions

The use of in-line microfilters failed to modulate systemic inflammation and clinical outcome parameters in critically ill adults.

Trial registration: Clinical Trials NCT01534390

Dextrose-mediated aggregation of therapeutic monoclonal antibodies in human plasma: Implication of isoelectric precipitation of complement proteins

Many therapeutic monoclonal antibodies (mAbs) are clinically administered through intravenous infusion after mixing with a diluent, e.g., saline, 5% dextrose. Such a clinical setting increases the likelihood of interactions among mAb molecules, diluent, and plasma components, which may adversely affect product safety and efficacy. Avastin® (bevacizumab) and Herceptin® (trastuzumab), but not Remicade® (infliximab), were shown to undergo rapid aggregation upon dilution into 5% dextrose when mixed with human plasma in vitro; however, the biochemical pathways leading to the aggregation were not clearly defined. Here, we show that dextrose-mediated aggregation of Avastin or Herceptin in plasma involves isoelectric precipitation of complement proteins. Using mass spectrometry, we found that dextrose-induced insoluble aggregates were composed of mAb itself and multiple abundant plasma proteins, namely complement proteins C3, C4, factor H, fibronectin, and apolipoprotein. These plasma proteins, which are characterized by an isoelectronic point of 5.5–6.7, lost solubility at the resulting pH in the mixture with formulated Avastin (pH 6.2) and Herceptin (pH 6.0). Notably, switching formulation buffers for Avastin (pH 6.2) and Remicade (pH 7.2) reversed their aggregation profiles. Avastin formed little, if any, insoluble aggregates in dextrose-plasma upon raising the buffer pH to 7.2 or above. Furthermore, dextrose induced pH-dependent precipitation of plasma proteins, with massive insoluble aggregates being detected at pH 6.5–6.8. These data show that isoelectric precipitation of complement proteins is a prerequisite of dextrose-induced aggregation of mAb in human plasma. This finding highlights the importance of assessing the compatibility of a therapeutic mAb with diluent and human plasma during product development.

Compatibility of medications during multi-infusion therapy: A controlled in vitro study on a multilumen infusion device

OBJECTIVE

Drug incompatibilities can jeopardize the safety and effectiveness of intravenous drug therapies, especially in the field of anaesthesia and intensive care. Patients receive many drugs simultaneously through limited venous accesses. This study was designed to confirm the impact of a multilumen infusion device on the occurrence of known physical drug incompatibilities.

STUDY DESIGN

In vitro laboratory work.

METHODS

Two infusion devices were studied: a standard single-lumen set and a multilumen infusion access device (Edelvaiss Multiline-8, Doran International). Up to six drugs were infused simultaneously: three acidic solutions of midazolam, amiodarone and dobutamine, and three alkaline solutions of furosemide, pantoprazole and amoxicillin/clavulanate. Saline, Ringer' solution and 5% dextrose were used as hydration vehicles with an infusion rate initially set at 100 mL/h and with stepwise decreases of 10 mL/h until precipitation. Two methods were used to highlight physical drug compatibility according to the European Pharmacopoeia: visual inspection of the extension set and an obscured-light sub-visible particle count test of infusions. The lowest infusion rate value for vehicle infusion to satisfy the two tests in all trials is reported for each infusion device.

RESULTS

The standard set did not satisfy the test in 82% of the assessed drug combinations. The Edelvaiss Multiline-8 was able to prevent the occurrence of drug incompatibilities in 49% of the drug combinations tested. This device is therefore advantageous, especially when simultaneously infusing two or four incompatible drugs.

CONCLUSIONS

Infusion device characteristics have an impact on physical drug incompatibilities. Our results confirm that the Edelvaiss Multiline-8 device prevents physical drug incompatibilities under specified conditions.

In Vitro Assessment of Interaction Between Amino Acids and Copper in Neonatal Parenteral Nutrition

BACKGROUND

The repeated blackening of in-line filters has been observed during the infusion of parenteral nutrition 2-in-1 mixtures (binary parenteral nutrition [BPN]) delivered in a neonatal intensive care unit. This study aimed to examine the elemental content of precipitates isolated from infused BPN bags and determine the main physicochemical interactions occurring in these bags.

MATERIALS AND METHODS

The infusion of BPN mixtures was simulated in vitro following hospital practices. Filter membranes were examined by scanning electron microscopy and energy dispersion spectroscopy (EDS). Amino acid (AA) profiles were obtained from BPN mixtures to determine the concentrations of each AA.

RESULTS

Analyzed filter membranes revealed conglomerates of particles on filter surfaces. An EDS analysis generated spectra from isolated particles, identifying copper and sulfur as the major chemical elements. AA mean concentrations were relatively close to the expected value for each AA, except cysteine. Cysteine concentrations were very significantly lower than the expected values.

CONCLUSION

A specific interaction was identified between 1 AA (cysteine) and a trace element (copper) in our BPN mixtures.

Applying Theory to Understand and Modify Nurse Intention to Adhere to Recommendations regarding the Use of Filter Needles: An Intervention Mapping Approach

The manipulation of glass ampoules involves risk of particle contamination of parenteral medication, and the use of filter needles has often been recommended in order to reduce the number of particles in these solutions. This study aims to develop a theory-based intervention to increase nurse intention to use filter needles according to clinical guideline recommendations produced by a large university medical centre in Quebec (Canada). Using the Intervention Mapping framework, we first identified the psychosocial determinants of nurse intention to use filter needles according to these recommendations. Second, we developed and implemented an intervention targeting nurses from five care units in order to increase their intention to adhere to recommendations on the use of filter needles. We also assessed nurse satisfaction with the intervention. In total, 270 nurses received the intervention and 169 completed the posttest questionnaire. The two determinants of intention, that is, attitude and perceived behavioral control, were significantly higher after the intervention, but only perceived behavioral control remained a predictor of intention. In general, nurses were highly satisfied with the intervention. This study provides support for the use of Intervention Mapping to develop, implement, and evaluate theory-based interventions in order to improve healthcare professional adherence to clinical recommendations.

IV injection of polystyrene beads for mouse model of sepsis causes severe glomerular injury

Background

Infusion fluids may be contaminated with different types of particulates that are a potential health hazard. Particulates larger than microvessels may cause an embolism by mechanical blockage and inflammation; however, it has been reported that particulates smaller than capillary diameter are relatively safe. Against such a background, one report showed that polystyrene beads smaller than capillary diameter decreased tissue perfusion in ischemia–reperfusion injury. This report suggested that polystyrene beads from 1.5- to 6-μm diameter (dia.) may have unfavorable effects after pretreatment.

Here, we investigated whether injection of polystyrene beads (3- and 6-μm dia.) as an artificial contaminant of intravenous fluid after lipopolysaccharide (LPS) injection affected mortality and organ damage in mice.

Methods

Mice were divided into four groups and injected: polystyrene beads only, LPS only, polystyrene beads 30 min after LPS, or saline. A survival study, histology, blood examination, and urine examination were performed.

Results

The survival rate after LPS and polystyrene bead (6-μm dia.) injection was significantly lower than that of the other three groups. In the kidney sections, injured glomeruli were significantly higher with LPS and polystyrene bead injection than that of the other three groups. LPS and polystyrene bead injection decreased the glomerular filtration rate and led to renal failure. Inflammatory reactions induced with LPS were not significantly different between with or without polystyrene beads. Polystyrene beads were found in urine after LPS and polystyrene bead injection.

Conclusions

Injection of polystyrene beads after LPS injection enhanced glomerular structural injury and caused renal function injury in a mouse sepsis model.

In-line filtration minimizes organ dysfunction: new aspects from a prospective, randomized, controlled trial

BACKGROUND

Infused particles induce thrombogenesis, impair microcirculation and modulate immune response. We have previously shown in critically ill children, that particle-retentive in-line filtration reduced the overall complication rate of severe events, length of stay and duration of mechanical ventilation. We now evaluated the influence of in-line filtration on different organ function and thereby elucidated the potential underlying pathophysiological effects of particle infusion.

METHODS

In this single-centre, prospective, randomized controlled trial 807 critically ill children were assigned to either control (n = 406) or filter group (n = 401), the latter receiving in-line filtration for complete infusion therapy. Both groups were compared regarding the differences of incidence rates and its 95% confidence interval (CI) of different organ dysfunction as defined by the International Pediatric Sepsis Consensus Conference 2005.

RESULTS

The incidence rates of respiratory (-5.06%; 95% CI, -9.52 to -0.59%), renal (-3.87%; 95% CI, -7.58 to -0.15%) and hematologic (-3.89%; 95% CI, -7.26 to -0.51%) dysfunction were decreased in the filter group. No difference was demonstrated for the occurrence rates of cardiovascular, hepatic, or neurologic dysfunction between both groups.

CONCLUSIONS

In-line filtration has beneficial effects on the preservation of hematologic, renal and respiratory function in critically ill patients. The presented clinical data further support our hypothesis regarding potential harmful effects of particles. In critically ill patients infused particles may lead to further deterioration of the microcirculation, induce a systemic hypercoagulability and inflammation with consecutive negative effects on organ function.

TRIAL REGISTRATION

ClinicalTrials.gov number; NCT00209768.

A literature review on flow-rate variability in neonatal IV therapy

AIM

To provide an overview of factors influencing the flow rate in intravenous (IV) therapy for newborns.

METHODS

We conducted a review of the literature from 1980 to 2011 in PubMed and Web of Knowledge. Articles focusing on flow-rate variability and possible complications due to flow-rate variability were included.

RESULTS

Forty-one articles were selected for this review. IV therapy in (preterm) neonates is prone to significant start-up delays and flow-rate variability. The sudden changes in the volume delivered to (preterm) neonates may have serious consequences. Low preprogrammed flow rates, total compliance, and volume of the IV administration set, the presence or absence of antisiphon valves or inline filters and the vertical displacement of syringe pumps all contribute to flow-rate variability in IV therapy for neonates.

CONCLUSIONS

Flow-rate variability in IV therapy and its clinical relevance are due to the preprogrammed flow rate, the hydrostatic pressure changes, the complete IV administration set compliance and the type of substances supplied to the patient. To improve IV therapy, the internal compliance of the complete IV administration set should be minimized and the highest possible preprogrammed flow rate should be used in combination with small syringes and low-resistance valves.

Analysis of particulate contaminations of infusion solutions in a pediatric intensive care unit

Purpose

To examine the physical properties and chemical composition of particles captured by in-line microfilters in critically ill children, and to investigate the inflammatory and cytotoxic effects of particles on endothelial cells (HUVEC) and macrophages in vitro.

Methods

Prospective, observational study of microfilters following their use in the pediatric intensive care unit. In vitro model utilizing cytokine assays to investigate the effects of particles on human endothelial cells and murine macrophages.

Results

Twenty filter membranes from nine patients and five controls were examined by electron microscopy (EM) and energy dispersion spectroscopy (EDX). The average number of particles found on the surface of the used membranes was 550 cm². EDX analysis confirmed silicon as a major particle constituent. Half of the filter membranes showed conglomerates containing an uncountable number of smaller particles. In vitro, glass particles were used to mimic the high silicon content particles. HUVEC and murine macrophages were exposed to different contents of particles, and cytokine levels were assayed to assess their immune response. Levels of interleukin-1beta, interleukin-6, interleukin-8, and tumor necrosis factor alpha were suppressed.

Conclusions

Particle contamination of infusion solutions exists despite a stringent infusion regiment. The number and composition of particles depends on the complexity of the applied admixtures. Beyond possible physical effects, the suppression of macrophage and endothelial cell cytokine secretion in vitro suggests that microparticle infusion in vivo may have immune-modulating effects. Further clinical trials are necessary to determine whether particle retention by in-line filtration has an influence on the outcome of intensive care patients.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-010-1775-y) contains supplementary material, which is available to authorized users.

Physical compatibility of neonatal total parenteral nutrition admixtures containing organic calcium and inorganic phosphate salts in a simulated infusion at 37 degrees C

OBJECTIVE

Within an incubator environment at 37 degrees C, we evaluated the physical compatibility of calcium (Ca) and phosphate (P) in simulated neonatal total parenteral nutrition (TPN) infusions.

DESIGN

Representative neonatal TPN formulas containing four concentrations of amino acids [AA] (1-4 g/dL) and two levels of dextrose [D] (5 and 10 g/dL) were monitored for calcium-phosphate precipitate formation over 24 hours using a laser-based particle counting technique.

SETTING

Research Laboratory.

SUBJECTS

None.

MEASUREMENTS AND MAIN RESULTS

Of the eight AA-D combinations studied, two formulas containing 1 g/dL AA with either 5 g/dL or 10 g/dL of D and high amounts of Ca and P resulted in significant increases in particle counts and visibly evident precipitation during the 24-hour infusion. Precipitation was noted only after the infusion passed through the incubator, but not in the TPN bags, demonstrating the heightened risk of calcium-phosphate incompatibility with increased temperatures.

CONCLUSIONS

Low AA concentrations and high temperatures are significant risk factors for the precipitation of the insoluble dibasic calcium phosphate that may be fatal upon intravenous infusion. When thermoregulation is required, the AA concentration of the TPN formula should not be less than 1.5 g/dL (and ideally > or =3 g/dL) when high intakes of calcium (60 mg/dL) and phosphate (46.5 mg/dL) are prescribed.

Particulate and microbial contamination in in-use admixed intravenous infusions

We compared particulate and microbial contamination in residual solutions of peripheral intravenous admixtures after the termination of drip infusion between intravenous fluids admixed with glass ampoule drugs and those admixed with pre-filled syringe drugs. The mean number of particles>or=1.3 microm in diameter per 1 ml of residual solution was 758.4 for fluids (n=60) admixed with potassium chloride in a glass ampoule (20 ml volume), 158.6 for fluids (n=63) admixed with potassium chloride in a pre-filled syringe (20 ml volume), 736.5 for fluids (n=66) admixed with sodium chloride in a glass ampoule (20 ml volume), 179.2 for fluids (n=15) admixed with sodium chloride in a pre-filled syringe (20 ml volume), 1884.5 in fluids (n=30) admixed with dobutamine hydrochloride in 3 glass ampoules (5 ml volume), and 178.9 (n=10) in diluted dobutamine hydrochloride in pre-filled syringes (50 ml volume: For these samples alone, particulate and microbial contamination were evaluated in sealed products.) Thus, for potassium chloride or sodium chloride for injection, the number of particles>or=1.3 microm in diameter in the residual intravenous solution was significantly higher for fluids admixed with glass ampoule drugs than for those admixed with pre-filled syringe drugs (p<0.0001). For dobutamine hydrochloride for injection, the number of particles>or=1.3 microm in diameter in the residual intravenous solution was estimated to be higher for fluids admixed with its glass ampoule drug than for those admixed with its pre-filled syringe drug. Observation of the residual solutions of fluids admixed with potassium chloride, sodium chloride, or dobutamine hydrochloride in glass ampoules using an electron microscope with an X-ray analyzer showed glass fragments in each residual solution. Therefore, for the prevention of glass particle contamination in peripheral intravenous admixtures, the use of pre-filled syringe drugs may a useful method. No microbial contamination was observed in any of the residual solutions of 5 types of admixture.

The use of in-line intravenous filters in sick newborn infants

AIM

This study assesses the improvement in outcome for newborn infants by decreasing major complications associated with intravenous fluid therapy by using an in-line filter, and evaluates the economical impact this might have in relation to daily changing of i.v. lines.

METHODS

In a prospective controlled study, 88 infants were randomly assigned to receive either filtered (except for lipids, blood and blood products) or non-filtered infusions via a central catheter. Main outcome measures such as bacteraemia, phlebitis, extravasation, thrombosis, septicaemia and necrosis were all scored. The costs attributable to patients during a standard 8-day stay were also recorded.

RESULTS

Significant reductions were found in major complications such as thrombi and clinical sepsis (control group (21), filter group (8); p < 0.05). Bacterial cultures of the filters showed a contamination rate on the upstream surface of 15/109 filters (14%). The mean costs of disposables were less in the filter group, showing a reduction from 31.17 euros to 23.79 euros.

CONCLUSIONS

The use of this in-line filter leads to a significant decrease in major complications and substantial cost savings.

Intravenous in-line filters: filtering the evidence

PURPOSE OF REVIEW

The routine use of intravenous in-line filters on infusion lines has been controversial for many years, with strong advocates, detractors and many fence-sitting observers. The purpose of this review was to examine the literature for new developments and to cast the net a little wider than in previous reviews in an attempt to draw useful parallels.

RECENT FINDINGS

There were recent major policy statements or recommendations from a working party of the British Pharmaceutical Nutrition Group and from the US Centres for Disease Control. The first was focussed on filters and was broadly in favour, the second was not focussed on the subject but made quite a strong statement against, on microbiological issues alone. The major purpose of filters, however, is particulate contamination, and whilst there was little in the literature directly on this subject, useful parallels could be drawn from papers describing the therapeutic use of particles and also from their effects in intravenous drug users.

SUMMARY

When all the available information is considered, and the role of filters in particulate contamination, in-line chemical precipitates, identifying problems in parenteral therapy practice, microbial contamination and entrapped air is examined, the case for routine use appears strong.

Particulate contamination in parenteral nutrition solutions: still a cause for concern?

OBJECTIVES

In consideration of a US Federal Drug Administration recommendation that all parenteral nutrition admixtures should be administered through an in-line filtration device, this observational study examined the number, size distribution, and sources of particulate contamination in parenteral nutrition admixture infusion systems.

METHODS

Samples were drawn from the terminal connection of the infusion tubing before connection to the patient. The particles were sized and counted by optical microscopy and further investigated by electron microscopy and energy disperse spectroscopy.

RESULTS

Large numbers of particles were found, and information gained about their possible origin.

CONCLUSIONS

This study provides further support for the adoption of this Federal Drug Administration recommendation.