In-line filtration of intravenous infusion may reduce organ dysfunction of adult critical patients

Evaluation of Strategies for Reducing Vancomycin-Piperacillin/Tazobactam Incompatibility

BACKGROUND

Drug incompatibility is defined as a physical-chemical reaction between two or more injectable drugs and that results mainly in precipitation or insolubility. Several strategies for reducing incompatibilities have been implemented empirically in intensive care units. However, these strategies have never been compared directly (and particularly in terms of the particulate load and drug mass flow rate) under standardized conditions. The objective of the present in vitro study was to evaluate the impact of various strategies for preventing incompatibility between simultaneously infused vancomycin and piperacillin/tazobactam.

METHODS

An in-line filter, a dilute vancomycin solution (5 mg/mL), and an alternative saline administration line were evaluated separately. The infusion line outlet was connected to a dynamic particle counter. The antibiotic concentration was measured in an HPLC-UV assay.

RESULT

The use of an in-line filter and an alternative saline administration route did not significantly reduce the particulate load caused by vancomycin-piperacillin/tazobactam incompatibility. Dilution of the vancomycin solution was associated with a significantly lower particulate load and maintenance of the vancomycin mass flow rate.

DISCUSSION

It is important to systematically compare the efficacy of strategies for preventing drug incompatibility. The use of diluted vancomycin solution gave the best results in the case of vancomycin-piperacillin/tazobactam incompatibility.

Nursing strategies for the mechanically ventilated patient

The goal of this manuscript is to provide a comprehensive and multi-disciplinary review of the best nursing practices of caring for mechanically ventilated patients. By reviewing human medicine literature, the authors will extrapolate procedures that have been found to be most effective in reducing the risk of mechanical ventilation (MV) complications. Paired with review of the current standards in veterinary medicine, the authors will compile the best practice information on mechanically ventilated patient care, which will serve as a detailed resource for the veterinary nursing staff. Written from a nursing standpoint, this manuscript aims to consolidate the nursing assessment of a mechanically ventilated patient, addressing both systemic and physical changes that may be encountered during hospitalization. The goal of this review article is to present information that encourages a proactive approach to nursing care by focusing on understanding the effects of polypharmacy, hemodynamic changes associated with MV, complications of recumbent patient care, and sources of hospital acquired infections. When applied in conjunction with the more technical aspects of MV, this manuscript will allow veterinary technicians involved in these cases to understand the dynamic challenges that mechanically ventilated patients present, provide guidance to mitigate risk, address issues quickly and effectively, and create an up-to date standard of practice that can be implemented.

Physicochemical properties of brand and generic infusion fluid preparations (Part 3): Investigation of type 1 hypotonic infusion fluids

In Japan, the increasing use of generic drugs has led to a reduction in drug prices, which affect the steady supply of drugs. A "basic drug" system was introduced to rescue these drugs by eliminating gaps in drug prices among preparations with the same constituents. "Type 1" hypotonic infusion fluids, which are potassium-free and commonly used to treat dehydration, meet the definition of a "basic drug" in Japan, and there are no drug price gaps. However, there is a lack of information on the physicochemical properties of "type 1" hypotonic infusion fluids, making it difficult to identify differences among them. Extracellular fluid-replacement solutions and "type 3" hypotonic infusion fluids have different pH and titratable acidity. Here, we measured the pH, titratable acidity, and osmolality of six different "type 1" hypotonic infusion fluids and compared the results with respect to risk avoidance considering metabolic acidosis, changes upon mixing, and vascular pain. There was a significant difference, or trend toward significance, in titratable acidity, which is a risk factor for metabolic acidosis in patients with impaired renal function, and pH, which is a risk factor for change upon mixing, among all combinations except one of the infusion fluids. Thus, the selection of "type 1" hypotonic infusion fluids for children with immature renal function, elderly patients with impaired renal function, and patients with unknown pathophysiology, considering titratable acidity and pH, is an effective strategy for risk avoidance.

Assessing the Utility of In-Line Intravenous Infusion Filters

The use of in-line filters to remove fibrous material in the administration of intravenous fluids dates to the early 1830's. Following advancements in therapeutic interventions, high volume fluid support and parenterally administered drugs and biologic preparations, some observers are calling for a routine use of bedside filtration. Unfortunately, the assessment of filter components, their interaction and compatibility with the drug product, and the impact of use on clinical outcomes cannot be conducted by a single entity. Recommendations for use are often predicated upon fragmented and incomplete information. The current challenges in evaluating the benefit/risk profile for the use of in-line filters should not be ignored. While there are select instances showing well-defined therapeutic settings where in-line filtration of intravenous infusions would likely provide an additional safety margin and hence, net benefit, the majority of observational studies to date fail to provide sufficient scientific support for broad-based routine use. While infusion set filters are appropriate where expert opinion is well corroborated by scientific evidence, the general and routine use of filters used during parenteral administration cannot be supported by substantive studies and should not be routinely utilized. Ultimately, the determination falls to a healthcare provider with the information available at-hand.

Strategies to prevent drug incompatibility during simultaneous multi-drug infusion in intensive care units: a literature review

PURPOSE

Drug protocols in intensive care units may require the concomitant administration of many drugs as patients' venous accesses are often limited. A major challenge for clinicians is to limit the risk of simultaneously infusing incompatible drugs. Incompatibilities can lead to the formation of particles and inactivation of drugs, whose consequences on the body have already been indicated. Our objective was to assess current strategies to counter the risk of incompatible infusions and control the resulting clinical consequences.

METHODS

This review was independently conducted by three investigators in respect of the PRISMA statement. Three online databases were consulted. Full-text articles, notes, or letters written in English or French, published or in press between the 1990s and the end of February 2020, with clinical study design, were eligible. Parameters of interest were mainly number and size of particles, and a number of observed/avoided incompatibilities.

RESULTS

All in all, 382 articles were screened, 17 meeting all the acceptance criteria. The strategies outlined and assessed were filtration, the use of multi-lumen devices, the purging of infusion lines, incompatibility tables and databases, and the use of standard operating procedures.

CONCLUSION

Although many strategies have been developed in recent years to address drug incompatibility risks, clinical data is still lacking. All studies with in vitro design were excluded although some current innovative strategies, like niosomes, should be considered and studied by means of clinical data in the future.

Challenges in reducing the risk of infection when accessing vascular catheters

Injection safety is essential to reduce the risk of healthcare-associated infections (HAIs) when accessing vascular catheters. This general review evaluates the contamination of vascular catheter access ports and associated HAIs in acute care settings, focusing on open lumen stopcocks (OLSs) and disinfectable needleless closed connectors (DNCCs). PubMed was searched from January 2000 to February 2021. OLS intraluminal surfaces are frequently contaminated during patient care, increasing the risk of HAIs, and neither an isopropyl alcohol (IPA) pad nor a port-scrub device can reduce contamination effectively. In contrast, DNCCs can be disinfected, with most studies indicating less intraluminal contamination than OLSs and some studies showing decreased HAIs. While the optimal DNCC design to reduce HAIs needs to be determined, DNCCs alone or stopcocks with a DNCC bonded to the injection port should replace routine use of OLSs, with OLSs restricted to use in sterile fields. Compliance with disinfection is essential immediately before use of a DNCC as use of a non-disinfected DNCC can have equivalent or greater risk of HAIs compared with use of an OLS. The recommendations for access port disinfection in selected national and international guidelines vary. When comparing in-vitro studies, clinical studies and published guidelines, consensus is lacking; therefore, additional studies are needed, including large randomized controlled trials. IPA caps disinfect DNCCs passively, eliminate scrubbing and provide a contamination barrier; however, their use in neonates has been questioned. Further study is needed to determine whether IPA caps are more efficacious than scrubbing with disinfectant to decrease HAIs related to use of central venous, peripheral venous and arterial catheters.

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.