THE HARMFUL EFFECTS OF PARTICLES IN INTRAVENOUS FLUIDS

Medication Safety in Intravenous Therapy: Compatibility of Etoposide with Frequently Drugs Used in Tumour Critical Care During Simulated Y-Site Administration

Objective

Etoposide is an antineoplastic agent widely used to treat pediatric and adult cancers. Critically ill patients are expected to receive several intravenous pharmaceutical drugs while admitted to hospitals. When compatibility data are available, intravenous drugs may be administered simultaneously through the Y-site. This study aimed to determine the compatibility of etoposide during simulated Y-site administration with 45 continuous-infusion drugs that are commonly administered in tumor critical care units.

Methods

Etoposide was diluted to a concentration of 0.25 mg/mL in 0.9% sodium chloride (NS) and other intravenously tested drugs were reconstituted according to the manufacturer's recommendations to the final clinical desired concentrations. Y-site administration was simulated in vitro by mixing 5 mL etoposide with other diluted intravenous medications under aseptic conditions in a 1:1 ratio. Compatible solutions were withdrawn at certain time intervals (0, 1, 2, 4 hours) after mixing and tested visually, using a Tyndall beam, pH, turbidity, insoluble particles, and UV absorption as measures of compatibility.

Results

Etoposide was compatible with 38 (84%) of the 45 drugs tested within four hours. Glutathione and human granulocyte colony-stimulating factor immediately showed incompatibility with etoposide. Within 1 h, four medications (cefuroxime sodium, ilaprazole sodium, mycophenolate, and xuebijing) were incompatible. Within 4 h, one medications (ceftazidime) were also found to be incompatible with etoposide under observation.

Conclusion

Seven of the 45 common medications in tumor critical care tested with etoposide were incompatible within 4 h. If co administration is inevitable and the drug is infused through a port catheter, a larger volume of saline (NS) or dextrose 5% in water (D5W) should be used to flush the port catheter before and after the etoposide infusion to clean the lumen of the port catheter.

Visible particles in parenteral drug products: A review of current safety assessment practice

Parenteral drug products (PDPs) are administered extensively to treat various diseases. Product quality plays a critical role in ensuring patient safety and product efficacy. One important quality challenge is the contamination of particles in PDPs. Particle presence in PDPs represents potential safety risk to patients. Differential guidance and practice have been in place for visible (VPs) and subvisible particles (SVPs) in PDPs. For SVPs, the amount limits have been harmonized in multiple Pharmacopeias. The pharmaceutical industry follows the guided limits for regulatory and quality compliance. However, for VPs, no such acceptable limit has been set. This results in not only quality but also safety challenges for manufacturers and drug developers in managing and evaluating VPs. It is important to understand the potential safety risk of VPs so these can be weighed against the benefit of the PDPs. To evaluate their potential risk(s), it is necessary to understand their nature, origin, frequency of their occurrence, safety risk, the risk mitigation measures, and the method to evaluate their safety. The current paper reviews the critical literature on these aspects and provides insight into considerations when performing safety assessment and managing the risk(s) for VPs in PDPs.

Direct entry of micro(nano)plastics into human blood circulatory system by intravenous infusion

Understanding the pathways of human exposure to micro(nano)plastics (MNPs) is crucial for assessing their health impacts. Intravenous infusion can induce MNPs direct entry into the human blood, posing serious risks on human health, but remains unclear. Herein, we developed comprehensive analytical methods to detect polyvinyl chloride (PVC) MNPs down to 20 nm, and found about 0.52 μg equal to 105-1011 particles of PVC-MNPs released from intravenous infusion products (IVIPs) during each intravenous infusion of 250 mL injection. The released amounts of MNPs from IVIPs were dependent on the plastic materials, and the injection volume and composition. These findings indicated that the released MNPs should be directly introduced into the human blood circulatory system, causing serious impacts on human health. Our study reveals a previously ignored but important pathway of human exposure to MNPs, and calls for further research on the potential risks of these MNPs on human health.

Frequency and component analysis of contaminants generated in preparation of anticancer agents using closed system drug transfer devices (CSTDs)

Occupational exposure of anticancer agents during their preparation has been recognized as a serious hazard. Closed system drug transfer devices (CSTDs) enable “safe” preparation of agents for medical personnel and ensure a safe hospital environment. However, artificial particles of infusion materials have been reported during CSTD use. Here, the incidence of insoluble fine particles during preparation of anticancer agents using CSTDs was examined. Visible insoluble fine particles were found in 465 (9.4%) of 4948 treatment cases at Ehime University Hospital with CSTD use. Contaminants occurred more frequently during preparation of monoclonal antibodies than cytotoxic anticancer agents (19.4% vs. 4.1%, respectively, P < 0.01). A similar survey was conducted at nine hospitals to investigate the incidence of insoluble fine particles with or without CSTDs. Insoluble fine particles were detected in 113 (15.4%) of 732 treatment cases during preparation of monoclonal antibodies with CSTD use. In contrast, the occurrence of insoluble fine particles without CSTDs was found in only 3 (0.073%) of 4113 treatment cases. Contamination with CSTDs might cause harmful effects on patients during cancer therapy. We strongly recommend the use of in-line filters combined with infusion routes after CSTD use to avoid contamination-associated adverse events.

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.

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.

Separation, Characterization and Discriminant Analysis of Subvisible Particles in Biologics Formulations

Background:

The presence of subvisible particles (SVPs) in parenteral formulations of biologics is a major challenge in the development of therapeutic protein formulations. Distinction between proteinaceous and non-proteinaceous SVPs is vital in monitoring formulation stability.

Methods:

The current compendial method based on light obscuration (LO) has limitations in the analysis of translucent/low refractive index particles. A number of attempts have been made to develop an unambiguous method to characterize SVPs, albeit with limited success.

Results:

Herein, we describe a robust method that characterizes and distinguishes both potentially proteinaceous and non-proteinaceous SVPs in protein formulations using Microflow imaging (MFI) in conjunction with the MVAS software (MFI View Analysis Suite), developed by ProteinSimple. The method utilizes two Intensity parameters and a morphological filter that successfully distinguishes proteinaceous SVPs from non-proteinaceous SVPs and mixed aggregates.

Conclusion:

he MFI generated raw data of a protein sample is processed through Lumetics LINK software that applies an in-house developed filter to separate proteinaceous from the rest of the particulates.

The need for new control strategies for particulate matter in parenterals

An undesirable characteristic in lyophilized parenteral products is the potential presence of particulate matter in the final product, which may affect patient safety. In this study, quality risk management tools described in the International Conference on Harmonization Guideline Q9 were used to estimate the risks for a pharmaceutical manufacturing line, based on three critical quality attributes: (1) visible particulate matter; (2) lyo-cake collapse traces; and (3) lyo-cake melt-back traces. Together with a Process Failure Mode Effect Analysis (PFMEA), an input-output analysis of the individual unit operations identified seven major material classes of extrinsic particulate matter. In addition to the process assessment, an experimental investigation of the location of impurities in lyophilized products was performed. To that end, intentionally contaminated vials were examined to locate the particulate matter and its possible migration. The results emphasize the importance of a full transmission mode release testing since the particles may enter the interior of the lyo-cake. A theoretical explanation of the observed impurity locations is provided.

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.

Development and evaluation of a test program for Y-site compatibility testing of total parenteral nutrition and intravenous drugs

Background

There is no standardized procedure or consensus to which tests should be performed to judge compatibility/incompatibility of intravenous drugs. The purpose of this study was to establish and evaluate a test program of methods suitable for detection of physical incompatibility in Y-site administration of total parenteral nutrition (TPN) and drugs.

Methods

Eight frequently used methods (dynamic light scattering, laser diffraction, light obscuration, turbidimetry, zeta potential, light microscopy, pH-measurements and visual examination using Tyndall beams), were scrutinized to elucidate strengths and weaknesses for compatibility testing. The responses of the methods were tested with samples containing precipitation of calcium phosphate and with heat destabilized TPN emulsions. A selection of drugs (acyclovir, ampicillin, ondansetron and paracetamol) was mixed with 3-in-1 TPN admixtures (Olimel® N5E, Kabiven® and SmofKabiven®) to assess compatibility (i.e. potential precipitates and emulsion stability). The obtained compatibility data was interpreted according to theory and compared to existing compatibility literature to further check the validity of the methods.

Results

Light obscuration together with turbidimetry, visual inspection and pH-measurements were able to capture signs of precipitations. For the analysis of emulsion stability, light obscuration and estimation of percent droplets above 5 μm (PFAT5) seemed to be the most sensitive method; however laser diffraction and monitoring changes in pH might be a useful support. Samples should always be compared to unmixed controls to reveal changes induced by the mixing. General acceptance criteria are difficult to define, although some limits are suggested based on current experience. The experimental compatibility data was supported by scattered reports in literature, further confirming the suitability of the test program. However, conflicting data are common, which complicates the comparison to existing literature.

Conclusions

Testing of these complex blends should be based on a combination of several methods and accompanied by theoretical considerations.

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

Intravenous in-line filters for preventing morbidity and mortality in neonates

BACKGROUND

Venous access is an essential part of caring for the sick neonate. However, problems such as contamination of fluids with bacteria, endotoxins and particulates have been associated with intravenous infusion therapy. Intravenous in-line filters claim to be an effective strategy for the removal of bacteria, endotoxins and particulates associated with intravenous therapy in adults and are increasingly being recommended for use in neonates.

OBJECTIVES

To determine the effect of intravenous in-line filters on morbidity and mortality in neonates.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group. We searched the electronic databases MEDLINE (from 1966 to May, 2015), EMBASE (from 1980 to May, 2015), CINAHL (from 1982 to May 2015) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 5). We did not impose any language restrictions. Further searching included cross references, abstracts, conferences, symposia proceedings, expert informants and journal handsearching.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-RCTs that compared the use of intravenous in-line filters with placebo or nothing in neonates.

DATA COLLECTION AND ANALYSIS

We followed the procedures of the Cochrane Neonatal Review Group throughout. We checked titles and abstracts identified from the search. We obtained the full text of all studies of possible relevance. We independently assessed the trials for their methodological quality and subsequent inclusion in the review. We contacted authors for further information as needed. Statistical analysis followed the procedures of the Cochrane Neonatal Review Group.

MAIN RESULTS

There were four eligible studies that recruited a total of 704 neonates. This review of low to very low quality evidence found that the use of in-line filters compared with unfiltered fluids for intravenous infusion had no statistically significant difference in effectiveness on overall mortality (typical RR 0.87, 95% CI 0.52 to 1.47; typical RD -0.01, 95% CI -0.06 to 0.04; two studies, 530 infants), proven and suspect septicaemia (typical RR 0.86, 95% CI 0.59 to 1.27; typical RD -0.02, 95% CI -0.09 to 0.04; two studies, 530 infants), or other secondary outcomes (including local phlebitis and thrombus, necrotising enterocolitis, duration of cannula patency, length of stay in hospital, number of catheters inserted and financial costs).

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend the use of intravenous in-line filters to prevent morbidity and mortality in neonates.

Aggregation of biopharmaceuticals in human plasma and human serum: implications for drug research and development

Analytical methods based on light microscopy, 90° light-scattering and surface plasmon resonance (SPR) allowed the characterization of aggregation that can occur when antibodies are mixed with human plasma. Light microscopy showed that aggregates formed when human plasma was mixed with 5% dextrose solutions of Herceptin^® (trastuzumab) or Avastin^® (bevacizumab) but not Remicade^® (infliximab). The aggregates in the plasma-Herceptin^®-5% dextrose solution were globular, size range 0.5–9 μm, with a mean diameter of 4 μm. The aggregates in the plasma-Avastin^®-5% dextrose samples had a mean size of 2 μm. No aggregation was observed when 0.9% NaCl solutions of Herceptin^®, Avastin^® and Remicade^® were mixed with human plasma. 90° light-scattering measurements showed that aggregates were still present 2.5 h after mixing Herceptin^® or Avastin^® with 5% dextrose-plasma solution. A SPR method was utilized to qualitatively describe the extent of interactions of surface-bound antibodies with undiluted human serum. Increased binding was observed in the case of Erbitux^® (cetuximab), whereas no binding was measured for Humira^® (adalimumab). The binding of sera components to 13 monoclonal antibodies was measured and correlated with known serum binding properties of the antibodies. The data presented in this paper provide analytical methods to study the intrinsic and buffer-dependent aggregation tendencies of therapeutic proteins when mixed with human plasma and serum.

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.

Glass ampoules: risks and benefits

BACKGROUND AND OBJECTIVES

Glass ampoules have been widely used in packaging injection drugs. Glass has important characteristics that allow it to be widely used in fabrication of recipients for drugs and other sterile substances. However, contamination of solutions with glass microparticles on breaking open glass ampoules, the presence of metals, percutaneous injury, and biological contamination justify the need of educational materials to orient the manipulation of ampoules.

CONTENTS

Glass microparticles generated in the snap-opening of ampoules, as well as metals that contaminate their contents can be aspirated and injected through several routes. Exogenous contaminations by glass and metals can reach several sites in the organism. They trigger organic reactions that may give rise to injuries. Opening ampoules can expose professionals to the risk of percutaneous injuries. These lesions increase the biological risk as they are the gateway for viruses and bacteria. Ampoules opening systems (VIBRAC and OPC) have been developed to reduce the incidence of such accidents. Alternative materials to glass may represent an interesting strategy to increase safety. The use of prefilled syringes may represent an evolution regarding safety.

CONCLUSIONS

Team training and information provided by the pharmaceutical industry on the use of ampoules are fundamental in the prophylaxis of accidents and contaminations. The search for safer materials to replace glass is also important.

A strategy for reducing particulate contamination on opening glass ampoules and development of evaluation methods for its application

A single-dose glass ampoule was developed for ease of administration. When glass ampoules are opened, resulting in contamination by particulate matter. Reducing its contamination may minimize the risk in patients due to particulates. This study reports on an attempt to reduce insoluble particulate contamination by developing methods for the precise measurement of this. A vacuum machine (VM) was used to reduce the level of insoluble particulate contamination, and a microscopy, scanning electron microscopy-energy dispersive X-ray spectrometer (SEM-EDS) and inductively coupled plasma-atomic emission spectrometer (ICP-AES) were used to evaluate the level of reduction. The method permitted the insoluble particle content to be reduced by up to 87.8 and 89.3% after opening 1 and 2 mL-ampoules, respectively. The morphology of the glass particulate contaminants was very sharp and rough, a condition that can be harmful to human health. The total weight of glass particles in the opened ampoules was determined to be 104 ± 72.9 μg and 30.5 ± 1.00 μg after opening 1 and 2 mL-ampoules when the VM was operated at highest power. The total weights were reduced to 53.6 and 50.6%, respectively for 1 and 2 mL-ampoules, compared to opening by hand. The loss of ampoule contents on opening by the VM was 6.50 and 4.67% for 1 and 2 mL-ampoules, respectively. As a result, the VM efficiently reduced glass particulate contamination and the evaluation methods used were appropriate for quantifying these levels of contamination.

Quantitation of protein particles in parenteral solutions using micro-flow imaging

The U.S. and European Pharmacopeias require subvisible (> or =10 and > or =25 microm) and visible particulate testing of therapeutics to ensure their safety and suitability for clinical use. The objective of this article is to compare the sizing and counting accuracies of light obscuration, which is the standard technique used to measure subvisible particulate matter, and Micro-Flow Imaging (MFI), a new imaging-based technology. An immunoconjugate was selected as the model protein for this study since it could be induced to form particulate matter in PBS. Light obscuration was performed as described in USP chapter <788> while MFI measurements were conducted per the manufacturer's procedures. The two techniques yielded similar results when polystyrene standards were analyzed. However, the MFI measurements indicated the presence of significantly more particles in the protein-containing solution compared to the light obscuration measurements. The presence of nonspherical protein particles as well as particles that possess a refractive index similar to the solvent that they are in appear to be detected by MFI, but not by light obscuration, leading to the difference in the results. Imaging-based technologies could aid in developing formulations and processes that would minimize the formation of protein particulates.

Intravenous in-line filters for preventing morbidity and mortality in neonates

BACKGROUND

Venous access is an essential part of caring for the sick neonate; however, problems such as contamination of fluids with bacteria, endotoxins and particulates have been associated with intravenous infusion therapy. Intravenous in-line filters claim to be an effective strategy for the removal of bacteria, endotoxins and particulates associated with intravenous therapy in adults and are increasingly being recommended for use in neonates.

OBJECTIVES

To assess whether in-line filters on intravenous lines prevent morbidity and mortality in neonates.

SEARCH STRATEGY

Searches were made of the electronic databases MEDLINE (from 1966 to September 2005), EMBASE (from 1980 to September 2005), CINAHL (from 1982 to September 2005) and the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3 2005 ). There was no language restriction. Further searching included cross references, abstracts, conferences, symposia proceedings, expert informants and journal handsearching.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials that compared the use of intravenous in-line filters with placebo or nothing in neonates were included in the review.

DATA COLLECTION AND ANALYSIS

The procedures of the Cochrane Neonatal Review Group (CNRG) were followed throughout. Titles and abstracts identified from the search were checked by the review authors. The full text of all studies of possible relevance were obtained. The review authors independently assessed the trials for their methodological quality and subsequent inclusion in the review. Statistical analysis followed the procedures of the Cochrane Neonatal Review Group. Dichotomous data is expressed as relative risk and 95% confidence intervals, and risk difference and 95% confidence intervals.

MAIN RESULTS

There were three eligible studies, which recruited a total of 262 neonates. For most of the outcomes for this review, only one study of 88 neonates contributed eligible data. This review found no significant effect of in-line filters in any of the reported outcomes of overall mortality, proven and unproven septicaemia, phlebitis, necrotizing enterocolitis, duration of cannula patency, number of catheters inserted and financial costs.

AUTHORS' CONCLUSIONS

There are insufficient data to determine whether or not the use of intravenous in-line filters prevent morbidity and mortality in neonates. The wide confidence intervals on outcomes indicate the imprecise estimates of treatment effect due to the small numbers of patients and events.

Glass contamination in parenterally administered medication

AIM

This paper reports a study examining glass particle contamination in two ampoule sizes under three different experimental conditions (n = 18 in each group).

BACKGROUND

While existing literature is clear that glass contamination occurs on opening single-dose glass ampoules, the clinical significance of intramuscular administration of glass particles is equivocal. Current nursing practice standards do not adequately address this issue in terms of aspiration or filtration techniques that can minimize risk to patients.

METHODS

A computer microscope was used to compare the number and size of glass particles aspirated into a syringe between two needle sizes [18 gauge (G) (130 microm lumen diameter) and 21 gauge (90 microm lumen diameter)] without filters and 19G (110 microm lumen diameter) filtered needles. Data were collected in 2002.

RESULTS

At least one glass particle was found in 22% of the 1-mL ampoules, and 56% and 39% of the 2-mL ampoules, using 18G and 21G needles, respectively, had glass contaminants. Many of the 2-mL ampoules produced multiple glass particles on opening. Use of 19G filtered needles resulted in no glass particles. There was a significant difference in mean particle size between the 18G and 21G groups of 2-mL ampoules.

CONCLUSION

Our results support the existing literature in that larger bore unfiltered needles increased the risk of aspirating more glass and other particles than smaller bore or filter needles. These data add further support to the use of filtered needles in administering IM medications to patients who receive ongoing scheduled IM injections.

Maximizing patient safety: filter needle use with glass ampules

Particle contamination of medications obtained from glass ampules can pose serious hazards to patients. Particle contamination may be reduced by using a filter needle when obtaining medication from glass ampules prior to administration. The purpose of this article is 2-fold, to educate nursing staff caring for neonates about (1) the potential risk and resultant complications related to particle contamination and the benefit of utilizing a filter needle when obtaining medication from glass ampules, prior to administration of the medication to patients, and (2) the construction of a unit-specific filter needle protocol. The article promotes the continued change in nursing practice regarding nurses erring on the side of safety, with the ultimate goal of improving patient safety and outcome.

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.

First choice for total parenteral nutrition: the peripheral route

Historically, total parenteral nutrition (TPN) has been administered by the central venous route because of the rapid development of thrombophlebitis when TPN solutions are administered into peripheral veins. The insertion and placement of central venous catheters is, however, associated with morbidity and mortality and is the main cause of TPN-related complications. By avoiding central venous catheterization, TPN can be made safer. Current awareness about the pathophysiology of peripheral vein thrombophlebitis and the use of a number of techniques that prevent or delay onset of peripheral vein thrombophlebitis mean it is now possible to administer TPN via the peripheral route. These techniques and changes in the practice of TPN in recent years (eg, reduction of caloric loads and use of lipid emulsions) mean peripheral parenteral nutrition is a technique that is now applicable to the majority of hospitalized, nutritionally compromised patients for whom intravenous feeding is anticipated for less than 10 to 14 days.

Particulate contaminants of intravenous medications and infusions

Particulate contamination in small volume parenteral medications has been studied and compared with that found in a selection of large volume infusions. Particle counts in 39 commonly used small volume medications and 7 large volume infusions were performed by an automated light blockage method (HIAC) or by optical microscopy. Based on these results and a random survey of drug therapy of intensive care patients, it is concluded that the contribution of intravenous medications to the total particle load received by such patients is likely to be many times greater than from infusion fluids. Until firm evidence regarding the harmful systemic effects of drug particles is available and the manufacturing regulations adjusted appropriately, final in-line filtration of infusions immediately proximal to the intravenous cannula should be considered when drugs are being given intravenously.

Hazards of glass ampoules

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Microparticulate-induced phlebitis. Its prevention by in-line filtration

We carried out a double-blind prospective study of the effect of a filter on the incidence of phlebitis associated with intravenous infusion in 541 patients. A total of 277 patients received infusions through intravenous sets with 0.22-micron IVEX-HP filters, and 264 received infusions without filters. Each infusion was evaluated daily for a maximum of three days. The incidence of phlebitis on Days 1, 2, and 3 of the study was 14.3, 31.1, and 27 per cent for patients receiving infusions without filters and 6.8, 9.7, and 11.3 per cent for those receiving infusions through the filters (P less than 0.001). Thus, the incidence was reduced by approximately two thirds in the patients who received infusions through the IVEX-HP filters. We conclude that infusion-related phlebitis is a pervasive problem in hospitalized patients, and that it is usually caused by microparticulate components that are present in the infusion fluids and can be removed by in-line filtration.

Injectable debris associated with dental anesthetic delivery

Injectable foreign matter may originate in part from: anesthetic cartridge diaphragm surfaces, diaphragm polymer materials, and debris in the lumen of sterile, manufacturer-sealed needles. Particles ranging from 30 to 305 microns were collected from four brands of dental anesthetic cartridges (320 cartridges/brand). Results of this study suggest that rubber and aluminum debris may commonly be injected with anesthetic solutions. Debris on the outer surface of the needle may also be drawn into injection sites. Possible health implications of injectable matter are discussed and remain conjectural.

Isomeric purity and supersaturation of iopamidol

We have found that iopamidol 370 mg I/ml solutions may be greatly supersaturated and iopamidol 300 mg I/ml solutions slightly supersaturated at 4 degrees C and at 25 degrees C. The solubility and degree of supersaturation probably depend on the isomeric purity of the preparation. Some possible implications are discussed.

Final inline filtration for intravenous infusions: a prospective hospital study

Phlebitis is the most common complication of intravenous therapy affecting more than 50 per cent of infusions. Particles in or added to infusions have been implicated, hence a filter with pore size of 0.2 micron containing both hydrophobic and hydrophilic elements (Pall Biomedical) has been evaluated. All infusions of likely duration greater than 48 h, set up in a 2-month period at this hospital, were randomized to filter or identical dummy. The endpoints and statistical power of the study were determined at the outset. Of the 226 infusions randomized, 32 failed within 24 h and were excluded leaving 194 of whom 93 had dummy and 101 filter. Only 38 infusions with dummy survived until no longer required compared to 63 infusions with filter (chi 2 = 7.68, P less than 0.01). Analysed by life table, the trend for filtered infusions to survive longer failed to achieve statistical significance, but inline filtration prolonged the phlebitis-free survival of infusions (P less than 0.01). These benefits were most marked in the 49 infusions where antibiotics were administered via the drip site. Inline filtration delays the onset of phlebitis, thus more infusions survive until they are no longer required. This effect is not sufficiently strong to institute an overall hospital policy but filters may be indicated in patients requiring intravenous antibiotics.