The Stability of Drugs Commonly Used in Intensive Care Units Co-Administered via Feeding Tube and Its Dependence on pH: An in vitro Study

Medication safety has become an important healthcare topic due to the increasing awareness of the prevalence and incidence of errors and the implications in terms of rising healthcare costs. Drug administration is seen as a common cause of medication error or failure, with mixing of incompatible parenteral drugs seen as an important medication error. This chapter provides information relating to the pharmaceutical chemistry of compatibility and stability of drugs in solution. The terms incompatibility and instability are defined, along with some of the common causes. The possibility of predicting incompatibility from first principles using rudimentary acid–base chemistry is postulated. Factors that may affect the compatibility and stability of drug combinations administered by CSCI are discussed.

Older adults are particularly vulnerable to medication administration errors, especially when malnutrition coexists with polypharmacy, highlighting the need for tailored healthcare approaches in this population. In this narrative review, it is aimed to emphasis the importance of medication administration via feeding tube in older adults and provide the list of appropriate administration of common medications in older adults. Feeding tubes used primarily for enteral nutrition and water administration, however when the patient needs medication administration feeding tubes considered as an administration route even though feeding tubes generally not design for medication administration. Therefore, this approach is prone to administration errors. Appropriate administration of medication is important in order to provide optimum pharmaceutical treatment for the older patients, prevent negative outcomes, complications and adverse medication events. However, appropriate administration of medication via feeding tube is challenging due to limited evidence and generally based on best practice. Pharmacists play an important role in providing comprehensive information regarding medication characteristics, the suitability of dosage forms, potential drug interactions, physicochemical stability, and appropriate administration techniques. The recommendations should be made for individual patients and medications with the contribution of multidisciplinary nutrition support team in order to maintain comprehensive evaluation of patient.

The aim is to evaluate the medication incidents relating to incorrect oral medication preparation and administration through enteral feeding tubes in hospitalized patients. A cross-sectional design was used to observe 374 doses of medications at three Brazilian hospitals. The patients consisted mostly of females (48.6%), elderly (65.71%), using polyurethane tubes (82.9%), with jejunal access (82.9%), and circulatory system diseases (45.71%). The most common medication incidents identified were: mixing tablets with other drug(s) (43.5%) and not labelling the prepared medication (60.4%). With regards to incorrect medication administration, not flushing the tube between medications (86.5%) and administering medications together (65.6%) were the most common errors. Tube obstruction was identified in 36.5% of doses administered. There was an association between tube obstruction and mixing tablet with other drug(s); tablet incorrectly reconstituted; tube not flushed prior to medication administration; tube not properly flushed between medications; concurrent administration of a medication and enteral formula; and enteral feeding not interrupted prior to medication administration. The results contribute to the development of knowledge in order to improve hospital nursing practice, especially in developing countries. Future studies should be conducted in order to access patients’ outcomes related to incorrect oral medication preparation and administration through feeding tubes. Key words: Feeding tube, wrong medication preparation, wrong medication administration, incidents.

Background: To maximize patient safety in our academic The Joint Commission-designated Comprehensive Stroke Center, dysphagia screening is essential in preventing aspiration. Feeding tubes (FT) allow safe medication administration to patients with identified swallow dysfunction. Thorough review of our dysphagia fallouts revealed oral (PO) route medications ordered and documented as administered PO for patients with “nothing by mouth” (NPO) orders who also had FTs. Purpose: We developed and implemented a safety alert using the electronic health record (EHR) to ensure right route medication orders. Right route is one of the Five Rights of Medication Administration. Patients NPO with FT require a non-oral route for medication administrations. Methods: Our team retrospectively analyzed one year of dysphagia fallouts, noting a trend of PO medication administrations documented for stroke patients who had both NPO orders and FT. Review with unit leadership and clinical staff revealed these medications were being appropriately given via FT, indicating the fallouts were documentation, rather than administration, errors. The etiologies of wrong route medication documentations were incorrect medication ordering (providers), EHR medication administration record (MAR) entry (pharmacists), and administration (nurses). An interdisciplinary team partnered with clinical informatics to develop an EHR best practice alert (BPA) for patients NPO with FT, alerting providers to the ordering discrepancy. Evaluation included new PO medication orders entered for Neurology patients NPO with FT before and after BPA implementation. Results: Our 10-week pre-intervention sample contained 306 new PO medication orders, with 153 (50%) PO MAR entries, and 47 (15.4%) nursing PO administration documentations. The 10-week post-BPA activation sample had 406 new PO medication orders, with 74 (18.2%) PO MAR entries, and 19 (4.7%) nursing PO administration documentations. After dysphagia BPA alert implementation, Χ 2 comparisons (α=.05) revealed significant reductions in wrong-route PO MAR entries (63.6%, P<.001, Fig.1) and nursing PO administration documentation errors (69.5%, P<.001, Fig.2). Conclusions: This project suggests a multidisciplinary approach to leverage the EHR to improve right route medication orders and nursing documentation in patients NPO with FT. Other centers may replicate this approach utilizing the EHR to reduce medication documentation errors and improve patient safety.

Determination of the ideal medication characteristics for the safe and effective administration of medications via enteral feeding tubes

Endoscopic approaches to enteral feeding and nutrition core curriculum

PurposeDrug administration via feeding tubes is considered a process with many uncertainties. This review aimed to give a comprehensive overview of data available on feeding tube application and to carry out risk assessments for drug substances commonly administered to stroke patients.MethodsDrugs frequently administered via feeding tubes were identified through a retrospective analysis of discharge letters from a stroke unit. Physicochemical, pharmacokinetic, and stability properties of these drugs and data on drug-enteral nutrition interactions were systematically searched for in the European Pharmacopoeia, Hagers Handbook of Pharmaceutical Practice, Birchers clinical-pharmacological data compilation, and the Martindale Complete Drug Reference, as well as from databases including DrugBank, DrugDex, PubChem, Google Scholar, and PubMed.ResultsOf the drugs most commonly administered via feeding tubes in the present stroke patient cohort, bisoprolol, candesartan, and ramipril could be considered the least critical due to their overall favourable properties. Acetylsalicylic acid, amlodipine, hydrochlorothiazide, omeprazole and esomeprazole, simvastatin, and torasemide pose risks based on pH or light-dependent instability or proposed food effects. The most critical drugs to be administered via feeding tubes are considered to be furosemide, levodopa, and levothyroxine as they show relevant instabilities under administration conditions and substantial food effects; the latter two even possess a narrow therapeutic index. However, little information is available on drug-tube and drug-formula interactions.ConclusionFeeding tube administration of medications turned out to be a highly complex process with several unmet risks. Therefore, investigations that systematically assess these risk factors using clinically relevant model systems are urgently needed.

Evidence-Based Review and Discussion Points.

Background: Accurate clinical documentation is crucial for demonstrating safe and appropriate patient care. Review of dysphagia screening performance revealed oral (PO) route medication documentation for patients with “nothing by mouth” (NPO) diet orders and feeding tubes (FT). Patients NPO with FT require a non-oral route for medication administration. This performance improvement project aimed to decrease medication administration documentation errors (MADE), defined as PO medications documented for patients with NPO diet and current use of a FT, with clinical decision support (CDS) alert functionality. Methods: An interdisciplinary team retrospectively analyzed all dysphagia fallouts, focusing on MADE. Review revealed all MADE medications were appropriately administered via FT, indicating the errors were documentation errors, rather than wrong route medication administrations. Partnering with clinical informatics, our team developed an EHR CDS alert notifying providers of the route discrepancy. A pilot study was completed for patients NPO with FT admitted to Neurology services. Results: 10-week pre-intervention sample included 306 new PO medication orders, resulting in 153 (50%) PO medication administration record (MAR) entries, and 47 (15.4%) MADE. The 10-week post-CDS alert activation sample included 406 new PO medication orders, resulting in 74 (18.2%) PO MAR entries, and 19 (4.7%) MADE. Χ2 comparisons (α=.05) demonstrated significant reductions in wrong-route, PO, MAR entries (63.6%, P<.001, fig. 3) and MADE (69.5%, P<.001, fig. 4). Conclusions: This pilot study suggests leveraging the EHR improves right route medication orders, decreasing MADE for patients NPO with FT. Other centers may replicate this approach to improve patient safety and documentation accuracy.

A simple high performance liquid chromatography assay for simultaneous: determination of omeprazole and metronidazole in human plasma and gastric fluid

The stability of a moisture-sensitive drug in tablet formulations depends particularly on the environment's relative humidity (RH) and the products' prior exposure to moisture. This study was designed to understand drug stability in relation to the moisture interaction of the excipients, moisture history of the tablets, and RH of the environment. The stability study was performed on tablets containing acetylsalicylic acid (ASA), formulated with common pharmaceutical excipients like native maize starch, microcrystalline cellulose (MCC), partially pregelatinized maize starch (PGS), dicalcium phosphate dihydrate (DCP), lactose, and mannitol. The tablets were subjected to storage conditions with RH cycling alternating between 53% and 75%. Results were also compared to tablets stored at a constant RH of 53% or 75%. The excipients demonstrated marked differences in their interactions with moisture. They could be broadly grouped as excipients with RH-dependent moisture content (native maize starch, MCC, and PGS) and RH-independent moisture content (DCP, lactose, and mannitol). As each excipient interacted differently with moisture, degradation of ASA in the tablets depended on the excipients' ability to modulate the moisture availability for degradation. The lowest ASA degradation was observed in tablets formulated with low moisture content water-soluble excipients, such as lactose and mannitol. The impact of RH cycling on ASA stability was apparent in tablets containing native maize starch, MCC, PGS, or DCP. These findings suggested that the choice of excipients influences the effect of moisture history on drug stability. The results from studies investigating moisture interaction of excipients and drug stability are valuable to understanding the inter-relationship between excipients, moisture history, and drug stability.

SummaryWhat is known and objectivesThe use of enteral tube feeding at home is becoming more widespread, with patients ranging in age and diseases. Dysphagia and swallowing difficulties can compromise nutritional intake and the administration of oral medications, affecting therapeutic outcomes negatively. Carers’ experiences of medicines administration and medicines optimization have not been explored fully. The objectives of this study were to identify issues carers experience in medicines administration; the strategies they have developed to cope; and suggestions to improve the medicines administration process.MethodsAn online survey was promoted nationally; 42 carers completed it. Descriptive statistical analysis was applied, as well as thematic analysis of open‐ended responses. Results were compared against the 4 principles of medicines optimization.Results and discussion93% of respondents administered medications with enteral feeding tubes, but only 62% had received advice from healthcare professionals and only 8% had received written information on how to do so. Responses identified 5 medicines administration issues experienced by carers; 4 strategies they developed to cope; and 3 main areas of suggestions to improve medicines administration via enteral feeding at home.What is new and conclusionThe 4 principles of medicines optimization have not previously been applied to enteral feeding. We present a novel account of carers’ experiences, for example coping with ill‐suited formulations and a lack of training and support, which should inform better practice (Principle 1). Carers sometimes experience suboptimal choice of medicines (Principle 2). Carers’ practices are not always well‐informed and may affect therapeutic outcomes and safety (Principle 3). There is scope for improvement in carer training, education and support to better support medicines optimization (Principle 4).

Care of patients with enteral feeding tubes often is based on tradition and textbook guidance rather than best evidence. Care practices can vary widely both between and within institutions, and this was the case at a northeastern military medical center that served as the site for this evidence-based protocol development and implementation project. The purpose of this study was to describe the development and implementation of an evidence-based clinical protocol for care of patients with enteral feeding tubes. This was an evidence-based implementation project with pretest-posttest measures. Protocol data collection occurred both before and after implementation of the protocol. Data collection tools were based on the literature review and included three domains: (a) documentation of patient procedures, (b) nursing knowledge of each of the specific procedures, and (c) environment of care. Descriptive statistics and data were analyzed using independent samples t tests. Overall staff knowledge of enteral feedings and methods used to unclog both large- and small-bore feeding tubes differed significantly before and after implementation (p < .05). Staff knowledge regarding the danger of using blue dye in feeding solution was significant (p < .001). There was improvement also in administration of medications separately rather than mixed together and in head of bed elevation of patients with feeding tubes. There was a 10% improvement in documentation of patient family education and a 15% improvement in recording fluid flushes during medication administration. After implementation, environment of care data collection showed 100% of patients with head of bed elevated and with functioning suction available, an improvement over levels before implementation. Care must be taken in the interpretation of these findings because it was generally not the same nurses who answered both surveys. High staff turnover within this military hospital also affected sustainment of the protocol implementation. Maintenance activities must be constant and visible within the organization. A champion for evidence-based practice greatly enhances uptake and maintenance of nursing practice change.

Dose-dependent competitive block by topical acetylsalicylic and salicylic acid of low pH-induced cutaneous pain

High-performance liquid chromatographic on-line flow-through radioactivity detector system for analyzing amino acids and metabolites labeled with nitrogen-13