Intravenous Tubing Research Articles

Illustrative neonatal cases regarding drug delivery issues.

Illustrative neonatal cases regarding drug delivery issues.

Establishing an international baseline for medication safety in oncology: Findings from the 2012 ISMP International Medication Safety Self Assessment® for Oncology.

In 2012, the Institute for Safe Medication Practices (ISMP) and the Institute for Safe Medication Practices Canada (ISMP Canada) collaborated with an international panel of oncology practitioners to develop the ISMP International Medication Safety Self Assessment® for Oncology. This self-assessment was designed to assist oncology practitioners in hospitals, ambulatory care centers, and office practice settings throughout the world to evaluate safe practices related to medication use in the oncology setting and to identify opportunities for improvement. The self-assessment consists of 175 items organized into 10 key elements subdivided into 18 core characteristics of safe medication use. Assessment results were submitted via a secure online portal. The online program allows participants to print and graph their results and to compare their findings with those of similar organizations both nationally and internationally. Complimentary access to the self-assessment was made available for a seven-month "snapshot" period in 2012. A total of 352 organizations from 13 countries submitted assessment results. Key opportunities for improvement were identified in five areas: implementation of the World Health Organization recommendations for management of vinCRIStine and other vinca alkaloids, safe management of oral chemotherapy, labeling of distal ends of intravenous tubing, implementation of technology-based safeguards, and patient education. This international snapshot provides important data about the level of implementation of system-based safeguards in oncology practice, key improvement opportunities, and represents a baseline for future improvement efforts. A collaborative approach to identifying vulnerabilities and developing solutions for safe medication use in oncology will enhance the care of patients with cancer internationally.

Intravenous misplacement of nephrostomy tube following percutaneous nephrolithotomy: Three new cases and review of seven cases in the literature

We investigated the characteristics and management of patients with intravenous misplacement of a nephrostomy tube. Between July 2007 and July 2013, 4148 patients with urolithiasis underwent percutaneous nephrolithotomy (PCNL) in our hospital. Intravenous misplacement of a nephrostomy tube occurred in two of these patients. Another patient with intravenous misplacement of a nephrostomy tube, who underwent PCNL in another hospital, was transferred to our hospital. The data of the three patients were retrospectively analyzed. The incidence of intravenous misplacement of a nephrostomy tube following PCNL was 0.5% (2/4148) at our hospital. A solitary kidney was present in one of the three patients. The tip of tube was located into the inferior vena cava (IVC) in two patients and into the renal vein in one patient. All three patients were successfully managed with strict bed rest, intravenous antibiotics and one-step (one patient) or two-step (two patients) tube withdrawal under close monitoring. None of the patients underwent antithrombotic therapy. The original operations were performed successfully under close observation in two patients and changed to another operation in one patient. All patients were discharged uneventfully. The incidence of intravenous misplacement of a nephrostomy tube following PCNL is 0.5% at our hospital. Intravenous nephrostomy tube misplacement is an uncommon complication of PCNL. A solitary kidney may render patients susceptible to this complication. Most patients may be managed conservatively with strict bed rest, intravenous antibiotics and one-step or two-step tube withdrawal under close monitoring.

Doxycycline-Induced Pancreatitis

Introduction: A 49-year-old man presented to the emergency department with complaints of 2-day history of abdominal pain without any significant nausea, vomiting, diarrhea, or constipation. He was started on doxycycline 100 mg twice daily for tooth infection 5 days ago. Physical examination showed abdominal distention and epigastric tenderness without guarding. Past medical history included, seizures, and COPD. Home medications were pantoprazole, phenobarbital, and tegretol. Labs were significant for mild leukocytosis, hemoglobin of 11, and hematocrit of 34, and metabolic profile showed normal aspartate transaminase, alanine transaminase, alkaline phosphatase, amylase, lipase, and normal lipid profile. Abdominal ultrasound did not show any gallstones, but CT abdomen with contrast showed pancreatitis with peripancreatic fluid. Doxycycline was discontinued and patient was started on intravenous fluids, pain control, and tube feedings. Patient’s symptoms have significantly improved and he was able to tolerate oral feedings. Patient was discharged after uncomplicated course and was told not to take doxycycline again. Drug-induced pancreatitis represents 1.4% of all causes of acute pancreatitis. Diagnostic criteria include: pancreatitis develops during drug therapy, other possible causes of pancreatitis should be eliminated, pancreatitis should resolve after discontinuing the suspected drug, and the reoccurrence of pancreatitis after reusing the same drug. Drug-induced pancreatitis classified into definite, highly probable, or weakly probable in correlation with mentioned criteria. Our patient developed acute pancreatitis 3 days after the administration of doxycycline and was resolved 3 days after discontinuation of the drugs. All other possible factors, such as alcohol use, gallstones, hypercalcemia, hyperlipidemia, and malignancy were eliminated by physical examination, blood tests, and imaging studies. Adverse effects of doxycycline include elevation of liver and renal function tests, nausea, vomiting, and dysphagia. Doxycycline is part of the tetracycline group of antibiotics, which is linked to few cases of acute pancreatitis. Suggested theories include intrinsic toxins versus idiosyncratic reactions. Our patient most likely suffered from acute pancreatitis due to doxycycline since other causes of pancreatitis were eliminated. Although this adverse effect is not well known, it is probably quite rare. Physicians should consider acute pancreatitis in patients who develop nausea, vomiting, and epigastric pain when taking doxycycline. If doxycycline is suspected as the causative agent, it should be discontinued and readministration should be avoided.

Antifungal Activity of Endosequence Root Repair Material and Mineral Trioxide Aggregate

IntroductionThe purpose of this study was to investigate the antifungal activity of Endosequence Root Repair Material (ERRM; Brasseler USA, Savannah, GA) as compared with mineral trioxide aggregate (MTA) using Candida albicans. MethodsAll materials were packed into sterilized intravenous tubing to obtain standardized samples and allowed to set for 3 or 24 hours and then exposed to a suspension of C. albicans for incubations of 24 or 48 hours. To analyze the mechanisms of the material's antifungal activity, additional samples of each test material were prepared in the same manner and allowed to set for 24 hours; these were then incubated in a culture medium for 24 hours. The pH of each conditioned media was measured before transferring to wells containing C. albicans. The development of biofilm was analyzed after 24 and 48 hours with 2,3-bis (2-methoxy-4-nitro-5-sulfophenyl)-5-([phenyl amino] carbonyl)-2H-tetrazolium hydroxide reduction assay. ResultsMaterials in both experimental groups significantly limited biofilm formation at each interval (ie, 24 and 48 hours). After incubating for a 24-hour period in the presence of C. albicans, ERRM in both experimental groups showed a reduction in biofilm formation that was statistically significant in comparison with MTA. However, when set for 24 hours and incubated for 48 hours, gray MTA and white MTA showed a more substantial reduction in biofilm formation than comparable samples of ERRM. Cultured media conditioned with test materials showed statistically significant antifungal biofilm activity after 48 hours. ConclusionsAll materials tested have comparable antifungal biofilm activity. It appeared that changing the environment, such as the pH, contributed to this activity.

Medication Safety

Medication Safety

Commentary

Commentary

Cryptococcal Meningitis Management in Tanzania With Strict Schedule of Serial Lumber Punctures Using Intravenous Tubing Sets

Cryptococcal meningitis (CM) has a mortality rate of ∼70% among HIV-infected adults in low-income countries. Controlling intracranial pressure (ICP) is essential in CM, but it is difficult in low-income countries because manometers and practical ICP management protocols are lacking. As part of a continuous quality improvement project, our Tanzanian hospital initiated a new protocol for ICP management for CM. All adult inpatients with CM are included in a prospective patient registry. At the time of analysis, this registry included data from 2 years before the initiation of this new ICP management protocol and for a 9-month period after. ICP was measured at baseline and at days 3, 7, and 14 by both manometer and intravenous (IV) tubing set. All patients were given IV fluconazole according to Tanzanian treatment guidelines and were followed until 30 days after admission. Among adult inpatients with CM, 32 of 35 patients (91%) had elevated ICP on admission. Cerebrospinal fluid pressure measurements using the improvised IV tubing set demonstrated excellent agreement (r = 0.96) with manometer measurements. Compared with historical controls, the new ICP management protocol was associated with a significant reduction in 30-day mortality (16/35 [46%] vs. 48/64 [75%] in historical controls; hazard ratio = 2.1 [95% CI: 1.1 to 3.8]; P = 0.018]. Increased ICP is almost universal among HIV-infected adults admitted with CM in Tanzania. Intensive ICP management with a strict schedule of serial lumbar punctures reduced in-hospital mortality compared with historical controls. ICP measurement with IV tubing sets may be a good alternative in resource-limited health facilities where manometers are not available.

Cost of opioid intravenous patient-controlled analgesia: results from a hospital database analysis and literature assessment.

BackgroundIntravenous patient-controlled analgesia (PCA) equipment and opioid cost analyses on specific procedures are lacking. This study estimates the intravenous PCA hospital cost for the first 48 postoperative hours for three inpatient surgeries.MethodsDescriptive analyses using the Premier database (2010–2012) of more than 500 US hospitals were conducted on cost (direct acquisition and indirect cost for the hospital, such as overhead, labor, pharmacy services) of intravenous PCA after total knee/hip arthroplasty (TKA/THA) or open abdominal surgery. Weighted average cost of equipment and opioid drug and the literature-based cost of adverse events and complications were aggregated for total costs.ResultsOf 11,805,513 patients, 272,443 (2.3%), 139,275 (1.2%), and 195,062 (1.7%) had TKA, THA, and abdominal surgery, respectively, with approximately 20% of orthopedic and 29% of abdominal patients having specific intravenous PCA database cost entries. Morphine (57%) and hydromorphone (44%) were the most frequently used PCA drugs, with a mean cost per 30 cc syringe of $16 (30 mg) and $21 (6 mg), respectively. The mean number of syringes used for morphine and hydromorphone in the first 48 hours were 1.9 and 3.2 (TKA), 2.0 and 4.2 (THA), and 2.5 and 3.9 (abdominal surgery), respectively. Average costs of PCA pump, intravenous tubing set, and drug ranged from $46 to $48, from $20 to $22, and from $33 to $46, respectively. Pump, tubing, and saline required to maintain patency of the intravenous PCA catheter over 48 hours ranged from $9 to $13, from $8 to $9, and from $20 to $22, respectively. Supplemental non-PCA opioid use ranged from $56 for THA to $87 for abdominal surgery. Aggregated mean intravenous PCA equipment and opioid cost per patient were $196 (THA), $204 (TKA), and $243 (abdominal surgery). Total costs, including for adverse events, complications, and intravenous PCA errors, ranged from $647 to $694.ConclusionAlthough there is variation between different types of surgery, the hospital cost of intravenous PCA after major surgery is substantial. Novel technology should demonstrate cost-effectiveness in addition to clinical superiority.

Simple, inexpensive, and effective injector for descemet membrane endothelial keratoplasty.

We describe an inexpensive, simple, and effective endothelium-Descemet membrane (EDM) graft injector assembled from regular operating room supplies in Descemet membrane endothelial keratoplasty (DMEK). To assemble the injector, standard intravenous tubing was cut approximately 2 inches from the Luer lock end, leaving a steep bevel. The cut end of the tubing was firmly wedged bevel up and advanced into the back of an Alcon IOL B cartridge. The Luer lock end of the tubing was then attached to a 5- or 10-mL syringe filled with BSS Plus. The EDM graft was then placed into a Petri dish filled with BSS. After the graft was sucked into an injector with bevel-side up under the surgical microscope, the graft was then inserted into the anterior chamber with the injector through the main incision in the superotemporal quadrant. In seven eyes of seven patients with Fuchs endothelial corneal dystrophy treated with DMEK using our injector, clear attached grafts and improved visual acuity were achieved. This simple, inexpensive, and effective injector is a safe and viable device to facilitate this part of DMEK surgery.

Emission of volatile organic compounds from medical equipment inside neonatal incubators.

To determine emission of volatile organic compounds (VOCs) from plastic medical equipment within an incubator. Air samples from incubators before and after adding medical equipment were analyzed using EPA TO-15 methodology. Headspace analysis was used to identify VOC emissions from each medical equipment item. Air changes per hour (ACH) of each incubator were determined and used to calculate the emission rate of identified VOCs. Cyclohexanone was identified in all incubator air samples. At 28 °C, the mean concentration before and after adding medical equipment items was 2.1 ± 0.6 and 57.2 ± 14.9 μg m(-3),respectively (P<0.01). Concentrations increased to a mean of 83.8 ± 23.8 μg m(-)(3) (P<0.01) at 37(o)C and 93.0 ± 45.1 μg m(-)(3) (P=0.39) after adding 50% humidity. Intravenous tubing contributed 89% of cyclohexanone emissions. ACH were determined with access doors closed and open with means of 11.5 ± 1.7 and 44.1 ± 6.7 h(-1), respectively. Cyclohexanone emission rate increased from a mean of 102.2 μg h(-1) at 28(°C to 148.8 μg h(-1) (P<0.01) at 37 °C. Cyclohexanone was quantified in all incubator air samples containing plastic medical equipment. The concentration of cyclohexanone within the incubator was inversely related to ACH in the closed mode. The cyclohexanone concentration as well as the emission rate increased with higher temperature.

Intravenous Angiocatheters as a Novel Alternative to Semmes–Weinstein Monofilament Evaluation in Testing Protective Sensation

Semmes-Weinstein monofilament (SWM) evaluation for protective sensation in diabetic feet is a widely used tool to guide patient care. Little evidence is available for alternative testing modalities for use when monofilament is not available or is deformed. Multiple varieties of intravenous angiocatheter tubing were subjected to biomechanical testing on a digital scale to assess the force generated once bending was observed by five independently tested raters. A 5.07 SWM (10 g) was tested in similar manner to establish a baseline and validate testing methodology. The 24 gauge × 0.75 in angiocatheter measured the closest to the 5.07 SWM (10 g) at an average force of 22 ± 0.91 g compared with 10.2 ± 0.13 g. Large-gauge angiocatheters measured greater forces. High intra-rater and inter-rater reliability was observed with all values greater than 0.98 (p < 0.001). A 24 gauge × 0.75 in angiocatheter tubing can be used as an alternative to the standard 5.07 SWM (10 g) for testing protective sensation in diabetic feet. Reviewing previously published receiver operating characteristics, this modality would yield estimated sensitivity and specificity values greater than 0.8 and 0.7, respectively, for detecting insensate feet tested at the bilateral metatarsal heads.

Management of parotid sialocele after facial trauma creating a transoral salivary fistula: two case reports

Sharp penetrating trauma of the face, besides causing a cosmetic defect, may also injure deeper anatomic structures. Lacerations in the cheek region may involve branches of the facial nerve, parotid gland or its duct, and vascular structures such as the transverse facial artery. Failure to recognize a parotid duct injury may result in the formation of a sialocele or cutaneous fistula. We describe a simple technique using intravenous tubing for the management of a persistent parotid sialocele.

Peripheral air embolism

A 51-year-old man had venesection for haemochromatosis at his local clinic. After application of a tourniquet, a 14 gauge intravenous cannula was attached to intravenous tubing and a plastic collection bag, and inserted into a right antecubital fossa vein. Upon completion of the procedure, the tourniquet was released without previous clamping of the tubing system. The patient had a sudden gurgling sensation travelling up his arm, which was followed by severe central crushing chest pain with radiation to the jaw and left arm, severe dyspnoea, and left sided hemiparesis and dysphasia. Medical emergency services were contacted and the patient was transferred to hospital.On arrival he was hypoxic (oxygen saturation of 88% on room air). The left hemiplegia resolved within 15 minutes and the hypoxia, chest pain, and dyspnoea improved with application of high fl ow oxygen therapy. His initial ECG showed T-wave inversion inferiorly, which resolved within 12 hours of admission (appendix). Troponin I was raised at 0·14 μg/L (ref 0–0·08 μg/L) and fell to 0·08 6 hours later. Computed tomographic pulmonary angiography (CTPA) showed a fi lling defect in a subsegmental branch of the lingula (fi gure), which was suggestive of pul mon-ary embolism. Non-contrast CT brain scan was normal. 320-slice CT scan of the coronary arteries did not reveal any coronary abnormality but did show a patent foramen ovale. Transthoracic echocardiography with bubble study showed evidence of right-to-left shunting during both normal respiration and with Valsalva. Estimated baseline right heart pressures were normal. Transoesophageal echocardiogram confi rmed a patent foramen ovale and the passage of bubbles (appendix). The patient had an uncomplicated recovery and declined interventional closure of his patent foramen ovale.We postulate that air emboli were created when the tourniquet was released, resulting in pulmonary embolism with air emboli also crossing the patent foramen ovale to cause transient cerebral and myocardial ischaemia. Systemic air embolism and paradoxical air embolism through a cardiac defect have been well described and can occur in many types of vascular intervention.

Defizite bei der Prävention der ZVK-assoziierten Sepsis: Wissenslücken oder Complianceprobleme?

Intensive care units (ICUs) with high rates of central venous catheter (CVC) -associated bloodstream infections (BSI) were invited to implement a bundle on BSI prevention during an educational programme which was created by the German national reference center for surveillance of nosocomial infections (NRZ). Training of health care workers (HCWs) was the main component and will be presented in the following. The intervention was realized by local infection control staff from April 2006 to March 2007. Modules were lecture, script and poster. Before the intervention HCWs completed an anonymous multiple choice questionnaire about BSI prevention measures. Lectures could be modified in accordance to the ICUs knowledge of prevention measures. Processes and CVC-BSI rates were surveyed and analysed before and after the intervention and also during an additional 24-months follow-up period. Thirty-two ICUs with 1,622 HCWs realized the intervention. Knowledge of BSI prevention of 1,251 HCWs was assessed. Knowledge gaps could predominantly be shown for the favored insertion site and the changing intervals of intravenous tubing for aqueous infusions. One third of HCWs said that a daily CVC's dressing change was indicated. After the intervention ICUs showed a significant decrease in the pooled CVC-BSI rate. ICUs showed a significant decrease of the pooled CVC-BSI rate during the follow-up. In this first assessment of more than 1,200 HCWs' knowledge of BSI prevention in German ICUs knowledge gaps could be identified. During the 12-months intervention the implementation of evidence based IC recommendations improved and the pooled CVC-BSI rate decreased significantly.

Ambiguity

Smoke from the fire permeated the air as we moved quickly up the porch stairs. I was not able to see her when I first walked in the door. “Jenny” was hidden by the 2 paramedics working at her side to dress her wounds and care for her while they awaited our arrival. The bandages covering her legs were barely visible as a sheet was being placed around her lower body. Her right arm was partially wrapped and out from under the sheet, with intravenous tubing snaking between folds of gauze. My partner moved around her feet to her right side to prepare her for the trip by getting more history and connecting equipment.

Using Higher Doses to Compensate for Tubing Residuals in Extended-Infusion Piperacillin-Tazobactam

To mathematically assess drug losses due to infusion line residuals and evaluate methods to compensate for drug loss due to residual volumes in intravenous pump tubing. Literature was accessed through Ovid MEDLINE (1996-February 2013), using combinations of the search terms tubing residuals, residual volume, residual medication, intravenous infusions, intravenous injections, piperacillin, piperacillin-tazobactam, β-lactams, equipment design, infusion pumps, extended infusion, extended administration, and prolonged infusion. In addition, select reference citations from publications identified were reviewed. All articles that involved extended-infusion piperacillin-tazobactam implementation strategies were included in the review. Infusion pump characteristics and tubing residuals can affect extended-infusion piperacillin-tazobactam dosing strategies. Two studies addressing tubing residuals were identified. Both studies recommended increasing infusion volumes to compensate for tubing residuals. One study also recommended decreasing infusion-line dead space by using alternative infusion pump systems. Study calculations suggest that higher doses of piperacillin-tazobactam may be used to account for medication left in tubing residuals if alternative infusion pump systems cannot be obtained, and increased infusion volumes are not an option. Extended-infusion piperacillin-tazobactam has been used as a method of maximizing pharmacodynamic target attainment. Use of higher doses of piperacillin-tazobactam may be a reasonable method to compensate for drug loss due to residual volumes in large-bore intravenous pump tubing.

Complex imaging features of accidental cerebral intraventricular gadolinium administration

Gadolinium diethylenetriamine pentaacetic acid (Gd-DTPA) is a contrast agent commonly used for enhancing MRI. In this paper, the authors report on 2 cases of postoperative inadvertent administration of Gd-DTPA directly into a ventriculostomy tubing side port that was mistaken for intravenous tubing. Both cases demonstrated a low signal on MRI throughout the ventricular system and dependent portions of the subarachnoid spaces, which was originally believed to be CSF with areas of T1 shortening in the nondependent portions of the subarachnoid spaces, and misinterpreted as basal leptomeningeal enhancement and meningitis. The authors propose that the appearance of profound T1 hypointensity within the ventricles and diffuse susceptibility artifact along the ependyma is pathognomonic of intraventricular Gd-DTPA and should be recognized.

Central Venous Catheter Protective Connector Caps Reduce Intraluminal Catheter-Related Infection

BackgroundCentral line-associated blood stream infection (CLABSI) rates in adult care intensive care units have been decreasing across the board. However, we continued to see just a few infections in patients whose catheters are in for >4 days. Therefore, we looked at infections associated with intraluminal contamination to help reduce our infection rate. MethodsA protective cap trial was developed and implemented in 2 intensive care units. All of the central venous catheter and intravenous tubing access valves were covered with a protective cap saturated with alcohol. This intervention eliminated the need to wipe off intravenous access points with an alcohol swab. The study was done as a nonrandomized prospective trial occurring March 1, 2011 through February 29, 2012. ResultsDuring 2010, there were 4 CLABSI-related infections. By the end of the trial, we had incurred 1 catheter-associated blood stream infection. CLABSI rate reduced from 1.9 in 2010 to 0.5 during the 1-year trial period. ConclusionsThe implementation of the port protector cap system resulted in lower infection rates compared with an alcohol swab technique. Our results indicate that consistent use of the caps in tandem with strict compliance does influence CLABSI rates.

Evaluation of a Luer-Activated Intravenous Administration System

Needlestick and other sharps-related injuries are largely preventable with proper education, training, and the use of safety-engineered devices. In 2009, a review of clinical practice was completed at Thunder Bay Regional Health Sciences Centre. The review revealed that despite needle-free legislation, numerous years of education on the dangers of using needles, and the availability and importance of using safety devices, nurses and physicians continued to use needles when accessing intravenous tubing to administer medication.During 2010, a luer-activated intravenous administration system was introduced to replace the current split-septum intravenous administration system. Implementation of the luer-activated system was expected to decrease needlestick injuries, positively affect nursing practice, and demonstrate a commitment to a safe working environment. Reported needlestick injuries were reviewed and analysed pre- and post-implementation and a survey on nurse perception of the new system and organizational safety was distributed.Results showed that there was a 46% decrease in needlestick injuries post-implementation, along with 80% of nursing staff reporting that the new system had a positive influence on their nursing practice and belief that the organization was committed to providing a safe work environment.The results of this study emphasize and support the replacement of needles with alternative needleless products to improve the safety of the work environment.