Parenteral Medication Research Articles

Management of an Outbreak of Exophiala dermatitidis Bloodstream Infections at an Outpatient Oncology Clinic.

We report the presentation and management of 17 cases of Exophiala dermatitidis and Rhodotorula mucilaginosa bloodstream infections caused by a compounded parenteral medication at an oncology clinic. Twelve patients were asymptomatic. All central venous catheters were removed and antifungal therapy, primarily voriconazole, was administered to patients. Three patients died.

Caregiver Education Reduces the Incidence of Community-Acquired CLABSIs in the Pediatric Patient With Intestinal Failure.

Pediatric patients with intestinal failure often require central venous catheters for extended periods of time for parenteral nutrition, blood sampling, and medication administration, increasing morbidity, mortality, and costs. In 2007, we reported a central line-associated bloodstream infection rate of 7.0 per 1,000 catheter line-days in our pediatric patients with intestinal failure. On the basis of this high rate of catheter-associated infections, we developed and implemented a central line care curriculum for patients/family caregivers and home health nurses. We aim to show with the implementation of patient/family caregiver and home health nurse standardized education, the central line-associated bloodstream infection rate can be significantly reduced and that this is sustainable. A retrospective review of 80 pediatric outpatients with intestinal failure and long-term central venous access was performed between January 1, 2009, and December 31, 2014. During this time period, the nursing department at Children's Medical Center of Dallas implemented a systematic central line care education program for patients and/or caregivers. The number of community-acquired central line-associated bloodstream infections during this time period was collected and compared with our previously reported data from 2005 to 2007 prior to the implementation of education program. With the implementation of standardized care guidelines and a central venous catheter care curriculum, the community-acquired rate decreased from 4.8 to 2.9 per 1,000 catheter-days in 80 patients with intestinal failure between January 1, 2009, and December 31, 2014 (p < .001). This was also a significant decrease compared with the initial central line-associated bloodstream infection rate of 7.0 per 1,000 central line days in 2007 (p < .001) prior to the development of the central venous catheter care curriculum. We have shown that the incidence of community-acquired central line-associated bloodstream infections in children with intestinal failure can be reduced through formal education of central venous catheter care to family members.

Does the Heparin Infusion Decrease the Risk of Catheter Related Thrombosis in Neonates with Central Venous Catheters?

A preterm newborn baby needs a peripherally inserted central venous catheter (PICVC) for the administration of parenteral nutrition (PN), intravenous (IV) fluids and medications. Echocardiogram is performed on this baby to ascertain the presence of PDA. Echocardiogram shows an incidental finding of inferior vena cava (IVC) thrombosis that is partially blocking the IVC. Here the question arises whether administration of continuous infusion of heparin through the central venous catheters including the umbilical venous catheters (UVC) or peripherally (percutaneous) inserted central venous catheters, commonly referred as long lines can reduce the incidence of catheter related thrombosis in neonates.

266 The Relative Frequency of Akathisia from Parenteral Antidopaminergics: A Systematic Review and Meta-Analysis

Parenteral antidopaminergic medications are frequently administered in the acute setting for nausea, vomiting, and headache. Extrapyramidal symptoms, which are extremely distressing to patients, may develop in the near term after parenteral administration of these medications. In this study, we performed a systematic review and meta-analysis to determine how frequently these symptoms arise in the aftermath of antidopaminergic medication use. PubMed, EmBase, Web of Science, and the Cochrane Library were searched in January 2017 for randomized controlled trials and prospective cohort studies in which a parenteral antidopaminergic drug was administered for headache, migraine, nausea, or vomiting. Articles were selected based on independent determinations of two investigators. Data was abstracted into a standardized form. Evidence was graded using the Cochrane risk of bias tool. Weighted mean frequencies were calculated for each type of extrapyramidal symptom. Meta-analysis, using random effects models, was performed, when appropriate—results are reported as OR (95% CI). A total of 36 studies with 4643 participants were included (median number of participants=98). Most were set in the emergency department. Baseline demographics were generally comparable amongst the included studies. In general, the quality of the studies was good with low risk of bias. Akathisia was the only consistently reported extrapyramidal side effect. The overall rate of acute drug-induced akathisia was 16.3% (642/3942). Prochlorperazine induced the highest rates of akathisia at 27.3% (95% CI [24.8%, 30.0%]), followed by haloperidol at 19.6% (95% CI [10.8%, 32.7%]), droperidol at 13.1% (95% CI [10.4%, 16.4%]), promethazine at 11.6% (95% CI [6.4, 19.7%]), and metoclopramide at 11.0% (95% CI [9.5%, 12.2%]). Overall, dystonic reactions occurred in 2.9% (6/206) of antidopaminergic administrations. For metoclopramide the frequency of dystonic reactions was 3.9% (95% CI [1.2%, 10.0%]) and for droperidol 1.9% (95% CI [0.1%, 7.2%]). There were no reported cases of tardive dyskinesia. Metoclopramide was more likely to cause akathisia than non-antidopaminergic standard therapy (OR 15.5 95% CI [2.1, 117.1]). Similarly, prochlorperazine was more likely to cause akathisia than non-antidopaminergic therapy (OR 4.7 95% CI [1.2, 18.8]). Slow infusion was less likely to cause akathisia than bolus administration for both metoclopramide (OR 3.0 95% CI [2.0, 4.6]) and prochlorperazine (OR 1.3 95% CI [0.8, 2.2]). Antidopaminergics other than metoclopramide were more likely to cause akathisia than metoclopramide itself (OR 2.2 95% CI [1.0, 5.1]), while antidopaminergics other than prochlorperazine were less likely than prochlorperazine to cause akathisia (OR 0.6 95% CI [0.4, 1.0]). Overall, akathisia occurs in 16.3% of patients administered a parenteral antidopaminergic. Other extrapyramidal side effects were much less common. Akathisia is much more common after administration of antidopaminergics than when non-antidopaminergic therapy is given. Metoclopramide is less likely to cause akathisia than other antidopaminergics while prochlorperazine is more likely to cause akathisia.

Multicenter, Prospective Study of Prehospital Administration of Analgesia in the U.S. Combat Theater of Afghanistan

Background: Published data on prehospital medical care in combat is limited, likely due to the chaotic and unpredictable nature of care under fire and difficulty in documentation There is limited data on how often analgesic agents are administered, which drug are being used, and whether there is an association with injury patterns. Methods: This study was a prospective, multicenter, observational study to determine which analgesic agents are being used prehospital and whether there is an association with injury patterns. Data was collected and recorded as casualties were brought into combat surgical hospitals in Afghanistan from October 2012 to April 2014. Onsite, trained investigators collected the data as part of a IRB approved protocol. Outcome data to 30 days was obtained from the DoD Trauma Registry (DODTR) within the Joint Trauma System. Results: During the study period 532 patient encounters available for inclusion with 378 receiving an analgesic agent (total of 541 administrations). The average age was 27 (range 21–31), 99% male, 40% were US or coalition forces. Parenteral medications used were ketamine, fentanyl, morphine, hydromorphone and ketorolac. Penetrating injuries were more likely to receive analgesic agent (89% vs 79%, p=0.0057). Blunt trauma was less likely to receive ketamine (p=0.008). Fentanyl was used more for patients with an Injury Severity Score (ISS) >15 (p=0.016). Conclusion: Patients with penetrating trauma are more likely to receive analgesic agents in the combat prehospital setting. The most common analgesic used was ketamine. Patient ISS was not associated with administration of analgesia. Patients receiving analgesia were more likely to still be hospitalized at 30 days. The prospective nature of this study supports feasibility for future, larger, more comprehensive projects.

A Pilot Project Demonstrating that Combat Medics Can Safely Administer Parenteral Medications in the Emergency Department.

In this limited case series, combat medics safely administered parenteral medications under indirect provider supervision. Future research is needed to further develop this training model for both the military and civilian setting. Schauer SG , Cunningham C W, Fisher AD , DeLorenzo RA . A pilot project demonstrating that combat medics can safely administer parenteral medications in the emergency department. Prehosp Disaster Med. 2017;32(6):679-681.

Parenteral product error detection before and after implementation of intravenous workflow management technology.

To assess the difference in pharmacy error detection rates when using a manual process compared to an intravenous workflow management system for the preparation of parenteral medications. Baseline error data were collected by staff using a standard form over a four-day time period before intravenous workflow management system implementation and compared to 48 weeks of electronically collected data following implementation. The chi-square test was used for statistical comparisons. The ability to detect an error during the intravenous preparation process increased immediately following implementation, but this difference was not sustained and was not statistically different when the entire post-implementation time period was compared to the baseline sample. The most prevalent errors at baseline were wrong drug amount (36.4%) and wrong base solution (22.7%). Post-implementation product expiration (26.1%), wrong diluent or base (17.9%), and wrong drug amount (19.2%) were the most prevalent errors. Barcode scanning technology detected 60% of the errors during the post-implementation period. A decrease in error detection over time was observed post-implementation and was attributed to corrections and additions to the intravenous workflow management library and better prospective identification of potential errors by staff as they adjusted to the system. The use of serial imaging enabled pharmacists to detect errors prospectively, which may have previously been undetected using the traditional intravenous preparation process. The implementation of intravenous workflow management technology was unable to detect a statistically significant greater percentage of sterile product preparation errors compared with the baseline time period. Statistical significance was achieved during three of the first four months following implementation ( P < 0.05); however, this statistically significant increase was not maintained when the entire post-implementation sample was included.

Prevalence of Hepatitis B, C, and D among Thalassemia patients in Sulaimani Governorate

Infectious diseases are the leading cause of mortality worldwide, with hepatitis viruses in particular making global impact on socioeconomic development and this infection remains a serious public health issue. This study was performed to investigate the prevalence of Hepatitis B, C and D among multi-transfused risk groups in Sulaimani Governorate, 120 major thalassemic patients were tested by serological and enzyme-linked immunosorbent assay (ELISA) technique and Recombinant ImmunoBlot Assay (RIBA) test was done as a confirmatory test for all HCV ELISA positive patients. It was observed that the prevalence of HCV was higher (29.1%) comparing to HBV (22.5%) and HDV (3.3%). The prevalence of HCV-HBV coinfection was (5%), HCV-HBV-HDV coinfections were (0.83%). Statistical analysis showed that the age was significantly effective on the prevalence of HBV (p = 0.009), parenteral medication users showed a significant relation with HBV and HCV prevalence (p = 0.03 and 0.041) respectively. The blood transfusion frequency was significantly related to HBV and HCV prevalence (p = 0.042 and 0.035) respectively. It was noticed that vaccination significantly related to HBV prevalence among thalassemic patients (p = 0.002).

Medication Use as a Contributor to Fluid Overload in the PICU: A Prospective Observational Study.

In this prospective observational study, we explored the association of daily fluid intake from medication use with fluid overload in 75 children beginning 24 hours after intubation. The mean percent daily fluid intake from medications was 29% in the overall cohort. Excess intake and inadequate output contributed significantly to fluid overload. In the 28 patients who became ≥10% fluid overloaded, the mean percent daily fluid intake from medications was 34%, but just 23% in the patients who did not. Awareness of volume contribution and maximized concentration of parenteral medications when able may lessen the burden of fluid overload.

Guide of Hypertensive Crisis Pharmacotherapy

Cardiovascular diseases (CVD) are the number one cause of death globally compared to any other cause. CVD accounts for approximately 17.3 million deaths per year and are rising. Hypertension is the leading risk factor for cardiovascular diseases. Approximately, 80 million people suffer from hypertension in the U.S. While, majority of these individuals are on antihypertensive medications only 54% of individuals with hypertension are optimally controlled. Heart failure and stroke are some of the devastating complications of uncontrolled hypertension. Hypertensive crisis can be classified as either an urgency or emergency; difference between the two is the presence of end organ damage, which is noted in hypertensive emergency. Hypertensive crisis is usually treated by parenteral antihypertensive medications. The main drug classes of drugs for treatment are nitrates, calcium channel blockers, dopamine-1 agonists, adrenergic-blocking agents etc. In this review, we discuss approach to management of hypertensive crisis and each drug class with its physiology and complications.

Determination of Polycyclic Aromatic Hydrocarbons in Commercial Parenteral Formulations and Medications Using High-Performance Liquid Chromatography with Diode Array Detection.

HPLC coupled to UV diode array detection (DAD) is proposed for the determination of polycyclic aromatic hydrocarbons (PAHs) in pharmaceutical products for parenteral administration. Because rubber is a possible source of PAHs for these products, samples stored in containers with rubber parts were selected for the analysis. The basis for method optimization was EPA Method 8310, which determines 16 priority PAHs in ground water and wastewater by HPLC using both UV and fluorescence detection. Using DAD, two channels were selected for detection, with one operating at 254 nm for the detection of nine PAHs and the other at 225 nm for the detection of seven PAHs. This method allowed for the detection of PAHs using external calibration with LODs and LOQs ranging from 0.001 to 0.060 µg/mL and from 0.003 to 0.167 µg/mL, respectively. Within-day precision, expressed as RSD, varied from 1.24 to 7.76% for PAH concentrations from 0.05 to 0.50 µg/mL, and intraday precision varied from 3.10 to 9.40% for the same concentration range. Method accuracy was confirmed by recoveries of 75-120% of the spiked samples. This method was applied for the determination of PAHs in three commercial infusion solutions and in nine different medications stored in syringes prior to administration to patients. Twelve of 16 PAHs were found in these samples. Total PAH concentrations varied from 0.13 to 13.50 µg/mL. Pyrene was the most prevalent contaminant, being present in 11 of 12 samples in concentrations ranging from 0.17 to 4.80 µg/mL. This method presented good sensitivity for the measurement of PAH in the target samples, allowing for the determination of the 16 priority PAHs in one run and in 30 min.

Don't Label Me: A Qualitative Study of Patients' Perceptions and Experiences of Sedation During Behavioral Emergencies in the Emergency Department.

Behavioral emergencies are commonly seen in emergency departments (EDs). Acutely agitated patients can be difficult to manage and sedation may be required to decrease dangerous behavior and to ensure the safety of both the patient and the staff. While the experience of staff caring for this population has been reported, patients' experiences with their overall management remains unknown. We aimed to describe the perceptions and experiences of patients regarding the use of sedation during acute behavioral emergencies. Face-to-face semistructured interviews were conducted with adults aged 18 years or older, who had received parenteral sedative medication for the management of a behavioral emergency and were deemed capable to participate. The participants were asked about their experiences of receiving care in the ED during the episode and their perceptions of sedation. All interviews were transcribed verbatim and analyzed thematically. Data saturation was reached after 13 interviews. Two broad themes emerged: trusting relationships and needs or wants following sedation. A trusting relationship is built through 1) confidence in care, 2) sedation as an appropriate treatment, 3) insight into own behavior, and 4) humane treatment. Four subthemes of needs or wants were identified: 1) empathy, 2) debrief, 3) addressing concerns, and 4) follow-up. A trusting relationship was identified as crucial to minimize the negative impact of coercive measures used to manage behavioral emergencies. Participants expressed similar needs to patients presenting with medical problems. This study illustrates their needs for compassionate communication, adequate information about the treatment provided, and follow-up care.

Investigation of Turkish nurses frequency and knowledge of administration of intramuscular injections to the ventrogluteal site: Results from questionnaires

BackgroundIntramuscular injection is important in the administration of parenteral medication and is a frequently-performed nursing responsibility. ObjectiveThe objective of this study was to identify the frequency of use of the ventrogluteal site and the level of nurses' knowledge of administering an intramuscular injection to this site. DesignA descriptive cross-sectional study was conducted of nurses working in four hospitals (n=362). Data collection tools included a 12 item sociodemographic questionnaire and a 24 item questionnaire on knowledge of the ventrogluteal site for intramuscular injection. Findings17.1% of participants reported using the VG site frequently in intramuscular injections. On the other hand, 35.9% reported that they do not use the VG site in intramuscular injections just because they are not used to giving injections on this site. Level of knowledge of ventrogluteal site was also limited with the mean score of correct answers from 24 questions being 14.37. ConclusionIt was found in the study that nurses' knowledge of the ventrogluteal site was limited, and they are not preferentially using the ventrogluteal site for intramuscular injections to adults even though it is recommended in recent nursing literature.

Experiences with Lean Six Sigma as improvement strategy to reduce parenteral medication administration errors and associated potential risk of harm

In this controlled before-after study the effect of improvements, derived from Lean Six Sigma strategy, on parenteral medication administration errors and the potential risk of harm was determined.During baseline measurement,...

Monitoring for the Oral and Maxillofacial Surgeon

Parenteral medications are titrated in the oral and maxillofacial surgery office to achieve moderate sedation, deep sedation, or general anesthesia while continuously maintaining spontaneous ventilation with an open airway. After initial drug administration, the provider assesses and interprets both the level of anesthesia and the presence/severity of adverse side effects, both of which guide further drug titration, cessation, reversal, or medical management. This assessment is called monitoring, which guides the conduct of anesthesia delivery and becomes the essence of this art.

Handling of parenteral drugs in Swiss hospitals – a systematic analysis and potential improvement strategies

Background & objectives Medication errors with parenteral drugs can seriously harm patients. To identify problems within the medication process with parenteral drugs the society of Swiss Hospital Pharmacists GSASA has developed the “parenteralia self assessment tool (PSAT)” project. The most fatal medication errors are those concerning high-alert medications, nevertheless the Swiss practice is still lacking a consistent definition of these potent and risky medications. Methods In the scope of a master's thesis, the PSAT completed by Swiss hospitals was analysed in order to identify national parenteral drug-related safety hotspots. Evidence-based interventions addressing these hotspots were identified through a systematic literature review, complemented by practice-based approaches gathered through structured interviews in Swiss hospitals. Furthermore, the lacking consistent definition of high-alert medications were addressed reviewing international recommendations and using an expert panel. Results The analysis of 18 completed tools revealed eight national hotspots. These concern medication preparation areas; lacking definitions of minimum/maximum dosages; the implementation of double checks to verify pump-programming; regular clinical pharmacy services including documentation and the education program of institutions (e.g., medication safety orientation of new employees). The systematic literature review provided 40 studies with potentially helpful interventions to rectify the hotspots. Additionally, several guidelines and recommendations concerning patient or medication safety from different national and international organisations could be found. Through structured interviews in six hospitals, useful practice-based approaches were identified. A list of parenteral high-alert medications was created to be used in Swiss hospitals as well as a matrix to estimate the potential risk of additional potentially risky medications. An educational PowerPoint® presentation was compiled to provide information about the PSAT-project, its results and the problems with high-alert medications to any interested hospitals. Discussion & conclusions The PSAT-project proved to be a useful tool to identify hotspots in the parenteral medication process in Switzerland. Limited literature made it difficult to find evidence-based interventions. Due to the poor overall evidence, no particular intervention could unequivocally be recommended for the hotspots. Nevertheless, several interesting approaches were identified and two auxiliaries addressing the identification of high-alert medications were created.

SGLT2 Inhibitors in Diabetes Mellitus Treatment.

Type 2 Diabetes Mellitus (T2DM) is a chronic illness with high prevalence in Mexico, Latin- America, and the world and is associated to high morbidity, disability, and mortality rate, especially in developing countries. T2DM physiopathology is very complex; insulin resistance in the muscle, liver, and adipose tissue, a reduction in the production of incretins (mainly GLP-1) in the intestine, increased glucagon synthesis, an insufficient response of insulin generation, and increased glucose reabsorption in the kidney lead all together to an hyperglycemic state, which has been closely associated with the development of micro and macrovascular complications. Sodium Glucose Linked Transporter 2 inhibitors (SGLT2i) are the most recent therapeutic class available for treating T2DM. SGLT2i central effect is a glycosuric action, and they can reverse the deleterious effect of tubular reabsorption of glucose in the diabetic patient resulting in greater hyperglycemia. Because their mechanism of action is completely different to current drugs, they can be considered as monotherapy or in combination with any other oral or parenteral medication, including different types of insulin or its analogues. This therapeutic synergy accomplishes a greater percentage of patients achieving glycemic control goals.

Hot and Cold Drugs: National Park Service Medication Stability at the Extremes of Temperature

Study Objective: National Park Service (NPS) Parkmedics provide medical care in austere environments. The objective of this study was to evaluate the stability of specific medications used by Parkmedics at extremes of temperatures likely to be faced in the field. Methods: This is a bench research study conducted in the laboratory setting over a 4-week period. Parenteral medications were separated into 4 temperature exposure groups: A) 45°C (hot); B) −20°C (cold); C) hot then cold temperatures alternating weekly; and D) cold then hot temperatures alternating weekly. At study start and the end of each week, three aliquots from each group were sampled to determine the remaining drug concentration through liquid chromatography-quadrupole time-of-flight mass spectrometry (Agilent LC 1260- QTOF/MS 6550). Quantitative analysis was done using Agilent MassHunter Quantitative Analysis software. The mean drug concentration from triplicate aliquots was expressed as percentage of its baseline concentration to monitor the drug's stability during storage. Results: Eight medications were analyzed (atropine, diphenhydramine, fentanyl, hydromorphone, midazolam, morphine, naloxone, ondansetron). Hydromorphone, morphine, and ondansetron showed the greatest stability, at above 90% of original concentration in all study arms. Diphenhydramine, fentanyl and midazolam showed heat independent degradation, degrading the same way regardless of heat exposure. By the end of the study period, 51–56% midazolam remained in all groups. Atropine and naloxone showed heat dependent degradation, degrading more when exposed to heat. Atropine had the most degradation, being undetectable after 4 weeks of heat exposure. Conclusions: We recommend that EMS providers replace atropine, naloxone, diphenhydramine, fentanyl, and midazolam frequently if they are practicing in low call volume or high-temperature environments. Further studies will be needed to determine if re-dosing midazolam, naloxone, and atropine is the appropriate clinical strategy in this setting if adequate clinical effect is not reached with a single dose.

Determination of Polycyclic Aromatic Hydrocarbons in Commercial Parenteral Formulations and Medications Using High-Performance Liquid Chromatography with Diode Array Detection.

HPLC coupled to UV diode array detection (DAD) is proposed for the determination of polycyclic aromatic hydrocarbons (PAHs) in pharmaceutical products for parenteral administration. Because rubber is a possible source of PAHs for these products, samples stored in containers with rubber parts were selected for the analysis. The basis for method optimization was EPA Method 8310, which determines 16 priority PAHs in ground water and wastewater by HPLC using both UV and fluorescence detection. Using DAD, two channels were selected for detection, with one operating at 254 nm for the detection of nine PAHs and the other at 225 nm for the detection of seven PAHs. This method allowed for the detection of PAHs using external calibration with LODs and LOQs ranging from 0.001 to 0.060 &#x03BC;g/mL and from 0.003 to 0.167 &#x03BC;g/mL, respectively. Within-day precision, expressed as RSD, varied from 1.24 to 7.76% for PAH concentrations from 0.05 to 0.50 &#x03BC;g/mL, and intraday precision varied from 3.10 to 9.40% for the same concentration range. Method accuracy was confirmed by recoveries of 75&#x2013;120% of the spiked samples. This method was applied for the determination of PAHs in three commercial infusion solutions and in nine different medications stored in syringes prior to administration to patients. Twelve of 16 PAHs were found in these samples. Total PAH concentrations varied from 0.13 to 13.50 &#x03BC;g/mL. Pyrene was the most prevalent contaminant, being present in 11 of 12 samples in concentrations ranging from 0.17 to 4.80 &#x03BC;g/mL. This method presented good sensitivity for the measurement of PAH in the target samples, allowing for the determination of the 16 priority PAHs in one run and in 30 min.

The effect of education intervention on parenteral medication preparation and administration among nurses in a general intensive care unit

AbstractThe preparation and administration of parenteral medications in intensive care units is associated with high error rates. Lack of knowledge has been identified as the main reason for these errors. This study aims to measure the effects of education intervention on the incidence and types of parenteral medication preparation and administration errors, adherence to good practices, and the accuracy of drug infusions' concentrations. This prospective, pre‐ and post‐interventional study was conducted in a General Intensive Care Unit of a tertiary teaching hospital in Malaysia using an observation method. The preparation and administration of parenteral medications by the nurses was observed directly during pre‐ and post‐intervention. The concentrations of drug infusions (noradrenaline) prepared by the nurses were analysed. The education intervention significantly reduced the error rate from 79% to 50% (p &lt; 0.001), and improved good practices' adherence. However, there was no significant difference in the concentration error rate of the drug infusions prepared in pre‐ (48%) and post‐intervention (53%) (p = 0.70). Future studies may look into the effectiveness of providing practical sessions targeting skills and technique to improve the quality of the drug infusions prepared.