Hazards of glass ampoules

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.

Determination of the Contents of Antioxidants and Their Degradation Products in Sodium Chloride Injection for Blood Transfusion

The infusion bag is mainly made up of polyolefin polymer. Antioxidants are usually added to these polymer materials in the production process to prevent the materials from aging and enhance the stability of the materials. Because of the potential harm of antioxidants to human body, it is necessary to limit the amount of antioxidants migrating to the pharmaceutical solutions. In the present study, we developed and validated the HPLC method for the simultaneous quantification of antioxidants and their degradation products migrating to sodium chloride solution for injection. A total of six antioxidants and six their degradation products were separated and simultaneously determined by using a Waters Symmetry RP18 column (250 × 4.6 mm, 5 μm) and gradient elution of methanol/acetonitrile/acetic acid-water (1 : 99, v/v) at a flow rate of 1.0 mL/min. The detective wavelength was set at 277 nm, and the column temperature was maintained at 35°C. The method was validated in terms of limit of detection (LOD, 0.011-0.151 μg/mL), limit of quantification (LOQ, 0.031-0.393 μg/mL), intraday precision (0.25%-3.17%), interday precision (0.47%-3.48%), linearity (0.1-46.8 μg/mL, r > 0.9994), stability (0.35%-3.29%), and accuracy (80.39%-104.31%). In the extraction experiment, antioxidants, BHT, 1010, 1330, 1076, and 168, and their degradation products, 1310 and DBP, were detected in the packaging materials. Only 1310 was detected in the migration experiment. The maximum daily dosage of sodium chloride for blood transfusion is three bags, and the content of 1310 in long-term testing samples is from 0 to 12 months ranging from 37.44 μg/3 bags to 48.71 μg/3 bags. The daily intake of 1310 did not exceed 48.71 μg, which was much lower than its permitted daily exposure (PDE, 300 μg/day). Therefore, the antioxidants and their degradation products migrating into the drug solution would not cause drug safety risks.

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.

The effect of different methods of intravenous injection on glass particle contamination from ampules

There have been many studies on glass particle contamination from glass ampules during the injection of glass ampules, but only the contamination from direct IV bolus injection has been measured. This research aimed to study the difference in glass particle contamination from ampules with different intravenous administration methods commonly used in clinical practice. Four methods were studied: IV bolus injection directly after immediate aspiration, IV bolus injection directly after 2 min’ delayed aspiration, IV bolus injection directly after aspiration with a filter needle, and side shooting to an infusion set with an in-line filter. 45 ampules per method for a total of 180 ampules were used. The number and length of glass particles were measured using a slide scanner. Aspiration was performed without specifically using a slow aspiration method. The longest glass particle was observed in the immediate aspiration group. The side shooting group showed the lowest maximum number of glass particles per ampule. The side shooting group also showed the smallest number of glass particles, but it was statistically insignificant. Using a filter needle syringe and 2 min’ delayed aspiration, which are frequently recommended to minimize contamination, may not be as effective as commonly believed, unless combined with a slow and low pressure aspiration method. Using a side shooting to an infusion set with an in-line filter may minimize glass particle contamination from ampules even without a slow and low pressure aspiration method, but more evidence from a larger study is needed.

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.

IV injection of polystyrene beads for mouse model of sepsis causes severe glomerular injury

Background

Infusion fluids may be contaminated with different types of particulates that are a potential health hazard. Particulates larger than microvessels may cause an embolism by mechanical blockage and inflammation; however, it has been reported that particulates smaller than capillary diameter are relatively safe. Against such a background, one report showed that polystyrene beads smaller than capillary diameter decreased tissue perfusion in ischemia–reperfusion injury. This report suggested that polystyrene beads from 1.5- to 6-μm diameter (dia.) may have unfavorable effects after pretreatment.

Here, we investigated whether injection of polystyrene beads (3- and 6-μm dia.) as an artificial contaminant of intravenous fluid after lipopolysaccharide (LPS) injection affected mortality and organ damage in mice.

Methods

Mice were divided into four groups and injected: polystyrene beads only, LPS only, polystyrene beads 30 min after LPS, or saline. A survival study, histology, blood examination, and urine examination were performed.

Results

The survival rate after LPS and polystyrene bead (6-μm dia.) injection was significantly lower than that of the other three groups. In the kidney sections, injured glomeruli were significantly higher with LPS and polystyrene bead injection than that of the other three groups. LPS and polystyrene bead injection decreased the glomerular filtration rate and led to renal failure. Inflammatory reactions induced with LPS were not significantly different between with or without polystyrene beads. Polystyrene beads were found in urine after LPS and polystyrene bead injection.

Conclusions

Injection of polystyrene beads after LPS injection enhanced glomerular structural injury and caused renal function injury in a mouse sepsis model.

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.

Should in-line filters be used in peripheral intravenous catheters to prevent infusion-related phlebitis? A systematic review of randomized controlled trials

BACKGROUND

In this systematic review, we assessed the effect of in-line filters on infusion-related phlebitis associated with peripheral IV catheters. The study was designed as a systematic review and meta-analysis of randomized controlled trials. We used MEDLINE and the Cochrane Controlled Trial Register up to August 10, 2009.

METHODS

Two reviewers independently assessed trial quality and extracted data. Data on phlebitis were combined when appropriate, using a random-effects model. The impact of the risk of phlebitis in the control group (baseline risk) on the effect of in-line filters was studied by using meta-regression based on the bivariate meta-analysis model. The quality of the evidence was determined by using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) method.

RESULTS

Eleven trials (1633 peripheral catheters) were included in this review to compare the effect of in-line filters on the incidence of phlebitis in hospitalized patients. Baseline risks across trials ranged from 23% to 96%. Meta-analysis of all trials showed that in-line filters reduced the risk of infusion-related phlebitis (relative risk, 0.66; 95% confidence interval, 0.43-1.00). This benefit, however, is very uncertain, because the trials had serious methodological shortcomings and meta-analysis revealed marked unexplained statistical heterogeneity (P < 0.0000, I(2) = 90.4%). The estimated benefit did not depend on baseline risk.

CONCLUSION

In-line filters in peripheral IV catheters cannot be recommended routinely, because evidence of their benefit is uncertain.

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.

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.

Pharmaceutical quality of ceftriaxone generic drug products compared with Rocephin

The pharmaceutical qualities of 34 ceftriaxone generic products were compared with Rocephin as the reference standard. Quality standards specified in the European and US Pharmacopoeias were violated on 18 occasions, including those for sterility (4 products) and impurities (5 products). All 34 generics tested failed to meet Roche specifications for Rocephin, with 100 contraventions of the Roche Pharmaceutical standards. The most common failures amongst generic drug products were clarity of solution (30 products) and presence of thiotriazinone (33 products).

Hazards of parenteral treatment: do particles count?

After prolonged parenteral nutrition a 12 month old infant died with pulmonary hypertension and granulomatous pulmonary arteritis. A review of necropsy findings in 41 infants who had been fed parenterally showed that two of these also had pulmonary artery granulomata, while none of 32 control patients who died from sudden infant death syndrome had similar findings. Particulate contaminants have been implicated in the pathogenesis of such lesions and these were quantified in amino acid/dextrose solutions and fat emulsions using automated particle counting and optical microscope counting respectively. Parenteral feed infusions compounded for a 3000 g infant according to standard nutritional regimens were found to include approximately 37,000 particles between 2 and 100 microns in size in one day's feed, of which 80% were derived from the fat emulsion. In-line end filtration of intravenous infusions may reduce the risk of particle associated complications. A suitable particle filter is required for use with lipid.