DRUG INCOMPATIBILITIES : decision supporting tools for ... · King 2008 cross-table King Neofax...
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DRUG INCOMPATIBILITIES : decision supporting tools for their management Dre Caroline Fonzo-Christe Pharmacie des HUG Symposium « Zentralvenose Katheter: wissen wir, was wir tun? » Kinderspital Zürich November 10 th 2011
Transcript of DRUG INCOMPATIBILITIES : decision supporting tools for ... · King 2008 cross-table King Neofax...
DRUG INCOMPATIBILITIES : decision supporting tools
for their managementDre Caroline Fonzo-Christe
Pharmacie des HUGSymposium « Zentralvenose Katheter:
wissen wir, was wir tun? » Kinderspital ZürichNovember 10th 2011
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PREVENTION OF PROBLEMS
• ward• pharmacy • ward
FailureDrug administration process
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PREVENTION OF PROBLEMS
• ward• pharmacy • ward
FailureDrug administration process
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TOOLSBooks
Databases
Cross-tablespH-colorcode
Software
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SITUATIONS
A + B compatible in the same line (Y)A + B incompatible two different lines
A B
A + B no dataA + B contradictory results
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TOOLSPrimary informations on drug compatibillity
Management of infusions
Real life: • No drug pairs but a lot of drugs• No information for some drugs or
contradictory informations• Not the same concentrations, diluent,
material
Assessment interpretation !
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TOOLSBooks and databases
Cross-tables
pH-colorcode
Electronic management
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STUDIES WITH IMPACT?
9Bertsche T et al. AJHP 2008;65:1834-40
• Critically ill adult patients, gastroenterologic ICU• SOP on the most frequent administered pairs of drugs
SOP-IMPLEMENTATION
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pH COLOR CODE
• Adult ICU in Schaffhausen (Switzerland) since 10 years
Vogel Kahmann I. et al. Anaesthesist 2003;52:409-12
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pH COLOR CODE
Vogel Kahmann I. et al. Anaesthesist 2003;52:409-12
On IV-lines
Pharmacy ward
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pH COLOR CODEAbout 78 drug combinations (636 different drugs)
Vogel Kahmann I. et al. Anaesthesist 2003;52:409-12
Y-site infusion of potentially incompatible drugs
pH AND DRUG CLASSES
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AKH 2005 ALLGEMEINES Krankenhaus der Stadt Wien
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COMPARISON OF TOOLS?
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Reference and its abreviation Trissel handbook 14th ed. Ref
Tools and their abreviations CHUV 9.0 cross-table CHUV KIK 3.0 database KIK King 2008 cross-table King Neofax 2007 handbook NeoF Perfysi 2 database Perf pH 2007 cross-table pH Stabilis 3 database Stab Thériaque 2007 database Thé
COMPARISON OF TOOLS
De Giorgi I et al. PWS 2010;32520-9
• Evaluation by 2 pharmacists • 40 drug pairs usually used in NICU
and PICU • Trissel’s as gold reference
CROSS-TABLES
http://files.chuv.ch/internet-docs/pha/medicaments/pha_phatab_compatibilitessip.pdfhttp://www.adhb.govt.nz/newborn/DrugProtocols/IVCompatibilities.htm
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HUG NURSE EVALUATION
17Gschwind L et al. ESCP 2010. http://pharmacie.hug-ge.ch/rd/posters/ESCP2010_lg_incompat.pdf
HUG NURSE EVALUATION
18Gschwind L et al. ESCP 2010. http://pharmacie.hug-ge.ch/rd/posters/ESCP2010_lg_incompat.pdf
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KIK program BBRAUN
http://www.kik-service.de/
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PREVENTION OF PROBLEMS
• ward• pharmacy • ward
FailureDrug administration process
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IN VITRO STUDY
Humbert Delaloye V et al. ESCP 2009. http://files.chuv.ch/internet-docs/pha/recherche/pha_poster_2009escp_compatibilites.pdf
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CALCIUM/PHOSPHATE IN PN
Phosphate mmol/L (Na2HPO4)
Cal
cium
mm
ol/L
(CaC
l 2)
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10
8
7
6
5
4.5
4
3.5
3
2
1
121087654.543.5321
StabilityZone
IntermediateZone
PrecipitateZone
Phosphate mmol/L (Na2HPO4)
Cal
cium
mm
ol/L
(CaC
l 2)
12
10
8
7
6
5
4.5
4
3.5
3
2
1
121087654.543.5321
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10
8
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5
4.5
4
3.5
3
2
1
121087654.543.5321
StabilityZone
IntermediateZone
PrecipitateZone
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40
30
20
10
5040302010
Phosphate mmol/L (G1P)
Cal
cium
mm
ol/L
(CaC
l 2or
Ca-
Glu
)
Stability Zone
50
40
30
20
10
5040302010
50
40
30
20
10
5040302010
Phosphate mmol/L (G1P)
Cal
cium
mm
ol/L
(CaC
l 2or
Ca-
Glu
)
Stability Zone
Use of organic calcium and phosphates salts
Bouchoud L et al. JPEN J Parenter Enteral Nutr. 2010;4:542-5
Visual inspection and particles counter
IN VITRO STUDY
Compatibility lipid emulsions and drugs
Granulometry• mean size < 500 nm• % globule > 5µm < 0.4%Zeta potential measurementpH measureVisual inspection (microscope)
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NUTRIFLEX LIPID SPECIAL
DCI Concentration tested
Y-site Compatibility with NPT / 1h
Y-site Compatibility with NPT / 4h
Heparin 417 UI/ml C CFurosemide 10 mg/ml C CEsomeprazole 0.8 mg/ml I IOctreotide 25 µg/ml C CCyclosporine 2.5 mg/ml C CCefepime 100 mg/ml C IMeropeneme 50 mg/ml C CCo-Amoxicilline 50 mg/ml (amox.) C IMetronidazole 5 mg/ml C CParacetamol 10 mg/ml C CVancomycine 10 mg/ml C CMidazolam 2.5 mg/ml C COndansetron 2 mg/ml C C
Bouchoud L et al. SFNEP 2009. http://pharmacie.hug-ge.ch/ens/conferences/lb_incomp_sfnep.pdf 24
INTERNET SITE PHARMACY
http://pharmacie.hug-ge.ch/infomedic/utilismedic.html25
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PREVENTION OF PROBLEMS
• ward• pharmacy • ward
FailureDrug administration process
Drug PreparationBW 5 kg
conc. [mg/ml]
BW 10 kg BW 20 kg
min max
Furosemide 5 mg x BW ad 50 ml NaCl 0.9% 0.5 1 2 0.05 0.85
Midazolam 4 mg x BW ad 20 ml NaCl 0.9% 1 2 4 0.03 0.3
Infusion rate
[mg/kg/h]
• Four infusion rate tested: • F 0.05 and 0.85 mg/kg/h, M 0.03 and 0.3 mg/kg/h• With and without in-line filters• Occlusion alarm?
Fonzo-Christe C. et al. ESCP 2009. http://pharmacie.hug-ge.ch/rd/posters/ACCP_ESCP09_pumps_cf.pdf
conc. [mg/ml] conc. [mg/ml]
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OCCLUSION ALARMS: useful?
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OCCLUSION ALARMS
ConnectubSyringes
Stopcock
+/-in-line filter
CVC • Module DPS
Fresenius Kabi• Pressure offset :
300 mm Hg
Fonzo-Christe C. et al. ESCP 2009. http://pharmacie.hug-ge.ch/rd/posters/ACCP_ESCP09_pumps_cf.pdf
PRECIPITATION
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PRECIPITATION: furosemide
furosemide
midazolamPALL Corporation 11.2009
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OCCLUSION ALARMS
Pressure offset at 300 mm Hg not efficient with very low infusion rates Pressure management (lower alarm levels) or in-line filters
Fonzo-Christe C. et al. ESCP 2009. http://pharmacie.hug-ge.ch/rd/posters/ACCP_ESCP09_pumps_cf.pdf
NICU and PICU HUG: IN-LINE FILTERS
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BLOCKED FILTERS
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Nexium® + Dormicum®
+ Morphine®
Esomeprazole discoloration ± precipitation in acidic solutions
WHICH TOOL?
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CONCLUSION
MANAGEMENT Adapted to the hospital or unit
Type of patients, medicationsClinical pharmacist presenceLanguageComputerized prescription, electronic medicalrecord
Multimodal approach probably betterTools (pocket, internet, color code, electronic)TeachingHigh-risk situations: in-line filter
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LEARNING I-TOOLS: COIMLearn to make yourself safer Learn about injection compatibility • nurses who administer injections• nurses and physicians in training• ward-based pharmacists in training
36http://fr.appbrain.com/app/injectable-medicines/air.coim
TAKE HOME MESSAGE
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Hospital and clinical pharmacists
can help!
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LIPID EMULSION
Lipofundin or Disoprivan
+ GaramycinePhase separation over 24h
Oil phase + fat soluble-dye (Sudan red III)
