PHARMACY UPDATES

Keywords: Extravasation,Neonates,Hyaluronidase,Amphadase,Vascular

N

From the Good Samaritan Hospital, Cincinnati,

OH.

Address correspondences to Katherine O’Con-

nor, BS, Pharm, RPh, Clinical Pharmacist, Good

Samaritan Hospital, 375 Dixmyth Avenue, Cincin-

nati, OH 45220, USA.

n 2006 Elsevier Inc. All rights reserved.

1527-3369/06/0604-0167$10.00/0

doi:10.1053/j.nainr.2006.09.010

Vascular Issues

By Katherine O’Connor, BSPharm, RPh, Column Editor

Pharmacy Perspectives

Hyaluronidase

Shortages or discontinuation of pharmaceutical products causes challenges

for clinicians; adequate substitutes are sought or changes in practice occur if

replacements are unavailable. When Wydase brand Hyaluronidase was

discontinued in 2001, the medication could be compounded, yet guidelines to

compound sterile preparations issued by the United States Pharmacopeia must

be strictly followed.1 New United States Pharmacopeia (USP) 797 requirements

include the highest level of pharmacy clean room for compounding sterile

products from nonsterile sources; therefore, some pharmacies contract outside

vendors to compound substitutes if their facility is not able to meet these

regulations. Hyaluronidase is used as an adjunctive agent to facilitate the

dispersion and absorption of other drugs. Hyaluronidase (Wydase) was

frequently used emergently for extravasation issues. Wyeth stopped manufac-

turing Hyaluronidase injection in 2001, and there was no other Food and Drug

Administration (FDA)-approved source for the product.

Hyaluronidase is usually derived from bovine testicular tissue extracts. Use

of foreign bovine tissue could potentially result in the development of bovine

spongiform encephalopathy in drug recipients. There is concern about the

increasing number of drug products that are unavailable from manufacturers and

the lack of control and oversight of compounding pharmacies. Health systems

need to weigh the risks of using compounded preparations from outsourced

pharmacies.1 The return of commercially available products (Amphadase-

Amphastar Pharmaceuticals) is very welcome!2

Osmolarity and Vascular Access

In prescribing and dispensing medications, fluids, and nutrition to neonatal

intensive care unit (NICU) patients, the risks and benefits of the solution

concentration, osmolarity, and route of administration are a balancing act.

Osmolarity limits for peripheral administration are typically set between 600

and 1000 milliosmole per liter.3 Therefore, providing adequate nutrition in

clinically appropriate volumes often requires percutaneously inserted central

catheter (PICC) access.4 Higher osmolarities carry a higher risk of peripheral

extravasation.5 Potential damage from peripheral extravasation may be

minimized by immediate treatment (within 1 hour) of Amphadase or Vitrase.6,7

Table 1 presents an example of a prepared medication sheet for Amphadase

(Hyaluronidase). Consistent administration and dosing using these medications

are important.8

ewborn and Infant Nursing Reviews, Vol 6, No 4 (December), 2006: pp 245-246 245

Table 1. Medication Sheet

Amphadase (Hyaluronidase)

Classification:

Protein enzyme.

Action:

Wydase is a mucolytic enzyme that disrupts the normal

intercellular barrier and allows rapid dispersion of extravasated

fluids through tissues.

Indications:

Prevention of tissue injury caused by IV extravasation. Suggested

indications are for extravasations involving drugs that are

irritating to veins because of hyperosmolarity or extreme pH

(eg, aminophylline, acyclovir, amphotericin B, calcium,

methicillin, nafcillin, potassium chloride, sodium bicarbonate,

vancomycin, TPN, and concentrated IV solutions).

Contraindications:

Not recommended for IV use. It is not indicated for treatment of

extravasations of vasoconstrictive agents (eg, dopamine, epi

nephrine, norepinephrine).

Dosage, route, dilution:

Dose, route: subcutaneous or intradermal; inject 1 milliliter

(150 units) as 5 separate 0.2-milliliter injections around

periphery of extravasation site. Prepare skin and use a 25- or

26-gauge needle to administer. Use within 1 hour of

extravasation for best results.

Dilution: supplied as a stabilized solution.

Comments:

1. The chances of therapeutic success may be increased by:

(a) Initiating treatment within 1 hour of extravasation;

(b) Subcutaneously flushing the affected area with normal

saline after the hyaluronidase treatment;

(c) Covering with a Hydrogel dressing for 48 hours.

Courtesy of Good Samaritan Hospital, Cincinnati, Ohio.

246 Katherine O’Connor

References

1. Young D. Compounding sterile preparations raises informed-

consent issues. Am J Health-Syst Pharm. 2003;1209 -1210.2. Young TE, Mangum B. Neofax: a manual of drugs used in

neonatal care. (19th ed). Raleigh, (NC)7 Acorn; 2006.3. Beauman S, Swanson S. Neonatal infusion therapy: preventing

complications and improving outcomes. In Altimier L, ed. Newborn and

Infant Nursing Reviews. 2006;6:186-192.4. Pettit J. Fostering a new era of vascular access device selection

in neonates. In Altimier L, ed. Newborn and Infant Nursing Reviews.

2006;6:193-201.5. Clifton-Koeppel R. Wound care following peripheral intravenous

extravasation: what is the evidence? In Altimier L, ed. Newborn and

Infant Nursing Reviews. 2006;6:202-211.6. Ramasethu J. Prevention and management of extravasation injuries

in neonates. NeoReviews. 2004;5:e491-e497.7. Lehr VT, Lulic-Botica M, Lindblad WJ, et al. Management of

infiltration injury in neonates during duoderm hydroactive gel. Am JPerinatol. 2004;21:409-414.

8. Altimier L, Brown B, Tedeschi L. NANN guidelines for neonatal

nursing policies, procedures, competencies, and clinical pathways, 2006.

www.NANN.org/publications.