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 10th 2011 PREVENTION OF PROBLEMS Drug administration process • ward • pharmacy Failure • ward 2 PREVENTION OF PROBLEMS Drug administration process • ward • pharmacy Failure • ward 3 Books TOOLS pH-colorcode Cross-tables Software Databases 4 SITUATIONS A B A + B compatible A + B incompatible Î Î in the same line (Y) two different lines A + B no data Î A + B contradictory results Î 5 TOOLS Primary informations on drug compatibillity 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 Î interpretation ! Management of infusions 6 TOOLS Books and databases Cross-tables Electronic management pH-colorcode 7 STUDIES WITH IMPACT? 8 SOP-IMPLEMENTATION • Critically ill adult patients, gastroenterologic ICU • SOP on the most frequent administered pairs of drugs Bertsche T et al. AJHP 2008;65:1834-40 9 pH COLOR CODE • Adult ICU in Schaffhausen (Switzerland) since 10 years Vogel Kahmann I. et al. Anaesthesist 2003;52:409-12 10 pH COLOR CODE Pharmacy ward On IV-lines Vogel Kahmann I. et al. Anaesthesist 2003;52:409-12 11 pH COLOR CODE About 78 drug combinations (636 different drugs) Ð Y-site infusion of potentially incompatible drugs Vogel Kahmann I. et al. Anaesthesist 2003;52:409-12 12 pH AND DRUG CLASSES AKH 2005 ALLGEMEINES Krankenhaus der Stadt Wien 13 COMPARISON OF TOOLS? 14 COMPARISON OF TOOLS Reference and its abreviation Trissel handbook 14th ed. Ref To ols 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 • Evaluation by 2 pharmacists • 40 drug pairs usually used in NICU and PICU • Trissel’s as gold reference De Giorgi I et al. PWS 2010;32520-9 15 CROSS-TABLES http://files.chuv.ch/internet-docs/pha/medicaments/pha_phatab_compatibilitessip.pdf http://www.adhb.govt.nz/newborn/DrugProtocols/IVCompatibilities.htm 16 HUG NURSE EVALUATION Gschwind L et al. ESCP 2010. http://pharmacie.hug-ge.ch/rd/posters/ESCP2010_lg_incompat.pdf 17 HUG NURSE EVALUATION Gschwind L et al. ESCP 2010. http://pharmacie.hug-ge.ch/rd/posters/ESCP2010_lg_incompat.pdf 18 KIK program BBRAUN http://www.kik-service.de/ 19 PREVENTION OF PROBLEMS Drug administration process • ward • pharmacy Failure • ward 20 IN VITRO STUDY Humbert Delaloye V et al. ESCP 2009. http://files.chuv.ch/internet-docs/pha/recherche/pha_poster_2009escp_compatibilites.pdf 21 CALCIUM/PHOSPHATE IN PN Visual inspection and particles counter Use of organic calcium and phosphates salts Phosphate mmol/L (Na2HPO4) 2 3 3.5 4 4.5 5 6 7 Calcium mmol/L (CaCl2) 2 3 3.5 4 4.5 Stability Zone Intermediate Zone 5 6 7 8 10 12 Precipitate Zone 8 10 12 10 Calcium mmol/L (CaCl2 or Ca-Glu) 1 1 Phosphate mmol/L (G1P) 20 30 40 50 10 20 Stability Zone 30 40 50 Bouchoud L et al. JPEN J Parenter Enteral Nutr. 2010;4:542-5 22 IN VITRO STUDY Compatibility lipid emulsions and drugs Granulometry • mean size < 500 nm • % globule > 5µm < 0.4% Zeta potential measurement pH measure Visual inspection (microscope) 23 NUTRIFLEX LIPID SPECIAL DCI Concentration tested Heparin Furosemide Esomeprazole Octreotide Cyclosporine Cefepime Meropeneme Co-Amoxicilline Metronidazole Paracetamol Vancomycine Midazolam Ondansetron 417 UI/ml 10 mg/ml 0.8 mg/ml 25 µg/ml 2.5 mg/ml 100 mg/ml 50 mg/ml 50 mg/ml (amox.) 5 mg/ml 10 mg/ml 10 mg/ml 2.5 mg/ml 2 mg/ml Y-site Compatibility with NPT / 1h C C I C C C C C C C C C C Y-site Compatibility with NPT / 4h C C I C C I C I C C C 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.html 25 PREVENTION OF PROBLEMS Drug administration process • ward • pharmacy Failure • ward 26 OCCLUSION ALARMS: useful? • 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? BW 5 kg Drug Preparation conc. [mg/ml] BW 10 kg conc. [mg/ml] BW 20 kg conc. [mg/ml] Infusion rate [mg/kg/h] 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 Fonzo-Christe C. et al. ESCP 2009. http://pharmacie.hug-ge.ch/rd/posters/ACCP_ESCP09_pumps_cf.pdf 27 OCCLUSION ALARMS Connectub Syringes CVC Stopcock • Module DPS Fresenius Kabi • Pressure offset : 300 mm Hg +/-in-line filter Fonzo-Christe C. et al. ESCP 2009. http://pharmacie.hug-ge.ch/rd/posters/ACCP_ESCP09_pumps_cf.pdf 28 PRECIPITATION 29 PRECIPITATION: furosemide furosemide midazolam PALL Corporation 11.2009 30 OCCLUSION ALARMS Î Pressure offset at 300 mm Hg not efficient with very low infusion rates Î 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 31 NICU and PICU HUG: IN-LINE FILTERS 32 BLOCKED FILTERS Nexium® + Dormicum® + Morphine® Î Esomeprazole discoloration ± precipitation in acidic solutions 33 CONCLUSION WHICH TOOL? 34 MANAGEMENT Adapted to the hospital or unit Type of patients, medications Clinical pharmacist presence Language Computerized prescription, electronic medical record Multimodal approach probably better Tools (pocket, internet, color code, electronic) Teaching High-risk situations: in-line filter 35 LEARNING I-TOOLS: COIM Learn to make yourself safer Learn about injection compatibility • nurses who administer injections • nurses and physicians in training • ward-based pharmacists in training http://fr.appbrain.com/app/injectable-medicines/air.coim 36 TAKE HOME MESSAGE Hospital and clinical pharmacists can help! 37 LIPID EMULSION Oil phase + fat soluble-dye (Sudan red III) Lipofundin or Disoprivan + Garamycine Phase separation over 24h 38
