Letters
based but thoughtful of patient-specific characteristics. The remaining students, however, performed at varying levels of competency that indicated either ignorance of the need for appropriate drug information skills or a lack of adequate training. The primary literature results were markedly different for each student. For instance, different case reports and case series of equal quality were referenced by each student responding to the same case, suggesting that students accepted the first literature results and halted the search. Possibly more concerning is the fact that some students claimed that they were unable to find any information in secondary references, while other students reviewing the same case found it in abundance. Only the one student receiving full credit identified the “actual question” asked. As teachers of this course, a clear trend toward inadequate performance on these cases has been noted. One possible cause of this issue is the failure to tailor the teaching of drug information to the current student generation. This generation of students was raised with the Internet—access to endless resources, search engines, and immediate answers has always been at their fingertips. This could lead to sloppy and inadequate searches that do not incorporate valid and reputable resources, necessitating a different approach to their education. Teaching this “Google” generation may require additional focus on and reinforcement of techniques for valid search methods, identification of reputable information, and synthesis of gathered evidence into appropriate recommendations. It is also possible that drug information skills are no longer being taught in an active manner or are not given appropriate importance in pharmacy curricula.2 For many years, drug information was considered the only clinical contribution of a largely production-focused profession. As the field of clinical pharmacy has grown and expanded in an environment welcoming multidisciplinary care, drug information as a specialty has been increasingly overlooked. Simultaneously,
the Internet provides access to medical resources to a wide range of clinical professionals, causing the perceived value of drug information skills—the basic ability to retrieve, analyze, and interpret the information necessary to provide appropriate and complete answers—to markedly decrease. The delivery of multiple answers to the same question on this simple case-based homework assignment should alert pharmacy practitioners to the real and concerning effects that a lack of drug information skills can have on the profession, not to mention appropriate patient care, when practitioners cannot provide clear, consistent, and quality information. 1. Mosdell KW, Malone PM. Drug information resources. In: Malone PM, Mosdell KW, Kier KL, Stanovich JE, eds. Drug information: a guide for pharmacists. 1st ed.
Stamford, CT: Appleton & Lange; 1996:2865. 2. Wang F, Troutman WG, Seo T et al. Drug information education in doctor of pharmacy programs. Am J Pharm Educ. 2006; 70:51.
Chelsey McIntyre, Pharm.D., Drug Information Clinical Pharmacy Specialist [email protected] Connie Law, Pharm.D., Drug Information Clinical Pharmacy Specialist Sarah Erush, Pharm.D., BCPS, Clinical Pharmacy Manager Department of Pharmacy Children’s Hospital of Philadelphia Philadelphia, PA
The authors have declared no potential conflicts of interest. DOI 10.2146/ajhp130805
Incompatibility of esmolol hydrochloride and furosemide in a central venous access port
T
he venous access port is an implantable medical appliance for frequent blood sample collection or injectable drug administration in patients with various chronic diseases.1 Few articles have described port catheter occlusion caused by i.v. injection incompatibility.2,3 We report a case in which occlusion occurred after esmolol and furosemide were coadministered through the central venous access port. A 94-year-old man was receiving a continuous i.v. infusion of esmolol hydrochloride 10 mg/mL in 0.9% sodium chloride injection through a central venous access port at a rate of 2 mL/hr. A nurse injected furosemide 20 mg through another site of the catheter into the port during the infusion. After about 10 minutes, the esmolol pump generated an alarm indicating occlusion. The nurse replaced the winged infusion set but the alarm continued to signal. The physi-
cians and nurses doubted the occlusion formed in the central venous access port, so they consulted the pharmacist. Trissel4 found that a cloudy white precipitate formed immediately after esmolol hydrochloride 10 mg/mL was mixed with furosemide 10 mg/mL in a Y-site catheter. Since the port in the patient’s body was not available for examination, we conducted an in vitro study to test the compatibility of esmolol and furosemide in a central venous access port by stimulating the in vivo environment. We filled the pump with 10 mg/mL esmolol hydrochloridea and infused the drug into the catheter and port at a rate of 2 mL/hr. After the system was stabilized for 10 minutes, we slowly injected furosemide 10 mg/mLb through another site of the winged infusion set. White cloudiness immediately formed during Continued on page 902
Am J Health-Syst Pharm—Vol 71 Jun 1, 2014
901
Letters Continued from page 901
the mixing of drugs in the exit catheter of the port, but the system was not occluded throughout the study. We concluded that esmolol and furosemide are incompatible when coadministered in a central venous access port. Our study validated and extended the findings reported by Trissel.4 As esmolol and furosemide are commonly used in patients with cardiac problems, this injectable drug incompatibility is of particular importance. In this case, since the patient’s port and catheter were used many times, the suboptimal surface roughness of the catheter also may have contributed to the occlusion. In addition, since the catheter of the winged infusion set is short, the nurses may not have been able to detect the incompatibility issue instantly after drug administration. Drug incompatibility in venous access ports is often more risky than drug incompatibility in other drug delivery systems due to the risk of embolic events. Infusion Nursing Standards of Practice suggests that vascular access devices should be flushed after each infusion to clear the infused medication from the catheter lumen, preventing contact between incompatible medications.5 In addition to this suggestion, we recommend consulting a pharmacist before mixing any injectable drugs in a venous access port. 1. Walser EM. Venous access ports: indications, implantation technique, follow-up, and complications. Cardiovasc Intervent Radiol. 2012; 35:751-64. 2. Bruch HR, Esser M. Catheter occlusion by calcium carbonate during simultaneous infusion of 5-FU and calcium folinate. Onkologie. 2003; 26:469-72. 3. Lentz YK, Joyce M, Lam X. In vitro stability and compatibility of tenecteplase in central venous access devices. Hemodial Int. 2011; 15:264-72. 4. Trissel LA. Handbook on injectable drugs, 16th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2011:613. 5. Infusion Nurses Society. Infusion nursing standards of practice. Norwood, MA: Lippincott Williams & Wilkins; 2011:S59. a Esmolol hydrochloride 10 mg/mL (100 mg/mL, 2 mL diluted with 18 mL 0.9% sodium chloride injection), Qilu Pharmaceutical Co., Ltd., Jinan, China, lot 3020032ED. b Furosemide 10 mg/mL (20 mg/2 mL), Tianjin Jinyao Amino Acid Co., Ltd., Tianjin, China, lot 1302271.
Bin Zhao, B.S.Pharm., Clinical Pharmacist Pharmacy Department Wenyan Sun, R.N., Professor Parenteral and Enternal Nutrition Department [email protected] Peking Union Medical College Hospital Beijing, China
The authors have declared no potential conflicts of interest. DOI 10.2146/ajhp130526
902
Am J Health-Syst Pharm—Vol 71 Jun 1, 2014
Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
based but thoughtful of patient-specific characteristics. The remaining students, however, performed at varying levels of competency that indicated either ignorance of the need for appropriate drug information skills or a lack of adequate training. The primary literature results were markedly different for each student. For instance, different case reports and case series of equal quality were referenced by each student responding to the same case, suggesting that students accepted the first literature results and halted the search. Possibly more concerning is the fact that some students claimed that they were unable to find any information in secondary references, while other students reviewing the same case found it in abundance. Only the one student receiving full credit identified the “actual question” asked. As teachers of this course, a clear trend toward inadequate performance on these cases has been noted. One possible cause of this issue is the failure to tailor the teaching of drug information to the current student generation. This generation of students was raised with the Internet—access to endless resources, search engines, and immediate answers has always been at their fingertips. This could lead to sloppy and inadequate searches that do not incorporate valid and reputable resources, necessitating a different approach to their education. Teaching this “Google” generation may require additional focus on and reinforcement of techniques for valid search methods, identification of reputable information, and synthesis of gathered evidence into appropriate recommendations. It is also possible that drug information skills are no longer being taught in an active manner or are not given appropriate importance in pharmacy curricula.2 For many years, drug information was considered the only clinical contribution of a largely production-focused profession. As the field of clinical pharmacy has grown and expanded in an environment welcoming multidisciplinary care, drug information as a specialty has been increasingly overlooked. Simultaneously,
the Internet provides access to medical resources to a wide range of clinical professionals, causing the perceived value of drug information skills—the basic ability to retrieve, analyze, and interpret the information necessary to provide appropriate and complete answers—to markedly decrease. The delivery of multiple answers to the same question on this simple case-based homework assignment should alert pharmacy practitioners to the real and concerning effects that a lack of drug information skills can have on the profession, not to mention appropriate patient care, when practitioners cannot provide clear, consistent, and quality information. 1. Mosdell KW, Malone PM. Drug information resources. In: Malone PM, Mosdell KW, Kier KL, Stanovich JE, eds. Drug information: a guide for pharmacists. 1st ed.
Stamford, CT: Appleton & Lange; 1996:2865. 2. Wang F, Troutman WG, Seo T et al. Drug information education in doctor of pharmacy programs. Am J Pharm Educ. 2006; 70:51.
Chelsey McIntyre, Pharm.D., Drug Information Clinical Pharmacy Specialist [email protected] Connie Law, Pharm.D., Drug Information Clinical Pharmacy Specialist Sarah Erush, Pharm.D., BCPS, Clinical Pharmacy Manager Department of Pharmacy Children’s Hospital of Philadelphia Philadelphia, PA
The authors have declared no potential conflicts of interest. DOI 10.2146/ajhp130805
Incompatibility of esmolol hydrochloride and furosemide in a central venous access port
T
he venous access port is an implantable medical appliance for frequent blood sample collection or injectable drug administration in patients with various chronic diseases.1 Few articles have described port catheter occlusion caused by i.v. injection incompatibility.2,3 We report a case in which occlusion occurred after esmolol and furosemide were coadministered through the central venous access port. A 94-year-old man was receiving a continuous i.v. infusion of esmolol hydrochloride 10 mg/mL in 0.9% sodium chloride injection through a central venous access port at a rate of 2 mL/hr. A nurse injected furosemide 20 mg through another site of the catheter into the port during the infusion. After about 10 minutes, the esmolol pump generated an alarm indicating occlusion. The nurse replaced the winged infusion set but the alarm continued to signal. The physi-
cians and nurses doubted the occlusion formed in the central venous access port, so they consulted the pharmacist. Trissel4 found that a cloudy white precipitate formed immediately after esmolol hydrochloride 10 mg/mL was mixed with furosemide 10 mg/mL in a Y-site catheter. Since the port in the patient’s body was not available for examination, we conducted an in vitro study to test the compatibility of esmolol and furosemide in a central venous access port by stimulating the in vivo environment. We filled the pump with 10 mg/mL esmolol hydrochloridea and infused the drug into the catheter and port at a rate of 2 mL/hr. After the system was stabilized for 10 minutes, we slowly injected furosemide 10 mg/mLb through another site of the winged infusion set. White cloudiness immediately formed during Continued on page 902
Am J Health-Syst Pharm—Vol 71 Jun 1, 2014
901
Letters Continued from page 901
the mixing of drugs in the exit catheter of the port, but the system was not occluded throughout the study. We concluded that esmolol and furosemide are incompatible when coadministered in a central venous access port. Our study validated and extended the findings reported by Trissel.4 As esmolol and furosemide are commonly used in patients with cardiac problems, this injectable drug incompatibility is of particular importance. In this case, since the patient’s port and catheter were used many times, the suboptimal surface roughness of the catheter also may have contributed to the occlusion. In addition, since the catheter of the winged infusion set is short, the nurses may not have been able to detect the incompatibility issue instantly after drug administration. Drug incompatibility in venous access ports is often more risky than drug incompatibility in other drug delivery systems due to the risk of embolic events. Infusion Nursing Standards of Practice suggests that vascular access devices should be flushed after each infusion to clear the infused medication from the catheter lumen, preventing contact between incompatible medications.5 In addition to this suggestion, we recommend consulting a pharmacist before mixing any injectable drugs in a venous access port. 1. Walser EM. Venous access ports: indications, implantation technique, follow-up, and complications. Cardiovasc Intervent Radiol. 2012; 35:751-64. 2. Bruch HR, Esser M. Catheter occlusion by calcium carbonate during simultaneous infusion of 5-FU and calcium folinate. Onkologie. 2003; 26:469-72. 3. Lentz YK, Joyce M, Lam X. In vitro stability and compatibility of tenecteplase in central venous access devices. Hemodial Int. 2011; 15:264-72. 4. Trissel LA. Handbook on injectable drugs, 16th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2011:613. 5. Infusion Nurses Society. Infusion nursing standards of practice. Norwood, MA: Lippincott Williams & Wilkins; 2011:S59. a Esmolol hydrochloride 10 mg/mL (100 mg/mL, 2 mL diluted with 18 mL 0.9% sodium chloride injection), Qilu Pharmaceutical Co., Ltd., Jinan, China, lot 3020032ED. b Furosemide 10 mg/mL (20 mg/2 mL), Tianjin Jinyao Amino Acid Co., Ltd., Tianjin, China, lot 1302271.
Bin Zhao, B.S.Pharm., Clinical Pharmacist Pharmacy Department Wenyan Sun, R.N., Professor Parenteral and Enternal Nutrition Department [email protected] Peking Union Medical College Hospital Beijing, China
The authors have declared no potential conflicts of interest. DOI 10.2146/ajhp130526
902
Am J Health-Syst Pharm—Vol 71 Jun 1, 2014
Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
