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IV TEMPERATURE, STABILITY AND WARMING FLUIDS Cont.

/ IV ADMINISTRATION, IV safety, IV therapy, PH

The question often comes up: “can I just heat the IV bag up so it is not as cold and painful as it infuses?” The answer, as with all things medical, is “it depends”. In emergency medicine, and during some surgeries, it is common to use a bag warmer for high volume infusions of NS or Ringers. As there are no IV components to degrade, this practice is considered acceptable. Concerns arise when other than base solutions are added to a compounded IV bag or syringe regarding heating those compounded substances. I have written about this in documents [1,2] in regard to stability of additives in relationship to heat, light, pH and other factors. To shorten the discussion and summarize I will state that in general when the following forces interact with an IV solution the potential for degradation occurs: Multiple additives, pH changes, heat, and in some cases light. This happens with ascorbate, glucose and some lipids most quickly, and with the B-Vitamins and some minerals slightly less quickly. Keep in mind that when one adds the physical changes mentioned above in combination the degradation is faster. As a general rule, multiple additive IV nutrient formulations should be used as quickly as possible after compounding. This is outlined in the FDA-USP document and an excerpt is reprinted here:

“The issue with this factor in the question ‘How long can I keep a syringe or IV bag after making it?’ is that while the BUD criteria may indicate storage of a medium-risk (appropriately compounded) sterile product for 9 days under refrigeration (as an example) the pharmacologic stability of that same mixture may degrade far sooner than the 9 day “BUD rule” seems to indicate. The above being the case, there does exist a separate but equally important set of parameters which should be clinically considered in IV nutrient bag preparation and storage. This clinical consideration is degradation and dismutation of the additives in the bag. The import of this portion is that while it may be technically acceptable to store an admixture in an IV bag for the time periods specified the potency of the nutrients in the admixture may not be maintained. This is why various documents and instructors recommend various limits on the time between compounding and use.This second issue of degradation and stability of additives is quite complex in that each nutrient has completely separate stability constants and when one adds them into an IV bag the interactions can accelerate the loss of potency and dismutation. The pharmacologic stability of vitamins and minerals in parenteral solutions is reasonably well studied and published, but becomes a confusing data set when attempting to apply the available data to particular admixtures.”[2]

Overall guidelines for compounding, storage and physical manipulation include the following factors which will include a “best practice”and a clinically and research based “allowable limit”:

Time between compounding the injection or IV solution:
Best practice:

  • Compound the injection or IV directly prior to administration.
  • Potentially allowable limit: Compound the injection or IV and store under refrigeration for up to 24 hours.
  • Storage of injection or IV solutions:Best practice:
  • Aside from immediate use, the compounded injection or IV should be stored in a cold and dark environment (i.e. refrigerator)

Potentially allowable limit:

  • Stored at room temperature in a light abated setting (under a towel or in a container.)

Heating of injection or IV solutions:
Best practice:

  • Compound at room temperature and infuse.

Potentially allowable limit:

  • If cool use an inline heating system rather than heating the solution in the syringe or IV bag.

pH adjustment:

Best practice:

  • Use pH adjuvants (sodium hydroxide, sodium bicarbonate, hydrochloricacid etc.)guided by pH testing to bring the pH of the solution to 6.5 to 7.5 directly prior to infusion.

Potentially allowable limit:

  • Use pH adjuvants (sodium hydroxide, sodium bicarbonate, hydrochloricacid etc.)guided by pH testing to bring the pH of the solution to 6.5 to 7.5on compounding and store up to 24 hours under refrigeration.

Light exposure:

Best practice:

  • Minimize light exposure via above mentioned practices. If a light sensitive product (such as alpha lipoic acid[ALA]) then keep stored and infuse under cover.

Potentially allowable limit:

  • Store and infuse in as low light possible using the time parameters mentioned above. If a light sensitive product (such as alpha lipoic acid) then keep stored and infuse under cover.

*Note: Most IV product does not require light abatement during infusion under normal indoor conditions with the exception of ALA.

References:

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    Bastyr University Clinical Research Center (BCRC) and Anderson Medical Specialty Associates ©
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