Central venous catheter infusions: A laboratory model shows large differences in drug delivery dynamics related to catheter dead volume*

Lovich, Mark A.; Peterfreund, Gregory L.; Sims, Nathaniel M.; Peterfreund, Robert A.

doi:10.1097/01.ccm.0000295587.04882.4f

Cited by 27 publications

(18 citation statements)

References 10 publications

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“…When the patient arrived in the PACU the bag was placed on an elevated hook and immediately delivered the phenylephrine that had accumulated in the infusion tubing as a bolus. In the second vignette, concentrated nitroglycerin was flowing into a 9 French introducer sheath and thus the common-volume shown in Figure 1A is over 3.2 mL [18]. As much as one mg of nitroglycerin was inadvertently administered to this patient when an inert carrier flow was either initiated or the rate increased by elevating the carrier bag.…”

Section: Clinical Vignettes Explainedmentioning

confidence: 99%

“…Benchtop (in vitro) modeling of initiating a drug infusion or changing the dose rate of an ongoing infusion shows that there can be a significant lag for the new concentration at the upstream side of the commonvolume to propagate to the patient and achieve the intended steady state delivery. This lag time can lead to delays in intended dose delivery that, under some conditions, can be surprisingly long [12,18,20,21,23]. For infusions into standard central venous catheters of sizeable dead-volume (9 Fr introducer sheath, dead volume~3.2 ml) with inert carrier flow rates designed to minimize excessive fluid administration (10 ml/hr), steady-state drug delivery rates may not be fully realized for over 20 min [18].…”

Section: Common-volume Analysismentioning

confidence: 99%

“…This lag time can lead to delays in intended dose delivery that, under some conditions, can be surprisingly long [12,18,20,21,23]. For infusions into standard central venous catheters of sizeable dead-volume (9 Fr introducer sheath, dead volume~3.2 ml) with inert carrier flow rates designed to minimize excessive fluid administration (10 ml/hr), steady-state drug delivery rates may not be fully realized for over 20 min [18]. Much iatrogenic morbidity and patient lability can be traced back to lack of appreciation for these potentially significant delays [1,18].…”

Section: Common-volume Analysismentioning

confidence: 99%

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Drug Flow Through Clinical Infusion Systems: How Modeling of the Common-volume Helps Explain Clinical Events

Lovich

Peterfreund

2017

Pharmaceutical Technology in Hospital Pharmacy

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AbstractThis review aims to describe analytic models of drug infusion that demonstrate the impact of the infusion system common-volume on drug delivery. The common-volume of a drug infusion system is defined as the volume residing between the point where drug and inert carrier streams meet and the patient’s blood. We describe 3 sets of models. The first is quantitative modeling which includes algebraic mathematical constructs and forward-difference computational simulation. The second set of models is with in vitro benchtop simulation of clinical infusion system architecture. This modeling employs devices including pumps, manifolds, tubing and catheters used in patient care. The final set of models confirms in vitro findings with pharmacodynamic endpoints in living large mammals. Such modeling reveals subtle but important issues inherent in drug infusion therapy that can potentially lead to patient instability and morbidity. The common-volume is an often overlooked reservoir of drugs, especially when infusions flows are slowed or stopped. Even with medications and carriers flowing, some mass of drug always resides within this common-volume. This reservoir of drug can be inadvertently delivered into patients. When infusions are initiated, or when dose rate or carrier flow is altered, there can be a significant lag between intended and actual drug delivery. In the case of vasoactive and inotropic drug infusions, these unappreciated time delays between intended and actual drug delivery can lead to iatrogenic hemodynamic instability. When a drug infusion is discontinued, drug delivery continues until the common-volume is fully cleared of residual drug by the carrier. The findings from all 3 sets of models described in this review indicate that minimizing the common-volume of drug infusion systems may enhance patient safety. The presented models may also be configured into teaching tools and possibly point to technological solutions that might mitigate sources of iatrogenic patient lability.

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Section: Clinical Vignettes Explainedmentioning

confidence: 99%

Section: Common-volume Analysismentioning

confidence: 99%

Section: Common-volume Analysismentioning

confidence: 99%

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Drug Flow Through Clinical Infusion Systems: How Modeling of the Common-volume Helps Explain Clinical Events

Lovich

Peterfreund

2017

Pharmaceutical Technology in Hospital Pharmacy

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“…In addition, there are specific constraints related to the diameter of the catheters and the number of accesses available [26,27]. The catheter characteristics, in particular the type of material which compose it [28] and the internal volume of the device [29,30], have an effect on the volumes delivered to the patient.…”

Section: Factorsmentioning

confidence: 99%

Avoid Drug Incompatibilities: Clinical Context in Neonatal Intensive Care Unit (NICU)

Flamein

Storme

Maiguy-Foinard

et al. 2017

Pharmaceutical Technology in Hospital Pharmacy

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AbstractThe administration of several intravenous products on the same catheter is a very common situation in neonatology, where the stakes are high and the dangers sometimes unknown to clinicians. A large number of factors are involved in this administration, directly related to the installation of the infusion line. Moreover, the therapeutics used are often limited, and excluding classic “Marketing Authorization”. Some of these products may prove to be incompatible and thus lose their effectiveness, or even generate particles that are likely to be administered to the patient. We must be aware of these risks in order to optimize the prescription and administration of these intravenous products, especially as we treat fragile and immature patients. The aim of this work is to review the literature on the subject for the prescribers of neonatology units.

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“…Clinicians presume that the CVC serves as a conduit to the central circulation, and provides a reliable method in the hospital setting to rapidly deliver drugs. 13 Surgeons generally choose the groin (femoral vein) as a the CVC in parathyroidectomy, because of the ease of operation. In addition, the position of the insertion does not affect the surgical site.…”

Section: Introductionmentioning

confidence: 99%

Peripherally inserted central catheters for calcium requirements after successful parathyroidectomy: a comparison with centrally inserted catheters

Yang

Zhang

et al. 2017

annals

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BACKGROUND Intravenous calcium supplements are often required following parathyroidectomy to avoid postoperative hypocalcaemia. The aim of this study was to compare application effect of a femoral central venous catheter (CVC) and peripherally inserted central catheter (PICC) on intravenous calcium supplements after parathyroidectomy. METHODS We retrospectively reviewed the hospital records of 73 patients with secondary hyperparathyroidism who underwent a successful parathyroidectomy at the Huashan Hospital attached to Fudan University between 1 April 2011 and 1 February 2016. RESULTS Of the 73 study participants, 39 (53.4%) had a PICC and 34 (46.6%) had a CVC, respectively. Patients in the CVC group needed 6-7 days of intravenous calcium supplements, while patients in PICC group needed only 2-3 days to achieve normal serum calcium concentration (2.2-2.6 mmol/L). Furthermore, the duration of calcium supplementation was 71.62 ± 4.48 hours in PICC group and 100.4 ± 5.43 hours in CVC group (P < 0.05). Of the patients in PICC group, the incidence of catheter occlusion, operation failure and hypocalcaemia was 0%, which was significantly lower than those in CVC group (2.56%, 7.69% and 7.69%, respectively). CONCLUSIONS PICC is a safe and efficient alternative in contrast to CVC for providing venous access for calcium supplementation in surgical patients after parathyroidectomy.

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Central venous catheter infusions: A laboratory model shows large differences in drug delivery dynamics related to catheter dead volume*

Cited by 27 publications

References 10 publications

Drug Flow Through Clinical Infusion Systems: How Modeling of the Common-volume Helps Explain Clinical Events

Drug Flow Through Clinical Infusion Systems: How Modeling of the Common-volume Helps Explain Clinical Events

Avoid Drug Incompatibilities: Clinical Context in Neonatal Intensive Care Unit (NICU)

Peripherally inserted central catheters for calcium requirements after successful parathyroidectomy: a comparison with centrally inserted catheters

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