Buprenorphine is a broad spectrum, highly lipophilic, and long-acting partial mu opioid receptor agonist that is noncross tolerant to other opioids. Buprenorphine can be given by several routes. Metabolism is through CYP3A4 and CYP2C8 and by conjugases. Constipation and sexual dysfunction appear to be less with buprenorphine than with other opioids. The recent development of a polymer matrix patch delivery system for buprenorphine prevents "dose dumping" and facilitates pain management in those unable to take oral analgesics. Sublingual buprenorphine has been combined with naloxone to prevent illicit conversion to parenteral administration. Buprenorphine has been used extensively to control cancer pain. In certain clinical situations, buprenorphine may have particular advantages over other opioids.

Buprenorphine in cancer pain

PURPOSE OF REVIEW Regional anesthesia is commonly used to provide intraoperative anesthesia and postoperative analgesia. Potential complications of both neuraxial and peripheral regional techniques include infectious sequelae. This review examines important components of practice that are known to minimize the risk of infection associated with regional anesthesia. RECENT FINDINGS Healthcare-associated infections increase morbidity and mortality, patient pain and suffering, direct medical costs, and hospital length-of-stay. Recently published national guidelines from subspecialty societies and government agencies emphasize the importance of strict aseptic technique in the prevention of infectious complications associated with regional anesthesia. Proper hand hygiene, the use of surgical masks, appropriate antiseptic selection and application, and proper preparation of local anesthetic infusate solutions are all considered essential components of asepsis. Anesthesia providers need to adhere to strict aseptic guidelines to minimize the risk of potentially devastating infectious complications. SUMMARY Infectious complications associated with regional anesthesia are exceedingly rare events. Adherence to strict aseptic guidelines as published by the American Society of Regional Anesthesia and Pain Medicine, American Society of Anesthesiologists, and the Royal College of Anaesthetists may reduce the risk of infectious complications.

Infectious complications of regional anesthesia.

Background: During pediatric cardiopulmonary resuscitation (CPR), vasoactive drug preparation for continuous infusion is both complex and time-consuming, placing children at higher risk than adults for medication errors. Following an evidence-based ergonomic-driven approach, we developed a mobile device app called Pediatric Accurate Medication in Emergency Situations (PedAMINES), intended to guide caregivers step-by-step from preparation to delivery of drugs requiring continuous infusion. Objective: The aim of our study was to determine whether the use of PedAMINES reduces drug preparation time (TDP) and time to delivery (TDD; primary outcome), as well as medication errors (secondary outcomes) when compared with conventional preparation methods. Methods: The study was a randomized controlled crossover trial with 2 parallel groups comparing PedAMINES with a conventional and internationally used drugs infusion rate table in the preparation of continuous drug infusion. We used a simulation-based pediatric CPR cardiac arrest scenario with a high-fidelity manikin in the shock room of a tertiary care pediatric emergency department. After epinephrine-induced return of spontaneous circulation, pediatric emergency nurses were first asked to prepare a continuous infusion of dopamine, using either PedAMINES (intervention group) or the infusion table (control group), and second, a continuous infusion of norepinephrine by crossing the procedure. The primary outcome was the elapsed time in seconds, in each allocation group, from the oral prescription by the physician to TDD by the nurse. TDD included TDP. The secondary outcome was the medication dosage error rate during the sequence from drug preparation to drug injection. Results: A total of 20 nurses were randomized into 2 groups. During the first study period, mean TDP while using PedAMINES and conventional preparation methods was 128.1 s (95% CI 102-154) and 308.1 s (95% CI 216-400), respectively (180 s reduction, P=.002). Mean TDD was 214 s (95% CI 171-256) and 391 s (95% CI 298-483), respectively (177.3 s reduction, P=.002). Medication errors were reduced from 70% to 0% (P<.001) by using PedAMINES when compared with conventional methods. Conclusions: In this simulation-based study, PedAMINES dramatically reduced TDP, to delivery and the rate of medication errors. [J Med Internet Res 2017;19(2):e31]

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A Mobile Device App to Reduce Time to Drug Delivery and Medication Errors During Simulated Pediatric Cardiopulmonary Resuscitation: A Randomized Controlled Trial.

Morphine, haloperidol and hyoscine N-butyl bromide combined in s.c. infusion solutions: compatibility and stability. Evaluation in terminal oncology patients.

The administration of drugs by s.c. infusion is routinely practiced in palliative medicine for the management of patients who are no longer able to take oral medication. It is not uncommon for two or more drugs to be combined in s.c. infusion solutions. Unfortunately, the compatibility and stability of haloperidol and hyoscine-N-butyl bromide has not yet been determined. The objective of this study was to study the compatibility and stability of solutions containing both drugs in polypropylene syringes. Nine different solutions were assessed for up to 15 days following preparation. The solutions were prepared in polypropylene syringes with 0.9% saline as a diluent and stored at 4°C and 25°C. High-performance liquid chromatography was the analytical technique used to measure haloperidol and hyoscine-N-butyl bromide. The initial concentration ranges were 0.3125–1.25 mg/ml for haloperidol and 2.5–10.0 mg/ml for hyoscine-N-butyl bromide. Haloperidol was precipitated at a concentration of ≥1.25 mg/ml when it was combined with hyoscine-N-butyl bromide. Concentrations of hyoscine-N-butyl bromide lower than 10 mg/ml in mixtures with haloperidol or 0.625 mg/ml of haloperidol in mixtures with hyoscine-N-butyl bromide for s.c. infusion allow for the administration of both drugs without any significant loss after storage at 25°C for periods of up to 15 days, with approximately ≥90% and 88%, respectively, of haloperidol and hyoscine-N-butyl bromide remaining. However, after storage of the mixtures for equivalent periods at 4°C the losses of hyoscine-N-butyl bromide observed at the end of the study were higher than 20%, while the percentages of haloperidol remaining after 15 days at this temperature were ≥94.37%.

Compatibility of haloperidol and hyoscine-N-butyl bromide in mixtures for subcutaneous infusion to cancer patients in palliative care

Stability of sufentanil and levobupivacaine solutions and a mixture in a 0.9% sodium chloride infusion stored in polypropylene syringes.

Combinations of opioids and adjuvant drug solutions are often used in clinical practice while little information is available on their microbiological or chemical stability. Currently there are no commercially available, prepacked, ready‐to‐use epidural or subcutaneous mixtures. Thus, epidural and subcutaneous analgesic mixtures must be prepared in the pharmacy on an as‐needed basis. Such mixtures are typically used for the treatment of severe pain in cancer patients. The aim of this study was to investigate the microbiological and chemical stability of a buprenorphine, haloperidol and glycopyrrolate mixture in a 0.9% sodium chloride solution. A high performance liquid chromatographic (HPLC) method and pH‐meter were used to conduct the analyses. Antimicrobial activity of each component was studied by an agar dilution method. According to the results from the chemical and microbiological stability studies, this mixture can be stored in polypropylene (PP) syringes and polyvinyl chloride (PVC) medication cassettes for at least 30 days at either 21 °C or 4 °C, and for 16 days in PP syringes at 36 °C, and for 9 days in PVC medication cassettes at 36 °C.

Stability of buprenorphine, haloperidol and glycopyrrolate mixture in a 0.9 % sodium chloride solution

Sufentanil is a potent micro-opioid and centrally acting analgesic. In the management of acute postoperative pain, sufentanil is often administered epidurally using a standard syringe pump. For epidural administration, sufentanil is diluted to a concentration of 1 to 2 micrograms/mL with 0.9% sodium chloride injection. The stability of sufentanil in a syringe pump under simulated epidural infusion was studied using a stability-indicating high-performance liquid chromatography method. The concentration of sufentanil was determined in polypropylene syringes connected with a polyethlyene or polyvinyl chloride (PVC) tubing, filter and epidural catheter. Sufentanil concentrations remained constant in polypropylene syringes connected to epidural catheters and in the whole epidural infusion system using polyethylene tubing. Sufentanil concentrations decreased 7% to 15% in syringes connected to PVC tubing, polyethylene tubing and the whole epidural infusion system using PVC tubing. Adsorption of 17% of the sufentanil onto an epidural filter occurred during the first hour of the infusion; thereafter, sufentanil concentration remained stable at levels that were 5% to 15% below the theoretical concentration. In conclusion, adsorption of sufentanil should be considered when a new filter and tubing of different materials are used.

Anu Rasi

Papers

Stability of sufentanil and levobupivacaine solutions and a mixture in a 0.9% sodium chloride infusion stored in polypropylene syringes.

Stability of buprenorphine, haloperidol and glycopyrrolate mixture in a 0.9 % sodium chloride solution

Stability of Sufentanil in a Syringe Pump Under Simulated Epidural Infusion