How long are drawn up meds considered sterile?

[TheLoneWolf]

A place I had formerly worked had an interesting issue. The only premade syringes in the anesthesia carts was the code concentration epinephrine. All other meds came in concentrated vials and were diluted to standard concentrations by us at the point of care. I had noticed that the majority of the partners would carry around their drawn-up syringes of different pressors and paralytics in zip lock biohazard bags, keep them in their lockers, and use them over several days ie nothing goes to waste. I guess it makes for an easier day to not have to draw up these meds each morning.

I think it's gross and junk anything that wasn't used that day. I simply cannot vouch for the continued sterility of the medication. Cannot find any data to support my concern, though in residency it was standard practice to junk everything at the end of the day.

Thoughts? Anyone ran into something similar? Successful in changing minds?

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[nimbus]

I toss everything at the end of the day. Not evidence based since I don’t know the evidence. Just habit.

 

[markneil]

A place I had formerly worked had an interesting issue. The only premade syringes in the anesthedsia carts was the code concentration epinephrine. All other meds came in concentrated vials and were diluted to standard concentrations by us at the point of care. I had noticed that the majority of the partners would carry around their drawn-up syringes of different pressors and paralytics in zip lock biohazard bags, keep them in their lockers, and use them over several days ie nothing goes to waste. I guess it makes for an easier day to not have to draw up these meds each morning.

I think it's gross and junk anything that wasn't used that day. I simply cannot vouch for the continued sterility of the medication. Cannot find any data to support my concern, though in residency it was standard practice to junk everything at the end of the day.

Thoughts? Anyone ran into something similar? Successful in changing minds?

I was taught 12 hours for propofol after drawing it up when I was a resident. I guess all the other drugs were also wasted at that time if they weren't used.


DIPRIVAN® (propofol) Injectable Emulsion. 451094A/Issued: February 2008. US Food and Drug Administration. http://www.accessdata.fda.gov/
drugsatfda_docs/label/2008/019627s046lbl.pdf. Accessed December 8, 2011

 

[GassYous]

I don't understand the rationale for having drawn up meds except in peds. I appreciate having premade syringes but is taking an extra ten seconds to draw up some prop or ephedrine life changing? It is a ridiculous amount of waste.

I especially hate watching people draw up two sticks of prop for the 45 kg 90 yo. Like why? I wouldn't use old prop but I don't see a problem with using drawn up meds a few days later.

 

[woopedazz]

I was taught 12 hours for propofol after drawing it up when I was a resident. I guess all the other drugs were also wasted at that time if they weren't used.


DIPRIVAN® (propofol) Injectable Emulsion. 451094A/Issued: February 2008. US Food and Drug Administration. http://www.accessdata.fda.gov/
drugsatfda_docs/label/2008/019627s046lbl.pdf. Accessed December 8, 2011

Isn't propofol 4-6 hours after drawing up? Unless it's an infusion, which is the 12 hour rule. I always bin it at 4 hours

 

[IMGASMD]

You guys must had JACHO “inspection” recently.

I will say this. I put everything in my bin at end of the day, whether they’re all squirted out, that’s another question.

We have pre made syringes for phenylephrine, ephedrine and neostigmine. All that being said. If you assume everything is sterile, the vial content, the needle and the syringe, I will even do you one better, someone wipes the top of diaphragm before drawing up the drug. Where is the bacteria being introduced? I think it’s certainly better than opening a room with all the instruments out for hours with people still occasionally walk in and out.

 

[2Fast2Des]

Why people have drugs pre-drawn is baffling, I mean literally you're not saving any meaningful amount of time. And if you are, you must suck at drawing up meds lol. I'm drawing up my induction meds into 1 syringe as the patient is being positioned, and takes me all of 30 seconds. Big cases or something more complex needed then yeah I will bite, but you're not saving time for bread and butter. Its the anesthesia dogma of appearance of preparedness if everything is drawn up, labeled, 3 different ETTs and LMAs lined up, IV start kits and cheaters ready at the helm, God forbid the oral airway isn't out or epi syringe not nearby on standby. Just so much waste!

 

[coffeebythelake]

Propofol 6 to 12 hours depending on formulation. Everything else toss everything at end of day.

 

[turnupthegas]

Toss everything. Everything was prepped as a resident. Attending wise, I draw it up when the patient is in the room. Takes 1 minute.

 

[BLADEMDA]

Physicochemical compatibility of propofol-lidocaine mixture - PubMed

The addition of lidocaine to propofol results in time- and dose-dependent increases in oil droplet diameters in emulsion. This mixture is physicochemically unstable over time and may cause pulmonary embolism, depending on the dose of lidocaine.

pubmed.ncbi.nlm.nih.gov

 

[BLADEMDA]

Recommendations and considerations by the FDA are:

• Both the vial and prefilled syringe formulation must be used on only 1 patient.
• Administration must commence immediately after the vial or syringe has been opened.
• In general anesthesia or procedural sedation: administration from a single vial or syringe must be completed within 6 hours of opening.
• In ICU sedation: propofol administered directly from a vial must be limited to only 1 patient, must commence immediately on opening the vial and must be completed within 12 hrs of opening the vial.

Package Insert Guidelines:​

• Strict aseptic technique must always be used during handling, including hand washing prior to use.
• Propofol should be visually inspected prior to use for:
  • particulate matter
  • discoloration
  • evidence of separation of the phases of the emulsion.
• Do not use if contaminated.
• Prepare for use just prior to administration to each patient.
• The vial rubber stopper should be disinfected using 70% isopropyl alcohol.
• Discard unused portions within the required time limits.

 

[TheLoneWolf]

You guys must had JACHO “inspection” recently.

I will say this. I put everything in my bin at end of the day, whether they’re all squirted out, that’s another question.

We have pre made syringes for phenylephrine, ephedrine and neostigmine. All that being said. If you assume everything is sterile, the vial content, the needle and the syringe, I will even do you one better, someone wipes the top of diaphragm before drawing up the drug. Where is the bacteria being introduced? I think it’s certainly better than opening a room with all the instruments out for hours with people still occasionally walk in and out.

I actually alcohol the tops if the patient is immunocompromised or poorly controlled diabetic. Not the norm where I am but something I picked up in residency from a cardiac anesthesiologist and haven't bothered to change.

 

[NVO]

Funny because during residency we're drilled into having everything imaginable prepped and ready (syringe of sux drawn up, glyco drawn up, additional propofol bottle, mac 3 and miller 2 both on the machine, Macgraph on the back table ready to go with disposable blade already on it, IV start kit, a line start kit, etc). Not allowed to pre-stage 2/2 JACHO so it all has to be done after dropping off the last pt in PACU and pre-oping the next pt. And if your next case is a TIVA youre really screwed running around getting the pumps set up

 

[GassYous]

Funny because during residency we're drilled into having everything imaginable prepped and ready (syringe of sux drawn up, glyco drawn up, additional propofol bottle, mac 3 and miller 2 both on the machine, Macgraph on the back table ready to go with disposable blade already on it, IV start kit, a line start kit, etc). Not allowed to pre-stage 2/2 JACHO so it all has to be done after dropping off the last pt in PACU and pre-oping the next pt. And if your next case is a TIVA youre really screwed running around getting the pumps set up

Yeah that's all dumb. I've had times when the lma doesn't sit or whatnot and I open all the stuff, draw up the paralytic and tube the patient. It doesn't take that long and the patient has never desatted. If they are obese or covid or whatnot I get it but for most patients it is totally unnecessary, especially if you can bag them.

I would probably insist on all that if I worked with some ****ty residents but I don't see why fully trained attendings do it.

 

[banister]

I usually draw up drugs on the back pyxis area for the next case when they're starting to close the current case. Nothing from the current case touches that back table. I sanitize my hands, draw up drugs and put them directly into an empty drawer.

A similar question: do you reuse syringes to draw up different drugs for the same patient (i.e. using your midazolam syringe to draw up decadron after intubation)?

 

[coffeebythelake]

I usually draw up drugs on the back pyxis area for the next case when they're starting to close the current case. Nothing from the current case touches that back table. I sanitize my hands, draw up drugs and put them directly into an empty drawer.

A similar question: do you reuse syringes to draw up different drugs for the same patient (i.e. using your midazolam syringe to draw up decadron after intubation)?

Yes. Yes.

 

[GassYous]

I usually draw up drugs on the back pyxis area for the next case when they're starting to close the current case. Nothing from the current case touches that back table. I sanitize my hands, draw up drugs and put them directly into an empty drawer.

A similar question: do you reuse syringes to draw up different drugs for the same patient (i.e. using your midazolam syringe to draw up decadron after intubation)?

Yes why wouldn't you? I use one 20 or 30 cc syringe for most outpatient cases. I'll save the block syringe and draw up prop in it or whatnot.

If I need to give versed I'll give it in a bigger syringe and draw up the prop in same syringe. then at the end use it to give zofran, toradol, sugammadex. Out plastic problem is big enough without wasting 10 syringes + packaging for basic cases.

 

[MirrorTodd]

I was taught that some study was done (can't remember name) on phenylephrine that found no bacterial contamination on 100ml bags with 10mg drug after at least 6 months.

 

[deleted875186]

I usually draw up drugs on the back pyxis area for the next case when they're starting to close the current case. Nothing from the current case touches that back table. I sanitize my hands, draw up drugs and put them directly into an empty drawer.

A similar question: do you reuse syringes to draw up different drugs for the same patient (i.e. using your midazolam syringe to draw up decadron after intubation)?

I draw up Zofran, dex, Suga all with the roc syringe.

Typically draw a 20mL prop, 5ml roc, push for induction, and use the roc syringe to draw every other med. Will have a 3 cc syringe with a small fent too, but now I’m thinking of eliminating it and just using the two syringes above.

The 10 cc syringe needed for the ETT kills me as well, such a waste. Maybe I’ll try pushing the prop and then using the 20 cc syringe for the cuff.

 

[GassYous]

I use a 20 cc syringe for prop/lido/roc. If I need a lot of prop I'll either use a 30 or 50 cc syringe. You don't need fentanyl until incision. I may give some esmolol if they have heart issues.

You can reuse the 10 cc syringe. I tube, never put anything in the mouth except laryngoscope and tube. I take my gloves off right away and fill the syringe then throw the syringe on the cart. I wipe it down with an alcohol pad although the only thing the syringe touches is the balloon.

 

[woopedazz]

I just get a 1L bag of saline, discard 200mL, and then put everything into that and run it. Propofol, roc, dex, fentanyl, paracetamol (tablet form, crushed up), parecoxib, ondansetron, neostigmine, glycopyrrolate, some phenylephrine if they're old. Hook it up, then I squeeze it. Saved the planet.

 

[GassYous]

I just get a 1L bag of saline, discard 200mL, and then put everything into that and run it. Propofol, roc, dex, fentanyl, paracetamol (tablet form, crushed up), parecoxib, ondansetron, neostigmine, glycopyrrolate, some phenylephrine if they're old. Hook it up, then I squeeze it. Saved the planet.

I've actually seen this anesthetic. Fent, midaz and roc in a bag + gas.

 

[nimbus]

I just get a 1L bag of saline, discard 200mL, and then put everything into that and run it. Propofol, roc, dex, fentanyl, paracetamol (tablet form, crushed up), parecoxib, ondansetron, neostigmine, glycopyrrolate, some phenylephrine if they're old. Hook it up, then I squeeze it. Saved the planet.

This “bag o’ anesthesia” needs to be trademarked.

 

[GassYous]

Funny because during residency we're drilled into having everything imaginable prepped and ready (syringe of sux drawn up, glyco drawn up, additional propofol bottle, mac 3 and miller 2 both on the machine, Macgraph on the back table ready to go with disposable blade already on it, IV start kit, a line start kit, etc). Not allowed to pre-stage 2/2 JACHO so it all has to be done after dropping off the last pt in PACU and pre-oping the next pt. And if your next case is a TIVA youre really screwed running around getting the pumps set up

Not having things ready for the next case can actually be dangerous. JCAHO told us in residency that we couldn't have stuff prepped which became a huge problem on OB. Why can't you have stuff out and ready to go if there's a stat section? I don't want to be held responsible for a bad outcome if a mom aspirates or a kid dies because a bunch of self important suits want to feel like they have a purpose.

I also always had a cardiac setup ready to go in my locker when I was on call. No way I'm going to sit around making hot lines and labelling syringes when I get the call for an emergent takeback.

 

[IMGASMD]

[

This “bag o’ anesthesia” needs to be trademarked.

Sig:

Titrate to minimum signs of life still remaining.

 

[Teillard]

the perfusionists leave primed circuits for weeks at a time on their backup machines

 

[zizzer]

I agree with the overall sentiment that people draw up and open too many things unnecessary, but I at least want a bag of phenylephrine ready usually so I can just draw out of it with a 10mL syringe, so use mine for multiple cases. Some of you may be thinking about cases where you work with CRNAs or residents or perhaps a somewhat healthier patient population. Sometimes when you're the only one with a complex case, having some of the more crucial things ready is the way to go I've found.

 

[2Fast2Des]

I just get a 1L bag of saline, discard 200mL, and then put everything into that and run it. Propofol, roc, dex, fentanyl, paracetamol (tablet form, crushed up), parecoxib, ondansetron, neostigmine, glycopyrrolate, some phenylephrine if they're old. Hook it up, then I squeeze it. Saved the planet.

I make my own diy succ. Roc and sugammadex in the same syringe and flush really fast 🤣

 

[Guillemot]

You hand or other non-sterile objects in the environment can and will touch will touch the pillar of the syringe plunger when the syringe is filled. As the syringe is emptied by pushing down the plunger, the pillar of the plunger then touches the interior of the barrel of the syringe rendering it non sterile.

 

[GassYous]

You hand or other non-sterile objects in the environment can and will touch will touch the pillar of the syringe plunger when the syringe is filled. As the syringe is emptied by pushing down the plunger, the pillar of the plunger then touches the interior of the barrel of the syringe rendering it non sterile.

And is it clinically relevant?

When you do a cardiac case are you changing the flush syringe every time you give a med?

 

[cchoukal]

The JC and USP 797 say that the label we make for medications is supposed to be the time the medication should expire, and that time should be ONE HOUR from when the drug is drawn up, assuming it is done at the bedside and not in a fume hood under sterile conditions. This is not what we're often told in training or in practice, but this is what the JC says.

 

[coffeebythelake]

The JC and USP 797 say that the label we make for medications is supposed to be the time the medication should expire, and that time should be ONE HOUR from when the drug is drawn up, assuming it is done at the bedside and not in a fume hood under sterile conditions. This is not what we're often told in training or in practice, but this is what the JC says.

JCAHO is a clown organization, that make up new rules every year to justify its own existence.

 

[cchoukal]

JCAHO is a clown organization, that make up new rules every year to justify its own existence.

no one is arguing that...