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Tuberculin syringe used in the study. Arrow represents zero volume marking of the syringe. When syringe hub contents are given in addition to the 0.25 mL, the administered volume will be 0.29 mL.
Source publication
Background:
In the perioperative period, anesthesiologists and postanesthesia care unit (PACU) nurses routinely prepare and administer small-volume IV injections, yet the accuracy of delivered medication volumes in this setting has not been described. In this ex vivo study, we sought to characterize the degree to which small-volume injections (≤0....
Contexts in source publication
Context 1
... Injection Deviation normal distribution, meaning that the injection volume dif- ferences between a practitioner's first and second injections were greater than expected. 14 Additionally, we modeled the proportional injection vol- ume error at each intended injection volume group if the volume of the syringe hub (0.04 mL) was administered in addition to the intended injection volume (Figure 2). This reflects the scenario in which a practitioner administers con- tents of the syringe hub in addition to the intended injection ...
Context 2
... Injection Deviation normal distribution, meaning that the injection volume dif- ferences between a practitioner's first and second injections were greater than expected. 14 Additionally, we modeled the proportional injection vol- ume error at each intended injection volume group if the volume of the syringe hub (0.04 mL) was administered in addition to the intended injection volume (Figure 2). This reflects the scenario in which a practitioner administers con- tents of the syringe hub in addition to the intended injection ...
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Citations
... However, this practice has the potential for errors and patient safety ( Figure). 2 There is no available evidence of Vitamin K toxicity in ELBW infants. Costakos et al 3 reported serum Vitamin K of over 500 times higher than fasting adult concentrations on day 10 of life in the preterm infant with no documented side effects after Vitamin K administration. ...
... Small volume measurements are associated with large errors (Parshuram et al. 2008;Muffly et al. 2017) and some literature suggest that errors in volume delivery using syringes leads to overdosing (Erstad et al. 2006) which can expose individuals to severe adverse effects. In human studies, dose administration errors are attributed to the volume measured relative to the syringe capacity (Jordan et al. 2019). ...
... The effect of target volume on medication errors is consistent with that reported in previous studies showing that accuracy of syringe measurements decreases as the percentage of nominal volume of the syringe decreases (Lee et al. 1996;Muffly et al. 2017). Muffly et al. (2017) showed that the median absolute error for volumes of 0.025 mL, 0.05 mL and 1 mL were 2.4%, 1.87% Figure 1 Absolute error as a percentage versus target volume (mL). ...
... The effect of target volume on medication errors is consistent with that reported in previous studies showing that accuracy of syringe measurements decreases as the percentage of nominal volume of the syringe decreases (Lee et al. 1996;Muffly et al. 2017). Muffly et al. (2017) showed that the median absolute error for volumes of 0.025 mL, 0.05 mL and 1 mL were 2.4%, 1.87% Figure 1 Absolute error as a percentage versus target volume (mL). Each measurement drawn up by the participants (triangles) is plotted against the target volume, showing the absolute error at each experiment. ...
... Published studies discuss the importance of injection port dead volume on bolus administration based on findings with water-soluble aqueous agents. (Muffly, Chen et al. 2017, Kuntz, Dudaryk et al. 2019 We speculate that, unlike hydrophilic medications, injection port or stopcock orientation impacts entry of medication emulsions into the main fluid pathway, thereby contributing to dose-response variations. ...
Critically ill and anesthetized patients commonly receive life-sustaining medications by pump-driven continuous intravenous infusion. Microinfusion refers to delivering concentrated drugs with low flow carriers to conserve fluid administration. Most infused medications are water-soluble. Delivery onset lag times have been identified for microinfusions of water-soluble drugs or experimental surrogates. Drugs may be formulated as emulsions. Initiation of emulsion microinfusions has not been described. We tested in vitro the hypothesis that an emulsion's physical characteristics would influence its microinfusion delivery onset. We adapted an established in vitro model of pump-driven continuous intravenous microinfusion to compare the delivery of methylene blue as a surrogate for water-soluble drugs and a 10% lipid emulsion as a surrogate for a drug formulated as an emulsion. The drug surrogates joined the carrier with carrier flow vertically upwards, vertically downwards or horizontally. We measured the times to 5%, 50% and 95% of plateau delivery. Emulsion entry into a vertical (upwards) carrier flow resulted in a rapid initial emulsion delivery exceeding predictions of delivery models. Emulsion entry into both horizontal and vertical (downwards) carrier flows resulted in long lag times to steady state. Methylene blue delivery was unaffected by carrier flow orientation. Initiating microinfusion emulsion delivery with upward flow can result in a relative bolus, whereas long delivery lags would be expected with horizontal or downwards flow. An emulsion might carry a high potency drug having significant physiologic effects, e. g. clevidipine. Unrecognized, differences in initial emulsion delivery kinetics depending on carrier flow orientation may have clinical implications for both efficacy and safety.
... The economic impact of drug wastage associated with needle and syringe dead space volumes has also been previously investigated, and for some drugs this can be considerable. The median cost of wastage for a single dose when using high dead space syringes was reported to be $5.40 in a recent study (Oramasionwu et al. 2016). ...
... As for the economic impact of syringe dead space, it can be minimized by selecting the syringe with the smallest dead space volume for the desired syringe size (Oramasionwu et al. 2016). However, here the association is less clear as the cost of the drug lost to dead space should be balanced against the cost of the syringe. ...
... For this reason, it is possible that the discard volumes suggested in this paper would underestimate the actual volume of drug lost. Accuracy and reproducibility of measurements can be influenced by operator experience, technique and fatigue (Muffly et al. 2017, Jordan et al. 2019. Therefore, another operator might generate different results. ...
Objective
To measure the dead space of various syringe volumes and brands and a range of needles gauges commonly used in clinical practice and to compare the results to the International Organization for Standardization (ISO) standard 7886-1:2018.
Study design prospective observational study.
Methods
Syringes of five brands and seven volumes: 1, 2.5, 5, 10, 20, 30, and 60 mL, 10 of each, 10 1 mL low dead space syringes and 10 23, 21 and 18 gauge needles were analyzed. Syringe dead space was estimated by weighing each syringe, drawing up and expelling its rated volume of water for injection and re-weighing the syringe. The difference in mass between the two measurements was calculated and converted to a volume based on the density of water. The dead space of the needles was estimated using a similar technique, each needle was attached to a 1 mL syringe of known dead space. A Mettler electronic balance was used for the measurements. Mean dead space was calculated for each syringe volume and needle gauge. Data were compared to the ISO standard.
Results
Syringe dead space for 1 and 2.5 mL was less than 0.07 mL. For 5 mL syringes 4/5 brands and for 10 mL syringes 1/5 brands did not comply with the ISO; the dead space was greater than 0.075 and 0.1 mL, respectively. For the 20, 30, 60 mL syringes the dead space was less than 0.2 mL. Needle dead space was 0.05 mL for 23 and 21 gauge and 0.07 mL for 18 gauge, similar in order of magnitude to syringe dead space.
Conclusions
The dead space of syringes differs between brands, some do not meet the ISO standard. When calculating the amount of drug lost due to dead space, both that of the syringe and needle used should be considered.
... For larger dosage volumes (300 μl) the relative error can reduce further from 6 to 1.67% (Supplementary Section 5). These error values are within the acceptable range for intraocular injections 37,38 . Alternatively, one could control the delivered dose by continuously monitoring the positions of the two plungers and stopping injecting at a predetermined relative position of plungers, to inject a known amount of dose. ...
The precision of the delivery of therapeutics to the desired injection site by syringes and hollow needles typically depends on the operator. Here, we introduce a highly sensitive, completely mechanical and cost-effective injector for targeting tissue reliably and precisely. As the operator pushes the syringe plunger, the injector senses the loss-of-resistance on encountering a softer tissue or a cavity, stops advancing the needle and delivers the payload. We demonstrate that the injector can reliably deliver liquids to the suprachoroidal space—a challenging injection site that provides access to the back of the eye—for a wide range of eye sizes, scleral thicknesses and intraocular pressures, and target sites relevant for epidural injections, subcutaneous injections and intraperitoneal access. The design of this simple and effective injector can be adapted for a broad variety of clinical applications. © 2019, The Author(s), under exclusive licence to Springer Nature Limited.
... Air contained in this dead-volume has also been attributed to fatal outcomes [7]. Furthermore, the inherent inaccuracy in small volume measurement [8,9] may exacerbate these inconsistencies with the precision of medication delivery. ...
... When attempting to deliver 0.5 units of insulin, the average delivered amount was nearly twice the intended dose. Muffly, et al. measured the accuracy of both pediatric anesthesiologists and pediatric nurses in measuring small volumes [8]. Their experimental design was similar to ours in that it involved the measurement of a fluorescent dye and determination of medication delivery by measurement of sample fluorescence. ...
Injection ports used to administer medications and draw blood samples have inherent dead-volume. This volume can potentially lead to inadvertent drug administration, contribute to erroneous laboratory values by dilution of blood samples, and increase the risk of vascular air embolism. We sought to characterize provider practice in management of intravenous (IV) and arterial lines and measure dead-volumes of various injection ports. A survey was circulated to anesthesiology physicians and nurses to determine practice habits when administering medications and drawing blood samples. Dead-volume of one and four-way injection ports was determined by injecting methylene blue to simulate medication administration or blood sample aspiration and using absorption spectroscopy to measure sample concentration. Among the 65 survey respondents, most (64.52%) increase mainstream flow rate to flush medication given by a 1-way injection port. When using 4-way stopcocks, 56.45% flush through the same injection site. To obtain a sample from an arterial line, 67.74% draw back blood and collect the sample from the same 4-way stopcock; 32.26% use a different stopcock. Mean (SD) dead-volume in microliters ranged from 0.1 (0.0) to 5.6 (1.0) in 1-way injection ports and from 54.1 (2.8) to 126.5 (8.3) in 4-way injection ports. The practices of our providers when giving medications and drawing blood samples are variable. The dead-volume associated with injection ports used at our institution may be clinically significant, increasing errors in medication delivery and laboratory analysis.
... Imagine the implications of a bolus of epinephrine, 8 μg, for the infant versus an adult. Errors associated with the dead volumes of injection ports potentially amplify the impact of errors with injections of small volumes [6]. ...
Somnolence following anesthesia has a broad differential diagnosis. In patients that are former premature infants and undergoing a neurosurgical procedure, the potential causes are even more varied. An understanding of the child’s neurological condition and presenting symptoms of a neurological complication is key. Furthermore, knowledge of the longer-lasting effects of anesthetic agents as well as the clinical presentation of electrolyte abnormalities is imperative to effectively treat this condition.KeywordsIntraventricular hemorrhageVentriculoperitoneal shuntPostanesthetic somnolenceElectrolyte disturbancesAnesthesia for premature infants
