Safe Injection Practices for Administration of Propofol

1 safe Injection Practices forAdministration of PropofolCECIL A. KING,MS, RN;MARY OGG,MSN, RN, CNORABSTRACTS epsis and postoperative infection can occur as a result of unsafe Practices in theadministration of Propofol and other injectable medications. Investigations of infec-tion outbreaks have revealed the causes to be related to bacterial growth in orcontamination of Propofol and unsafe medication Practices , including reuse ofsyringes on multiple patients, use of single-use medication vials for multiple pa-tients, and failure to practice aseptic technique and adhere to infection controlpractices.

2 Surveys conducted by AORN and other researchers have provided addi-tional information on perioperative Practices related to injectable medications. In2009, the US Food and Drug Administration and the Centers for Disease Control andPrevention convened a group of clinicians to gain a better understanding of the issuesrelated to infection outbreaks and injectable medications. The meeting participantsproposed collecting data to persuade clinicians to adopt new Practices , developingguiding principles for Propofol use, and describing Propofol -specific, site-specific,and practitioner-specific Injection techniques.

3 AORN provides resources to helpperioperative nurses reduce the incidence of postoperative infection related to med-ication J95 (March 2012) 365-372. AORN, Inc, 2012. words:sterile injectable medications, Propofol , sepsis, safe Injection prac-tices, safe medication the past 10 years, there has beengrowing concern regarding postoperativeinfections associated with the handling ofinjectable medications; more specifically, clustersof sepsis and postoperative infections have oc-curred related to the use of isa sterile, IV, lipid-based, emulsive anestheticagent.

4 It was approved by the US Food and DrugAdministration (FDA) in 1989 and has beenwidely used in the United States since that a lipid-based emulsion, this medication isknown to support bacterial 1990, one year after Propofol was ap-proved for use, the Centers for Disease Controland Prevention (CDC) investigated four clustersof postsurgical infections and hyperthermic investigators traced the infectionsand reactions to several factors, including ex-trinsic contamination of the agent that resultedfrom lapses in aseptic technique during the han-dling of the medication, use of Propofol by in-fusion pump, and preparation of the infusionpump by one anesthesia provider.

5 The sameinfusion pump, syringe, and provider weredoi: AORN, Inc, 2012 March 2012 Vol 95 No 3 AORN Journal365identified as risk factors in two of the outbreaks of infection prompted thepharmaceutical company that manufactures propo-fol to add language to the product circular statingthat strict aseptic technique must always bemaintained during handling .. 5and preparationof Propofol for Injection . The FDA issued propo-fol Administration guidelines based on recommen-dations from the CDC,4the American Society ofAnesthesiologists,6and the Anesthesia PatientSafety Foundation7that are similar to themanufacturer s recommendations summarized inTable 1.

6 All recommendations were based on thefollowing facts: Propofol is a lipid-based emulsion that sup-ports bacterial Bacterial contamination increases rapidly Disinfection of Propofol ampules or vials be-fore opening considerably reduces the risk ofbacterial contamination of the edetate, which inhibits bacterial growth,was added to Propofol in 1996; as a result, theincidence of Propofol Injection infections wasreduced but not a 10-year period from 1998 to 2008, 35documented outbreaks of hepatitis occurred innonhospital health care facilities (eg, pain clinics,endoscopy clinics, hemodialysis centers)

7 , whichput more than 60,000 patients at risk for develop-ing bloodborne pathogen out-breaks were traced to reuse of syringes on multiple patients, single-use medication vials used for multiplepatients, failure to practice aseptic technique, and failure to follow fundamentals of infectioncontrol 2002, the Oklahoma State Department ofHealth investigated an unexplained outbreak ofhepatitis C (HCV).12 All the infected patients hadbeen treated for pain at the same outpatient Oklahoma health department was able to test795 (88%) of the patients who had been treatedsince the clinic opened and found that 71 patientshad contracted HCV and 31 had contracted hepa-titis B during 2002.

8 Interviews with staff mem-bers regarding Injection Practices revealed thatcare providers used a single needle andsyringeto administer three different sedation medica-tions. In addition, these providers used theTABLE 1. Propofol Handling Guidelines1US Food and Drug AdministrationrecommendationsGeneral product insert guidelines Vials of Propofol and prefilled syringes are intendedfor single (ie, one patient) use. Begin infusion immediately after drawing up oropening the vial of medication. Infusion from prefilled syringes or vials must beginwithin 6 hours of opening/filling the syringe.

9 Propofol that is infused directly from a large volume(eg, 100 mL) vial is to be limited to one patient andmust be infused within 12 hours of opening the vialor spiking the stopper. Strict aseptic technique must always be used when handlingsterile injectable medications. Propofol should be inspected before use for particulatematter, discoloration, or evidence of separation of theemulsion. Do not use if contaminated. Fill syringes or spike the vial immediately before administrationto each patient. Disinfect the rubber stopper with 70% isopropyl alcohol.

10 Discard unused portions within 6 hours of filling syringes or 12hours after spiking a large volume vial for DIPRIVAN ( Propofol ) Injectable Emulsion. 451094A/Issued: February 2008. US Food and Drug Accessed December 8, 2012 Vol 95 No 3 KING OGG366 AORN Journalsame needle and syringe to administer thesemedications to all of the patients treated thatday. Results of the investigation suggest thatthe infections were transmitted from patient topatient after a provider used a syringe and nee-dle on a patient positive for hepatitis and thenused the same syringe and needle to administermedication to subsequent patients.