Research on the determinants of injection drug use behavior has traditionally concentrated on factors operating at the individual level. However, more recent studies have found that behaviors surrounding injection drug use are shaped, not only by individual-level characteristics, but also by the environment in which they occur. The risk environment paradigm, proposed by Rhodes and colleagues, describes how factors exogenous to the individual influence high-risk injection behavior and blood borne virus (BBV) transmission among people who inject drugs (PWID). To date, few elements of the risk environment have been evaluated as potential determinants of high-risk injection behavior. The purpose of this dissertation was to study the influence of two elements of the risk environment on unsafe injection practices among PWID – neighborhood socioeconomic disadvantage and social discomfort surrounding the acquisition of sterile syringes from syringe exchange programs (SEPs) and pharmacies. To this end, a systematic literature review was conducted on the relation between neighborhood context and injection drug use behavior. Research gaps and methodological challenges identified in this review were used to design analyses exploring relations among neighborhood disadvantage, social discomfort, and high-risk injection behavior. These analyses were conducted using data collected from 484 PWID enrolled in the Pharmacists as Resources Making Links to Community Services (PHARM-Link) study, combined with data from the American Community Survey. Poisson regression with robust error variance was used to estimate associations between measures of neighborhood socioeconomic disadvantage and high-risk injection behavior. SEP accessibility and drug-related police activity were evaluated as potential modifiers of these relations. Similar methods were used to estimate associations between measures of social discomfort and high-risk injection behavior, including neighborhood socioeconomic disadvantage as a potential effect modifier. The systematic literature review on neighborhood context and injection drug use behavior identified few articles pertaining to this relation (n=22). Selected studies primarily investigated the influence of structural aspects of the neighborhood environment on behaviors surrounding injection drug use, while aspects of the social environment and potential modifiers of neighborhood-behavior relations were understudied. Subsequent quantitative analyses revealed that neighborhood socioeconomic disadvantage was associated with safer injection behaviors among PWID. Injectors in disadvantaged neighborhoods reported less receptive syringe sharing and less unsterile syringe use than their counterparts in relatively better off neighborhoods. Drug-related police activity attenuated associations between neighborhood disadvantage and unsterile syringe use, while the direction of associations between neighborhood disadvantage and the use of unsafe syringe sources varied with levels of SEP accessibility. In neighborhoods with high SEP accessibility, neighborhood disadvantage was associated with decreased use of unsafe syringe sources, while in neighborhoods with low SEP accessibility, neighborhood disadvantage was associated with increased use of unsafe syringe sources. Social discomfort was not associated with high-risk injection behavior, but effect modification was detected between neighborhood disadvantage and two items measuring the quality of relationships between participants and syringe staff: “Pharmacists care about my health and well-being” and “The staff at syringe exchange programs seems to care about my health and well-being.” In disadvantaged neighborhoods, participants who reported positive relationships with syringe staff were less likely to engage in receptive syringe sharing. However, in relatively better off neighborhoods, positive relationships with syringe staff were associated with increased receptive syringe sharing. Overall, the results of this dissertation support the validity of the risk environment paradigm in shaping high-risk injection behavior among PWID. Future studies should continue to investigate contextual factors as determinants of behavior surrounding injection drug use. Understanding how aspects of local-area environments influence injection risk behavior will be essential to eliminating the transmission of BBVs among PWID.

Secondary infusions is a common method to deliver short infusions of intravenous (IV) drugs and fluids. Errors associated with this infusion method have led to patient safety concerns. This study's objective was to empirically evaluate interventions to mitigate secondary infusion risks. Three interventions, including a technology-based intervention (clamp detector on a smart pump), a training-based intervention (educational module), and a practice-based intervention (use of a separate pump for short infusions), were tested in a simulated inpatient unit. The technology-based intervention significantly decreased secondary clamp errors whereas the training-based intervention reduced complex pressure differential errors. The practice-based intervention was the only intervention that significantly decreased both secondary clamp errors and pressure differential errors, but introduced new risks due to mismanagement of residual volume in IV tubing. Study results highlight the need for a combination of mitigation strategies and can help guide the selection of interventions to reduce secondary infusion errors.

Secondary infusions is a common method to deliver short infusions of intravenous (IV) drugs and fluids. Errors associated with this infusion method have led to patient safety concerns. This study's objective was to empirically evaluate interventions to mitigate secondary infusion risks. Three interventions, including a technology-based intervention (clamp detector on a smart pump), a training-based intervention (educational module), and a practice-based intervention (use of a separate pump for short infusions), were tested in a simulated inpatient unit. The technology-based intervention significantly decreased secondary clamp errors whereas the training-based intervention reduced complex pressure differential errors. The practice-based intervention was the only intervention that significantly decreased both secondary clamp errors and pressure differential errors, but introduced new risks due to mismanagement of residual volume in IV tubing. Study results highlight the need for a combination of mitigation strategies and can help guide the selection of interventions to reduce secondary infusion errors.

Thesis (Dr. P.H.)--University of Texas Health Science Center at Houston, School of Public Health, 1994. / Typescript. Includes bibliographical references (leaves 167-172).

Thesis (MNutr)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: Objectives: The objectives of this study were to determine the nutritional content/ contribution of intravenous (IV) fluid and electrolyte administration on the total feeding prescription of intensive care unit (ICU) patients. Methods: Retrospective review of ICU charts of consecutive patients (>18 years) with APACHE II scores ≥10 and on ≥72 hours nutrition therapy (NT) admitted to a medical/surgical ICU. Total fluid, electrolyte, energy and macronutrient intake from nutritional and non-nutritional sources were reviewed from ICU admission until discharge, discontinuation of NT or death for ≤7 days. Energy and protein delivery were compared to calculated targets of 25.4 – 28.6kCal/kg and 1.3 – 1.5g/kg respectively. Summary statistics, correlation coefficients and appropriate analysis of variance were used to describe and analyse the data. Results: A total of 71 patients (49% male), average age 49.2 ± 17.1, average APACHE II score 21.0 ± 6.1, 68% medical and 32% surgical, were included. Fluid and nutrient intake were reviewed over a mean of 5.7 ± 1.1 days. Mean daily fluid delivery was 3.2 ± 0.6L. IV fluid therapy (IVFT) contributed 32.0 ± 12.0% to total fluid delivery (TFD), whereas IV drug administration, including fluids used for reconstitution and dilution purposes, contributed 20.7 ± 8.1% to TFD. Balanced electrolyte solutions (BES) were the crystalloid of choice, prescribed in 91.5% of patients with a mean daily volume (MDV) of 0.5 ± 0.4L. Hypertonic low molecular weight (LMW) 130/0.4kD hydroxyethyl starch (HES) was the colloid of choice, prescribed in 78.9% of patients with a MDV of 0.2 ± 0.1L. Potassium salts were the most frequently prescribed IV electrolyte supplement (IVES), prescribed in 91% of patients (±20 – 60mmol per administration). NT was initiated within 14.5 ± 14.1 hours. The majority (80%) received enteral nutrition (EN). The mean daily energy delivered was 1613 ± 380kCal (25.1kCal/kg), meeting 93.6 ± 17.7% of mean target range (MTR). Mean daily protein delivery (PD) was 72 ± 22g (1.1g/kg), meeting 82.8 ± 19.9% of MTR. Non-nutritional energy sources (NNES), mostly derived from carbohydrate-containing IV fluids, contributed 10.1 ± 7.5% to total energy delivered (156kCal/d). Mean cumulative energy and protein balance was -674.0 ± 1866.1kCal and -86.0 ± 106.9g respectively. The majority (73%) received >90% of the minimum energy target but only 49% >90% of minimum protein target; 59% of those with energy intake 90-110% of target had adequate protein intake. A significant negative correlation was found between cumulative energy/protein balance and the time to initiation of NT (energy: r=-0.28, p=0.02; protein: r=-0.32, p=0.01). Conclusion: In this ICU BES are the crystalloid of choice and hypertonic LMW 130/0.4kD HES the colloid of choice for IVFT. Potassium salts are the most frequently prescribed IVES. NNES added significantly to energy delivery and should be included in the calculation of feeding prescriptions to avoid the harmful effects of overfeeding. Early initiation of EN with conventional products which are energy rich is insufficient to achieve adequate PD. EN formulae with a more favorable nitrogen to non-protein energy ratio could help to optimise PD during the first week of ICU care. / AFRIKAANSE OPSOMMING: Doelwitte: Die doelwit van hierdie studie was om die voedingswaarde/ bydrae van intraveneuse (IV) vog en elektroliet toediening tot die totale voedings voorskrif van pasiënte in ‘n intensiewe sorg eenheid (ISE) te bepaal. Metodes: Retrospektiewe bestudering van die ISE kaarte van agtereenvolgende pasiënte (>18 jaar) opgeneem in ‘n mediese/chirurgie ISE en met APACHE II tellings ≥10 en ≥72 ure voedingsterapie (VT). Totale vog, elektroliet, energie en makronutriënt inname vanaf voedingsverwante en nie-voedingsverwante bronne is vanaf ISE opname tot en met ontslag, staking van VT of sterfte, vir ≤7 dae hersien. Energie en proteiën inname is vergelyk met berekende doelwitte van 25.4 – 28.6kKal/kg en 1.3 – 1.5g/kg onderskeidelik. Beskrywende statisitiek, korrelasie koeffisiënte en toepaslike analises van variansie is gebruik vir data analise. Resultate: 71 pasiënte (49% mans), gemiddelde ouderdom 49.2 ± 17.1, gemiddelde APACHE II telling 21.0 ± 6.1, 68% medies en 32% chirurgie, is ingesluit. Vog en voedingstof inname is hersien oor ‘n gemiddelde tydperk van 5.7 ± 1.1 dae. Gemiddelde vog inname was 3.2 ± 0.6L/dag. IV vog terapie (IVVT) het 32.0 ± 12.0% bygedra tot totale vog inname (TVI). IV medikasie toediening, insluitende die herkonstruksie en verwatering van medikasie, het 20.7 ± 8.1% bygedra tot TVI. Die mees voorgeskrewe kristalloiëd en kolloiëd vir IVVT was gebalanseerde elektroliet oplossings (GEO), voorgeskryf in 91.5% van pasiënte (gemiddeld 0.5 ± 0.4L/dag), en hipertoniese lae molekulêre gewig (LMG) 130/0.4kD hidroksie-etiel stysel (HES), voorgeskryf in 78.9% van pasiënte (gemiddeld 0.2 ± 0.1L/dag), onderskeidelik. Die mees voorgeskrewe IV elektroliet supplement was kalium soute, voorgeskryf in 91% van pasiënte (±20 – 60 mmol per toediening). VT is binne 14.5 ± 14.1 ure geinisieër. Die meerderheid (80%) het enterale voeding (EV) ontvang. Die gemiddelde daaglikse energie inname van 1613 ± 380kCal (25.1kKal/kg) het 93.6 ± 17.7% van die gemiddelde doelwit rykwydte (GDR) bereik. Die gemiddelde daaglikse proteiën inname van 72 ± 22g (1.1g/kg) het 82.8 ± 19.9% van die GDR bereik. Nie voedings-verwante energie bronne (NVEB), meestal vanaf koolhidraat-bevattende IV vloeistowwe, het 10.1 ± 7.5% tot totale energie inname (TEI) bygedra (156kKal/d). Die gemiddelde kumulatiewe energie en proteiën balans was -674.0 ± 1866.1kKal en -86.0 ± 106.9g onderskeidelik. Die meerderheid (73%) het >90% van die minimum energie doelwit (ED) bereik. Slegs 49% het >90% van die minimum proteiën doelwit (PD) bereik. Opsomming: Die kristalloiëd en kolloiëd van keuse vir IVT is GEO en hipertoniese LMG 130/0.4kD HES onderskeidelik. Kalium soute word mees algemeen voorgeskryf. NVEB dra beduidend by tot TEI en moet inaggeneem word tydens die berekening van voedingsvoorskrifte ten einde oorvoeding te voorkom. Vroeë inisiëring van EV met konvensionele energie-ryke EV produkte is onvoldoende om genoegsame proteiën inname te verseker. EV produkte met ‘n gunstiger stikstof tot nie-proteiën energie verhouding sal help om proteiën inname gedurende die eerste week van intensiewe sorg te optimaliseer.Slegs 59% van pasiënte met genoegsame energie inname (90-110% van ED) het hul minimum PD bereik. Daar was ‘n beduidende negatiewe korrelasie tussen kumulatiewe energie/proteiën balans en die tyd tot inisiëring van VT (energie: r=-0.28, p=0.02; proteiën: r=-0.32, p= 0.01).

Thesis (Mcur)--Stellenbosch University, 2012. / ENGLISH ABSTRACT: A literature study showed that the topics of medication safety and medication error prevention have been studied in depth. Findings from the literature revealed that medication errors are reported to be common in neonatal and paediatric ICUs, that more than half of these errors are preventable and that risk reduction measures protect patients against untoward outcomes or adverse events (Clifton-Koeppel, 2008:72). If and when there is a failure in the process of safe medication administration, it results in a medication error, which is defined as a breach of one or more of the five rights of medication administration (Institute for Safe Medication Practices Alert, 2007:1). Medication administration, which is predominantly a nursing task, is of high risk and high volume in the intensive care unit (ICU). The accuracy of intravenous medication administration is critical for a neonatal and paediatric ICU patient since it can potentially heighten the patient’s vulnerability if further harm is caused. In view of the complexity of medication administration for neonatal and paediatric ICU patients, researchers confirm the diverse role of the registered nurse in safe medication administration practices. The purpose of the study was to describe the perceptions of registered nurses (RNs) regarding the factors that influence IV medication safety practice in the neonatal intensive care unit (NICU); paediatric intensive care unit (PICU); and paediatric cardiac intensive care unit (CSICU) in Saudi Arabia. The study objectives were set to describe the actual factors that have an influence on IV medication safety practices of RNs working in these ICUs; to determine the knowledge of registered nurses in the selected ICUs with regard to safe intravenous medication administration practices and to describe nursing medication administration strategies that are focused on medication error prevention. A quantitative research approach was selected for this study which had a descriptive, survey design. An 85% non-probability purposive sampling method was used to draw a sample (n=103) of the target population of NICU-, PICU- and CSICU-registered nurses (N=121) who were responsible for administering intravenous medication at King Faisal Specialist Hospital and Research Centre in Jeddah (KFSHRC-J). A self-administered questionnaire with closed-ended Likert and open-ended question was designed to describe the objectives under study. A pilot study was conducted to pre-test the questionnaire. A quantitative method was used to analyse the study data. MS Excel was used to capture the quantitative data after which it was analysed using descriptive statistics by means of STATISTICA 9 software. The open–ended questions (indicating “other” and Question 70) were also interpreted quantitatively after exploring the main aspects in the responses. The main findings were that multiple perceived factors influence the intravenous medication safety practices of RN’s working with neonatal and paediatric ICU patients in a particular Saudi Arabian tertiary hospital. It was found that these nurses’ had knowledge regarding safe medication administration practice that constitutes that all five medication rights have to be checked through nursing ‘double-checks’ in the steps of medication administration, as the method of checking as per hospital policy. However, from the findings, it is reflected that RNs perceptions of completely and correctly checking medication rights through complete and independent nursing ‘double-checks’, do not match the steps required by policy and that their knowledge is inadequate. It is evident from the perceptions of RNs that they are aware of the multiple factors influencing IV medication safety practice in this vulnerable patient setting. As perceived by RNs, it is possible to implement more safety strategies. Key recommendations on conclusion of the study include that there are more nursing medication administration strategies that could still be implemented for medication error prevention. These strategies relate to medication safety awareness, the role of the nurse and nursing managers, mandatory staff education, and review of knowledge and skills. / AFRIKAANSE OPSOMMING: Gebaseer op ʼn literatuurstudie blyk dit dat medikasieveiligheid en voorkoming van medikasiefoute reeds in diepte bestudeer are. Bevindings dui daarop dat medikasiefoute algemeen voorkom in neonatale en pediatriese intensiewesorgeenhede, dat meer as die helfte daarvan voorkombaar is, en dat maatreëls om risiko te vermindering pasiënte teen voorkombare uitkomste beskerm (Clifton-Koeppel, 2008:72). Indien en wanneer die proses vir veilige medikasietoediening faal, kom ʼn medikasiefout voor, wat gedefinieer word as die verbreking van een of meer van die vyf medikasieregte (Institute for Safe Medication Practices Alert, 2007:1). Medikasietoediening is hoofsaaklik ʼn verpleegtaak, wat ʼn hoërisiko- en hoëvolume-taak behels. Die akkuraatheid van intraveneuse medikasietoediening is kritiek vir neonatale en pediatriese intensiewesorgpasiënte, aangesien hul weerloosheid verhoog word indien verdere skade veroorsaak word. Omrede medikasietoediening vir neonatale en pediatriese intensiewesorgpasiënte kompleks is, bevestig navorsers dat geregistreerde verpleegkundiges se rol ten opsigte van veilige medikasietoediening veelsoortig is. Die doel van die studie was om die persepsies van geregistreerde verpleegkundiges aangaande die faktore wat medikasieveiligheid in die neonatale en paediatriese intensiewe eenhede in Saoedi-Arabië beinvloed, te beskryf. Studiedoelwitte is gestel om die spesifieke faktore te beskryf wat aanleiding gee tot medikasietoedieningsfoute in die genoemde intensiewesorgeenhede; om geregistreerde verpleegkundiges in die geselekteerde intensiewesorgeenhede se kennis van veilige medikasietoediening te bepaal; en die medikasietoedieningstrategieë wat op die voorkoming van medikasietoedieningsfoute fokus, te beskryf. ʼn Kwantitatiewe navorsingsbenadering is geselekteer vir die studie wat ʼn beskrywende navorsingsontwerp gehad het. ʼn 85% nie-waarskynlike gerieflikheidsteekproef is gebruik om ʼn steekproef (n=103) te selekteer vanuit die teikenpopulasie geregistreerde verpleegkundiges (N=121) wat verantwoordelik was vir medikasietoediening in die geselekteerde intensiewesorgeenhede by King Faisal Specialist Hospital and Research Centre, Jeddah (KFSHRC-J). ʼn Self-geadministreerde vraelys met geslote Likert- en oop-eindevrae is opgestel om die gestelde studiedoelwitte te ondersoek. ʼn Vooraf-toetsing van die vraelys is tydens die loodsstudie uitgevoer. ʼn Kombinasie van kwantitatiewe en kwalitatiewe metodes is gebruik vir die ontleding van die studie-data. Die kwantitatiewe data is op MS Excel ingevoer, waarna beskrywende statistiek deur middel van Statistica 9-sagteware gebruik is om dit te ontleed. Die studie het hoofsaaklik bevind dat veelvuldige faktore die veiligheidspraktyk ten opsigte van intraveneuse medikasie van geregistreerde verpleegkundiges wat met neonatal en pediatriese intensiewesorgpasiënte in ʼn spesifieke tersiêre hospitaal in Saoedi-Arabië werk, beïnvloed. Dit blyk dat hierdie verpleegkundiges se kennis voldoende is aangaande ‘n veilige medikasie toedieningspraktyk wat bestaan uit die kontrolering van al vyf medikasieregte deur verpleegkundige dubbel-kontrolering, soos beskryf is in die hospitaalbeleid. Volgens die bevindinge blyk dit egter dat die verpleegkundiges se persepsie van volledige and korrekte verpleegkundige dubbel-kontrolering, nie met die stappe volgens die hospitaalbeleid ooreenstem nie en dat hulle kennis onvoldoende is. Dit is duidelik dat die verpleegkundiges bewus is van die veelvuldige faktore wat intraveneuse medikasieveiligheidpraktyk vir weerlose pasiënte beïnvloed. Die verpleegkundiges se persepsie is dat daar meer verpleegkundige medikasietoedieningstrategieë is wat geïmplementeer kan word om medikasiefoute te voorkom, insluitende veiligheidsbewustheid ten opsigte van medikasie, die rol van verpleegkundiges en verpleegbestuurders, verpligte personeelopleiding, en hersiening van kennis en vaardighede.

This ethnography of intravenous (IV) drug users challenges popular representations of a "junkie" subculture and stereotypes of users as rejecting the dominant cultural values of mainstream society. Users attempts to construct and maintain a moral identity are examined. Beyond "war stories" ennobling street life and survival, life narratives were constructed through a juxtaposition of voices and images establishing moral worth in opposition to others. Moral identity is a central concern for IV drug users, one influencing their response to risk. Social relations, responsibility, and an ethic of care were found to underlay the moral codes developed by users, codes socially-embedded and to some degree gender specific. Men tended to adopt a "tough guy," "independence" voice in which responsibility was largely framed around status and image as a role model. Women tended to see responsibility and morality within a web of interdependence and care. Social responsibility was a measure of moral goodness. The desire to be defined by mainstream values was strongly evident among women users who were mothers. Motherhood was a core symbol representing inherent goodness, a marker of moral identity, and a means toward achieving a socially acceptable identity. The identities of "junkie" and "mother" placed women in a state of perpetual tension and conflict as manifested in issues of child custody and welfare. Maintaining relationship with their children was central to the women's moral identity, be it based in daily interaction or visitations inspiring hopes for a future. This ethnography suggests that IV drug users, while chemically dependent, maintain a sense of agency. Contrary to stereotypes of irresponsibility, users are reflexive about their habit's control and their use of drugs to block suffering, social responsibility, and the pain they cause others. Displays of agency and exercises of control proved critical in identity construction, particularly for women users diagnosed HIV positive. Documented was the process whereby they redefined their "health" and moral identity in the company of others who assisted in constructing identities in contrast to the negative stereotypes of AIDS. Through discourse within these "life narrative groups" a positive diagnosis was transposed into a positive identity.

The goal of this elaborate work was to describe the most often medication misconducts, errors and risks during the intravenous drug administration and dilution in the field of primary care in the Intensive Care Unit - ICU. My interest was to find out about local ICU's standards and regulations and to survey how knowledgeable nursing stuff is towards medication hazard regulation and its affect. The first theoretical part concentrates on conception of IV drug administration and dilution. It charts and shows the situation at the current time. Empirical section of my elaborate work shows findings based upon questionnaire. It serves the purpose of hypothesis verification and confirms the goals of my study. Obtained information should be a foundation for future processing and utilization standards regulation or recommendation how to safely administrate intravenous drugs.

La perfusion intraveineuse occupe une large place dans les services de soins cliniques. Les patients reçoivent de nombreux médicaments simultanément dans la même voie centrale, où des problèmes de compatibilité entre les médicaments peuvent survenir. La maitrise de ces incompatibilités médicamenteuses, génératrices de particules, représente donc un enjeu majeur dans la prise en charge des patients polymédiqués.La première partie de ce travail est une analyse de la littérature portant sur les incompatibilités médicamenteuses et leurs principales conséquences sur le plan clinique. A ce titre, un chapitre est dédié à l’ensemble des moyens de prévention de ces problèmes, parmi lesquels l’usage de filtres en ligne de perfusion ou de dispositifs de perfusion multi-lumières.La première partie de nos travaux expérimentaux est consacrée à l’évaluation de la filtration terminale comme stratégie de prévention de l’administration de particules aux patients. Dans ce contexte, nos travaux ont porté sur le noircissement des filtres en ligne observé dans un service de réanimation néonatale. L’objectif était de définir la nature de l’incompatibilité en cause et de s’assurer, dans un second temps, de l’efficacité des filtres malgré les phénomènes de noircissement. Les filtres ont été examinés par microscopie électronique et comptage particulaire. Un aminogramme de la nutrition parentérale a également été réalisé. Une interaction spécifique a été mise en évidence entre un acide aminé (la cystéine) et un oligoélément (le cuivre) dans les poches. De plus, le maintien de la fonction des filtres en ligne a été démontré.La seconde partie de nos travaux est axée sur l’évaluation de l’intérêt d’un dispositif médical multi-lumières innovant dans la prévention des incompatibilités médicamenteuses. Le premier travail mené dans cette thématique a montré in vitro son intérêt à prévenir la survenue d’incompatibilités physiques entre plusieurs associations médicamenteuses, allant de deux à six médicaments administrés simultanément. Nos résultats indiquent que la conception de ces nouveaux dispositifs de perfusion et notamment leur géométrie interne permet de minimiser le temps de contact entre les produits, et ainsi d’améliorer la compatibilité entre les produits, au même titre que le type de solution d’hydratation. Le second travail consistait à poursuivre l’évaluation de ces dispositifs de perfusion multi-lumières en reproduisant un protocole de perfusion utilisé habituellement en hématologie pédiatrique et associant plusieurs médicaments incompatibles à l’origine de précipité. Un comptage particulaire réalisé de manière dynamique a permis de montrer que l’emploi de ces dispositifs permettait de réduire significativement la charge particulaire administrée aux patients, en comparaison avec les dispositifs standard de perfusion (rampes de robinets).Les résultats de l’ensemble de nos travaux sont prometteurs pour l’amélioration de la prise en charge des patients. Ils doivent être maintenant confirmés au travers d’une étude clinique. / Intravenous infusions are extensively used in clinical wards. Patients simultaneously receive many drugs through a limited number of venous accesses, thus increasing the risk of physical drug incompatibilities. Preventing incompatibility is therefore important for the safe administration of injectable drugs of polymedicated patients.The first part of this work consisted in analysing published literature on drug incompatibilities and their clinical consequences. This chapter includes a review of tools preventing drug incompatibilities, which include in-line filtration or the use of multi-lumen infusion sets.The first part of our experimental work is dedicated to the evaluation of terminal in-line filtration for preventing the injection of drug particles to patients. In this context, our research has focused on the blackening of in-line filters, which have been observed during the infusion of binary parenteral nutrition (BPN) delivered in a neonatal intensive care unit. The purposes of our study were, first, to examine the elemental content of precipitates isolated from infused BPN bags and so determine the main physicochemical interactions occurring in them and, second, to evaluate the blackening effect of in-line filters on filtration capacity. Filter membranes were examined by scanning electron microscopy and energy dispersion spectroscopy. Amino acid (AA) profiles were obtained from BPN mixtures to determine the concentrations of each AA. A specific interaction was identify between cysteine and copper in our BPN. Despite the gradual blackening of in-line filters during BPN bag infusion, the filter membranes continued to filter solutions efficiently and safely.The second part of our work focused on the assessment of the impact of new multilumen infusion access devices on the occurrence of known drug incompatibility.The first study used a well-documented incompatible combination of two to six drugs and three different carrier fluids. The multilumen infusion access device was able to prevent the occurrence of drug incompatibilities in nearly half of the drug combinations tested. This study confirmed that the characteristics of an infusion device have an impact on drug physical incompatibilities. The main hypothesis is those fluid dynamics differ according to infusion device and accesses, which modify the contact time between drugs and the infusion vehicle.The second in vitro study focused on a pediatric multidrug protocol for patients diagnosed with lymphoblastic leukemia and receiving allogeneic transplantation. A dynamic particle count test was used over 24 hours to evaluate the overall particulate contamination. The use of a multi-lumen infusion set reduces significantly overall particulate contamination compared to the standard infusion set.These results pave the way to performing a randomized controlled clinical trial assessing the multilumen infusion access device.

Ce travail de doctorat s’inscrit dans un projet de recherche destiné à évaluer la charge particulaire issue des incompatibilités physico-chimiques d’origine médicamenteuse de patients admis en réanimation pour un état de choc septique ou un syndrome de détresse respiratoire aigüe. Le corollaire est de faire le lien avec la survenue de certaines complications (syndrome inflammatoire et dysfonction d’organe) susceptibles de menacer le pronostic vital. En effet, la dysfonction microcirculatoire caractéristique de ces patients pourrait être majorée par la contamination particulaire aboutissant ainsi à une aggravation de l’hypo-perfusion tissulaire et à la survenue du syndrome de défaillance multi viscérale.La première partie de ce travail a consisté en une analyse de la littérature portant sur les incompatibilités médicamenteuses et leurs principales conséquences cliniques sous forme d’une revue systématique. Un des messages essentiels est l’intérêt grandissant de la filtration en ligne comme moyen de prévention de la contamination particulaire bien mis en évidence par certains essais contrôlés randomisés en particulier pédiatriques.La seconde partie de ce travail était de mener, dans une première phase, une étude d’observation clinique au lit du malade des dispositifs de perfusion intraveineux habituellement utilisés et des médicaments le plus souvent administrés à ces patients de réanimation du CHU de Lille. La deuxième phase consistait à reproduire in vitro le montage de perfusion utilisé en clinique avec les différentes solutions médicamenteuses dans le but de quantifier la charge particulaire à laquelle sont exposés les patients. Le comptage particulaire a été réalisé de manière dynamique, selon une technique innovante, grâce à un analyseur de particule connecté au montage de perfusion.Ce travail nous a permis finalement d’évaluer le risque particulaire pour ces patients fragiles et de proposer une stratégie de prévention des incompatibilités médicamenteuses. / Our PhD work aimed to evaluate the particulate exposure induced by drug incompatibilities in patients admitted in ICU for a septic shock or acute respiratory distress syndrome. The purpose was to establish a link with the occurrence of certain complications (inflammatory syndrome and organ dysfunctions) susceptible to aggravate life threatening. Indeed, the microcirculatory dysfunction characteristic of these patients could be increased by the particulate contamination, compromising tissue perfusion and leading to the occurrence of multi organ failureThe first part of this study consisted in a systematic literature review on the clinical implications of drug incompatibilities. One of the essential messages is the growing interest of inline filtration to prevent particulate contamination, highlighted by randomized controlled trials especially in pediatric ICU.The second part of the study was to conduct, in a first phase, an observational study, at the ICU patients’ bedsides, of the commonly used intravenous drugs and infusion sets. The second phase was to reproduce in vitro the previous observed infusion lines using the observed drugs combination, in order to quantify the particulate exposure, during a simulated 6-hour infusion period. The particle counting was performed using an innovative dynamic image analysis device.Our work indicates the amount of particulate matter potentially administered to critically-ill adult patients and paves the way to a strategy of prevention of drug incompatibilities.