Rx Update: July 2004
Joan Murhammer, R.Ph., Mary Ross, R.Ph., M.B.A., Kevin Bebout,
R.Ph.
Peer Review Status: Internally Reviewed
Warming Solutions
Warming intravenous solutions is sometimes desirable to prevent inducing hypothermia in trauma or surgical patients when massive or rapid infusions are required in a hypovolemic patient or for active core rewarming of hypothermic patients. Solution warming may also be desirable for irrigating solutions used on larger body surface areas or for peritoneal dialysis solutions for patient comfort. It is important to ensure that solutions that are warmed are stable at elevated temperatures, the integrity of the container is not compromised when warmed (e.g., contamination), and that physiologically safe temperatures are used to ensure patient safety.
If a solution is warmed, it must be warmed in a device specifically approved for that purpose. Blanket warmers, microwave ovens, heating pads, computer terminals, etc. should not be used for warming solutions. Irrigation and intravenous solutions in bags should not be heated in water due to an increased risk of infection. Microwave ovens should not be used because there is a potential to damage the solution container. Moreover, microwave oven heating may cause overheating and/or non-uniform heating of the solution that may result in patient injury or discomfort or product degradation. Solutions in bags should be warmed in their overpouches to help prevent evaporation.
The Warming Solution - Expiration Dating and Labeling policy is available on the UIHC Formulary and Handbook (http://www.vh.org/formulary/Hand/warmingsolutions.pdf) and should be consulted for information on whether or not a solution may be warmed and the maximum temperature/length of time it may be warmed. In general, intravenous solution in bags > 150 ml (e.g., NS, D5W, LR) are stable for 14 days up to 104oF. Irrigation solutions in pour bottles (e.g., NS, Sterile Water) are stable for 30 days at 104oF or 72 hours up to 150oF. If a product is not on the chart, the Drug Information Center should be consulted to see if information is available on warming the solution. If no information is available, the solution should not be warmed. All products should be dated when placed into a warming device. Once the solution has been warmed for its maximum time period, it should be removed from the warming device and identified as having been warmed. Solutions should not be re-warmed. The solution may then be used until the manufacturer's expiration date when stored at room temperature. The temperature of the warming device must be monitored daily to verify it is at the temperature safe for the warmed solution.
Antidepressant Medications - Worsening Depression and Suicidality
The FDA recommends close observation for worsening depression or the emergence of suicidality in adult and pediatric patients who are treated with the following antidepressants: fluoxetine (Prozac®), sertraline (Zoloft®), paroxetine (Paxil®), fluvoxamine (Luvox®), citalopram (Celexa®), escitalopram (Lexapro®), bupropion (Wellbutrin®), venlafaxine (Effexor®), nefazodone (Serzone®), and mirtazapine (Remeron®).
Health care providers should carefully monitor patients receiving antidepressants, especially at the beginning of therapy or when the dose either increases or decreases. Although FDA has not concluded that these drugs cause worsening depression or suicidality, worsening of symptoms could be due to the underlying disease or might be a result of drug therapy. Anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity, akathisia, hypomania, and mania have been reported in patients being treated with antidepressants. Although FDA has not concluded that these symptoms are a precursor to either worsening of depression or the emergence of suicidal impulses, there is concern that patients who experience one or more of these symptoms may be at increased risk for worsening depression or suicidality. Therefore, therapy should be evaluated, and medications may need to be discontinued when symptoms are severe, abrupt in onset, or were not part of the patient's presenting symptoms.
Health care providers should instruct patients, their families and their caregivers to be alert for the emergence of agitation, irritability, and the other symptoms described above, as well as the emergence of suicidality and worsening depression. Such symptoms should immediately be reported to the patent's health care provider.