Little bits of the propofol stopper

[deleted162650]

I love how people live in their own bubbles and then want to argue about stuff that they haven’t ever seen, know nothing about, as if it doesn’t exist.

Have you been to every hospital pharmacy in America? In your state? Even your city?

The DEA decides what is controlled and what isn’t. Not your local pharmacy.

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[DrZzZz]

The plastic cap is just a dust cover. The top of the vial is not - and wasn’t ever - sterile.

Are we not inoculating the vial every time we puncture the top to draw up meds, regardless of whether there was any coring of the top into the vial? I don't recall seeing high rates of sepsis postop being blamed on this. I'm not disagreeing that the top isn't sterile, just that it's inconsequential.

 

[deleted162650]

I agree it’s mostly inconsequential. But you probably end up with more bugs in there from a piece of stopper floating around than however many you drag in with the needle alone.

 

[chocomorsel]

The DEA decides what is controlled and what isn’t. Not your local pharmacy.

Thanks for that bit of knowledge. Clearly I was unaware that the DEA gave me hospital privileges and paid me. I follow the rules of my hospital if I want to continue working there and getting paid.
You do you.
I was not responding to you. I specifically quoted someone else.

 

[IMGASMD]

The plastic cap is just a dust cover. The top of the vial is not - and wasn’t ever - sterile.

So we all wipe the top of propofol or all drugs with alcohol and wait before we draw from the vial? (Not directly at you, salty. Because I will be the first to admit the chance that I don’t is much higher than the chance that I do)

Someone must have done a study to culture either the plastic too and/or rubber to see if there is actually any significant bugs that’s actually there?

 

[drmwvr]

Does anyone use a particular type of tool to pull off the tops of the propofol vials? If you have a particular tool that works well please post a picture or link.

works for any rubber stopper with aluminum collar. Just imagine using it on a beer bottle. One limb under the edge, one on top and rock back the cap.

 

[MoMoGesiologist]

Are we not inoculating the vial every time we puncture the top to draw up meds, regardless of whether there was any coring of the top into the vial? I don't recall seeing high rates of sepsis postop being blamed on this. I'm not disagreeing that the top isn't sterile, just that it's inconsequential.

Hmm someone could probably build a career on telling us our puncture technique is increasing post op sepsis and surgical site infections. Maybe I’ll write to the APSF. Better yet, I’m sure AAORN or JHACO is looking for more irrelevant rules to enforce on people.

 

[pgg]

A cored piece of propofol rubber cap after the cap was pierced with a blunt tip plastic needle to draw the medication. Such contamination has been linkedto latex sensitivity and fragment embolization.
[...]

I love articles that lead off with assertions like this, with no reference, no evidence to back it up.

Really - "contamination" by propofol rubber caps has been "linked to" latex sensitivity. Huh. Linked how? With what consequence? Was there a prospective trial in which 50 people got injected with pieces of rubber and 50 people got injected with saline and 50 people got injected with pieces of balsa wood?

 

[pgg]

The DEA decides what is controlled and what isn’t. Not your local pharmacy.

This is technically correct, which is the best kind of correct.

But it's also technically correct to note that lots of local pharmacies treat propofol as a controlled substance, and require it to be tracked by the mL with witnessed return/waste documentation. Technically one could refuse before (technically) getting their credentials to work there pulled.

 

[Ezekiel2517]

I have seen this w Ofirmev. I was drawing it up to give it quickly instead of running it in w tubing. Drew it up w a 16g and saw grey rubber in the syringe. I was actually surprised at how large it was. The tips of those 16 gauge's can really slice.

 

[pgg]

The top of the vial is supposedly non sterile. At least I have heard that multiple times.
Can’t say I have looked him up.

I know some people who pop the plastic top and immediately wipe it with an alcohol pad before puncturing it with a needle.

I admire their diligence and dedication to ensuring the chunks of rubber stopper they inject are sterile.

 

[leaverus]

Does anyone use a particular type of tool to pull off the tops of the propofol vials? If you have a particular tool that works well please post a picture or link.

This is the kind of "vial de-sealer" we had in residency:

It worked great, quick and easy to crimp off the top entirely.

 

[leaverus]

Seriously? You are in that much of a hurry that you can’t spare a couple of seconds?
I can’t imagine the 18G drawing up at a significantly slower rate than the plastic tips or the 16G.

yes, seriously. have you ever tried drawing up through those filtered blunts? it's not just a couple of seconds difference; and for 30 pain cases that time adds up significantly. I could tell them to wait, but then they'd just replace me and I don't need to lose my job right now.

 

[chocomorsel]

yes, seriously. have you ever tried drawing up through those filtered blunts? it's not just a couple of seconds difference; and for 30 pain cases that time adds up significantly. I could tell them to wait, but then they'd just replace me and I don't need to lose my job right now.

I was talking about the regular blunts. Or a regular 18G needle. Not the filtered ones. They draw up pretty fast and I have never seen and bits of rubber with those.

 

[MirrorTodd]

This topic is quite literally the equivalent argument as whether or not personal scrub caps should be allowed in the OR. Seriously, how many anesthetics are run in the US every single day? And how many of them use propofol? And how many of them have had any sort of sequelae from a cored propofol vial either bacterial or embolic?

 

[skypilot]

This topic is quite literally the equivalent argument as whether or not personal scrub caps should be allowed in the OR. Seriously, how many anesthetics are run in the US every single day? And how many of them use propofol? And how many of them have had any sort of sequelae from a cored propofol vial either bacterial or embolic?

So you are ok with that little piece of plastic in their vein?!

 

[MirrorTodd]

So you are ok with that little piece of plastic in their vein?!

My point is that it is most likely such a rare event that it's not really worth discussing. Of course I'm not ok injecting little bits of rubber into people, but the odds of that happening are so small that I'm not gonna start worrying about it and certainly won't change my method of drawing up propofol or anything other drug.

 

[BLADEMDA]

My point is that it is most likely such a rare event that it's not really worth discussing. Of course I'm not ok injecting little bits of rubber into people, but the odds of that happening are so small that I'm not gonna start worrying about it and certainly won't change my method of drawing up propofol or anything other drug.

It's not a rare event. It's also sloppy technique to inject VISIBLE rubber into a patient. Would you clean a syringe tip with alcohol that had just dropped on the floor? Do you wipe off the injection port prior to giving a medication?

 

[MirrorTodd]

It's not a rare event. It's also sloppy technique to inject VISIBLE rubber into a patient. Would you clean a syringe tip with alcohol that had just dropped on the floor? Do you wipe off the injection port prior to giving a medication?

How often are you visually inspecting each syringe you draw up for little rubber pieces? Like ya, no duh, if I see rubber in the syringe, I'll draw up a new batch. But you cannot convince me that each of you anesthesiologists are drawing up and personally inspecting each syringe for rubber material every single case, nor are you checking every single syringe that your AA or CRNA has drawn up.

 

[BLADEMDA]

These days I always inspect each propofol syringe for any visible black rubber pieces. If I see it then I don't inject the propofol. What you do or don't do with the obvious cored pieced of rubber is up to you.

 

[abolt18]

It's not a rare event. It's also sloppy technique to inject VISIBLE rubber into a patient. Would you clean a syringe tip with alcohol that had just dropped on the floor? Do you wipe off the injection port prior to giving a medication?

I'll wipe the injection port at the start of a case or if it's a line that come down from the ICU or something, but I definitely do not wipe it every time I inject through it. It's been sitting there suspended in air touching nothing since the last time I wiped it and injected.

 

[Mehd School]

The DEA decides what is controlled and what isn’t. Not your local pharmacy.

Interesting. I rotate at hospitals that are across the street from each other. In one hospital Propofol and Ephedrine are controlled. Across the street they are not...

Either way, I have seen the little rubber plug from the propofol top multiple times in the bottle after I have drawn it up, but never in the syringe. I often try to check but not always. The rubber plug is often pretty large and I doubt would make it through the IV catheters, unless they're cases I'm putting 16+ gauge IV's in.

 

[deleted162650]

Interesting. I rotate at hospitals that are across the street from each other. In one hospital Propofol and Ephedrine are controlled. Across the street they are not...

The hospital pharmacy could mandate that you document and waste NS. That doesn’t make it a controlled substance.

 

[nimbus]

I’ve found coring is more likely if you insert the needle straight (90deg) in through the stopper. You can prevent coring by piercing the stopper at an angle of 70-80deg with pressure on the shaft of the needle directed away from the bevel. When you remove the needle you’ll be able to see a semicircular incision through the stopper with all the stopper material intact.

 

[MirrorTodd]

Is this happening with any other medication besides propofol?

 

[drmwvr]

Is this happening with any other medication besides propofol?

Not in my experience anyway...which begs the question...for all of the gyrations to avoid injecting a rubber core into a patient, why not instead insist the pharmacy procure medications that don't come in defective containers? Other large stoppered vials don't have this issue, as I've never heard or seen it with large heparin vials, bicarb vials, whatever. If there are pharmacies that are OCD enough to demand cc for cc reckoning of their propofol you'd think they'd care if their stock includes fragile stoppers.

 

[Velefunt]

> Is anyone simply popping the tops from all vials first?

I pop the tops off propofol and 30ml vials of local with the handle end of my trauma shears. Draws faster and without risk of rubber stopper embolus/contamination. But mostly because it's faster - I don't pre-draw anything unless it's a true rapid sequence induction.

 

[BLADEMDA]

> Is anyone simply popping the tops from all vials first?

I pop the tops off propofol and 30ml vials of local with the handle end of my trauma shears. Draws faster and without risk of rubber stopper embolus/contamination. But mostly because it's faster - I don't pre-draw anything unless it's a true rapid sequence induction.

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[leaverus]

> Is anyone simply popping the tops from all vials first?

I pop the tops off propofol and 30ml vials of local with the handle end of my trauma shears. Draws faster and without risk of rubber stopper embolus/contamination. But mostly because it's faster - I don't pre-draw anything unless it's a true rapid sequence induction.

I almost never pre-draw either, but I also don't like the idea of lugging around a big pair of trauma shears with me; plus I'd lose them almost immediately.

This topic is quite literally the equivalent argument as whether or not personal scrub caps should be allowed in the OR. Seriously, how many anesthetics are run in the US every single day? And how many of them use propofol? And how many of them have had any sort of sequelae from a cored propofol vial either bacterial or embolic?

Yeah, I don't know the answers to your questions, which is why I started the thread. Like you, I think it's probably safe but I still prefer to practice in a way that minimizes potential risk when possible. I try to do the same for my patients as I'd want if I were on the table - in this case, I'd rather not have quantities of micro-rubber injected into my veins, if it can be avoided.

 

[Velefunt]

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Any large handled works well. I don't carry my own - our hospitals and most ASC's have a pair hanging on each anesthesia cart.

 

[Steege305]

I’ve seen it when I don’t use a blunt-tip needle... so I only use blunt-tipped needles.

I currently usually use a standard 16G needle to draw up propofol (haven't seen those "spikes" since residency) and once in a while I'll see a tiny gray piece of the rubber vial stopper in the drug that I've drawn up. I'll then either try to squirt the piece out or toss the entire syringe. But I wonder how many times I miss some small (or even microsopic) fragments of rubber that are being injected intravenously. Anyone else notice this? What do I do without those spikes that have the filter and what about all the other drugs that we draw up. Is anyone simply popping the tops from all vials first?

 

[deleted697127]

Two die in Japan days after receiving Moderna shots suspended over contamination risk | CNN

Two people have died in Japan days after receiving doses from a batch of Moderna Covid-19 vaccines whose use was suspended Thursday following concerns over a contamination risk, the country's Ministry of Health, Labor and Welfare said Saturday.

www.cnn.com

Tokyo, Japan(CNN)Two people have died in Japan days after receiving doses from a batch of Moderna Covid-19 vaccines whose use was suspended Thursday following concerns over a contamination risk, the country's Ministry of Health, Labor and Welfare said Saturday.

A causal link between the vaccine and the deaths has not yet been established, according to the ministry and Takeda Pharmaceutical Company, which distributes the Moderna vaccine in Japan.

Japan suspended the use of about 1.63 million doses of the Moderna vaccine on August 26 as a precaution after foreign substances were found in some vials.


————————————

Cause of Japan Moderna vaccine contamination likely found

Japan's health minister said the contamination that led to the suspension of millions of doses of COVID vaccine in Okinawa was likely caused when needles were incorrectly inserted into vials.

www.jpost.com

“Japan's health minister said on Tuesday it was highly likely that foreign matter found in Moderna Inc COVID-19 vaccines in the southern prefecture of Okinawa were caused when needles were stuck into the vials.”

——————————-


Lol. someone going to tell CNN about propofol? (Trolling, but thought this belonged in the thread)

 

[nimbus]

Two die in Japan days after receiving Moderna shots suspended over contamination risk | CNN

Two people have died in Japan days after receiving doses from a batch of Moderna Covid-19 vaccines whose use was suspended Thursday following concerns over a contamination risk, the country's Ministry of Health, Labor and Welfare said Saturday.

www.cnn.com

Tokyo, Japan(CNN)Two people have died in Japan days after receiving doses from a batch of Moderna Covid-19 vaccines whose use was suspended Thursday following concerns over a contamination risk, the country's Ministry of Health, Labor and Welfare said Saturday.

A causal link between the vaccine and the deaths has not yet been established, according to the ministry and Takeda Pharmaceutical Company, which distributes the Moderna vaccine in Japan.

Japan suspended the use of about 1.63 million doses of the Moderna vaccine on August 26 as a precaution after foreign substances were found in some vials.


————————————

Cause of Japan Moderna vaccine contamination likely found

Japan's health minister said the contamination that led to the suspension of millions of doses of COVID vaccine in Okinawa was likely caused when needles were incorrectly inserted into vials.

www.jpost.com

“Japan's health minister said on Tuesday it was highly likely that foreign matter found in Moderna Inc COVID-19 vaccines in the southern prefecture of Okinawa were caused when needles were stuck into the vials.”

——————————-


Lol. someone going to tell CNN about propofol? (Trolling, but thought this belonged in the thread)

1. Can you even inject “foreign material” with a 30g needle typically used for vaccination?

2. How can IM injection of rubber stopper material cause death?

 

[MirrorTodd]

1. Can you even inject “foreign material” with a 30g needle typically used for vaccination?

2. How can IM injection of rubber stopper material cause death?

I feel like that might've been meant for a different thread?