Concentration Of Glacial Acetic Acid

Hosp Pharm. 2015 Apr; 50(four): 304–309.

Glacial Acerb Acid Adverse Events: Case Reports and Review of the Literature

William Doles, PharmD,^* Garrett Wilkerson, PharmD,^† Samantha Morrison, BS, CPhT,^‡ and Rodney G. Richmond, MS, CGP, FASCP ^§

William Doles

^*Hickory Hill Pharmacy, Helena, Arkansas

Garrett Wilkerson

^†Walgreens, Middletown, Kentucky

Samantha Morrison

^‡The Mackenzie Group, LLC, Searcy, Arkansas

Rodney G. Richmond

^§Harding University College of Pharmacy, Searcy, Arkansas. Drs. Doles and Wilkerson and Ms. Morrison completed this work while serving as a doctor of pharmacy candidates at Harding University College of Pharmacy.

Abstract

Glacial acetic acid is a dangerous chemical that has been associated with several agin drug events involving patients over recent years. When diluted to the proper concentration, acetic acid solutions accept a variety of medicinal uses. Unfortunately, despite warnings, the improper dilution of concentrated glacial acetic acid has resulted in severe burns and other related morbidities. We study on 2 additional instance reports of adverse drug events involving glacial acerb acid also equally a review of the literature. A summary of published case reports is provided, including the intended and actual concentration of glacial acerb acid involved, the indication for use, degree of exposure, and resultant event. Strategies that accept been recommended to improve patient safety are summarized within the context of the central elements of the medication utilize process.

Keywords: adverse events, glacial acerb acid, medication errors

Glacial acetic acid is the trivial proper name used to refer to pure acetic acid in an anhydrous state. It is a colorless, hygroscopic, weak acid that is available in concentrations of 99.five% to 100%. Similar to the German name Eisessig (water ice-vinegar), the word "glacial" is derived from the ice-like crystals that form at 16.half-dozen°C (61.ix°F), slightly below room temperature.^ane Although classified as a weak acid, glacial acetic acid is a corrosive poison that can cause injury or death when human tissue is exposed to information technology. At concentrations of 10% to 25% (i.67-four.16 mol/50), it acts as an irritant; but at concentrations greater than 25% (>iv.16 mol/L), it is corrosive and should be handled in a fume hood.^two Skin contact may produce blistering or burns, while liquid or spray mist may produce tissue impairment particularly on mucous membranes of the eyes, mouth, and respiratory tract. ⁱⁱⁱ

Acerb acrid has been used for centuries in food production, manufacturing, cleaning, and even medical purposes. Generally, undiluted glacial acetic acid has no medical use, but a review of the literature reveals that acetic acid in diluted concentrations has been used for a variety of indications. Diagnostically, such indications include oral screening and lesion identification⁴ (1%, mouth rinse) and Barrett's esophagus⁵ (1.5%-2.5%, spray). As treatment, it has been used for bladder and wound irrigation^half-dozen (0.25%-0.5%, irrigation solution). Slightly higher concentrations take been used for otitis externa,⁷ iontophoresis,^eight ear wax removal,⁹ and cervicoscopy after an aberrant Pap smear¹⁰ (1%-5%, topical solution). Controversially, it has as well been used for wound infections,¹¹ vaginal douching,¹² and equally a neutralizing diluting agent for brine pare burns.¹³ Yet even more concentrated, acetic acid has a place in renal cyst sclerotherapy¹⁴ and hepatocellular carcinoma¹⁵ (50%, injection).

A number of acerb acid products are commercially available. Prediluted, ready-to-use USP formulations include products such as acerb acrid/aluminum acetate otic and premixed irrigation solutions. Dietary vinegar (5%) has as well been used medically for irrigation and topical awarding. Sometimes, nonetheless, full-bodied chemical-grade glacial acerb acid is used, but it requires a pharmacist'southward skill to compound and manipulate earlier it is acceptable for human being use. Despite alert labels on the container, repeated incidents of full-bodied glacial acetic acid beingness dispensed instead of a diluted grade have caused patient injury. We describe 2 reports of injuries due to glacial acetic acid and a review of the literature of similar cases with recommendations for patient rubber.

Case Reports

Patient Case one

A 59-year-sometime female was admitted to the hospital to undergo a broad local excision of a lesion on her vulva. Acetic acrid iv% was to exist used in the procedure to demarcate the abnormal epithelium. Although there was defoliation over whether the strength ordered electronically was 0.25% or 4%, ultimately the order that was delivered to the operating room was prepared past the chemist as acetic acid 80%. No caption was given regarding how this difference occurred. The acetic acrid solution was poured onto the indicated surface area; inside a minute of awarding, a strong acetic acid smell was noted. The surgeon requested the strength of the solution be verified, and an inspection of the characterization visible on the canteen indicated acetic acid 80%. The procedure was terminated and 4 50 of normal saline was used to irrigate the area, followed past an injection of bupivacaine 0.25% with epinephrine 1:200,000 and the application of silver sulfadiazine cream. The patient experienced 2nd-degree partial thickness chemical burns on her labia minora and majora, perineum, rectum, and sacrum extending to the lower lumbar back. Subsequent treatment included topical lidocaine, triple antibody cream, and oral opiate analgesia and antibiotics.

Patient Example 2

A 50-yr-erstwhile male paraplegic who had an indwelling suprapubic catheter adult problems with the build-up of particulate thing in the catheter. Acetic acrid solution 0.25% was ordered for catheter clearance, but an error occurred when the telephone order was placed resulting in a prescription for acetic acrid 25%. Because the pharmacist had never compounded an acerb acid solution at that concentration, he declined to manipulate the prescription and referred the patient back to his doc. Because the prescribing doc was unavailable, a covering doc recommended the patient look to speak with the prescriber because at that place was defoliation over the order. However, the patient was not brash that a 25% acerb acid solution posed a danger. In the interim, the patient went to a different pharmacy that agreed to compound the prescription. The pharmacist filling the prescription did non question the strength, even though they later stated that they knew it was inappropriate for the intended purpose. Use of the 25% solution acquired astringent burns to the urethra and bladder and "melted" the catheter around the patient's penis. The patient required inpatient treatment, after which he chronically complained of burning sensations in his penis and float.

Discussion

Multiple reports take been published advising of the dangers associated with the use of glacial acetic acid in clinical patient intendance. Tabular array 1 summarizes 18 cases of injury that have been reported in the literature.^16–27 An boosted report appears in the literature of v women who were treated in a colposcopy clinic with glacial acetic acid instead of acetic acid 5% as a result of a estimator entry error, although no detectable harm was reported.²⁸

Tabular array one.

Glacial acetic acid injuries reported in the literature

Reference	Strength intended	Strength dispensed	Indication for utilise	Duration of exposure	Upshot of exposure
16	0.25%	10%	Bladder irrigation	ii days	Hematuria and bladder tissue harm

sixteen	0.v%	50%	Irrigation	NS	NS

17	0.49%	47%	Wound irrigation	1 application	2nd and 3rd caste finger burns

18	4%	99%	Colposcopy	ane application	Cervical and vaginal burns

19	iii%	99.five%	Vulvar condyloma	1 application	Vaginal and vulvar burns requiring surgery

19	3%	99.5%	Scrotal application	2 applications	Severe scrotal burn down

19	99.5%	99.5%	Wart removal	1 awarding	Astringent pare burns due to inappropriate packaging

20	0.25%	99.five%	Wound irrigation	ii days	Burns necessitating bilateral amputation at hip

20	v%	99.five%	Colposcopy	i application	Vaginal bleeding and baking

20	three%	99.five%	Surgical irrigation	1 application	1st and 2d caste burns

21	NS	99.v%	Rectal condyloma	ane application	Tissue impairment requiring prolonged hospitalization

22	four%	99.v%	Anoscopy	1 awarding	Severe anal burns

22	5%	99.5%	Surgical procedure	one application	Astringent skin burns, permanent scarring

23	10%	99.5%	Iontophoresis	1 awarding	1st caste burn down, small-scale scarring, pare discoloration

24	v%	99.5%	Surgical procedure	1 application	Burns requiring pare grafts

25	5%	99.5%	Penile condyloma	1 awarding	Severe genital burns

26	NS	100%	Iontophoresis	one application	Total-thickness chemical burn to shoulder

27	five%	100%	Cervical biopsy	one application	Cervicitis and vaginal bleeding

Every bit tin can be seen from these cases, serious patient harm has resulted from the use of full-bodied glacial acetic acid. Root cause analyses have revealed that problems associated with inaccurate medication reconciliation; improper prescribing, dilution, and labeling; inappropriate packaging; an absence of checks and balances; inadequate drug information resources; and lack of familiarity regarding the backdrop of glacial acetic acrid are common causes of errors among health care providers. Other causes accept been attributed to the fact that glacial acerb acrid is not a drug and therefore not regulated past the United states Nutrient and Drug Administration (FDA). Thus, precautionary labels applied to product packaging by the chemical industry ( Figure i )²⁹ are often inconsistent, camouflaged, or even absent-minded when compared to those customarily seen on FDA-canonical drugs.

An external file that holds a picture, illustration, etc. Object name is hpj-50-304-g001.jpg

Based on these findings, several patient prophylactic strategies have been recommended in an attempt to avoid incidents with glacial acetic acrid. These recommendations are gathered from previous ISMP Medication Safety Warning! publications and other case reports^{nineteen–23,thirty} and have been organized according to ISMP'southward Primal Elements of the Medication Apply System³¹ ( Table ii ). This set of recommendations can serve as a tool for managing this recurring trouble.

Table 2.

Recommendations for safe use of glacial acerb acid

Patient Information
Perform an accurate medication reconciliation and utilize the patient as a historian in cases where they have been mixing their own irrigation solutions to avoid defoliation.

Drug Data
Maintain drug data references (eg, clinical, compounding, recipes, MSDS) on glacial acetic acid that are authentic and up to date.

Communication of Drug Orders
Require that acetic acid be ordered on a patient-specific basis.
Require prescribers to signal a specific acerb acid concentration and its intended employ.
Discourage the use of the term "glacial" in all patient orders for acetic acid solution.

Drug Labeling, Packaging, and Nomenclature
Social club acetic acrid five% as vinegar to reduce the potential for confusion with glacial acetic acid.
Dispense in appropriate packaging to facilitate ease of use and avoid adventitious spillage.
Prominently affix unique labels on packaging to differentiate acetic acid concentrations.

Drug Storage, Stock, Standardization, and Distribution
Completely remove concentrated glacial acerb acid (99.five%) from chemist's shop stock.
Just stock commercial formulations (eg, 2% otic, 0.25% irrigation) for patient use.
Chemical compound irrigation solutions from vinegar (v%) or other prediluted forms of acetic acid.
Segregate glacial acetic acid in a secured pharmacy area away from the compounding area.
Prominently post signage where glacial acetic acrid is stored indicating information technology must be diluted.
Dilute glacial acetic acid upon commitment and shop for future use.
Develop a standard formula for chemist's shop compounding of dilute acetic acrid solutions.
Ensure glacial acerb acid is only stored in the chemist's shop and not in clinical patient care areas.
Stock blistering soda as a neutralizing agent in each patient care surface area that uses acetic acid.

Drug Acquisition, Utilize, and Monitoring
Outsource preparation of acetic acid solutions to a reputable compounding pharmacy.
Require pharmacy to purchase acerb acid solutions for all patient care areas.
Restrict choices in purchasing software so glacial acetic acid cannot be selected by error.
Verify the right strength of acetic acid has been ordered and received from the vendor.

Staff Competency and Teaching
Educate staff about differences betwixt glacial acetic acid and diluted forms of acetic acid.

Quality Processes and Hazard Management
Determine the lowest acerb acid concentration required to be medically effective in your facility and standardize available concentrations.
Require that orders be sent to the pharmacy at least one day before an acerb acrid solution is to exist used to let sufficient time to chemical compound the production and avoid rushing the chore.
Require contained double-check procedures for glacial acetic acid for steps involving purchasing, order entry, compounding, labeling, and dispensing.
Maintain a compounding log of all glacial acetic acid dilutions for each step in the procedure including signatures of those who prepared and checked the product.

Conclusions

The storage and use of glacial acetic acrid inherently poses a potential danger and tin crusade patient injury when not properly diluted. Medication safety experts have advocated for several strategies that tin mitigate the risk, for both patients and health care providers, involved in the utilise of this chemic. The awarding of these strategies to the medication use procedure can work to establish a system with failsafes that prevent glacial acerb acid from reaching the patient.

Acknowledgments

The authors declare no conflicts of interest. Mr. Richmond has provided expert testimony every bit a pharmacist through The Mackenzie Grouping, LLC.

References

ane. Armarego WLF, Chai CLL. Purification of Laboratory Chemicals. 6th ed. Waltham, MA: Butterworth-Heinemann (Elsevier); 2009. [Google Scholar]

4. Farah CS, McCullough MJ. A pilot case command study on the efficacy of acetic acid wash and chemiluminescent illumination (ViziLite) in the visualisation of oral mucosal white lesions. Oral Oncol. 2007; 43(viii): 820–824. [PubMed] [Google Scholar]

5. Vázquez-Iglesias JL, Alonso-Aguirre P, Diz-Lois MT, Vázquez-Millán MA, Alvarez A, Lorenzo MJ. Acerb acid allows effective selection of areas for obtaining biopsy samples in Barrett's esophagus. Eur J Gastroenterol Hepatol. 2007;19(3):187–193. [PubMed] [Google Scholar]

viii. Shetty S, Moore TL, Jackson South, Brettle D, Herrick AL. A pilot study of acetic acid iontophoresis and ultrasound in the treatment of systemic sclerosis-related calcinosis. Rheumatology (Oxford). 2005;44(4):536–538. [PubMed] [Google Scholar]

x. Gaffikin L, Lauterbach M, Blumenthal PD. Performance of visual inspection with acetic acrid for cervical cancer screening: A qualitative summary of evidence to date. Obstet Gynecol Surv. 2003;58(viii):543–550. [PubMed] [Google Scholar]

xi. Johnston CS, Gaas CA. Vinegar: Medicinal uses and antiglycemic effect. MedGenMed. 2006;8(ii): 61. [PMC free article] [PubMed] [Google Scholar]

12. Martino JL, Vermund SH. Vaginal douching: Bear witness for risks or benefits to women's wellness. Epidemiol Rev. 2002;24(2):109–124. [PMC gratuitous article] [PubMed] [Google Scholar]

13. Andrews K, Mowlavi A, Milner SM. The handling of alkaline burns of the pare by neutralization. Plast Reconstr Surg. 2003;111(6):1918–1921. [PubMed] [Google Scholar]

xiv. Yoo KH, Lee SJ, Jeon SH. Uncomplicated renal cyst sclerotherapy with acetic acid: Our ten-year experience. J Endourol. 2008;22(11):2559–2563. [PubMed] [Google Scholar]

15. Ma H, Liu J, Liu F. CT-guided single loftier-dose percutaneous acerb acid injection for pocket-size hepatocellular carcinoma: A long-term follow-upwardly study. Eur J Radiol. 2012;81(6):1184–1186. [PubMed] [Google Scholar]

16. Institute for Safe Medication Practices. Messages in our mailbox-in response to our May 5, 2005 commodity. Terminate the ice historic period-is glacial acetic acid really needed? ISMP Medication Prophylactic Warning. 2005;10(13):3. [Google Scholar]

17. Dark-brown v. Southern Baptist Infirmary. No. 96-CA-1990. 715 So. 2nd 423; 1998. La. App. LEXIS 556.

eighteen. Johnson v. Settle, MD. No. M1999-01237-COA-R3-CV. 2001 Tenn. App. LEXIS 412. [Google Scholar]

xix. O'Donnell J. From the courtroom: Pharmacists get burned by acid. Pharm Pract News. 2004;31(two). [Google Scholar]

20. Institute for Prophylactic Medication Practices. End the ice age – Is glacial acetic acid really needed? ISMP Medication Rubber Alert. 2005;10(9):1–2. [Google Scholar]

21. Institute for Safe Medication Practices; Worth repeating: Is glacial acetic acid actually needed at your hospital? ISMP Medication Safety Alert. 2012;17(19):ane–2. [Google Scholar]

22. National Alert Network. Alarm! Astringent burns and permanent scarring after glacial acetic acid (>99.5%) mistakenly practical topically. NAN Alert. 2013:1–2. [Google Scholar]

23. Pennsylvania Patient Condom Authorization. Glacial acetic acid: Doing more than harm than good? Patient Safety Advisory. 2006;iii(1):26–28. [Google Scholar]

24. New Mexico Board of Pharmacy. Pregnant adverse drug events. New Mexico Board of Chemist's News. 2012;14(3):1. [Google Scholar]

25. Avery JK. Genital injuries–expensive. Tenn Med. 2004;97(8):353–354. [PubMed] [Google Scholar]

26. Hines five. Meyer. No. 6444/ten. 2011. Northward.Y. Misc. LEXIS 6804; 2011. NY Slip Op 33737(U). [Google Scholar]

27. Ou KY, Chen YC, Hsu SC, Tsai EM. Topical vainal oestrogen foam used for treatment of burn injury of vaginal mucosa after misapplication of 100% acerb acid in a perimenopausal woman: A case report. Aust N Z J Obstet Gynaecol. 2007;47(4):345–346. [PubMed] [Google Scholar]

28. Patients erroneously treated with concentrated acid [editorial]. Pharm J. 1987;238:129. [Google Scholar]

Articles from Hospital Pharmacy are provided hither courtesy of SAGE Publications