Worth repeating...Preventing ILE and ViperSlide mix-ups

A June 28, 2012, Safety Brief advised about the possibility of mix-ups between 100 mL bags of INTRALIPID (lipid injectable emulsion [ILE]) 20% and VIPERSLIDE, a non-drug product that acts as a lubricant to reduce friction with devices used during atherectomy procedures. The products have a similar milky white appearance, and both are packaged in flexible bags with a white and blue port (Figure 1). ViperSlide is a lipid emulsion that has similar components to Intralipid, including soybean oil, egg yolk phospholipids, glycerin, sodium hydroxide, and water. However, ViperSlide contains only 10 g of soybean oil per 100 mL (10%), compared to 20 g of soybean oil per 100 mL (20%) in Intralipid. Both products are sterile. ViperSlide may be combined with saline, nitroglycerin, and verapamil, or infused with those three ingredients via a Y-site, to control vasospasm. Sometimes, pharmacy has been asked to prepare ViperSlide admixtures, so the ViperSlide bags may be kept in the pharmacy.

In one reported mix-up, ViperSlide was purchased by the operating room (OR) but kept in the OR pharmacy to prepare admixtures. A bag was approaching the expiration date, so it was placed on the pharmacy counter for disposal. A technician thought the product was Intralipid and took it to the intravenous (IV) room for use prior to its expiration. The IV room technician also thought the product was Intralipid and used the ViperSlide to compound Intralipid neonatal syringes. Fortunately, a pharmacist detected the error during a validation check, so the error did not reach patients.

At another hospital, one of the totes used for delivery of Intralipid bags had a ViperSlide bag mixed in. The error was not noticed, and the ViperSlide bag was stocked in the IV room along with other Intralipid bags from the tote. Thankfully, a pharmacist noticed the error before medication preparation. The following week a pharmacist found another bag of ViperSlide mixed in with the Intralipid order.

More recently, a close call was reported in which a pharmacy inadvertently stocked a bag of ViperSlide instead of Intralipid in a neonatal intensive care unit (NICU) automated dispensing cabinet (ADC). Multiple Intralipid bags were being stocked during the ADC refill, but the barcodes on each bag were not scanned and the ViperSlide bag was not identified. A nurse received an error message when she scanned what she thought was Intralipid prior to administration, thus discovering the error.

In our prior Safety Brief, we mentioned that many procedural areas stock bags of ILE 20% as an antidote for local anesthetic and other lipophilic drug toxicities. However, due to the visual similarity of these products, one can imagine a scenario where a patient in cardiac arrest due to an inadvertent overdose of local anesthesia could receive ViperSlide in error. It is unknown how this might impact treatment effectiveness, given the lower lipid concentration of ViperSlide compared to ILE 20%.

Knowing the procedures where ViperSlide might be used and checking if these two look-alike products are available can help identify risks so strategies can be implemented to reduce potential mix-ups. Avoid storing ViperSlide in the pharmacy (even in an OR pharmacy), in a perioperative medication room, or in an ADC where lipid rescue kits are stored. Place “Caution: Surgical Lubricant” auxiliary labels on ViperSlide bags to help differentiate them from Intralipid bags.