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Textbook and Publication Errata
Errors reported in publications
From the April, 22,1998 Issue
The following caution statement in
the monograph for albumin will appear in the upcoming 10 th
edition (1998) of Trissel's Handbook on Injectable Drugs:
CAUTION: Substantial reduction in tonicity, creating the potential
for fatal hemolysis and acute renal failure, may result from
the use of sterile water as a diluent. The hemolysis and acute
renal failure that result from the use of a sufficient volume
of sterile water as a diluent may be life-threatening. This
strengthens a reminder in the 9 th edition (1996) that hemolysis
could occur if the tonicity of the final solution isn't taken
into account. The 8 th edition (1994) did not specifically
mention this consequence although it did mention sterile water
as a possible diluent. We are aware of two recent cases (ISMP Medication Safety Alert! January 14, 1998 and March 25, 1998)
where pharmacists consulted the long-expired 8 th edition
text and subsequently used large volumes of sterile water
to prepare albumin solutions for plasmapheresis. Both patients
hemolyzed. One patient did not recover. We urge pharmacy managers
to immediately seek out older versions of the text to include
the new caution! Then destroy and replace these older editions
when the 10 th edition is available later this year. FDA is
also alerting pharmacists not to dilute 25% human albumin
solution with sterile water for injection to provide a 5%
albumin solution for plasmapheresis.
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