Patent Grant
11045589
The present invention relates to the maintenance of catheters in a condition that is substantially free of blood and clots. More particularly, the invention relates to the use of a solution of citrate salt to prevent backflow and maintain patency in a catheter lumen.
Catheters, particularly intravenous (IV) catheters, may be used for infusing fluid, such as a medication, into a patient or withdrawing fluid, such as blood, from a patient. Catheters may include a lumen or reservoir which contains fluid or medication to be injected into, or removed from, a patient's body. In certain configurations an injection port may be provided with the catheter.
Complications associated with catheters include thrombosis, infection, and clotting. Catheter occlusions will often occur due to thrombotic complications related to the formation of a fibrin sheath within the lumen or at the tip of the catheter. Formation of a fibrin sheath may allow for adherence of bacteria to the interior of the catheter lumen and serve as a locus for catheter related infection.
To reduce problems associated with clotting and thrombus formation, it is common to “lock” intravascular access catheters between successive uses. Locking typically involves first flushing the catheter with saline to remove blood and other substances from the catheter lumen. After the catheter has been flushed, an anti-coagulant solution, typically heparin, is then injected to displace the saline and fill the lumen. The heparin locking solution prevents blood from entering the lumen and actively inhibits clotting and thrombus formation within the lumen.
The heparin lock solution is infused into the catheter lumen immediately after each use, and is left within the catheter until the catheter is accessed again. The heparin lock solution must be withdrawn from the catheter before the next use so that the heparin is not introduced into the body of the patient. In some instances, heparin lock solutions include up to 10,000 units of heparin per catheter lumen. Infusing this amount of heparin into a patient may result in excessive bleeding.
However, even with the use of a traditional heparin lock solution, the catheter can become occluded between uses from coagulation of blood within the catheter. Blood may be present within the catheter because an inadequate volume of heparin was infused within the catheter lumen, the heparin lock solution diffused from the lumen, or residual blood remains in the lumen. This can result in formation of a thrombus with concomitant loss of patency and decreased flow through the catheter lumen.
There remains a need for a catheter lock solution which can provide long-lasting action, increased safety, and without the need for additional applications in between uses of the catheter.
Accordingly, provided herein is a catheter lock solution that includes a citrate salt. In aspects the citrate salt is a sodium citrate salt. In further aspects, the citrate salt is trisodium citrate.
In aspects, the catheter lock solution further includes an acid. In aspects, the acid is a diluted acid. In some aspects, the diluted acid is diluted hydrochloric acid (HCl).
In aspects, the catheter lock solution includes the citrate salt in an amount between about 3.8% and 4.2% w/v.
In aspects, the lock solution includes the acid in an amount between about 0% and about 0.7% v/v.
In certain aspects, the catheter lock solution includes 4% w/v trisodium citrate, water-for-injection (WFI), and 0.7% v/v 10% HCl.
In certain aspects, the catheter lock solution is free of any additional component having anticoagulant or antimicrobial activity.
Also provided herein is a method of making a catheter lock solution. The method includes the steps of dissolving a citrate salt, preferably trisodium citrate, in WFI and adding a diluted acid, preferably 10% HCl, until the pH of the catheter lock solution is between about 6.4 and about 7.5.
Also provided herein is a catheter lock solution including only trisodium sodium, water-for-injection (WFI), and 10% HCl.
In aspects, the catheter lock solution The catheter lock solution of claim 11, wherein the lock solution includes only between about 3.8% and about 4.2% w/v trisodium citrate, WFI, and between about 0% and about 0.7% v/v of 10% HCl, and has a pH of between about 6.4 and about 7.5.
Also provided herein is a method of making a catheter lock solution. The method includes only the steps of dissolving trisodium citrate in WFI and adding 10% HCl until the pH of the catheter lock solution is between about 6.4 and about 7.5.
Also provided herein is a catheter lock solution including only about 4% w/v trisodium citrate, water-for-injection (WFI), and about 0.7% v/v 10% HCl, the catheter lock solution having a pH of about 7.
Also provided herein are pre-filled syringes including syringes containing a catheter lock solution as described herein.
Also provided herein are catheters including a tube defining a lumen therethrough, at least a portion of the lumen being infused with a catheter lock solution as described herein.
Also provided herein is a method of inhibiting coagulation and microbial activity in a catheter including the steps of providing a catheter including a tube defining a lumen therethrough and infusing into at least a portion of the lumen the catheter lock solution described herein.
The following description is provided to enable those skilled in the art to make and use the described aspects contemplated for carrying out the invention. Various modifications, equivalents, variations, and alternatives, however, will remain readily apparent to those skilled in the art. Any and all such modifications, variations, equivalents, and alternatives are intended to fall within the spirit and scope of the present invention.
Provided herein is a catheter lock solution including a citrate salt, a solvent, and a diluted acid. The lock solution described herein provides patency for a catheter and exhibits anticoagulation and antibiotic activity. Without wishing to be bound by the theory, it is believed that the citrate salt acts as an anticoagulant by chelating calcium (Ca2) ions in blood. Calcium ions are necessary for proper functioning of coagulation factors V and VII, which form tenase and prothrombinase complexes in the coagulation cascade. By chelating calcium, the cascade is blocked and coagulation is inhibited.
The lock solution and pre-filled syringe described herein also minimize syringe-induced reflux of blood into an implanted catheter. The lock solution described herein provides significant advantages over typical heparin-based locks, in that adverse events related to use of heparin, such as heparin-induced thrombocytopenia, systemic bleeding complications, and assay interference, can be avoided. In addition, a citrate salt-based lock offers significant cost and time savings over heparin-based solutions. A lock solution as described herein also offers advantages in terms of stable shelf-life, such as at least two years from time of manufacture. Moreover, the use of a pre-filled syringe saves time, improvise sterility, and thus safety, of the product and delivery thereof, and eliminates the likelihood of contamination that can occur during manual filling.
As used herein, the term “lock solution” or “locking solution” refers to a solution that is injected or otherwise infused into a lumen of a catheter with the intention of allowing a substantial portion of the solution to remain in the lumen until it is desired or required to access or re-access the lumen, typically for additional treatment or maintenance. Additional treatment may include, for example, infusion or withdrawal of fluid into/from the lumen of a catheter. The locking solution may be placed into the catheter to provide short or long-term protection. Preferably, the lock solution can remain in the lumen for a desired amount of time lasting to about one week, and in aspects up to about a month. However, the lock solution may be changed on a daily basis, such as during regular care or sterile maintenance of the catheter. The catheter may be changed or refreshed by aspirating the lock solution out of the catheter lumen, and locking the catheter with new catheter lock solution within the catheter for a desired amount of time. Use of a lock solution described herein may prolong the lifetime of the catheter, lengthen the interval between required replacements of the lock solution, and/or inhibit infection in a patient.
The term “catheter” as used herein refers to a tube defining a lumen therethrough that may be inserted into part of the body or provided in communication with a body or other biological culture to deliver a fluid thereto or remove a fluid therefrom. In aspects, the catheter lock solution as described herein may be used to provide anticoagulant activity (inhibit coagulation) and antimicrobial activity in a catheter, such as soft catheter or a hard catheter.
As used herein, the term “anticoagulant activity” refers to inhibition or prevention of blood coagulation.
As used herein, the term “antimicrobial activity” refers to destruction, inhibition, or prevention of the propagation, growth, or multiplication of unwanted micro-organisms, such as aerobic and anaerobic gram-positive and gram-negative bacteria, undulating bacteria, spirochetes, spores, spore-forming micro-organisms, yeasts, fungi, molds, viruses, aerobic organisms, anaerobic organisms, and mycobacteria.
The catheter lock solution as described herein can be used to inhibit microbial activity and coagulation of catheters that are placed into particular parts of the body to allow, for example, drainage of urine from the urinary bladder as in urinary catheterization; drainage of fluid collections; administration of intravenous fluids, medication, or prenatal nutrition; angioplasty; angiography; balloon septostomy; and direct measurement of blood pressure in an artery or vein. While the catheter lock solution as described herein may be used to inhibit microbial activity and coagulation of any catheter, the catheter lock solution may be used to inhibit microbial activity and coagulation of catheters that are used, for example, for hemodialysis and hemofiltration that rely on separate draw and return catheters implanted into a vein to allow extracorporeal treatment of the blood or for peritoneal dialysis, which relies on a single catheter implanted in the peritoneum to permit introduction and withdrawal of dialysate to permit in situ dialysis.
By preventing coagulation within the lumen of a catheter, the citrate salt lock solution as described herein maintains patency within the catheter. As used herein, the term “patency” refers to a catheter being open or unobstructed, for example by clots or fibrin sheaths within the lumen of the catheter.
As described above, the lock solution includes a citrate salt. As used herein, the term “citrate salt” refers to a salt of citric acid. Citric acid is a tricarboxylic acid having the formula C6H8O7, and is considered a weak acid. Examples of suitable citrate salts for use in the lock solution described herein are sodium salts and potassium salts. In aspects, the citrate salt is monosodium, disodium, or trisodium citrate. In particular aspects, the citrate salt is trisodium citrate. In some aspects, the trisodium citrate is trisodium citrate di-hydrate, a powder form of trisodium citrate that can be dissolved in a solvent.
As described above, it is believed that trisodium citrate functions as an anticoagulant by chelating calcium (Ca2+) ions in the blood, disrupting the coagulation cascade. As a lock solution, trisodium citrate acts in two ways to maintain catheter patency. First, the physical presence of the lock solution prevents backflow of blood from the patient into the catheter lumen, reducing the risk of clotting or occlusion of the lumen. Second, to the extent that any blood does backflow into the catheter lumen, by disrupting the coagulation cascade the trisodium citrate prevents clotting in the catheter lumen and at the catheter tip.
The lock solution includes a solvent in which the citrate salt is dissolved. The solvent can be any biocompatible solvent. In aspects, the solvent is water-for-injection (WFI). In aspects, the citrate salt is included in the solvent at a mass per volume concentration of between about 3.8% and about 4.2% weight per volume (w/v), all subranges and values therebetween inclusive. As used herein, the term “about” refers to a difference of ±10% of the value. In aspects, the lock solution is made by dissolving trisodium citrate di-hydrate at a mass per volume in WFI of about 4% (w/v).
The lock solution also includes a diluted acid to adjust the pH of the solution. The diluted acid can be any biocompatible organic or inorganic acid. In aspects, the diluted acid is 10% hydrochloric acid (HCl). In aspects, the lock solution includes between about 0 and about 0.7% v/v of diluted acid, all subranges and values therebetween inclusive. In aspects, the lock solution includes between about 0 and about 0.7% v/v of 10% HCl. However, those of skill in the art will understand that the amount of diluted acid can be adjusted to achieve a preferred pH of the lock solution of between about 6.4 and about 7.5.
In particular aspects of the lock solution described herein, the solution includes between about 3.8% and about 4.2% w/v of trisodium citrate in WFI, and the lock solution has a pH of between about 6.4 and about 7.5, and in some aspects between about 6.54 and about 7.25, all subranges therebetween inclusive. In some aspects, the pH of the lock solution when delivered to a syringe during preparation of pre-filled syringes is between about 6.57 and about 7.16, all subranges therebetween inclusive. In some aspects, the pH of the lock solution when delivered to a syringe during preparation of pre-filled syringes is about 6.87.
In aspects, between about 0 and about 0.7% v/v of 10% HCl is included in the lock solution. In some aspects, the lock solution includes about 4% w/v trisodium citrate di-hydrate in WFI, and sufficient diluted (e.g., 10%) HCl to provide a lock solution with a pH of about 6.9. In further aspects, the lock solution includes trisodium citrate, WFI, and, optionally, HCl to provide the required pH, and includes no additional anticoagulant or antimicrobial additives. In aspects the catheter lock solution is free of excipients. In some aspects the catheter lock solution is free of alcohols, glycerol, polyethylene glycols, citric acid, and/or polysorbate. In aspects the catheter lock solution is free of any component other than a citrate salt, WFI, and, optionally, HCl.
Also provided herein is an infusion device containing the lock solution as described above. In aspects, the infusion device is a pre-filled syringe including the lock solution as described above. In aspects, the pre-filled syringe includes a distal end, a proximal end, and a barrel therebetween defining a reservoir. The pre-filled syringe includes a plunger at the proximal end and a connector at the distal end configured to connect to a catheter, other needlefree connectors, Y-sites, and the like. In aspects, the connector at the distal end of the pre-filled syringe is a male or female luer connector. With reference to
In aspects, the pre-filled syringe 10 is designed or configured to reduce or prevent instances of reflux of blood into a catheter at the conclusion of flushing with a lock solution as described herein. In aspects, the pre-filled syringe is configured such that the plunger rod 14 is shorter than a typical plunger rod, such that compression of the stopper 16 following infusion of the lock solution 20 is substantially or completely prevented. In other aspects the stopper 16 is designed or configured such that the nose of the stopper comes into contact with a distal end of the barrel, adjacent the luer 18, and blocks the opening, preventing vacuum and thus reflux of blood into the catheter.
Also provided herein is a method of locking a catheter including the steps of infusing the lock solution as described above into a catheter lumen. In aspects, the method further includes the step of flushing the catheter lumen prior to infusing the lock solution.
In aspects, the method includes the steps of providing a catheter having an interior surface and an exterior surface, and infusing into at least a portion of the interior surface with the catheter locking solution. Preferably, the locking solution is infused into the interior surface such that the interior surface is substantially filled. Non-limiting examples of interior surfaces of the catheter that can be filled with the catheter locking solution described herein include the lumen, related tubing, plungers, caps, and extension sets. Other devices capable of being coated or filled with the catheter locking solution described herein include the inner lumen of vascular access devices, as well as, needle-less access devices. The locking solution can be infused by any conventional method well known to those skilled in the art, such as dipping, spraying, or injecting, for example and without limitation, using the pre-filled syringe as described herein.
When the lock solution described above is infused into the interior surface of the catheter, a sufficient amount of the lock solution can be injected to fill or substantially fill the interior volume/space of the catheter, as well as, any adjacent surfaces or lumens of any attached access device. Alternatively, a volume less than the amount of fluid needed to fill the catheter can be infused into the interior surface. For example, a sufficient amount of lock solution can be infused into the catheter to fill, for example, from 80% to 250% of the internal volume of the catheter, all subranges and percentages therebetween inclusive. In yet another aspect, an amount greater than the internal volume of the catheter can be infused. For example, an amount of the lock solution greater than the internal volume of the catheter can be infused into the lumen. Unlike heparin-based lock solutions, this overflow can be utilized without adverse effects on the clotting system of the patient. The lock solution may be infused or flushed into the catheter between 1 and 1000 times, all subranges and values therebetween inclusive.
The method of locking a catheter, as described above, is effective to prevent backflow of blood from the patient into the lumen of the catheter into which the lock solution is infused or introduced. In addition, the lock solution reduces the occurrence of, or prevents clot formation, maintaining catheter patency.
Also provided herein is a method of making a catheter lock solution as described above. The catheter locking solution can be prepared with simple mixing of the above-identified components at room temperature to provide anticoagulation and antimicrobial activity. In other aspects, the solution is prepared in bulk and loaded into syringes to prepare pre-filled syringes that can be distributed and stored until needed.
Also provided herein is a catheter including a tube defining a lumen therethrough that is pre-filled with the catheter locking solution described above prior to insertion within the patient.
In vitro testing was conducted on samples of the lock solution described herein. Briefly, 5 mL syringes prefilled with sterile 4% sodium citrate compounded at a pH of 6.9 were prepared. Six-hundred and thirty-five samples were tested for reflux with 4 FR, single lumen catheters (Bard, Covington Ga.), and the results are presented in
In addition to the above reflux testing, additional samples of sterile 4% sodium citrate compounded at a pH of 6.9 were prepared, and these additional samples underwent accelerated aging at 40° C.±2° C./75% RH±5% RH and real-time aging at 25° C.±2° C./60% RH±5% RH. Accelerated aging results were collected and analyzed at 0, 4, and 6.5 months while real-time aging results were collected and analyzed at 6 months. Results are presented below (average reflux in cm) in Tables 1 and 2.
As can be seen from the above tables, the aged samples demonstrated an average reflux of 0±0.6 cm.
Experimental samples were compounded using three lots of different trisodium citrate, each at a pH of 6.9. These samples underwent accelerated aging at 40° C.±2° C./25% RH±5% RH and real-time aging at 25° C.±2° C./40% RH±5% RH. The anticoagulation effectiveness of 4% sodium citrate lock solution on whole blood was determined using the Sonoclot® Coagulation & Platelet Function Analyzer (Sienco Inc., Boulder Colo.), which can calculate the onset of clot formation by monitoring mechanical changes that occur in blood samples during hemostasis. The mechanism is a tubular probe that moves up and down within a blood sample. As the sample progresses through various stages of clotting, electronic circuitry (a transducer) detects increasing resistance. This produces a series of electronic signals that are processed by a microcomputer. The output is the total time of clot formation where the blood is more viscous than initially introduced.
The results of the above testing demonstrated that by preventing clot formation during locking and flushing, a lock solution as described herein is able to maintain the patency of vascular access devices, such as catheters, by preventing/reducing catheter occlusion that may arise from blood clots. Specifically, accelerated aging results were collected and analyzed at 0, 2, 3, 4, 6, and 6.5 months, while real-time aging results were collected and analyzed at 3 and 6 months (Tables 3 and 4, below) and compared to heparin, saline, or blood only (controls).
Lastly, the results demonstrated that a sodium citrate lock solution delayed the onset of clots longer than compared to saline (
A sodium citrate lock solution, as described herein, demonstrated exceptional stability, and it is believed to have a guaranteed shelf life of 2 years from the date of manufacture. To test this, five batches of 3 mL and 5 mL experimental samples were compounded using three different salt lots, at a pH ranging from 6.8 to 7.0 to evaluate the concentration and pH of the 4% sodium citrate lock solution. As above, these samples underwent accelerated aging at 40° C.±2° C./25% RH±5% RH and real-time aging at 25° C.±2° C./40% RH±5% RH. Accelerated aging results were collected and analyzed at 0, 2, 3, 4, 6, and 6.5 months, while real-time aging results were collected and analyzed at 3 and 6 months. Tables 6 and 7 (below) present results for sodium citrate concentration and Tables 8 and 9 (also below) present results for pH.
As the data shows, throughout the two-year equivalent time point (6.01 months for 3 mL syringes and 5.04 months for 5 mL syringes) and beyond (6.5 months), the results of the five batches demonstrated that the solution concentration and pH was within the corresponding USP38-NF33 specification interval for anticoagulant 4% sodium citrate, 3.8-4.2% w/v (
While the present invention has been described in terms of the above detailed description, those of ordinary skill in the art will understand that alterations may be made within the spirit of the invention. Accordingly, the above should not be considered limiting, and the scope of the invention is defined by the appended claims.
The present application claims priority to U.S. Provisional Patent Application No. 62/561,859, filed Sep. 22, 2017, the contents of which are incorporated by reference herein in their entirety.
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| Entry |
|---|
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| Number | Date | Country | |
|---|---|---|---|
| 20190091379 A1 | Mar 2019 | US |
| Number | Date | Country | |
|---|---|---|---|
| 62561859 | Sep 2017 | US |
