Thursday, April 19, 2018

When and Why Glass IV Bottles Disappeared

Glass IV bottles were all fun and games until you dropped one.
Up until the early 1970s you could receive your IV dispensed from any container as long as it was a gleaming glass bottle. These time tested and trusted  vessels had been the workhorse of infusion therapy for decades and possessed a sense of inertia that suggested  they would be around almost forever.

Having been raised  with glass IV bottles, older  nurses had a special reverence  for them. It was easy to view the level of remaining fluid and  glass was inert to allay any worries of interactions with the fluid contents. A strip of ordinary adhesive  tape could be easily applied to the side of the bottle with the time marked for the fluid levels. Pumps and controllers were nonexistent so we counted gtts/minute (gtts is a Latin abreviation for "gutta" meaning drops.) It  always amused me how health care folks  used  Latin to obfuscate the issue, but alas, that's a post  for another day.

KCl  and B&C vitamin supplements could be added to bottles without even using a needle, just plug that naked syringe into the air vent and inject away. I used to relish the visual treat of the deep yellow vitamin solution as it merged and mixed with the clear IV fluid in the bottle. Inject the colorful solution rapidly and a model of a spinning water spout could be replicated. I've heard the term "lightening in a bottle," but a miniature water spout was even more impressive.

 Nurses mixed all  IV fluids  on the patient care  floors, no need to involve the pharmacy with all those superfluous phone calls or redundant paper work. The air vent had another feature nurse's came to know and love. As the air bubble gurgled it's way through the fluid in the resonant glass botle to equalize  pressure, the soothing noise  was an auditory cue that all was right with the infusion. Infiltrated IV sites never produced the  gurgle. Glass IV bottles had a special place in every nurse's heart. We never gave a thought to their disappearance. What could possibly replace such a dependable and familiar piece of equipment?

The beginning of the end for glass IV bottles occurred in July of 1970. Outbreaks of hospital acquired sepsis by the bacteria  Entrobacter cloacae  were linked to Abbott Labs newly designed glass IV bottles with screw caps. The decades old bottle cap was pealed off to open the bottle similar to a pop tab on a can. Occasionally the metal would peal off unevenly resulting in a problem opening the bottle. A new screw on cap was designed to eliminate the opening problems. There were also problems with spiking the old design caps. Sometimes a tiny portion of the black stopper would break free and float freely in the IV solution. We were always told not to worry about it, but foreign bodies like little black flecks of stopper made every nurse nervous. Who in the world would want something like that coursing through their veins?

The newly designed threaded cap was easy to use and the problematic  black stopper was retired. We all liked the new design, but problems were waiting in the wings that would spell the end for glass bottles.

Viable bacteria gained access to the IV fluid while it cooled following the autoclave procedure which created a vacuum drawing bacteria in through the threaded interstices of the newly designed  screw- on cap. The end result was 412 known infections among hospitalized patients and 50 deaths. All of Abbott Lab's intravenous solutions in glass bottles  were withdrawn from the market in March, 1971.

On May 29, 1973 a Federal grand jury indicted 5 corporate officers from Abbott Laboratories. Investigation revealed the Abbott IV plant in Rocky Mount, N.C. was contaminated with a variety of pathogenic bacteria. The proliferation of bacteria was exacerbated by glass bottles of D5W falling from the assembly line and breaking ( a problem nurses knew all too well)  which provided the bacteria with an ample supply of growth media. This was one of the initial cases of health care officials facing criminal charges.

Hospitals were desperate for a supply of IV fluids and Baxter Labs had just introduced a novel product - IV fluids in a flexible rectangular configuration featuring a plastic container that collapsed as fluids infused. The flexible IV bags were tagged with the clever  name "Viaflex" and the revolution had begun. These bags could be stored in any position and touted a completely closed system-the bags collapsed as the fluid exited. No venting required. With the old bottle system it was risky to piggyback antibiotics into a primary line because drugs like Keflin came in 2 gm. bottles requiring a vent and connecting a vented secondary bottle to a vented primary line could allow for air embolism. Small plastic bags of piggyback medication eliminated the air embolism risk. Baxter acquired a pharmaceutical company and began selling premixed drugs in small 100cc plastic bags. The IV piggy back was off to a running start with the closed system mini-bags.  Soon many drugs administered by IM injection were being given IV and fancy new fangled notions of determining peak and trough levels of drugs evolved.

For a brief time period (1976-1980) Viaflex bags and glass IV bottles assumed  a tenuous coexistence. Vented IV sets were bicultural so to speak and could be used with either Viaflex IV bags or glass bottles. Using  nonvented  Viaflex IV tubing set up on a glass bottle was strictly taboo. Hapless practitioners that pulled this stunt found that without a means to relieve intrabottle pressure the drip chamber collapsed like a lung in a punctured pleural cavity. If the problem was not promptly corrected the negative pressure could begin to draw venous blood through the angiocath producing a tell tale red streak of blood in the IV tubing. Spooky indeed and guaranteed the nurse a prominent position on the wall of shame and vulnerable to endless gossip..."You would not believe what Suzy did with her IV last night...yada..yada," nurses only made this mistake once.

By 1980 the intravenous therapy world was ruled by Vialflex like flexible bags and glass bottles were gone for good. Abbott even began producing their own IV bag that had an unusual feature that nurses disliked. The port for adding medications was a blue bull's eye  target about 3 inches up from the bottom of the bag. When adding drugs to an IV, nurses were used to holding the port in one hand to steady it while injecting with the other hand. There was nothing to grasp on that blue bull's eye and nurses in a hurry were known to poke a hole through the opposite wall of the bag resulting in much cursing and  general unpleasantness.

This transition from glass to plastic  was difficult for seasoned old nurses who by  nature of their basic constitution were resistant to change. Glass bottles had prominent labels and were easy to identify; bags were produced with an over wrap that obscured the label. Drip chambers on glass bottles hung perfectly vertical; on bags the drip chamber was often hanging at an angle. Patient transfers with a bottle always required the careful use of a pole to maintain the positioning of the bottle. Nurses were appalled at the occasional  practice of tossing the IV bag on the patient's lap or chest during brief transfers.  Bottles would roll off and break if this crude trick was attempted. It was easier to thread a solid object like a bottle through an opening for an arm when changing patient gowns. Those IV bags were like getting a grip on a handful of Jello.  Finally, hanging those flimsy bags could be difficult. It was necessary to free up the folded vinyl hanger and thread the small opening over the hook on an IV pole.

I am truly impressed by the variety of realistic sounds produced by electronic devices like that camera shutter clicking noise on cell phones or that  "whoosh" noise when sending an email. The Oldfoolrn  medical equipment design institute has come up with another innovation. How about an electronic IV pump or controller that emits a skeumorphic noise replicating that gurgling noise as a bubble coursing through a vented  glass IV bottle. Lots of old nurses would  truly love hearing  that reassuring noise again.

13 comments:

  1. I remember that transition, but as an orderly I could only observe. The newer nurses were able to adapt a little quicker and with less grumbling than the veterans.

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  2. I "grew up" with mostly plastic bags, except for Nitro and Lipids. Once knocked a FULL bottle of Lipids off a pole ~ YIKES!!! I thought the pharmacist was going to kill me!

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  3. Your last paragraph is georgeous! I did chuckle thanks OFRN. Sounds are interesting things - as someone who used to do lots of typing in my spare time, I still miss the satisfying wiz-clunk noise as I hit the carriage return at the end of each line...a computer just doesn't do it for me...

    I wish my father were alive to read this - his job was designing bottles! I remember the bottle caps you used to lift off like a can opener... when plastic containers/bottles first started to appear in shops my father forebade any of us in the family to buy them - our home was strictly glass only - however he finally had to admit that plastic shampoo bottles in the shower were a better idea than the glass ones. He would have completely understood your preference for glass IV bottles, in fact he would have applauded it! (They'd gone out before I started training, just as well as I know I would have dropped one... it was bad enough dropping a glass mercury thermometer).

    Personally I used to wish the awful beeping noise the electronic ones made when an IV ran through could be changed to a soothing voice telling the patient "It's OK you WON'T get an air bubble I promise" - I used to be constantly reassuring patients who were panicked by the frantic beeps emitted by their IV apparatus and were sure it meant there was an emergency... Cheers again, S.

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  4. Thanks for all your wonderful comments. I am toying with the idea of a post detailing the many ways a nurse could break one of those glass IV bottles. Dropping them was but on route to a really big mess and if it was D5W, a sticky one at that.

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  5. https://youtu.be/tvlFGIZdY9E

    I hope this link words OFRN - excuse me for being off-topic but I found this as I was Googling around the www - it's a New Zealand nursing recruitment video from 1965. I couldn't stop laughing! A school girl gets a tour from Matron of the hospital and what it's like to be a nurse... love the discussion about apple pie versus rice pudding. It's truly appalling! Oh, and there is actually a glass IV bottle in one scene!

    If the link doesn't work it's entitled The New Nurse (1965) New Zealand Archives.

    Only watch it when you've got nothing else to do - it's truly cringeworthy! Cheers, Sue.

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  6. Ahh..such a wonderful time of blissful innocence. No mention of insurance companies, big pharma, computers or utilization review nurses. This video deserves it's own post. Thanks, so much for sharing, Sue.

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  12. I dropped a nitroglycerin glass bottle once. It's amazing how quiet that can make a busy ER room, as all eyes turned to the source and just...stared. And the mess was incredible! Glass made it out of his room and somehow into the one next door.

    I was mortified. Ever since that day, I use extra caution with nitro bottles. Knock on wood, I haven't dropped one since!

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  13. The worse glass bottles to break were D5W or pooled plasma. The gooey, sticky solutions made the cleanup even more memorable. Dropping a glass bottle on your foot was always a mixed blessing. The cushioning of your foot often prevented the glass breakage but OUCH that really smarts.

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