Automatic versus manual changeovers of norepinephrine infusion pumps in critically ill adults: a prospective controlled study

Minimising haemodynamic lability during changeover of syringes infusing norepinephrine in adult critical care patients: a multicentre randomised controlled trial

BACKGROUND

Arterial pressure lability is common during the process of replacing syringes used for norepinephrine infusions in critically ill patients. It is unclear if there is an optimal approach to minimise arterial pressure instability during this procedures. We investigated whether 'double pumping' changeover (DPC) or automated changeover (AC) reduced blood pressure lability in critically ill adults compared with quick syringe changeover (QC).

METHODS

Patients requiring a norepinephrine infusion syringe change were randomised in a non-blinded trial undertaken in six ICUs. Randomisation was minimised by norepinephrine flow rate at inclusion and centre. The primary outcome was the frequency of increased/decreased mean arterial pressure (defined by </>15 mm Hg from baseline measurements) within 15 min of switching the syringe compared with QC.

RESULTS

Patients (mean age: 64 (range:18-88)) yr were randomly assigned to QC (n=95), DPC (n=95), or AC (n=96). Increased MAP was the commonest consequence of syringe changeovers. MAP variability was most frequent after DPC (89/224 changeovers; 39.7%) compared with 57/223 (25.6%) changeovers after quick syringe switch and 46/181 (25.4%) in patients randomised to receive automated changeover (P=0.001). Fewer events occurred with QC compared with DPC (P=0.002). Sensitivity analysis based on mixed models showed that performing several changeovers on a single patient had no impact. Both type of changeover and norepinephrine dose before syringe changeover were independently associated with MAP variations >15 mm Hg.

CONCLUSIONS

Quick changeover of norepinephrine syringes was associated with less blood pressure lability compared with DPC. The prevalence of MAP variations was the same between AC and QC.

CLINICAL TRIAL REGISTRATION

NCT02304939.

Nurse management of vasoactive medications in intensive care: A systematic review

AIM AND OBJECTIVE

To investigate how intensive care nurses prepare, initiate, administer, titrate, and wean vasoactive medications.

BACKGROUND

The management of vasoactive medications is core business for intensive care nurses, but little is known on how nurses manage these ubiquitous and potentially harmful medications.

DESIGN

A systematic review of the literature with narrative synthesis of data.

METHODS

The databases CINAHL Complete, Medline Complete and EMBASE were searched from 1965 to January 2019 with keywords under five concept headings and in a variety of configurations. This systematic review was conducted according to the PRISMA guidelines. Studies were assessed for quality and bias, and a modified narrative synthesis was used to analyse data, investigate findings and explore relationships within and between studies.

RESULTS

The review identified 13 studies: two observational studies, two pre and post intervention studies, four survey studies, two quasi-experimental studies, one longitudinal time series, one prospective controlled trial, and one interview incorporating content analysis. Four studies on preparing and initiating vasoactive medications described a lack of standardisation in infusion preparation and inconsistencies in dosing units and patient weights. Five of six studies on vasoactive medication administration examined nurses' use of syringe changeovers to reduce patient haemodynamic compromise and there were three studies on titration and weaning.

CONCLUSION

Further research on nurse management of vasoactive medications is needed to develop an evidence base for specialist education and standardised practices aimed at reducing risk for patient harm.

RELEVANCE TO CLINICAL PRACTICE

Nurses working in intensive care units in many parts of the world are responsible for the management of vasoactive medications. There is great variation in practices that include preparation, initiation, administration, titration and weaning of vasoactive medications, which increases the risk for medication errors and adverse events in a vulnerable population of critically ill patients.

Accuracy of low-weight versus standard syringe infusion pump devices depending on altitude

Background

Intravenous drug infusions in critically ill patients require accurate syringe infusion pumps (SIPs). This is particularly important during transportation of critically ill patients by helicopter emergency medical services (HEMS), where altitude may influence device performance. Because weight is a real concern in HEMS, new low-weight devices are very appealing.

The aim of this study was to compare infusion flow rates delivered by low-weight versus standard SIP devices, in the prehospital emergency medicine setting, at different altitudes.

Methods

We conducted a comparative bench study involving five SIP devices (two standard and three low-weight models) at 300, 1700 and 3000 m altitude. The primary endpoint was the flow rate delivered by SIPs for prespecified values. We used two methods to measure flow. The normative method consisted in measuring weight (method A) and the alternate method consisted in measuring instantaneous flow (method B).

Results

Using method A, no significant differences were found in median flow rates and interquartile range depending on device and altitude for a prespecified 10-mL/h flow. However, method B showed that low-weight SIPs delivered multiple sequential boluses with substantial variations (1.2–15.8 mL/h) rather than a prespecified continuous 5-mL/h flow. At 1700 m altitude, the interquartile range of delivered flows increased only for low-weight devices (p for interaction< 0.001).

Conclusions

Despite satisfactory normative tests, low-weight SIPs deliver discontinuous flow with potential clinical implications for critically ill patients receiving vasoactive drugs. This study also highlights a thus far unknown negative impact of altitude on SIP function. We believe that normative requirements for SIP approval should be revised accordingly.

Impact du nombre d’interventions infirmières sur la durée d’administration des catécholamines chez les patients de réanimation : étude INTERVAL

Objectifs : Bien que quotidiennement géré par les infirmier(ière)s diplômé(e)s d’État (IDE) de réanimation, le sevrage des catécholamines a rarement été étudié. L’hypothèse de notre étude était que l’augmentation du nombre d’interventions menées sur la vitesse de perfusion des catécholamines permettait de raccourcir la durée d’administration de celles-ci.

Patients et méthodes : Il s’agissait d’une étude prospective observationnelle dans 21 réanimations. Tous les patients traités par vasopresseurs pendant la période d’étude ont été inclus. Le nombre d’interventions effectuées par l’IDE en charge du patient sur la vitesse d’administration des catécholamines était noté toutes les quatre heures. La posologie de catécholamines en cours ainsi que la pression artérielle moyenne (PAM) du patient étaient également relevées. Les facteurs influençant la rapidité du sevrage des catécholamines étaient également analysés.

Résultats : Nous avons inclus 226 patients dont l’âge moyen était de 65 ± 14 ans. La durée moyenne du traitement par catécholamines était de 71,6 (±81) heures. Le nombre d’interventions IDE par quatre heures était de 1,9 (±2,8) intervention. La durée du traitement par catécholamines était significativement moindre lorsque le nombre d’interventions augmentait (p = 0,04). L’existence d’un protocole spécifique à la gestion des catécholamines raccourcissait leur durée de sevrage. Un IGS2 élevé, une PAM élevée ainsi que la période diurne étaient associés à une augmentation du nombre des interventions IDE.

Conclusion : Le nombre d’interventions par les IDEs menées sur la perfusion de catécholamines était inversement lié à la durée du traitement par catécholamines. Des études complémentaires permettront d’évaluer l’impact de ces interventions sur le pronostic des patients.

Criteria for choosing an intravenous infusion line intended for multidrug infusion in anaesthesia and intensive care units

OBJECTIVE

The aims are to identify critical parameters influencing the drug mass flow rate of infusion delivery to patients during multidrug infusion and to discuss their clinical relevance.

DATA SOURCES

A review of literature was conducted in January 2016 using Medline, Google Scholar, ScienceDirect, Web of Science and Scopus online databases.

DATA EXTRACTION

References relating to the accuracy of fluid delivery via gravity-flow intravenous (IV) infusion systems and positive displacement pumps, components of IV administration sets, causes of flow rate variability, potential complications due to flow rate variability, IV therapies especially at low flow rates and drug compatibilities were considered relevant.

DATA SYNTHESIS

Several parameters impact the delivery of drugs and fluids by IV infusion. Among them are the components of infusion systems that particularly influence the flow rate of medications and fluids being delivered. By their conception, they may generate significant start-up delays and flow rate variability. Performing multidrug infusion requires taking into account two main points: the common dead volume of drugs delivered simultaneously with potential consequences on the accuracy and amount of drug delivery and the prevention of drug incompatibilities and their clinical effects.

CONCLUSION

To prevent the potentially serious effects of flow rate variability on patients, clinicians should receive instruction on the fluid dynamics of an IV administration set and so be able to take steps to minimise flow rate changes during IV therapy.

Predictors of haemodynamic instability during the changeover of norepinephrine infusion pumps

Background

Changeovers of norepinephrine infusion pumps (CNIPs) frequently lead to haemodynamic instability. The aim of this study was to identify risk factors for haemodynamic instability associated with CNIP, independent of the method used to perform the relay.

Methods

We performed a prospective study, in a university-affiliated intensive care unit. Over a 1-year period, all adult patients who had at least one CNIP were included. CNIPs were automatically performed using smart pumps, in accordance with a standardised protocol. CNIP-induced haemodynamic instability was defined as a variation in mean arterial pressure (MAP) >25 %. A multivariate mixed effects logistic regression was fitted to assess the factors associated with CNIP-induced haemodynamic instability.

Results

From the 118 patients included in the study, 764 CNIPs were analysed. Most of the patients were treated with norepinephrine for septic shock of medical origin (n = 83, 70 %). Haemodynamic instability occurred 114 times (15 %) in 63 patients (53 %). Among the risk factors identified by the univariate analysis (age, heart rate, dose of norepinephrine infused, and change in the concentration of the vasoactive drug; p < 0.05), change in the norepinephrine concentration was the only independent risk factor for CNIP-induced haemodynamic instability identified in the multivariate analysis (adjusted OR 11.8, 95 % CI 7.2–19.5, p < 0.001).

Conclusions

Changes in the norepinephrine concentration during CNIPs lead to a high risk of haemodynamic instability, while the clinical severity of patients, as well as the doses of norepinephrine, was not.