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Bosch NA, Vail EA, Law AC, Homer-Bouthiette C, Walkey AJ, Moitra VK. Practice Patterns and Outcomes of Potassium Repletion Thresholds during Critical Illness. Ann Am Thorac Soc 2024; 21:456-463. [PMID: 38134433 PMCID: PMC10913769 DOI: 10.1513/annalsats.202308-750oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 12/20/2023] [Indexed: 12/24/2023] Open
Abstract
Rationale: Potassium repletion is common in critically ill patients. However, practice patterns and outcomes related to different intensive care unit (ICU) potassium repletion strategies are unclear. Objectives: 1) Describe potassium repletion practices in critically ill adults; 2) compare the effectiveness of potassium repletion strategies; and 3) compare effectiveness and safety of specific potassium repletion thresholds on patient outcomes. Methods: This was a retrospective analysis of the PINC AI Healthcare Database (2016-2022), including all critically ill adults admitted to an ICU on Hospital Day 1 and with a serum potassium concentration measured on Hospital Day 2. We determined the frequency of potassium repletion (any formulation) at each measured serum potassium concentration in each ICU, then classified ICUs as having threshold-based (a large increase in potassium repletion rates at a specific serum potassium concentration) or probabilistic (linear relationship between serum concentration and the repletion probability) patterns of repletion. Between patients in threshold-based and probabilistic repletion ICUs, we compared outcomes (primary outcome: potassium repletion frequency). We reported unadjusted percentages per exposure group and the adjusted odds ratios (from hierarchical regression models) for each outcome. Among patients in threshold-based ICUs with the most common repletion thresholds (3.5 mEq/L and 4.0 mEq/L), we conducted regression discontinuity analyses to examine the effectiveness of potassium repletion at each potassium threshold. Results: We included 190,490 patients in 88 ICUs; 35.0% received at least one dose of potassium on the same calendar day. Rates of potassium repletion were similar between 22 threshold-based strategy ICUs (33.5%) and 22 probabilistic strategy ICUs (36.4%). There was no difference in the adjusted risk of potassium repletion between patients admitted to threshold-based strategy ICUs versus probabilistic strategy ICUs (adjusted odds ratio, 1.09; 95% confidence interval [CI], 0.76-1.57). In regression discontinuity analysis, crossing the 3.5 mEq/L threshold from high to low potassium levels resulted in a 39.1% (95% CI, 23.7-42.4) absolute increase in potassium repletion but no change in other outcomes. Similarly, crossing the 4.0 mEq/L threshold resulted in a 36.4% (95% CI, 22.4-42.2) absolute increase in potassium repletion but no change in other outcomes. Conclusions: Potassium repletion is common in critically ill patients and occurs over a narrow range of "normal" potassium levels (3.5-4.0 mEq/L); use of a threshold-based repletion strategy to guide potassium repletion in ICU patients is not associated with clinically meaningful differences in outcomes.
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Affiliation(s)
- Nicholas A. Bosch
- Section of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Emily A. Vail
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Penn Center for Perioperative Outcomes Research and Transformation, Philadelphia, Pennsylvania; and
| | - Anica C. Law
- Section of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Collin Homer-Bouthiette
- Section of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Allan J. Walkey
- Section of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Vivek K. Moitra
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
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2
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O'Neill K, Bloomer MJ. An integrative review of potassium replacement protocol use in critical care: Development, use and critical care nurse autonomy. Intensive Crit Care Nurs 2023; 79:103524. [PMID: 37598503 DOI: 10.1016/j.iccn.2023.103524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/23/2023] [Accepted: 07/31/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND Potassium replacement protocols are used to standardise practice, reduce risk, and ensure timely potassium replacement, but there is considerable variability in their development and use, particularly as part of critical care nursing practice. AIM To synthesise the research evidence on how potassium replacement protocols are used in adult critical care; and how critical care nurses' role and practice is influenced by a potassium replacement protocol. The research question was 'How are protocols used by intensive care clinicians to guide potassium replacement in adult critical care?' DESIGN A structured integrative review was undertaken. A combination of keywords, synonyms, and Medical Subject Headings were used across the Ovid Medline and Embase databases. Records were independently assessed against inclusion and exclusion criteria. All papers were assessed for quality. A narrative synthesis was used to analyse and present the findings. RESULTS Ten studies were included in this review from 4076 records identified. Narrative synthesis revealed five categories: (i) protocol design demonstrating variation in protocol mechanisms, (ii) protocol rationale eliciting reasonings for protocol implementation, (iii) protocol use describing how protocols were nurse-driven enabling nursing autonomy (iv) protocol adherence highlighting variability in protocol compliance and (v) critical care nurse acceptability and feasibility coupling greater shared responsibility for patient care and improved clinician satisfaction. CONCLUSION Safe, high-quality care, supported by evidence continues to be a priority. Protocolised potassium replacement can improve patient outcomes and promote nurses' autonomy, efficiency, and job satisfaction. IMPLICATIONS FOR CLINICAL PRACTICE Recognising and promoting critical care nurses' expert assessment skills and clinical decision-making is essential for optimising efficient, safe, and high-quality patient care. Although protocol deviations are accommodated in protocol development, comprehensive documentation to justify protocol deviations is key to justifying practice. Understanding protocol deviations are crucial to inform future protocol development, improvements, and evaluation to further enhance critical care nursing practice.
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Affiliation(s)
- Kylie O'Neill
- Intensive Care Unit, Princess Alexandra Hospital, Metro South Hospital Health Service, Woolloongabba, QLD, Australia.
| | - Melissa J Bloomer
- Intensive Care Unit, Princess Alexandra Hospital, Metro South Hospital Health Service, Woolloongabba, QLD, Australia; School of Nursing & Midwifery, Griffith University, Nathan, QLD, Australia; Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
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3
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Guiding Efficient, Effective, and Patient-Oriented Electrolyte Replacement in Critical Care: An Artificial Intelligence Reinforcement Learning Approach. J Pers Med 2022; 12:jpm12050661. [PMID: 35629084 PMCID: PMC9143326 DOI: 10.3390/jpm12050661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 02/01/2023] Open
Abstract
Both provider- and protocol-driven electrolyte replacement have been linked to the over-prescription of ubiquitous electrolytes. Here, we describe the development and retrospective validation of a data-driven clinical decision support tool that uses reinforcement learning (RL) algorithms to recommend patient-tailored electrolyte replacement policies for ICU patients. We used electronic health records (EHR) data that originated from two institutions (UPHS; MIMIC-IV). The tool uses a set of patient characteristics, such as their physiological and pharmacological state, a pre-defined set of possible repletion actions, and a set of clinical goals to present clinicians with a recommendation for the route and dose of an electrolyte. RL-driven electrolyte repletion substantially reduces the frequency of magnesium and potassium replacements (up to 60%), adjusts the timing of interventions in all three electrolytes considered (potassium, magnesium, and phosphate), and shifts them towards orally administered repletion over intravenous replacement. This shift in recommended treatment limits risk of the potentially harmful effects of over-repletion and implies monetary savings. Overall, the RL-driven electrolyte repletion recommendations reduce excess electrolyte replacements and improve the safety, precision, efficacy, and cost of each electrolyte repletion event, while showing robust performance across patient cohorts and hospital systems.
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4
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Examination of Electrolyte Replacements in the ICU Utilizing MIMIC-III Dataset Demonstrates Redundant Replacement Patterns. Healthcare (Basel) 2021; 9:healthcare9101373. [PMID: 34683053 PMCID: PMC8536187 DOI: 10.3390/healthcare9101373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 09/27/2021] [Accepted: 10/05/2021] [Indexed: 11/17/2022] Open
Abstract
Electrolyte repletion in the ICU is one of the most ubiquitous tasks in critical care, involving significant resources while having an unclear risk/benefit ratio. Prior data indicate most replacements are administered while electrolytes are within or above reference ranges with little effect on serum post-replacement levels and potential harm. ICU electrolyte replacement patterns were analyzed using the MIMIC-III database to determine the threshold governing replacement decisions and their efficiency. The data of serum values for potassium, magnesium, and phosphate before and after repletion events were evaluated. Thresholds for when repletion was administered and temporal patterns in the repletion behaviors of ICU healthcare providers were identified. Most electrolyte replacements happened when levels were below or within reference ranges. Of the lab orders placed, a minuscule number of them were followed by repletion. Electrolyte repletion resulted in negligible (phosphate), small (potassium), and modest (magnesium) post-replacement changes in electrolyte serum levels. The repletion pattern followed hospital routine work and was anchored around shift changes. A subset of providers conducting over-repletion in the absence of clinical indication was also identified. This pattern of behavior found in this study supports previous studies and may allude to a universal pattern of over-repletion in the ICU setting.
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5
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Wang AS, Dhillon NK, Linaval NT, Rottler N, Yang AR, Margulies DR, Ley EJ, Barmparas G. The Impact of IV Electrolyte Replacement on the Fluid Balance of Critically Ill Surgical Patients. Am Surg 2020. [DOI: 10.1177/000313481908501021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Avoiding excess fluid administration is necessary when managing critically ill surgical patients. The aim of this study was to delineate the current practices of IVelectrolyte (IVE) replacement in a surgical ICU and quantify their contribution to the fluid balance (FB) status. Patients admitted to the surgical ICU over a six-month period were reviewed. Patients undergoing dialysis and those with ICU stay <72 hours were excluded. A total of 248 patients were included. The median age was 60 years, and 57 per cent were male. Overall, 1131 patient ICU days were analyzed. The median daily FB was 672 mL. IVEs were administered in 62 per cent of ICU days. In days that IVEs were used, negative FB was significantly less likely to be achieved (62% vs 69%, P = 0.02). The most commonly administered IVE was calcium (32% of ICU days); however, the largest volume of IVE was administered in the form of phosphorus (median 225 mL). Diuretics were administered in 17 per cent of ICU days. Patients who received diuretics were significantly more likely to receive IVE (70% vs 61%, P = 0.02). Administration of IVE may contribute to the daily positive FB of surgical ICU patients. Implementation of practices that can ameliorate this effect is encouraged.
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Affiliation(s)
- Andrew S. Wang
- Division of Trauma and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Navpreet K. Dhillon
- Division of Trauma and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nikhil T. Linaval
- Division of Trauma and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nicholas Rottler
- Division of Trauma and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Audrey R. Yang
- Division of Trauma and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel R. Margulies
- Division of Trauma and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J. Ley
- Division of Trauma and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Galinos Barmparas
- Division of Trauma and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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6
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Su K, McGloin R, Gellatly RM. Predictive Validity of a QT c Interval Prolongation Risk Score in the Intensive Care Unit. Pharmacotherapy 2020; 40:492-499. [PMID: 32259316 DOI: 10.1002/phar.2400] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 02/25/2020] [Accepted: 02/26/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Torsade de pointes is a form of polymorphic ventricular tachycardia associated with heart rate-corrected QT (QTc ) interval prolongation. With approximately 24-61% of critically ill patients experiencing QTc interval prolongation, a predictive tool to identify high-risk patients could assist in the monitoring and management in the intensive care unit (ICU). The Tisdale et al. Risk Score (TRS) is a predictive tool that was developed and validated in a cardiac critical care unit. OBJECTIVES The objective of this study was to evaluate the predictive validity (sensitivity and specificity) and likelihood ratios of the TRS in a medical ICU. METHODS This was a longitudinal, retrospective, cohort study of consecutive patients who met the inclusion criteria from October 2017 to June 2018 with a sample size of 264 patients. The sample size was derived based on the number of TRS covariates and an exploratory variable. Baseline characteristics and risk factors were documented from electronic health records. The first occurrence of QTc interval prolongation, defined as a QTc interval > 500 ms or an increase ≥ 60 ms above baseline, was the primary endpoint. MAIN RESULTS The sensitivity and specificity of the TRS for low-risk patients against the moderate-risk and high-risk patients were 97% (95% CI 91-99%) and 16% (95% CI 11-23%), respectively. These results corresponded to a positive likelihood ratio of 1.15 (95% CI 1.07-1.24) and a negative likelihood ratio of 0.20 (95% CI 0.06-0.65). CONCLUSIONS In conclusion, the TRS showed a high sensitivity, making it useful in identifying patients at risk of developing QTc interval prolongation. Furthermore, patients categorized as low risk by the tool can be considered as having minimal risk of developing QTc interval prolongation. Given the tool's low specificity, it does not reliably identify all patients at low risk of QTc interval prolongation.
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Affiliation(s)
- Ke Su
- Pharmacy Department, Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Rumi McGloin
- Pharmacy Department, Surrey Memorial Hospital, Surrey, British Columbia, Canada.,Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Rochelle M Gellatly
- Pharmacy Department, Surrey Memorial Hospital, Surrey, British Columbia, Canada.,Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada.,Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
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Hammond DA, King J, Kathe N, Erbach K, Stojakovic J, Tran J, Clem OA. Effectiveness and Safety of Potassium Replacement in Critically Ill Patients: A Retrospective Cohort Study. Crit Care Nurse 2019; 39:e13-e18. [PMID: 30710043 DOI: 10.4037/ccn2019705] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Rules of thumb for potassium replacement are used in intensive care units despite minimal empirical validation. OBJECTIVE To evaluate the effectiveness and safety of rule-of-thumb potassium replacement in critically ill patients with mild and moderate hypokalemia. METHODS A retrospective, observational study was done of patients with mild (potassium, 3-3.9 mEq/L) and moderate (potassium, 2-2.9 mEq/L) hypokalemia admitted to a medical intensive care unit who received potassium replacement. Expected and actual frequencies of replacement that achieved target potassium concentrations (≥ 4 mEq/L) were compared by using a χ2 test. Logistic regression analysis was used to assess whether rule-of-thumb administration affected the probability of target attainment within 24 hours of replacement. RESULTS Serum potassium concentrations were checked within 24 hours after potassium replacement on 354 of 577 days (61.4%) when replacement was provided. Concentrations were within target range in 82 instances (23.2%). Of 62 episodes of replacement expected to achieve the target according to the rule-of-thumb estimation, 22 did (35%). Rule-of-thumb administration was associated with greater likelihood of target attainment (odds ratio, 2.12; 95% CI, 1.18-3.85; P = .01). This difference in likelihood remained significant after adjustment for covariates (odds ratio, 2.18; 95% CI, 1.04-4.56; P = .04). CONCLUSION In critically ill patients given potassium replacement without regard to a formal protocol, the target serum potassium concentration was achieved more often than expected according to the rule-of-thumb estimation but less than one-third of the time.
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Affiliation(s)
- Drayton A Hammond
- Drayton A. Hammond is a clinical pharmacy specialist, medical and cardiac intensive care, Department of Pharmacy, Rush University Medical Center, Chicago, Illinois. .,Jarrod King and Kristina Erbach are pharmacy residents, Niranjan Kathe is a doctoral candidate in pharmaceutical evaluation and policy, and Oktawia A. Clem is a pharmacy student, Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, Arkansas. .,Jelena Stojakovic is a pharmacy resident, Department of Pharmacy, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas. .,Julie Tran is a pharmacy resident, Department of Pharmacy, Mercy Hospital, Springfield, Missouri.
| | - Jarrod King
- Drayton A. Hammond is a clinical pharmacy specialist, medical and cardiac intensive care, Department of Pharmacy, Rush University Medical Center, Chicago, Illinois.,Jarrod King and Kristina Erbach are pharmacy residents, Niranjan Kathe is a doctoral candidate in pharmaceutical evaluation and policy, and Oktawia A. Clem is a pharmacy student, Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, Arkansas.,Jelena Stojakovic is a pharmacy resident, Department of Pharmacy, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas.,Julie Tran is a pharmacy resident, Department of Pharmacy, Mercy Hospital, Springfield, Missouri
| | - Niranjan Kathe
- Drayton A. Hammond is a clinical pharmacy specialist, medical and cardiac intensive care, Department of Pharmacy, Rush University Medical Center, Chicago, Illinois.,Jarrod King and Kristina Erbach are pharmacy residents, Niranjan Kathe is a doctoral candidate in pharmaceutical evaluation and policy, and Oktawia A. Clem is a pharmacy student, Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, Arkansas.,Jelena Stojakovic is a pharmacy resident, Department of Pharmacy, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas.,Julie Tran is a pharmacy resident, Department of Pharmacy, Mercy Hospital, Springfield, Missouri
| | - Kristina Erbach
- Drayton A. Hammond is a clinical pharmacy specialist, medical and cardiac intensive care, Department of Pharmacy, Rush University Medical Center, Chicago, Illinois.,Jarrod King and Kristina Erbach are pharmacy residents, Niranjan Kathe is a doctoral candidate in pharmaceutical evaluation and policy, and Oktawia A. Clem is a pharmacy student, Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, Arkansas.,Jelena Stojakovic is a pharmacy resident, Department of Pharmacy, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas.,Julie Tran is a pharmacy resident, Department of Pharmacy, Mercy Hospital, Springfield, Missouri
| | - Jelena Stojakovic
- Drayton A. Hammond is a clinical pharmacy specialist, medical and cardiac intensive care, Department of Pharmacy, Rush University Medical Center, Chicago, Illinois.,Jarrod King and Kristina Erbach are pharmacy residents, Niranjan Kathe is a doctoral candidate in pharmaceutical evaluation and policy, and Oktawia A. Clem is a pharmacy student, Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, Arkansas.,Jelena Stojakovic is a pharmacy resident, Department of Pharmacy, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas.,Julie Tran is a pharmacy resident, Department of Pharmacy, Mercy Hospital, Springfield, Missouri
| | - Julie Tran
- Drayton A. Hammond is a clinical pharmacy specialist, medical and cardiac intensive care, Department of Pharmacy, Rush University Medical Center, Chicago, Illinois.,Jarrod King and Kristina Erbach are pharmacy residents, Niranjan Kathe is a doctoral candidate in pharmaceutical evaluation and policy, and Oktawia A. Clem is a pharmacy student, Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, Arkansas.,Jelena Stojakovic is a pharmacy resident, Department of Pharmacy, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas.,Julie Tran is a pharmacy resident, Department of Pharmacy, Mercy Hospital, Springfield, Missouri
| | - Oktawia A Clem
- Drayton A. Hammond is a clinical pharmacy specialist, medical and cardiac intensive care, Department of Pharmacy, Rush University Medical Center, Chicago, Illinois.,Jarrod King and Kristina Erbach are pharmacy residents, Niranjan Kathe is a doctoral candidate in pharmaceutical evaluation and policy, and Oktawia A. Clem is a pharmacy student, Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, Arkansas.,Jelena Stojakovic is a pharmacy resident, Department of Pharmacy, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas.,Julie Tran is a pharmacy resident, Department of Pharmacy, Mercy Hospital, Springfield, Missouri
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8
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Amirnovin R, Lieu P, Imperial-Perez F, Taketomo C, Markovitz BP, Moromisato DY. Safety, Efficacy, and Timeliness of Intravenous Potassium Chloride Replacement Protocols in a Pediatric Cardiothoracic Intensive Care Unit. J Intensive Care Med 2018; 35:371-377. [PMID: 29357785 DOI: 10.1177/0885066617752659] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Hypokalemia in children following cardiac surgery occurs frequently, placing them at risk of life-threatening arrhythmias. However, renal insufficiency after cardiopulmonary bypass warrants careful administration of potassium (K+). Two different nurse-driven protocols (high dose and tiered dosing) were implemented to identify an optimal K+ replacement regimen, compared to an historical low-dose protocol. Our objective was to evaluate the safety, efficacy, and timeliness of these protocols. DESIGN A retrospective cohort review of pediatric patients placed on intravenous K+ replacement protocols over 1 year was used to determine efficacy and safety of the protocols. A prospective single-blinded review of K+ repletion was used to determine timeliness. PATIENTS Pediatric patients with congenital or acquired cardiac disease. SETTING Twenty-four-bed cardiothoracic intensive care unit in a tertiary children's hospital. INTERVENTIONS Efficacy was defined as fewer supplemental potassium chloride (KCl) doses, as well as a higher protocol to total doses ratio per patient. Safety was defined as a lower percentage of serum K+ levels ≥4.8 mEq/L after a dose of KCl. Between-group differences were assessed by nonparametric univariate analysis. RESULTS There were 138 patients with a median age of 3.0 (interquartile range: 0.23-10.0) months. The incidence of K+ levels ≥4.8 mEq/L after a protocol dose was higher in the high-dose protocol versus the tiered-dosing protocol but not different between the low-dose and tiered-dosing protocols (high dose = 2.2% vs tiered dosing = 0.5%, P = .05). The ratio of protocol doses to total doses per patient was lower in the low-dose protocol compared to the tiered-dosing protocol (P < .05). Protocol doses were administered 45 minutes faster (P < .001). CONCLUSION The tiered-dosed, nurse-driven K+ replacement protocol was associated with decreased supplemental K+ doses without increased risk of hyperkalemia, administering doses faster than individually ordered doses; the protocol was effective, safe, and timely in the treatment of hypokalemia in pediatric patients after cardiac surgery.
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Affiliation(s)
- Rambod Amirnovin
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA.,Cardiothoracic Intensive Care Unit, Heart Institute, Los Angeles, CA, USA
| | - Phuong Lieu
- Pharmacy Department, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | | | - Carol Taketomo
- Pharmacy Department, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Barry P Markovitz
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA.,Cardiothoracic Intensive Care Unit, Heart Institute, Los Angeles, CA, USA
| | - David Y Moromisato
- Department of Pediatrics, Cardon Children's Medical Center, Mesa, AZ, USA
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9
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Osborne AD. Care of Metabolic and Endocrine Conditions in the Observation Unit. Emerg Med Clin North Am 2017; 35:589-601. [DOI: 10.1016/j.emc.2017.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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10
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Hammond DA, Stojakovic J, Kathe N, Tran J, Clem OA, Erbach K, King J. Effectiveness and Safety of Magnesium Replacement in Critically Ill Patients Admitted to the Medical Intensive Care Unit in an Academic Medical Center: A Retrospective, Cohort Study. J Intensive Care Med 2017; 34:967-972. [DOI: 10.1177/0885066617720631] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: “Rules of thumb” for the replacement of electrolytes, including magnesium, in critical care settings are used, despite minimal empirical validation of their ability to achieve a target serum concentration. This study’s purpose was to evaluate the effectiveness and safety surrounding magnesium replacement in medically, critically ill patients with mild-to-moderate hypomagnesemia. Methods: This was a single-center, retrospective, observational evaluation of episodes of intravenous magnesium replacement ordered for patients with mild-to-moderate hypomagnesemia (1.0-1.9 mEq/L) admitted to a medical intensive care unit from May 2014 to April 2016. The primary effectiveness outcome, achievement of target serum magnesium concentration (≥2 mEq/L) compared to expected achievement using a “rule of thumb” estimation that 1 g intravenous magnesium sulfate raises the magnesium concentration 0.15 mEq/L, was tested using 1-sample z test. Logistic regression analysis was conducted to assess the effect of infusion rate on target achievement. Results: Of 152 days on which magnesium replacements were provided for 72 patients, a follow-up serum magnesium concentration was checked within 24 hours in 89 (58.6%) episodes. Of these 89 episodes, serum magnesium concentration reached target in only 49 (59.8%) episodes compared to an expected 89 (100%; P < .0001). There was no significant association between infusion rate and achievement of the target serum magnesium concentration (odds ratio: 0.962, 95% confidence interval: 0.411-2.256). Conclusions: Medically, critically ill patients who received nonprotocolized magnesium replacement achieved the target serum magnesium concentration less frequently than the “rule of thumb” estimation predicted.
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Affiliation(s)
- Drayton A. Hammond
- Department of Pharmacy, Rush University Medical Center, Chicago, IL, USA
| | - Jelena Stojakovic
- Department of Pharmacy, Central Arkansas Veterans Healthcare System, Chicago, IL, USA
| | - Niranjan Kathe
- Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, Chicago, IL, USA
| | - Julie Tran
- Department of Pharmacy, Mercy Hospital, Chicago, IL, USA
| | - Oktawia A. Clem
- Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, Chicago, IL, USA
| | - Kristina Erbach
- Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, Chicago, IL, USA
| | - Jarrod King
- Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, Chicago, IL, USA
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11
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Zielenski C, Crabtree A, Le T, Marlatt A, Ng D, Tran A. Implementation of a timed, electronic, assessment-driven potassium-replacement protocol. Am J Health Syst Pharm 2017; 74:927-931. [DOI: 10.2146/ajhp160378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | | | - Tien Le
- Boulder Community Health, Boulder, CO
| | | | - Dana Ng
- Boulder Community Health, Boulder, CO
| | - Alan Tran
- Boulder Community Health, Boulder, CO
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12
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Pearson DJ, Sharma A, Lospinoso JA, Morris MJ, McCann ET. Effects of Electrolyte Replacement Protocol Implementation in a Medical Intensive Care Unit. J Intensive Care Med 2016; 33:574-581. [PMID: 27881698 DOI: 10.1177/0885066616679593] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
PURPOSE To evaluate the effects of electrolyte replacement protocol (ERP) implementation in the medical intensive care unit (MICU) setting. We hypothesized that a protocol would reduce the time of replacement dose administration and increase provider satisfaction with the process of electrolyte replacement. METHODS This was a retrospective review of electronic medical record data before and after implementation of a standardized ERP in an 18-bed military tertiary care MICU. RESULTS Median time from abnormal laboratory result to time of documented dose administration for potassium decreased from 180 to 98 minutes ( P < .01), phosphorus decreased from 190 to 135 minutes ( P < .01), calcium decreased from 95 to 61 minutes ( P < .01), and magnesium decreased from 155 to 149 minutes ( P < .01). Overall, there was a significant reduction in time to electrolyte repletion from 146 to 98 minutes ( P < .01) for all electrolytes. Nursing satisfaction for autonomy, timeliness, effectiveness, and the need to seek orders was all improved ( P < .01), and physicians saved 4.4 minutes/patient/day ( P = .04). CONCLUSIONS Electrolyte replacement protocols can be safely implemented in the MICU and reduce the time from abnormal laboratory result to electrolyte replacement dose administration. They can improve provider satisfaction and reduce physician time with the process of electrolyte replacement.
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Affiliation(s)
- Daniel J Pearson
- 1 San Antonio Military Medical Center, JBSA Fort Sam Houston, TX, USA
| | - Anit Sharma
- 1 San Antonio Military Medical Center, JBSA Fort Sam Houston, TX, USA
| | | | - Michael J Morris
- 1 San Antonio Military Medical Center, JBSA Fort Sam Houston, TX, USA
| | - Edward T McCann
- 1 San Antonio Military Medical Center, JBSA Fort Sam Houston, TX, USA
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DeCarolis DD, Kim GM, Rector TS, Ishani A. Comparative dose response using the intravenous versus enteral route of administration for potassium replenishment. Intensive Crit Care Nurs 2016; 36:17-23. [DOI: 10.1016/j.iccn.2015.08.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 08/19/2015] [Accepted: 08/20/2015] [Indexed: 12/12/2022]
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Angarita FA, Dueck AD, Azouz SM. Postoperative electrolyte management: Current practice patterns of surgeons and residents. Surgery 2015; 158:289-99. [DOI: 10.1016/j.surg.2015.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 02/15/2015] [Accepted: 02/28/2015] [Indexed: 10/23/2022]
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Scotto CJ, Fridline M, Menhart CJ, Klions HA. Preventing hypokalemia in critically ill patients. Am J Crit Care 2014; 23:145-9. [PMID: 24585163 DOI: 10.4037/ajcc2014946] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Many therapies used in critical care cause potassium depletion. Current practice relies on potassium replacement protocols after a patient becomes hypokalemic. Potassium bolus therapy creates risk for patients, is costly, and increases nurses' workload. OBJECTIVES To determine if administering potassium preemptively in maintenance intravenous fluid would prevent episodes of hypokalemia and reduce the need for potassium boluses. METHODS Medical records of 267 patients with normal potassium and creatinine levels at admission who did not receive total parenteral nutrition were reviewed. The 156 patients who met the study criteria were categorized by group: those who received potassium via maintenance intravenous fluid (treatment; n = 76) and those who did not (control; n = 80). The treatment group had potassium chloride or acetate added to intravenous fluid delivered at 36 to 72 mmol/d. RESULTS The 2 groups did not differ significantly in age, race, sex, or admitting diagnosis. Type of diagnosis, length of stay, and potassium and creatinine levels at admission did not affect the number of potassium boluses for either group. The patients given maintenance potassium preemptively received significantly fewer (P < .001) potassium boluses (0.8) than did the control group (2.73), for a mean savings of $231 per patient for the treatment group. CONCLUSIONS Patients with normal potassium and creatinine levels at admission benefitted from a maintenance intravenous dose of potassium of 72 to 144 mmol/L per day. Compared with control patients, patients receiving this dose avoided detrimental hypokalemic events, had fewer invasive procedures and lower costs, and required less nursing care.
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Affiliation(s)
- Carrie J. Scotto
- Carrie J. Scotto is an associate professor, School of Nursing, and Mark Fridline is an associate instructor, Department of Statistics, University of Akron, Akron, Ohio. Cinderella J. Menhart is a staff nurse in the intensive care unit, and Howard A. Klions is a medical intensivist, Western Reserve Hospital, Summa Health System, Cuyahoga Falls, Ohio
| | - Mark Fridline
- Carrie J. Scotto is an associate professor, School of Nursing, and Mark Fridline is an associate instructor, Department of Statistics, University of Akron, Akron, Ohio. Cinderella J. Menhart is a staff nurse in the intensive care unit, and Howard A. Klions is a medical intensivist, Western Reserve Hospital, Summa Health System, Cuyahoga Falls, Ohio
| | - Cinderella J. Menhart
- Carrie J. Scotto is an associate professor, School of Nursing, and Mark Fridline is an associate instructor, Department of Statistics, University of Akron, Akron, Ohio. Cinderella J. Menhart is a staff nurse in the intensive care unit, and Howard A. Klions is a medical intensivist, Western Reserve Hospital, Summa Health System, Cuyahoga Falls, Ohio
| | - Howard A. Klions
- Carrie J. Scotto is an associate professor, School of Nursing, and Mark Fridline is an associate instructor, Department of Statistics, University of Akron, Akron, Ohio. Cinderella J. Menhart is a staff nurse in the intensive care unit, and Howard A. Klions is a medical intensivist, Western Reserve Hospital, Summa Health System, Cuyahoga Falls, Ohio
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Karra V, Papathanassoglou ED, Lemonidou C, Sourtzi P, Giannakopoulou M. Exploration and classification of intensive care nurses' clinical decisions: a Greek perspective. Nurs Crit Care 2014; 19:87-97. [PMID: 24400657 DOI: 10.1111/nicc.12018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 01/18/2013] [Accepted: 02/05/2013] [Indexed: 11/27/2022]
Abstract
AIM The recording, identification, coding and classification of clinical decisions by intensive care nurses. BACKGROUND Clinical decision-making is an essential dimension of nursing practice as through this process nurses make choices to meet the goals of patient care. Intensive care nurses' decision-making has received attention because of the complexity and urgency associated with it, however, the types of nurses' clinical decisions have not been described systematically. METHODS Qualitative content analysis of daily diaries of clinical decisions recorded during nursing work by 23 purposefully selected intensive care nurses from three major hospitals of Greece. The process of data collection and analysis continued until the point of theoretical saturation. FINDINGS Eight categories of nursing clinical decisions emerged including decisions related to: (1) evaluation, (2) diagnosis, (3) prevention, (4) intervention, (5) communication with patients, (6) clinical information seeking, (7) setting of clinical priorities and (8) communication with health care professionals. Psychological assessment and support decisions were scarce, whereas patient input in care decisions appeared to be limited. The most frequent types of decisions were regarding intervention (29%), evaluation (25%) and clinical setting of priorities (17%), while clinical information seeking (3%) and communication with patients decisions (2%) were the least frequent. Additionally, recorded decisions were ranked in order of degree of urgency and of dependency on medical order. Non-urgent decisions were 78% of the total and 60% of nurses' intervention decisions were independent of medical order and were related to basic nursing care. CONCLUSIONS Intensive care nurses make multiple decisions that seem to be in line with the nursing process, although the latter is not officially implemented in Greek ICUs. RELEVANCE TO CLINICAL PRACTICE The types and frequency of clinical decisions made by intensive care nurses are related to features of ICU work environment, their professional autonomy and accountability, as well as their perceptions of their clinical role.
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Affiliation(s)
- Vassiliki Karra
- V. Karra, RN, MSN, MHCM, PhD(c), Faculty of Nursing, National and Kapodistrian University of Athens, Athens, Greece
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Couture J, Létourneau A, Dubuc A, Williamson D. Evaluation of an electrolyte repletion protocol for cardiac surgery intensive care patients. Can J Hosp Pharm 2013; 66:96-103. [PMID: 23616673 DOI: 10.4212/cjhp.v66i2.1231] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Implementation of electrolyte repletion protocols to facilitate and ensure the safety of electrolyte control is common practice in intensive care units (ICUs). However, few protocols have been evaluated and validated. OBJECTIVE To evaluate the effectiveness and safety of an electrolyte repletion protocol in a large, homogeneous group of postoperative patients. METHODS A retrospective study of patients admitted to the surgical ICU following coronary artery bypass grafting or heart valve replacement was undertaken at the Centre hospitalier universitaire de Sherbrooke, a 682-bed tertiary care hospital in Sherbrooke, Quebec. The proportion of measured values for serum potassium concentration that were within the desired range was compared between patients treated according to the electrolyte repletion protocol and those treated with the traditional approach to electrolyte repletion. Management of magnesium, phosphorus, and ionized calcium balance was also compared. The incidence of cardiac arrhythmias was documented, and the safety of the electrolyte repletion protocol was evaluated by determining and comparing proportions of values for serum electrolyte concentration that were above the desired range. RESULTS In total, 627 patients were included in the study: 312 in the control group and 315 in the protocol group. The proportion of patients with 100% of morning values for serum potassium concentration within the normal range was significantly higher in the protocol group than in the control group (66.1% versus 56.8%; p = 0.018). In the protocol group, significantly more patients received one or more replacement doses of magnesium and phosphorus (p < 0.001). The proportions of serum electrolyte values above the normal range were similar between the 2 groups, and there was no difference in the incidence of cardiac arrhythmias. CONCLUSIONS The electrolyte repletion protocol was more efficacious than traditional electrolyte repletion in maintaining normal serum potassium concentration and was safe.
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Affiliation(s)
- Jodianne Couture
- , BPharm, MSc, is a Pharmacist in the Pharmacy Department, Centre hospitalier universitaire de Sherbrooke, Hôpital Fleurimont, Sherbrooke, Quebec
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Hoekstra M, Vogelzang M, Drost JT, Janse M, Loef BG, van der Horst ICC, Zijlstra F, Nijsten MWN. Implementation and evaluation of a nurse-centered computerized potassium regulation protocol in the intensive care unit--a before and after analysis. BMC Med Inform Decis Mak 2010; 10:5. [PMID: 20100342 PMCID: PMC2826292 DOI: 10.1186/1472-6947-10-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Accepted: 01/25/2010] [Indexed: 12/23/2022] Open
Abstract
Background Potassium disorders can cause major complications and must be avoided in critically ill patients. Regulation of potassium in the intensive care unit (ICU) requires potassium administration with frequent blood potassium measurements and subsequent adjustments of the amount of potassium administrated. The use of a potassium replacement protocol can improve potassium regulation. For safety and efficiency, computerized protocols appear to be superior over paper protocols. The aim of this study was to evaluate if a computerized potassium regulation protocol in the ICU improved potassium regulation. Methods In our surgical ICU (12 beds) and cardiothoracic ICU (14 beds) at a tertiary academic center, we implemented a nurse-centered computerized potassium protocol integrated with the pre-existent glucose control program called GRIP (Glucose Regulation in Intensive Care patients). Before implementation of the computerized protocol, potassium replacement was physician-driven. Potassium was delivered continuously either by central venous catheter or by gastric, duodenal or jejunal tube. After every potassium measurement, nurses received a recommendation for the potassium administration rate and the time to the next measurement. In this before-after study we evaluated potassium regulation with GRIP. The attitude of the nursing staff towards potassium regulation with computer support was measured with questionnaires. Results The patient cohort consisted of 775 patients before and 1435 after the implementation of computerized potassium control. The number of patients with hypokalemia (<3.5 mmol/L) and hyperkalemia (>5.0 mmol/L) were recorded, as well as the time course of potassium levels after ICU admission. The incidence of hypokalemia and hyperkalemia was calculated. Median potassium-levels were similar in both study periods, but the level of potassium control improved: the incidence of hypokalemia decreased from 2.4% to 1.7% (P < 0.001) and hyperkalemia from 7.4% to 4.8% (P < 0.001). Nurses indicated that they considered computerized potassium control an improvement over previous practice. Conclusions Computerized potassium control, integrated with the nurse-centered GRIP program for glucose regulation, is effective and reduces the prevalence of hypo- and hyperkalemia in the ICU compared with physician-driven potassium regulation.
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Affiliation(s)
- Miriam Hoekstra
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
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Todd SR, Sucher JF, Moore LJ, Turner KL, Hall JB, Moore FA. A multidisciplinary protocol improves electrolyte replacement and its effectiveness. Am J Surg 2010; 198:911-5. [PMID: 19969151 DOI: 10.1016/j.amjsurg.2009.04.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Revised: 04/04/2009] [Accepted: 04/08/2009] [Indexed: 11/25/2022]
Abstract
BACKGROUND We implemented a multidisciplinary electrolyte replacement protocol in a tertiary referral center surgical intensive care unit. The purpose of this study was to evaluate its efficacy. METHODS This was a retrospective study. The electrolyte replacement protocol was designed for the replacement of potassium, magnesium, and phosphorous and was nurse driven. Data evaluated included patient demographics and details specific to electrolyte replacement. Univariate analyses were performed by using the Student t test and the Fisher exact test. A P value of <.05 was considered significant. RESULTS After implementation of the protocol, overall electrolyte replacement improved from 70% to 79% (P = .03), and its overall effectiveness increased from 50% to 65% (P = .01). Individual electrolyte replacement, effectiveness, and dosing varied. CONCLUSIONS The implementation of a multidisciplinary electrolyte replacement protocol in a tertiary referral center surgical intensive care unit significantly improved both overall electrolyte replacement and its effectiveness.
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Affiliation(s)
- S Rob Todd
- Department of Surgery, The Methodist Hospital, Weill Cornell Medical College, 6550 Fannin Street, Smith Tower 1661, Houston, TX 77030, USA.
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Kanji Z, Jung K. Evaluation of an electrolyte replacement protocol in an adult intensive care unit: a retrospective before and after analysis. Intensive Crit Care Nurs 2009; 25:181-9. [PMID: 19398203 DOI: 10.1016/j.iccn.2009.03.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2008] [Revised: 03/23/2009] [Accepted: 03/27/2009] [Indexed: 11/26/2022]
Abstract
BACKGROUND Electrolyte imbalances are frequently encountered in the Intensive Care Unit (ICU) and protocol-driven interventions may facilitate more timely and uniform care. OBJECTIVE To compare the effectiveness and timeliness of electrolyte replacement in an adult ICU before and after implementation of an Electrolyte Replacement Protocol (ERP) and to assess nurse and physician satisfaction with the ERP. METHODS Health records of adult patients who experienced hypokalaemia, hypomagnesaemia, or hypophosphataemia in the ICU during the study periods were retrospectively reviewed. Effectiveness of the ERP was assessed by the number of replacement doses indicated but not given and the number of doses and total dose required to normalise the low electrolyte level. Timeliness was evaluated by the time between the laboratory reporting the low electrolyte level and administration of the replacement dose. Nurse and physician satisfaction with the ERP was assessed through a written survey. RESULTS After implementation of the ERP, the number of replacement doses indicated but not given was reduced for magnesium from 60% to 35% (p=0.18) and for phosphate from 100% to 64% (p=0.04). The time to replacement was reduced for potassium from 79 to 60 min (p=0.066) and for magnesium from 307 to 151 min (p=0.15). Nurses and physicians were satisfied with the ERP. CONCLUSIONS Implementation of an ERP resulted in improvements in the effectiveness and timeliness of electrolyte replacement and nurses and physicians were satisfied with the ERP.
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Affiliation(s)
- Zahra Kanji
- Pharmacy Department and Intensive Care Unit, Lions Gate Hospital, 231 East, 15th Street, North Vancouver, British Columbia, Canada.
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Brooks G. Potassium additive algorithm for use in continuous renal replacement therapy. Nurs Crit Care 2006; 11:273-80. [DOI: 10.1111/j.1478-5153.2006.00185.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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