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Álvarez-Moreno CA, Nocua-Báez LC, Ortiz G, Torres JC, Montenegro G, Cervera W, Zuluaga LF, Gómez A. Efficacy of Continuous vs. Intermittent Administration of Cefepime in Adult ICU Patients with Gram-Negative Bacilli Bacteremia: A Randomized Double-Blind Clinical Study. Antibiotics (Basel) 2024; 13:229. [PMID: 38534664 DOI: 10.3390/antibiotics13030229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/14/2024] [Accepted: 01/20/2024] [Indexed: 03/28/2024] Open
Abstract
INTRODUCTION The objective of this study was to compare the continuous infusion of cefepime with the intermittent infusion in patients with sepsis caused by Gram-negative bacilli (GNB). METHODS Randomized 1:1 multicenter double-blinded placebo-controlled study with allocation concealment; multicenter study in the intensive care units of Colombia. Patients with sepsis, severe sepsis or septic shock, and GNB-suspected bacteremia. Cefepime was administered for 7 to 14 days over 30 m intermittently every 8 h over 24 h plus continuous saline solution (0.9%) (G1) or 3 g administered continuously plus saline solution every 8 h (0.9%) (G2). The percentage of clinical response at 3, 7, and 14 days, relapse at 28 days, and mortality at discharge were measured. RESULTS The recruitment was stopped at the suggestion of the Institutional Review Board (IRB) following an FDA alert about cefepime. Thirty-two patients were randomized; 25 received the intervention, and GNB bacteremia was confirmed in 16 (9 G1 and 7 G2). Favorable clinical response in days 3, 7, and 14 was 88.8%, 88.8%, and 77.8% (G1) and was similar for G2 (85.7%). There were no relapses or deaths in G2, while in G1, one relapse and two deaths were observed. CONCLUSIONS The results of this study support the use of cefepime for the treatment of Gram-negative infections in critically ill patients, but we could not demonstrate differences between continuous or intermittent administration because of the small sample size, given the early suspension of the study.
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Affiliation(s)
| | - Laura Cristina Nocua-Báez
- Department of Internal Medicine, Infectious Diseases, Universidad Nacional de Colombia, Bogotá 111321, Colombia
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Park J, Lee DK, Kim JE, Bae JS, Kim JS, Moon YE. Postoperative pain management using an intravenous combination of ibuprofen and acetaminophen compared with acetaminophen alone after thyroidectomy: A prospective randomized controlled trial. Head Neck 2024. [PMID: 38404166 DOI: 10.1002/hed.27701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 01/22/2024] [Accepted: 02/09/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND Multiple medications are more effective than single agents for postoperative pain management. We investigated the analgesic effects of an intravenous combination of acetaminophen and ibuprofen immediately after thyroidectomy. METHODS In this double-blind clinical trial, 62 patients who underwent thyroidectomies were randomized to either the treatment (1000 mg acetaminophen, 300 mg ibuprofen) or control (1000 mg acetaminophen) group. Postoperative pain intensity was assessed using the visual analog scale (VAS) 0, 15, and 30 min after recovery room admission. Opioid rescue consumption was also recorded. RESULTS The VAS scores were significantly lower in the treatment than in the control group 15 [3 (2-4.3) vs. 5 (3-6); p = 0.015] and 30 [3 (2-4.3) vs. 4 (3-5); p = 0.018] min after recovery room admission, as were the opioid rescue dose requirements (p = 0.033). CONCLUSIONS Combined intravenous acetaminophen and ibuprofen may be better than acetaminophen alone for immediately acute postoperative pain after thyroidectomy.
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Affiliation(s)
- Jaesik Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Do Kyung Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ji Eun Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ja Seong Bae
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jeong-Soo Kim
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yung Eun Moon
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Leu JH, Vermeulen A, Abbes C, Arroyo S, Denney WS, Ling LE. Pharmacokinetics and pharmacodynamics across infusion rates of intravenously administered nipocalimab: results of a phase 1, placebo-controlled study. Front Neurosci 2024; 18:1302714. [PMID: 38362023 PMCID: PMC10867144 DOI: 10.3389/fnins.2024.1302714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/03/2024] [Indexed: 02/17/2024] Open
Abstract
Introduction Nipocalimab is a high-affinity, fully human, aglycosylated, effectorless, immunoglobulin G (IgG) 1 monoclonal antibody that targets the neonatal Fc receptor (FcRn), decreases systemic IgG including autoantibodies, and is under development in several IgG autoantibody- and alloantibody-mediated diseases, including generalized myasthenia gravis, chronic inflammatory demyelinating polyneuropathy, maternal-fetal medicine, and multiple other therapeutic areas. An initial phase 1 study with single and multiple ascending doses of nipocalimab infused intravenously (IV) over 2 h demonstrated dose-dependent serum pharmacokinetics and IgG reductions, with an adverse event (AE) profile comparable to placebo. Methods The current investigation evaluates the safety, tolerability, pharmacokinetics, and pharmacodynamics of single doses of nipocalimab across various IV infusion rates in a randomized, double-blind, placebo-controlled, sequential-dose study. Forty participants were randomized to receive nipocalimab 30 mg/kg over 60, 30, 15 or 7.5 min (0.5, 1, 2, or 4 mg/kg/min); nipocalimab 60 mg/kg over 15 min (4 mg/kg/min); or matching placebo. Results At doses up to 60 mg/kg and infusion rates up to 4 mg/kg/min (maximum clinically feasible rate), single doses of nipocalimab were tolerable, with 12 (40%) participants experiencing AEs across nipocalimab cohorts compared with 1 (10%) participant in the placebo cohort. AEs deemed treatment related occurred in 6 (20%) participants receiving nipocalimab and 1 (10%) participant receiving placebo. None of the AEs were severe, and no participants discontinued treatment due to AEs. Nipocalimab provided consistent, dose-dependent serum pharmacokinetics and IgG reductions, regardless of infusion rate. Discussion This study supports the use of shortened durations of nipocalimab infusion for future studies.
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Affiliation(s)
- Jocelyn H. Leu
- Janssen Research & Development, LLC, Spring House, PA, United States
| | - An Vermeulen
- Janssen Research & Development, LLC, a Division of Janssen Pharmaceutica NV, Beerse, Belgium
| | - Claudia Abbes
- Momenta Pharmaceuticals, Inc., Cambridge, MA, United States
| | | | | | - Leona E. Ling
- Janssen Research & Development, LLC, Cambridge, MA, United States
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Hilley P, Wong D, Ma R, Peterson A, De Cruz P. Transitioning patients from intravenous to subcutaneous infliximab and vedolizumab for inflammatory bowel disease: what is the opportunity cost of improving access to healthcare? Intern Med J 2024. [PMID: 38214034 DOI: 10.1111/imj.16311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 11/21/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Biologic drugs are highly effective for inflammatory bowel disease (IBD) management but are key drivers of costs of care especially when administered intravenously (i.v.). Availability of subcutaneous (SC) formulations has increased convenience for patients and improved access to care, but at the cost of revenue to health services. AIMS To evaluate the economic impact of transitioning a tertiary centre IBD cohort from i.v. to SC biologic administration and assess the implications for key stakeholders. METHODS A retrospective analysis of all patients who received i.v. infliximab or vedolizumab in the outpatient infusion centre of a tertiary IBD centre between July 2019 and June 2021 was undertaken. Data were collated from electronic medical records, pharmacy dispensing systems and the hospital business intelligence unit. An economic analysis and theoretical financial/capacity impact analysis of a transition to an SC model were estimated under two scenarios using a random 10% and 30% of the patient cohort. RESULTS Transitioning our IBD cohort from i.v. to SC administration would result in a loss to our health service of AU$2 732 123.75, composed of AU$1 463 003.75 in Weighted Inlier Equivalent Separation (WIES) and AU$1 269 120 in drug procurement revenue. However, it would ease capacity in the infusion centre by up to 5256 h. CONCLUSIONS Transitioning patients to SC administration results in improved access to infusion centres and substantial savings to state governments; however, switching results in a loss of i.v. biologic-generated WIES to health services. Alternative funding models are required to achieve sustainability in IBD care and reduce reliance on i.v. biologic-generated income.
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Affiliation(s)
- Patrick Hilley
- Department of Gastroenterology, The Austin Hospital, Melbourne, Victoria, Australia
| | - Darren Wong
- Department of Gastroenterology, The Austin Hospital, Melbourne, Victoria, Australia
- Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, Victoria, Australia
| | - Ronald Ma
- Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, Victoria, Australia
| | - Adam Peterson
- Department of Gastroenterology, The Austin Hospital, Melbourne, Victoria, Australia
| | - Peter De Cruz
- Department of Gastroenterology, The Austin Hospital, Melbourne, Victoria, Australia
- Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, Victoria, Australia
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Rios Campillo C, Sanz de Pedro M, Iturzaeta JM, Qasem AL, Alcaide MJ, Fernandez-Puntero B, Rioja RG. Design of an algorithm for the detection of intravenous fluid contamination in clinical laboratory samples. Clin Chem Lab Med 2023; 61:2002-2009. [PMID: 37270688 DOI: 10.1515/cclm-2023-0200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/18/2023] [Indexed: 06/05/2023]
Abstract
OBJECTIVES Contamination of blood samples from patients receiving intravenous fluids is a common error with potential risk to the patient. Algorithms based on the presence of aberrant results have been described but have the limitation that not all infusion fluids have the same composition. Our objective is to develop an algorithm based on the detection of the dilution observed on the analytes not usually included in infusion fluids. METHODS A group of 89 cases was selected from samples flagged as contaminated. Contamination was confirmed by reviewing the clinical history and comparing the results with previous and subsequent samples. A control group with similar characteristics was selected. Eleven common biochemical parameters not usually included in infusion fluids and with low intraindividual variability were selected. The dilution in relation to the immediate previous results was calculated for each analyte and a global indicator, defined as the percentage of analytes with significant dilution, was calculated. ROC curves were used to define the cut-off points. RESULTS A cut-off point of 20 % of dilutional effect requiring also a 60 % dilutional ratio achieved a high specificity (95 % CI 91-98 %) with an adequate sensitivity (64 % CI 54-74 %). The Area Under Curve obtained was 0.867 (95 % CI 0.819-0.915). CONCLUSIONS Our algorithm based on the global dilutional effect presents a similar sensitivity but greater specificity than the systems based on alarming results. The implementation of this algorithm in the laboratory information systems may facilitate the automated detection of contaminated samples.
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Affiliation(s)
- Cristian Rios Campillo
- Laboratory Medicine, La Paz - Cantoblanco - Carlos III University Hospital, Madrid, Spain
| | - Maria Sanz de Pedro
- Laboratory Medicine, La Paz - Cantoblanco - Carlos III University Hospital, Madrid, Spain
| | - Jose Manuel Iturzaeta
- Laboratory Medicine, La Paz - Cantoblanco - Carlos III University Hospital, Madrid, Spain
| | - Ana Laila Qasem
- Laboratory Medicine, La Paz - Cantoblanco - Carlos III University Hospital, Madrid, Spain
| | - Maria Jose Alcaide
- Laboratory Medicine, La Paz - Cantoblanco - Carlos III University Hospital, Madrid, Spain
| | | | - Rubén Gómez Rioja
- Laboratory Medicine, La Paz - Cantoblanco - Carlos III University Hospital, Madrid, Spain
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Park S, Kim Y, Nam D, Lee J, Song SH. Superficial venous morphometry in the antecubital fossa: An autonomous robotic ultrasound-based analysis. J Vasc Access 2023:11297298231186651. [PMID: 37448206 DOI: 10.1177/11297298231186651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND The antecubital fossa is an important site for venepuncture and intravenous procedures. The size and location of a vein can affect the success of venepuncture and intravenous access. Several studies have investigated the superficial vein morphometry, but they had small sample sizes or focused on specific populations or groups. Therefore, we conducted a prospective study with large participants in general population to analyse the morphology of the antecubital superficial vein and identify the association of sex, age and body mass index (BMI) with the size and location of the vein. METHODS This study collected images of superficial veins prospectively using autonomous robotic ultrasound on the antecubital area between October and November 2020. We measured the superficial vein depth, vertical diameter and horizontal diameter at the antecubital area, extracted population characteristics (sex, age and BMI), and analysed a relationship between the vein dimensions and the characteristics. RESULTS In this study, data from 461 participants (201 males and 260 females) with mean age of 41.1 years were produced. The mean vein depth, mean vertical diameter and mean horizontal diameter (±standard deviation) were 4.81 (±2.17), 3.01 (±1.10) and 4.46 (±1.60) mm, respectively. We found significant differences in vein dimensions between males and females, with males having larger vertical and horizontal diameters than females (p < 0.001). The study also revealed significant differences in vein depth and dimensions among age groups and BMI subgroups (p < 0.001). CONCLUSIONS These findings revealed that the superficial vein in the antecubital area was oval, with a larger horizontal diameter than vertical diameter. Morphometry revealed differences in sex, age and BMI. Understanding variations in vein dimensions among different subgroups can help medical professionals improve success rate of venous access and patient safety.
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Affiliation(s)
| | | | | | - Jooran Lee
- Division of Life Science and Department of Chemical and Biological Engineering, The Hong Kong University of Science of Technology, Hong Kong SAR, China
| | - Sang Hoon Song
- Department of Laboratory Medicine, Seoul National University Hospital and College of Medicine, Seoul, Republic of Korea
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Cura JD. Comparing successful insertions, dwell time, reinsertions and the costs of supplies between integrated and simple short peripheral catheters. J Vasc Access 2023; 24:771-779. [PMID: 34751057 DOI: 10.1177/11297298211054893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Along with the challenges to strengthen patient safety in the use of short peripheral catheters (SPCs), various studies have been conducted in the past to explore differences between two main types of SPCs-integrated SPC (ISPC) and simple SPC (SSPC) in terms of clinical performance. The accumulated evidence from the literature lean toward the benefits of ISPC use in preventing complications leading to longer dwell time and more economical savings than SSPC use. The study aimed to compare ISPC and SSPC in terms of first-attempt successful insertions, number of attempts before successful insertion, perceived ease of insertion, dwell time, reinsertion rate, reasons for removal, and costs of supplies used for the insertions. Furthermore, it aimed to verify whether the previous results of referenced work in the use of ISPC were similar, and its use provided more foreseeable benefit for patient safety and cost-efficiency. METHODS This quasi-experimental study was conducted in a 650-bed tertiary academic medical center in the Philippines. Eligible participants were adult patients who were required SPC for at least 72 h by the physician. Using inferential statistics, comparisons were done among adult patients with integrated (n = 350) and simple (n = 350) SPC. Comparisons were also made according to insertion site and gauge of SPC. RESULTS The successful first-attempt insertions did not vary significantly at around 80% in both groups (p = 0.428). No significant differences were found in terms of attempts before successful insertion (p = 0.677), dwell time (p = 0.144), reinsertions (p = 0.934), and reasons for removal (p = 0.424). Meanwhile, comparable differences were noted in terms of perceived ease of insertion (p < 0.001) and cost of supplies used during the insertions (p < 0.001). CONCLUSION ISPCs can yield the same results with that of SSPCs while being easier to use and less costly.
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Affiliation(s)
- Jonathan D Cura
- Nursing Research, Systems Management and Accreditation, St. Luke's Medical Center, Quezon City, Philippines
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Roberts K, Shah ND, Parrish CR, Wall E. Navigating nutrition and hydration care in the adult patient with short bowel syndrome. Nutr Clin Pract 2023; 38 Suppl 1:S59-S75. [PMID: 37115029 DOI: 10.1002/ncp.10951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/12/2022] [Accepted: 12/17/2022] [Indexed: 04/29/2023] Open
Abstract
Attending diligently to the nutrition and hydration needs of patients with short bowel syndrome (SBS) is a key tenet of their care, both postoperatively and in the years that follow. For, without each, patients are left to themselves to navigate the nutrition consequences of SBS, including malnutrition, nutrient deficiencies, renal compromise, osteoporosis, fatigue, depression, and impaired quality of life. The intent of this review is to discuss the initial nutrition assessment, oral diet, hydration, and home nutrition support for the patient with SBS.
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Affiliation(s)
- Kristen Roberts
- College of Medicine, Department of Medical Dietetics, The Ohio State University, Columbus, Ohio, USA
| | - Neha D Shah
- Colitis and Crohn's Disease Center, University of California, San Francisco, California, USA
| | | | - Elizabeth Wall
- GI/Nutrition Support Team, The University of Chicago Medicine, Chicago, Illinois, USA
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Bering J, DiBaise JK. Short bowel syndrome: Complications and management. Nutr Clin Pract 2023; 38 Suppl 1:S46-S58. [PMID: 37115034 DOI: 10.1002/ncp.10978] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/07/2023] [Accepted: 02/09/2023] [Indexed: 04/29/2023] Open
Abstract
Short bowel syndrome (SBS) occurs when a patient loses bowel length or function significantly enough to cause malabsorption, oftentimes requiring lifelong parenteral support. In adults, this occurs most commonly in the setting of massive intestinal resection, whereas congenital anomalies and necrotizing enterocolitis predominate in children. Many patients with SBS develop long-term clinical complications over time related to their altered intestinal anatomy and physiology or to various treatment interventions such as parenteral nutrition and the central venous catheter through which it is administered. Identifying, preventing, and treating these complications can be challenging. This review will focus on the diagnosis, treatment, and prevention of several complications that can occur in this patient population, including diarrhea, fluid and electrolyte imbalance, vitamin and trace element derangements, metabolic bone disease, biliary disorders, small intestinal bacterial overgrowth, d-lactic acidosis, and complications of central venous catheters.
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Affiliation(s)
- Jamie Bering
- Division of Gastroenterology and Hepatology, Mayo Clinic in Arizona, Scottsdale, Arizona, USA
| | - John K DiBaise
- Division of Gastroenterology and Hepatology, Mayo Clinic in Arizona, Scottsdale, Arizona, USA
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Massouh A, Kwan SW, Fidelman N, Higgins M, Abujudeh H, Charalel RA, Guimaraes MS, Gupta A, Lam A, Majdalany BS, Patel PJ, Stadtlander KS, Stillwell T, Teo EYL, Tong RT, Kapoor BS. ACR Appropriateness Criteria® Central Venous Access Device and Site Selection. J Am Coll Radiol 2023; 20:S3-S19. [PMID: 37236750 DOI: 10.1016/j.jacr.2023.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 05/28/2023]
Abstract
The use of central venous access devices is ubiquitous in both inpatient and outpatient settings, whether for critical care, oncology, hemodialysis, parenteral nutrition, or diagnostic purposes. Radiology has a well-established role in the placement of these devices due to demonstrated benefits of radiologic placement in multiple clinical settings. A wide variety of devices are available for central venous access and optimal device selection is a common clinical challenge. Central venous access devices may be nontunneled, tunneled, or implantable. They may be centrally or peripherally inserted by way of veins in the neck, extremities, or elsewhere. Each device and access site presents specific risks that should be considered in each clinical scenario to minimize the risk of harm. The risk of infection and mechanical injury should be minimized in all patients. In hemodialysis patients, preservation of future access is an additional important consideration. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Alan Massouh
- Research Author, University of Utah, Salt Lake City, Utah.
| | - Sharon W Kwan
- University of Utah, Salt Lake City, Utah; and JACR editorial board
| | - Nicholas Fidelman
- Panel Chair, University of California San Francisco, San Francisco, California
| | - Mikhail Higgins
- Panel Vice-Chair, Boston University School of Medicine, Boston, Massachusetts
| | - Hani Abujudeh
- Detroit Medical Center, Tenet Healthcare and Envision Radiology Physician Services, Detroit, Michigan
| | - Resmi A Charalel
- Weill Cornell Medicine, New York, New York; and SIR Quality Data Analytics Committee Co-Chair
| | | | - Amit Gupta
- Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | - Alexander Lam
- University of California, San Francisco, San Francisco, California
| | | | - Parag J Patel
- Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Terri Stillwell
- University of Michigan, Ann Arbor, Michigan; Infectious Diseases Society of America; PIDS Education Committee; SHEA Education Committee; and Panelist, IDSA
| | - Elrond Y L Teo
- Piedmont Atlanta Hospital, Atlanta, Georgia; Society of Critical Care Medicine
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Mulvihill C, McDonald D. Standardized neonatal continuous infusion concentrations: A quality improvement initiative. Am J Health Syst Pharm 2023; 80:61-67. [PMID: 36255033 DOI: 10.1093/ajhp/zxac299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Medication errors are a significant and preventable source of patient harm, especially in the neonatal population. Standardized infusion concentrations increase patient safety and streamline the workflow for pharmacists, nurses, and physicians. METHODS Neonatal continuous infusion concentrations were standardized and implemented into the electronic health record using an automated order panel. Pre- and postimplementation data were collected to assess the impact of this quality improvement initiative. The primary endpoint was the proportion of neonatal intensive care unit infusion orders that were compatible with "bolus from infusion" functionality in the syringe pump. RESULTS Before implementation, only 40% of eligible infusions were compatible with the "bolus from infusion" function, compared to 93% after implementation (P < 0.00001). Within the syringe pump, the ratio of total options to the number of concentrations per medication was reduced by 31%. CONCLUSION Implementation of an order panel with defaulted standard infusion concentration selection improved workflow and optimized technology in the neonatal intensive care unit.
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Affiliation(s)
- Christine Mulvihill
- Children's Regional Hospital at Cooper University Health Care, Camden, NJ, USA
| | - Danielle McDonald
- Children's Regional Hospital at Cooper University Health Care, Camden, NJ, USA
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Garcia‐Expósito J, Sánchez‐Meca J, Almenta‐Saavedra JA, Llubes‐Arrià L, Torné‐Ruiz A, Roca J. Peripheral venous catheter-related phlebitis: A meta-analysis of topical treatment. Nurs Open 2022; 10:1270-1280. [PMID: 36335576 PMCID: PMC9912403 DOI: 10.1002/nop2.1449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 03/26/2022] [Accepted: 10/12/2022] [Indexed: 11/08/2022] Open
Abstract
AIM To systematically evaluate the efficacy of different topical treatments for PVC-related phlebitis in hospital in-patients. DESIGN A systematic review and meta-analysis. METHODS A selection was made of experimental and quasi-experimental studies published in English or Spanish. These should provide data on the degree of phlebitis, pain and infiltration (means and standard deviations, mainly) of hospitalized patients with phlebitis secondary to peripheral venous catheter. All those studies that reflected systemic or exclusive prevention treatments were excluded. Searches were from inception to April 2020. The date of data collection was from December 2020 to May 2021. The selection criteria were based on the PICOS model. Risk of bias was assessed using the Cochrane Collaboration tool. RESULTS Twelve studies (726 patients) met the inclusion criteria. With respect to the decrease in the degree of phlebitis, was found ichthammol glycerine, followed by heparinoids. As for degree of pain, sesame oil obtained the most marked reduction. In terms of degree of infiltration, heparinoids and ichthammol glycerine were the only products to achieve a statistically significant reduction. The most important limitations are the low quantity and quality of the trials included. Insufficient data are available to draw valid conclusions about the efficacy of any treatment.
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Affiliation(s)
- Judith Garcia‐Expósito
- Department of Nursing and Physiotherapy, Faculty of Nursing and PhysiotherapyUniversity of LleidaLleidaSpain
| | - Julio Sánchez‐Meca
- Meta‐Analysis Unit, Department of Basic Psychology and MethodologyUniversity of MurciaMurciaSpain
| | | | | | - Alba Torné‐Ruiz
- Department of Nursing and Physiotherapy, Faculty of Nursing and PhysiotherapyUniversity of LleidaLleidaSpain
| | - Judith Roca
- Department of Nursing and Physiotherapy, Faculty of Nursing and PhysiotherapyUniversity of LleidaLleidaSpain,Health Care Research Group (GRECS)Biomedical Research Institute of LleidaLleidaSpain
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Park J, You SB, Kim H, Park C, Ryu GW, Kwon S, Kim Y, Lee S, Lee K. Experience of Nurses with Intravenous Fluid Monitoring for Patient Safety: A Qualitative Descriptive Study. Risk Manag Healthc Policy 2022; 15:1783-1793. [PMID: 36171867 PMCID: PMC9512022 DOI: 10.2147/rmhp.s374563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/12/2022] [Indexed: 12/04/2022] Open
Abstract
Purpose Medication administration is a complex process and constitutes a substantial component of nursing practice that is closely linked to patient safety. Although intravenous fluid administration is one of the most frequently performed nursing tasks, nurses’ experiences with intravenous rate control have not been adequately studied. This study aimed to explore nurses’ experiences with infusion nursing practice to identify insights that could be used in interventions to promote safe medication administration. Patients and methods This qualitative descriptive study used focus group interviews of 20 registered nurses who frequently administered medications in tertiary hospitals in South Korea. Data were collected through five semi-structured focus group interviews, with four nurses participating in each interview. We conducted inductive and deductive content analysis based on the 11 key topics of patient safety identified by the World Health Organization. Reporting followed the consolidated criteria for reporting qualitative research (COREQ) checklist. Results Participants administered infusions in emergency rooms, general wards, and intensive care units, including patients ranging from children to older adults. Two central themes were revealed: human factors and systems. Human factors consisted of two sub-themes including individuals and team players, while systems encompassed three sub-themes including institutional policy, culture, and equipment. Conclusion This study found that nurses experienced high levels of stress when administering infusions in the correct dose and rate for patient safety. Administering and monitoring infusions were complicated because nursing processes interplay with human and system factors. Future research is needed to develop nursing interventions that include human and system factors to promote patient safety by reducing infusion-related errors.
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Affiliation(s)
- Jeongok Park
- Mo-Im Kim Nursing Research Institute, Yonsei University College of Nursing, Seoul, South Korea
| | - Sang Bin You
- Yonsei University College of Nursing, Seoul, South Korea
| | - Hyejin Kim
- Severance Hospital, Yonsei University Health System, Seoul, South Korea
| | - Cheolmin Park
- Department of Materials Science and Engineering, Yonsei University, Seoul, South Korea
| | - Gi Wook Ryu
- Department of Nursing, Hansei University, Gunpo-si, South Korea
| | - Seongae Kwon
- Yonsei University College of Nursing, Seoul, South Korea
| | - Youngkyung Kim
- College of Nursing and Brain Korea 21 FOUR Project, Yonsei University, Seoul, South Korea
| | - Sejeong Lee
- College of Nursing and Brain Korea 21 FOUR Project, Yonsei University, Seoul, South Korea
| | - Kayoung Lee
- Gachon University College of Nursing, Incheon, South Korea
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14
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Blake JWC, Fiske SM, Giuliano KK. A qualitative analysis of intravenous smart pump usability. Nurs Open 2022; 9:2171-2178. [PMID: 35591755 PMCID: PMC9190672 DOI: 10.1002/nop2.1227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 02/25/2022] [Accepted: 04/03/2022] [Indexed: 11/05/2022] Open
Abstract
AIM To understand the experience of critical care nurses when performing common, yet error-prone, programming tasks on two unfamiliar intravenous smart pumps. DESIGN A qualitative descriptive study using data collected during a previous quantitative pilot study. METHODS Following completion of common intravenous programming tasks each participant was interviewed using a semi-structured interview guide. All interview data were coded line-by-line and thematic analysis revealed themes across all participants' interviews. RESULTS The following four themes were identified: appreciation for attractive design features, the need for efficiency, the importance of intuitive use and concern for patient outcomes. Overall, these themes provide evidence that nurses strongly prefer a more usable intravenous smart pump interface that integrates safeguards to efficiently improve patient outcomes. Findings support the need for intravenous smart pump technology to be developed with an intuitive interface that decreases the level of cognitive demand and will lead to improved patient safety.
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Affiliation(s)
- Jeannine W C Blake
- Elaine Marieb Center for Nursing and Engineering Innovation, Elaine Marieb College of Nursing & Institute for Applied Life Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, USA
| | - Sarah M Fiske
- Elaine Marieb College of Nursing, University of Massachusetts Amherst, Amherst, Massachusetts, USA
| | - Karen K Giuliano
- Elaine Marieb Center for Nursing and Engineering Innovation, Elaine Marieb College of Nursing & Institute for Applied Life Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, USA
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15
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Skog J, Rafie S, Schnock KO, Yoon C, Lipsitz S, Lew P. The Impact of Smart Pump Interoperability on Errors in Intravenous Infusion Administrations: A Multihospital Before and After Study. J Patient Saf 2022; 18:e666-e671. [PMID: 35344977 PMCID: PMC9359779 DOI: 10.1097/pts.0000000000000905] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to assess the frequency, type, and severity of errors associated with intravenous medication administration before and after smart pump interoperability. METHODS We conducted an observational study at a community healthcare system before and after implementing smart pump interoperability. Point prevalence methodology was used to collect data on medication administration and errors in adult inpatient settings. RESULTS Observations were completed for 350 infusions preintervention (178 patients) and 367 postintervention (200 patients). Total errors significantly decreased from 401 (114.6 per 100 infusions) to 354 (96.5 per 100 infusions, P = 0.02). Administration errors decreased from 144 (41.1 per 100 infusions) to 119 (32.4 per 100 infusions, P = 0.12). Expired medication errors significantly reduced from 11 (3.1 per 100 infusions) to 2 (0.5 per 100 infusions, P = 0.02). Errors involving high-risk medications significantly reduced from 45 (12.8 per 100 infusions) to 25 (6.8 per 100 infusions, P = 0.01). Errors involving continuous medications significantly reduced from 44 (12.6 per 100 infusions) to 22 (6.0 per 100 infusions, P = 0.005). When comparing programming type, manual programming resulted in 115 (77.2%) of administration and user documentation errors compared with 34 errors (22.8%) that occurred when autoprogramming was used. Of these, errors involving high-risk medications reduced from 21 (84.0%) to 4 (16.0%) after using autoprogramming. CONCLUSIONS Smart pump interoperability resulted in a 16% reduction in medication administration errors. Despite using dose error reduction software and autoprogramming, some types of errors persisted. Further studies are needed to understand how technology use can be optimized.
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Affiliation(s)
| | - Sally Rafie
- Department of Pharmacy, University of California San Diego Health, San Diego, California
| | | | | | | | - Pauline Lew
- Sharp Grossmont Hospital, Pharmacy, La Mesa, California
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16
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Klang MG, Gura KM. Criticism of methods used in medication Y-site mixing study. Am J Health Syst Pharm 2021; 78:1553-1554. [PMID: 33764402 DOI: 10.1093/ajhp/zxab127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Mark G Klang
- Research Pharmacy Memorial Sloan Kettering Cancer Center New York, NY
| | - Kathleen M Gura
- Clinical Research Program Department of Pharmacy Boston Children's Hospital Boston, MA.,Harvard Medical School Boston, MA
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Ross EL, Carpenter JF. Validity of methods used in medication Y-site mixing study. Am J Health Syst Pharm 2021; 78:1554-1555. [PMID: 33770161 DOI: 10.1093/ajhp/zxab126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Emma L Ross
- Children's Hospital Colorado Aurora, CO, USA
| | - John F Carpenter
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences Aurora, CO, USA
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18
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Foushee JA, Meredith P, Fox LM, Wilder AG. Y-site physical compatibility of hydrocortisone continuous infusions with admixtures used in critically ill patients. Am J Health Syst Pharm 2021; 77:1144-1148. [PMID: 32537625 DOI: 10.1093/ajhp/zxaa118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Critically ill patients with septic shock often receive multiple intravenous medications, necessitating either the placement of separate lines for medication administration or administration of medications concurrently through a Y-site connector only where compatibility has been demonstrated. The purpose of this study was to examine the physical compatibility of hydrocortisone infusions and select intravenous medications through a simulated Y site. METHODS The medications tested for simulated Y-site physical compatibility with hydrocortisone included acetaminophen, albumin, cefepime, ciprofloxacin, cisatracurium, doripenem, epinephrine, esomeprazole, ibuprofen, levofloxacin, levothyroxine, meropenem, and norepinephrine. Hydrocortisone in solution with 0.9% sodium chloride injection was combined with an equivalent volume of solutions of each test drug at maximum or commercially available concentrations used clinically in intensive care units, as appropriate. The samples were evaluated using turbidimetric measurements and examined visually against light and dark backgrounds to determine physical compatibility. Observations and analyses were completed over a one-hour period at 15-minute intervals beginning immediately after mixing. Each test was performed in triplicate. RESULTS All study medications demonstrated visual and/or turbidimetric physical compatibility when combined with hydrocortisone in a simulated Y-site infusion. No medications demonstrated a visual physical incompatibility when combined with hydrocortisone. CONCLUSION Acetaminophen, albumin, cefepime, ciprofloxacin, cisatracurium, doripenem, epinephrine, esomeprazole, ibuprofen, levofloxacin, levothyroxine, meropenem, and norepinephrine exhibited physical compatibility with hydrocortisone via Y-site infusion.
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Affiliation(s)
- Jaime A Foushee
- Edward Via College of Osteopathic Medicine-Carolinas Campus, Spartanburg, SC
| | | | - Laura M Fox
- Presbyterian College School of Pharmacy, Clinton, SC
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19
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Hashimoto W, Takenaka I, Yasunami K, Minami T, Sano H. Comparison of effectiveness of the piston-pump method versus the pressure-infusor method for rapid infusion of crystalloids: A bench study. Indian J Anaesth 2021; 64:1059-1063. [PMID: 33542570 PMCID: PMC7852453 DOI: 10.4103/ija.ija_864_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/11/2020] [Accepted: 09/29/2020] [Indexed: 11/04/2022] Open
Abstract
Background and Aims The piston-pump method is a simple method for rapid administration of fluids but some problems are unsolved. We compared the effectiveness of using the piston-pump method with that of the pressure-infusor method. Methods Twelve anaesthetists were classified randomly into the piston-pump and pressure-infusor groups. They were asked to infuse 500 ml of saline three times successively through a 16-G intravenous cannula as rapidly as possible using a pump with a 50-ml syringe or a pressure-infusor at 300 mmHg. The time taken for infusion and the maximum or minimum pressure in the infusion circuit and substitute vessel were measured. Bacterial culture of the saline infused sterilely was performed to estimate bacterial contamination. Results The pressure-infusor group led to faster infusion of 500 ml of saline (233 ± 19 s) than the piston-pump group (301 ± 48 s) (P < 0.01). The infusion time at the third attempt (316 ± 43 s) was significantly longer than that at the first attempt (285 ± 53 s) only in the piston-pump group (P < 0.05). The maximum pressure (mmHg) in the circuit was 131 ± 9 and > 200 (P < 0.01) and in the substitute vessel was 5 ± 1 and 17 ± 7 (P < 0.01) in the pressure-infusor and piston-pump groups, respectively. A pressure of <-200 mmHg occurred at all infusion attempts in the piston-pump group. Bacterial contamination was not observed in either group. Conclusion If fluids must be administered rapidly, the pressure-infusor method is more efficient than the piston-pump method because the latter is less effective in infusing fluids rapidly and associated with excessive positive and negative pressure in the infusion circuit.
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Affiliation(s)
- Wataru Hashimoto
- Department of Anaesthesiology, University of Occupational Environmental Health, Japan, 1-1-1 Iseigaoka, Yahatanishi, Kitakyushu, Japan
| | - Ichiro Takenaka
- Department of Anaesthesia, Kyushu Rosai Hospital, 1-1 Sonekita, Kokuraminami, Kitakyushu, Japan
| | - Keisuke Yasunami
- Department of Anaesthesiology, University of Occupational Environmental Health, Japan, 1-1-1 Iseigaoka, Yahatanishi, Kitakyushu, Japan
| | - Tomoko Minami
- Department of Anaesthesia, Kyushu Rosai Hospital, 1-1 Sonekita, Kokuraminami, Kitakyushu, Japan
| | - Haruhiko Sano
- Department of Anaesthesia, Kyushu Rosai Hospital, 1-1 Sonekita, Kokuraminami, Kitakyushu, Japan
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20
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Jung KT, So KY, Kim SU, Kim SH. The Optimizing Background Infusion Mode Decreases Intravenous Patient-Controlled Analgesic Volume and Opioid Consumption Compared to Fixed-Rate Background Infusion in Patients Undergoing Laparoscopic Cholecystectomy: A Prospective, Randomized, Controlled, Double-Blind Study. ACTA ACUST UNITED AC 2021; 57:medicina57010042. [PMID: 33419086 PMCID: PMC7825461 DOI: 10.3390/medicina57010042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/02/2021] [Accepted: 01/04/2021] [Indexed: 02/06/2023]
Abstract
Background and objectives: The fixed-rate continuous background infusion mode with bolus dosing is a common modality for intravenous patient-controlled analgesia (PCA). However, some patients suffer from inadequate analgesia or opioid-related adverse effects due to the biphasic pattern of postoperative pain. Therefore, we investigated the postoperative analgesic efficacy of PCA using an optimizing background infusion mode (OBIM) where the background injection rate varies depending on the patient’s bolus demand. Materials and Methods: We prospectively enrolled 204 patients who underwent laparoscopic cholecystectomy in a randomized, controlled, double-blind study. Patients were allocated to either the optimizing (group OBIM) or the traditional background infusion group (group TBIM). The numeric rating scale (NRS) score for pain was evaluated at admission to and discharge from the recovery room, as well as at the 6th, 24th, and 48th postoperative hours. Data on bolus demand count, total infused volume, and background infusion rate were downloaded from the PCA device at 30-min intervals until the 48th postoperative hour. Results: The NRS score was not significantly different between groups throughout the postoperative period (p = 0.621), decreasing with time in both groups (p < 0.001). The bolus demand count was not significantly different between groups throughout (p = 0.756). The mean total cumulative infused PCA volume was lower in group OBIM (84.0 (95% confidence interval: 78.9−89.1) mL) than in group TBIM (102 (97.8−106.0) mL; p < 0.001). The total cumulative opioid dose in fentanyl equivalents, after converting sufentanil to fentanyl using an equipotential dose ratio, was lower in group OBIM (714.1 (647.4−780.9) μg) than in group TBIM (963.7 (870.5−1056.9) μg); p < 0.001). The background infusion rate was significantly different between groups throughout the study period (p < 0.001); it was higher in group OBIM than in group TBIM before the 12th postoperative hour and lower from the 18th to the 48th postoperative hour. Conclusions: The OBIM combined with bolus dosing reduces the cumulative PCA volume and opioid consumption compared to the TBIM combined with bolus dosing, while yielding comparable postoperative analgesia and bolus demand in patients undergoing laparoscopic cholecystectomy.
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Affiliation(s)
- Ki Tae Jung
- Department of Anesthesiology and Pain Medicine, School of Medicine, Chosun University, 309 Pilmun-daero, Dong-gu, Gwangju 61452, Korea; (K.T.J.); (K.Y.S.)
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, 365 Pilmun-daero, Dong-gu, Gwangju 61453, Korea;
| | - Keum Young So
- Department of Anesthesiology and Pain Medicine, School of Medicine, Chosun University, 309 Pilmun-daero, Dong-gu, Gwangju 61452, Korea; (K.T.J.); (K.Y.S.)
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, 365 Pilmun-daero, Dong-gu, Gwangju 61453, Korea;
| | - Seung Un Kim
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, 365 Pilmun-daero, Dong-gu, Gwangju 61453, Korea;
| | - Sang Hun Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Chosun University, 309 Pilmun-daero, Dong-gu, Gwangju 61452, Korea; (K.T.J.); (K.Y.S.)
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, 365 Pilmun-daero, Dong-gu, Gwangju 61453, Korea;
- Correspondence: ; Tel.: +82-62-2203223
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21
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Forshay CM, Hansen KN, Eckel SF. Using intravenous pump infusion data to optimize continuous infusion concentrations and reduce drug and fluid waste. Am J Health Syst Pharm 2020; 77:1497-1503. [PMID: 32779706 DOI: 10.1093/ajhp/zxaa199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To outline a data-driven analysis involving use of intravenous (i.v.) pump data to identify optimal drug and fluid amounts for various continuous infusions, with the primary goal of minimizing medication waste. This methodology incorporates analysis of vial sizes, infusion rates, number of bag exchanges, and bag volumes to determine optimal concentrations that improve operational efficiencies and decrease drug and fluid waste. METHODS A retrospective evaluation of i.v. infusion pump utilization data for continuous infusions of norepinephrine, phenylephrine, vasopressin, and cisatracurium was performed using data provided by 9 hospitals in North Carolina during January, April, and June of 2015. RESULTS The recommended medication concentrations and fluid volumes were determined using a novel 4-step analysis, the VERB (Vial, Exchange, Rate, and Bag) analysis, which applied optimal practices for cost reduction, operational efficiency, and patient safety. The application of the VERB analysis to the i.v. infusion pump utilization data resulted in the following recommended medication concentrations: norepinephrine, 4 mg/100 mL (final concentration, 40 µg/mL) and 16 mg/250 mL (final concentration, 64 µg/mL); phenylephrine, 10 mg/100 mL (final concentration, 100 µg/mL); vasopressin, 20 units/100 mL (final concentration, 0.2 unit/mL); and cisatracurium, 200 mg/100 mL (final concentration, 2 mg/mL). It was determined that implementation of the recommended concentrations by the 9 study hospitals would result in significant medication cost savings and fluid volume savings. CONCLUSION Analysis of i.v. infusion pump data from multiple hospitals using VERB analysis resulted in standardized medication concentrations and bag sizes for continuous infusions that reduce drug and fluid waste and improve operational efficiencies.
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Affiliation(s)
- Charlotte M Forshay
- University of North Carolina (UNC) Eshelman School of Pharmacy, Chapel Hill, NC
| | | | - Stephen F Eckel
- University of North Carolina (UNC) Eshelman School of Pharmacy, Chapel Hill, NC.,University of North Carolina Medical Center, Chapel Hill, NC
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22
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Oli AN, Ibeabuchi MU, Enweani IB, Emencheta SC. Pharmaceutical Quality of Selected Metronidazole and Ciprofloxacin Infusions Marketed in South Eastern Nigeria. Drug Healthc Patient Saf 2020; 12:103-112. [PMID: 32765114 PMCID: PMC7369296 DOI: 10.2147/dhps.s246050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 06/11/2020] [Indexed: 11/27/2022]
Abstract
Background Pharmaceutical products need to be of good quality and it is even more critical when it comes to life saving medicaments like infusions. Objective This research surveyed the quality fitness of some ciprofloxacin and metronidazole infusion samples marketed in South-eastern of Nigeria. Methods Using Official Compendial methods, microbiological quality, active pharmaceutical ingredients quantitation, pH and particle count tests were evaluated on eighty infusion bottles (from eight pharmaceutical companies) of each of the two drugs. Results Out of the sixteen brands tested, 2 metronidazole brands and 1 ciprofloxacin brand (representing 18.75% of the total 16 brands/makes) were contaminated while the remaining 13 brands (81.25%) were found sterile. The active pharmaceutical ingredients quantitative assay showed that all the brands of ciprofloxacin infusion were between the 95% and 105% limit of label claim while one metronidazole brand has <95–110% limit label claim. Six brands each of the two drugs evaluated fall below the acceptable pH range [ciprofloxacin (3.5–4.6) and metronidazole (4.8–5.2)], while the other two brands of both drugs passed the test. In the antibacterial study, Pseudomonas aeruginosa and Escherichia coli were susceptible to the ciprofloxacin (5 µg). However, Salmonella typhi recorded inhibition zone diameters within resistant and intermediate range. Peptostrepococcus spp was susceptible (at minimum inhibitory concentrations of 100 µg/mL) to all the brands of metronidazole, while none of the brands were effective on Lactobacillus spp. All the brands passed the test for particulate contamination. The particles size range was <10µm. Conclusion About eighty-one percent (81.25%) of the infusions have acceptable good microbiological quality. However, 18.75% that failed the tests is a concern knowing that these are lifesaving products.
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Affiliation(s)
- Angus Nnamdi Oli
- Department of Pharmaceutical Microbiology and Biotechnology, Faculty of Pharmaceutical Sciences, Nnamdi Azikiwe University, Awka, Anambra State, Nigeria
| | - MaryRose Ukamaka Ibeabuchi
- Department of Pharmaceutical Microbiology and Biotechnology, Faculty of Pharmaceutical Sciences, Nnamdi Azikiwe University, Awka, Anambra State, Nigeria
| | - Ifeoma Bessie Enweani
- Department of Medical Laboratory Science, Faculty of Health Sciences and Technology, Nnamdi Azikiwe University, Nnewi Campus, Nnewi, Anambra State, Nigeria
| | - Stephen Chijioke Emencheta
- Department of Pharmaceutical Microbiology and Biotechnology, Faculty of Pharmaceutical Sciences, Nnamdi Azikiwe University, Awka, Anambra State, Nigeria.,Department of Pharmaceutical Microbiology and Biotechnology, Faculty of Pharmaceutical Sciences, University of Nigeria, Nsukka, Enugu State 41001, Nigeria
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23
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Myers KL, Leong CR, Mahmoud AA. Hemodynamic Safety of Continuous Infusion Labetalol Versus Esmolol Combination Therapies for Type B Aortic Dissections. J Pharm Pract 2020; 34:870-874. [PMID: 32552306 DOI: 10.1177/0897190020929807] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Medical management for type B aortic dissections (TBADs) require aggressive blood pressure and heart rate control to minimize further dissection extension and to restore perfusion to vital organs. Current guidelines recommend β-blockers (BB) as first-line therapy, however do not differentiate an ideal agent for use. OBJECTIVE This study evaluated the hemodynamic safety of continuous infusion labetalol compared to esmolol combination (EC) therapies for TBADs. METHODS This single-center, retrospective analysis identified patients with a TBAD who received high dose continuous intravenous labetalol (HD-CIVL) or EC therapies. Patients who received HD-CIVL or EC therapies for a minimum of 2 hours, during which a minimum of 4 blood-pressure readings were recorded, were included. The primary end point was the incidence of hemodynamic instability with the use of HD-CIVL versus EC therapies. RESULTS A total of 20 patients receiving HD-CIVL and 22 patients receiving EC therapy were included in the analysis. Ten (50%) of patients receiving HD-CIVL and 7 (32%) of patients receiving EC therapies met the clinical definition of hemodynamic instability (P = .23). Patients experiencing hemodynamic instability were all due to hypotension, with one also being due to bradycardia. Over half the patients in both groups had discontinued therapy ( P = .06) and were administered bolus fluids (P = .27). Only one patient receiving HD-CIVL required vasopressor administration while none in the EC group (P = .48). CONCLUSION Our study suggests that HD-CIVL is associated with a nonstatistical significant higher incidence of hemodynamic instability compared to an EC regimen in TBADs. Further studies are warranted in this patient population.
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Affiliation(s)
- Kayla L Myers
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA
| | | | - Ahmed A Mahmoud
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA
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24
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Mahlangu J, Lopez Fernandez MF, Santagostino E, Lalezari S, Tseneklidou-Stoeter D, Beckmann H, Church N. BAY 81-8973 demonstrated efficacy, safety and joint status improvement in patients with severe haemophilia A in the LEOPOLD I extension for ≤2 years. Eur J Haematol 2020; 104:594-601. [PMID: 32112434 PMCID: PMC7383510 DOI: 10.1111/ejh.13402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 02/24/2020] [Accepted: 02/26/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVES BAY 81-8973 (Kovaltry® ), a full-length, unmodified, recombinant human factor VIII, provided excellent bleeding control for patients with haemophilia A in the pivotal 1-year LEOPOLD I trial. The LEOPOLD I extension evaluated long-term efficacy and safety of BAY 81-8973 prophylaxis. METHODS After completing LEOPOLD I, patients continued receiving 20-50 IU/kg BAY 81-8973 two- or three-times weekly in the extension. Outcomes included annualised bleeding rate (ABR) and haemostasis during surgery. RESULTS Fifty-five patients aged 12-65 years participated in the extension. Median (range) exposure days during the 2-year total study period was 309 (115-355). No patient switched regimens. Median (Q1; Q3) ABR for all bleeds was 2.0 (1.0; 6.1) during the pivotal study, 2.0 (0.0; 5.2) during the extension, and 2.0 (0.5; 5.5) combined. The proportion of joint bleeds affecting target joints decreased (pivotal study: 90.9%, extension: 60.0%). Haemostasis was assessed as excellent/good in all five major surgeries. One serious adverse event (myocardial infarction) occurred in a patient with cardiovascular risk factors. No patients developed inhibitors. CONCLUSIONS BAY 81-8973 prophylaxis efficacy outcomes in the pivotal study were maintained or, in the case of joint protection, improved during the extension, with a safety and tolerability profile consistent with previous experience.
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Affiliation(s)
- Johnny Mahlangu
- Hemophilia Comprehensive Care Center, Faculty of Health Sciences, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, and National Health Laboratory Service, Johannesburg, South Africa
| | | | - Elena Santagostino
- Foundation IRCCS Ca' Granda, A. Bianchi Bonomi Hemophilia and Thrombosis Center, Maggiore Hospital Policlinico, Milan, Italy
| | - Shadan Lalezari
- Israel National Haemophilia Center, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
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25
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Lalezari S, Reding MT, Pabinger I, Holme PA, Negrier C, Chalasani P, Shin HJ, Wang M, Tseneklidou-Stoeter D, Maas Enriquez M. BAY 94-9027 prophylaxis is efficacious and well tolerated for up to >5 years with extended dosing intervals: PROTECT VIII extension interim results. Haemophilia 2019; 25:1011-1019. [PMID: 31621991 PMCID: PMC6900134 DOI: 10.1111/hae.13853] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/30/2019] [Accepted: 09/04/2019] [Indexed: 02/06/2023]
Abstract
Introduction BAY 94‐9027 is an extended‒half‐life, site‐specifically PEGylated, B‐domain‒deleted recombinant factor VIII (FVIII). The PROTECT VIII main study demonstrated efficacy of bleed control using extended‐interval prophylaxis with BAY 94‐9027 for 36 weeks. Aim To report long‐term efficacy and safety of prophylaxis with BAY 94‐9027 in a descriptive analysis of the ongoing PROTECT VIII extension with a total treatment time of up to >5 years. Methods Previously treated males aged 12‐65 years with severe haemophilia A who completed the PROTECT VIII main study were eligible for the open‐label extension. Patients received on‐demand treatment or prophylaxis (30‒40 IU/kg twice weekly, 45‒60 IU/kg every 5 days, or 60 IU/kg every 7 days) and could switch regimens as needed. Results Patients (N = 121; on demand, n = 14; prophylaxis, n = 107) accumulated a median (range) of 3.9 years (297‒1965 days) and 223 (23‒563) total exposure days by 31 January 2018. During the extension, median (quartile [Q]1; Q3) annualized bleeding rates (ABRs) for total bleeds were 1.6 (0.3; 4.6) for patients receiving prophylaxis and 34.1 (20.3; 36.6) for patients receiving on‐demand treatment. ABRs for twice‐weekly (n = 23), every‐5‐days (n = 33), every‐7‐days (n = 23) and variable frequency (n = 28) treatments were 1.7, 1.2, 0.7 and 3.1, respectively. Of prophylaxis patients, 20.6% were bleed‐free throughout the extension (median time, 3.2 years), and 51.0% were bleed‐free during the last 6 months. No patients developed FVIII inhibitors. Conclusions BAY 94‐9027 prophylaxis was efficacious and well tolerated with dosing intervals up to every 7 days for a median (range) of 3.9 years (0.8‐5.4 years).
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Affiliation(s)
- Shadan Lalezari
- Israel National Hemophilia Center, Chaim Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel Hashomer, Israel
| | - Mark T Reding
- Center for Bleeding and Clotting Disorders, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Pal Andre Holme
- Department of Haematology, Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Claude Negrier
- Hemophilia Comprehensive Care Center and Hematology Department, Louis Pradel University Hospital, Lyon, France
| | | | - Ho-Jin Shin
- Division of Hematology-Oncology, Department of Internal Medicine, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Korea
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26
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Wheeler C, Furniss D, Galal-Edeen GH, Blandford A, Franklin BD. Patients' Perspectives on the Quality and Safety of Intravenous Infusions: A Qualitative Study. J Patient Exp 2019; 7:380-385. [PMID: 32821798 PMCID: PMC7410139 DOI: 10.1177/2374373519843921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background The administration of medication or fluids via the intravenous route is a common intervention for many hospital inpatients. However, little research has explored the safety and quality of intravenous therapy from the patient's perspective, despite the role of the patient in patient safety receiving increased attention in recent years. Objective To explore patients' perspectives on the perceived quality and safety of intravenous infusions and identify implications for practice. Method Qualitative semistructured interviews were conducted with 35 hospital patients receiving intravenous infusions in critical care, oncology day care, general medicine, and general surgery areas within 4 National Health Service hospitals in England. Data were analyzed thematically. Results Four underlying and interlinked themes were identified: knowledge about intravenous infusions, challenges associated with receiving intravenous infusions, the role of health-care professionals, and patients' attitudes toward receiving infusions. Conclusions Patients were generally satisfied with receiving infusions; however, factors that contributed to decreased feelings of quality and safety were identified, suggesting areas for intervention. Issues to do with infusion pump alarms, reduced mobility, cannulation, and personal preferences for information, if given more attention, may improve patients' experiences of receiving intravenous infusions.
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Affiliation(s)
- Carly Wheeler
- Centre for Medication Safety and Service Quality, Pharmacy Department, Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | - Galal H Galal-Edeen
- UCL Interaction Centre, London, United Kingdom.,Faculty of Computers and Information, Cairo University, Giza, Egypt
| | | | - Bryony Dean Franklin
- Centre for Medication Safety and Service Quality, Pharmacy Department, Imperial College Healthcare NHS Trust, London, United Kingdom.,Research Department of Practice and Policy, UCL School of Pharmacy, London, United Kingdom
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27
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Sutherland A, Canobbio M, Clarke J, Randall M, Skelland T, Weston E. Incidence and prevalence of intravenous medication errors in the UK: a systematic review. Eur J Hosp Pharm 2018; 27:3-8. [PMID: 32064081 PMCID: PMC6992970 DOI: 10.1136/ejhpharm-2018-001624] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 09/10/2018] [Accepted: 09/18/2018] [Indexed: 12/19/2022] Open
Abstract
Objectives Medication error is the most common type of medical error, and intravenous medicines are at a higher risk as they are complex to prepare and administer. The WHO advocates a 50% reduction of harmful medication errors by 2022, but there is a lack of data in the UK that accurately estimates the true rate of intravenous medication errors. This study aimed to estimate the number of intravenous medication errors per 1000 administrations in the UK National Health Service and their associated economic costs. The rate of errors in prescribing, preparation and administration, and rate of different types of errors were also extracted. Methods MEDLINE, Embase, Cochrane central register of clinical trials, Database of Abstracts of Reviews of Effectiveness, National Health Service Economic Evaluation Database and the Health Technology Appraisals Database were searched from inception to July 2017. Epidemiological studies to determine the incidence of intravenous medication errors set wholly or in part in the UK were included. 228 studies were identified, and after screening, eight papers were included, presenting 2576 infusions. Data were reviewed and extracted by a team of five reviewers with discrepancies in data extraction agreed by consensus. Results Five of eight studies used a comparable denominator, and these data were pooled to determine a weighted mean incidence of 101 intravenous medication errors per 1000 administrations (95% CI 84 to 121). Three studies presented prevalence data but these were based on spontaneous reports only; therefore it did not support a true estimate. 32.1% (95% CI 30.6% to 33.7%) of intravenous medication errors were administration errors and ‘wrong rate’ errors accounted for 57.9% (95% CI 54.7% to 61.1%) of these. Conclusion Intravenous medication errors in the UK are common, with half these of errors related to medication administration. National strategies are aimed at mitigating errors in prescribing and preparation. It is now time to focus on reducing administration error, particularly wrong rate errors.
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Affiliation(s)
- Adam Sutherland
- Division of Pharmacy and Optometry, University of Manchester; Faculty of Biology, Medicine and Health, Manchester, UK.,Pharmacy Department, Royal Manchester Children's Hospital, Manchester, UK
| | | | - Janine Clarke
- Department of Pharmacy, Princess Elizabeth Hospital, Saint Andrew, Guernsey
| | - Michelle Randall
- Department of Pharmacy, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Tom Skelland
- Department of Pharmacy, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Emma Weston
- Pharmacy Department, Hampshire Hospitals NHS Foundation Trust, Winchester, UK
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28
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Abstract
Drug calculations for intravenous (IV) medicines and infusions are more complex than those for oral medicines. This article aims to assist nurses in evaluating and improving their competence in undertaking drug calculations for the IV route. Although nurses enter the professional register with an assessed level of medicines competence, nursing is a dynamic profession and competency can decrease over time, with literature demonstrating that nurses often have suboptimal drug calculation skills. This article enables nursing students to enhance their knowledge and understanding of IV drug calculations, and registered nurses to revisit this essential nursing skill. It is necessary to enhance nurses' mathematical skills and conceptual knowledge related to drug calculations to reduce the incidence of medication errors.
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Affiliation(s)
- Jane Brindley
- Adult nursing, School of Nursing, Canterbury Christ Church University, Canterbury, England
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29
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Abstract
Initiation or continuation of artificial hydration (AH) at the end of life requires unique considerations. A combination of ethical precedents and medical literature may provide clinical guidance on how to use AH at the end of life. The purpose of this review is to describe the ethical framework for and review current literature relating to the indications, benefits, and risks of AH at the end of life. Provider, patient, and family perspectives will also be discussed.
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Affiliation(s)
- Alexandria J Bear
- 1 Department of Medicine, Division of Palliative Care, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Elizabeth A Bukowy
- 2 Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jayshil J Patel
- 3 Department of Medicine, Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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30
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Mehdi SMA, Atlas SE, Qadir S, Musselman D, Goldberg S, Woolger JM, Corredor R, Abbas MH, Arosemena L, Caccamo S, Campbell CSG, Farooqi A, Gao J, Konefal J, Lages LC, Lantigua L, Lopez J, Padilla V, Rasul A, Ray AM, Simões HG, Tiozzo E, Lewis JE. Double-blind, randomized crossover study of intravenous infusion of magnesium sulfate versus 5% dextrose on depressive symptoms in adults with treatment-resistant depression. Psychiatry Clin Neurosci 2017; 71:204-211. [PMID: 27862658 DOI: 10.1111/pcn.12480] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 10/24/2016] [Accepted: 11/06/2016] [Indexed: 12/28/2022]
Abstract
AIM Treatment-resistant depression patients are more likely to suffer from comorbid physical and mental disorders, experience marked and protracted functional impairment, and incur higher health-care costs than non-affected individuals. Magnesium sulfate is a treatment option that may offer great potential for patients with treatment-resistant depression based on prior work in animals and humans. METHODS Twelve subjects with mild or moderate treatment-resistant depression were randomized into a double-blind crossover trial to receive an infusion of 4 g of magnesium sulfate in 5% dextrose or placebo infusion of 5% dextrose with a 5-day washout in between the 8-day intervention period. Subjects were assessed before and after the intervention for serum and urine magnesium, lipid panel, the Hamilton Rating Scale for Depression, and the Patient Health Questionnaire-9. RESULTS We found a difference in serum magnesium from day 2 to 8 (pre-infusion) (P < 0.002) and from baseline to day 8 (P < 0.02). No changes were noted on the Hamilton Rating Scale for Depression or the Patient Health Questionnaire-9 24 h post-treatment, but as serum magnesium increased from baseline to day 7, the Patient Health Questionnaire-9 decreased from baseline to day 7 (P = 0.02). CONCLUSION Magnesium sulfate did not significantly affect depression 24 h post-infusion, but other results were consistent with the literature. The association between changes in serum magnesium and the Patient Health Questionnaire-9 supports the idea that magnesium sulfate may be used to address treatment-resistant depression, an ongoing medical challenge.
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Affiliation(s)
- Syed M A Mehdi
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, USA
| | - Steven E Atlas
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, USA
| | - Sidra Qadir
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, USA
| | - Dominique Musselman
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, USA
| | - Sharon Goldberg
- Department of Medicine, University of Miami Miller School of Medicine, Miami, USA
| | - Judi M Woolger
- Department of Medicine, University of Miami Miller School of Medicine, Miami, USA
| | - Raul Corredor
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, USA
| | - Muhammad H Abbas
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, USA
| | - Leopoldo Arosemena
- Department of Medicine, University of Miami Miller School of Medicine, Miami, USA
| | - Simone Caccamo
- Department of Medicine, University of Miami Miller School of Medicine, Miami, USA
| | - Carmen S G Campbell
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, USA
| | - Ashar Farooqi
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, USA
| | | | - Janet Konefal
- Department of Family Medicine and Community Health, University of Miami Miller School of Medicine, Miami, USA
| | - Lucas C Lages
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, USA
| | - Laura Lantigua
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, USA
| | - Johanna Lopez
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, USA
| | - Vanessa Padilla
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, USA
| | - Ammar Rasul
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, USA
| | - Anna M Ray
- Department of Medicine, University of Miami Miller School of Medicine, Miami, USA
| | - Herbert G Simões
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, USA
| | - Eduard Tiozzo
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, USA
| | - John E Lewis
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, USA
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31
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Dale GJ, Phillips S, Falk GL. The analgesic efficacy of intravenous lidocaine infusion after laparoscopic fundoplication: a prospective, randomized, double-blind, placebo-controlled trial. Local Reg Anesth 2016; 9:87-93. [PMID: 27980437 PMCID: PMC5144913 DOI: 10.2147/lra.s119483] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
This study aimed to determine if intravenous lidocaine infusion reduces postoperative pain intensity following laparoscopic fundoplication surgery and to also validate the safety of intravenous lidocaine at the dose tested. This was an equally randomized, double-blind, placebo-controlled, parallel-group, single center trial. Adult patients undergoing laparoscopic fundoplication were recruited. The intervention group received 1 mg/kg intravenous lidocaine bolus prior to induction of anesthesia, then an intravenous infusion at 2 mg/kg/h for 24 hours. The primary outcome was pain, measured using a numeric rating scale for 30 hours postoperatively. Secondary outcomes were nausea and vomiting, opioid requirements, adverse events, serum lidocaine concentration, and length of hospital stay. The study was terminated after an interim analysis of 24 patients showed evidence of futility. There was no difference in postoperative pain scores (lidocaine versus control, mean ± standard deviation) at rest (2.0 ± 2.7 vs 2.1 ± 2.4, P=0.286) or with movement (2.0 ± 2.6 vs 2.6 ± 2.7, P=0.487). Three adverse events occurred in the lidocaine group (25% of patients). Intravenous lidocaine did not provide clinically significant analgesia to patients undergoing laparoscopic fundoplication. The serum lidocaine concentration of patients who experienced adverse events were within the therapeutic range. This trial cannot confirm the safety of intravenous lidocaine at the dose tested.
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Affiliation(s)
- Gregory J Dale
- Westmead Hospital Clinical School, The University of Sydney
| | | | - Gregory L Falk
- Concord Clinical School, The University of Sydney, Sydney, Australia
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32
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Bailey GP, Wood DM, Archer JRH, Rab E, Flanagan RJ, Dargan PI. An assessment of the variation in the concentration of acetylcysteine in infusions for the treatment of paracetamol overdose. Br J Clin Pharmacol 2016; 83:393-399. [PMID: 27558662 DOI: 10.1111/bcp.13099] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 07/12/2016] [Accepted: 08/18/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Intravenous acetylcysteine is the treatment of choice for paracetamol poisoning. A previous UK study in 2001 found that 39% of measured acetylcysteine infusion concentrations differed by >20% from anticipated concentrations. In 2012, the UK Commission on Human Medicines made recommendations for the management of paracetamol overdose, including provision of weight-based acetylcysteine dosing tables. The aim of this study was to assess variation in acetylcysteine concentrations in administered infusions following the introduction of this guidance. METHODS A 6-month single-centre prospective study was undertaken at a UK teaching hospital. After preparation, 5-ml samples were taken from the first, second and third/any subsequent acetylcysteine infusions. Acetylcysteine was measured in diluted (1:50) samples by high-performance liquid chromatography. Comparisons between measured and expected concentrations based on prescribed weight-based dose and volume were made for each infusion. RESULTS Ninety samples were collected. There was a variation of ≤10% in measured compared to expected concentration for 45 (50%) infusions, of 10-20% for 27 (30%) infusions, 20.1-50% for 14 (16%) infusions and >50% for four (4%) infusions. There was a median (interquartile range) variation in measured compared to expected concentration of -3.6 mg ml-1 (-6.7 to -2.3) for the first infusion, +0.2 mg ml-1 (-0.9 to +0.4) for the second infusion and -0.3 mg ml-1 (-0.6 to +0.2) for third and fourth infusions. CONCLUSION There has been a moderate improvement in the variation in acetylcysteine dose administered by infusion. Further work is required to understand the continuing variation and consideration should be given to simplification of acetylcysteine regimes to decrease the risk of administration errors.
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Affiliation(s)
- George P Bailey
- Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Emergency Department, St. Mary's Hospital, Imperial College NHS Trust, London, UK
| | - David M Wood
- Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - John R H Archer
- Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Edmund Rab
- Toxicology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Robert J Flanagan
- Toxicology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,Toxicology Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
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33
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Bailey GP, Najafi J, Elamin MEMO, Waring WS, Thomas SHL, Archer JRH, Wood DM, Dargan PI. Delays during the administration of acetylcysteine for the treatment of paracetamol overdose. Br J Clin Pharmacol 2016; 82:1358-1363. [PMID: 27412926 DOI: 10.1111/bcp.13063] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 06/23/2016] [Accepted: 07/09/2016] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The licensed intravenous acetylcysteine regimen for treating paracetamol overdose in most countries uses three separate infusions over 21 h. This complex regimen, requiring different infusion concentrations and rates, has been associated with administration errors. The aim of the present study was to assess the extent of administration delays occurring during this acetylcysteine regimen. METHOD A 6-month retrospective observational study was conducted at three English teaching hospitals with clinical toxicology services from October 2014. Patients aged 16 years and over, treated with intravenous acetylcysteine for paracetamol overdose, were included. The start times for infusions were recorded and the delays compared with the prescribed infusion times were calculated. Anaphylactoid reactions, intravenous cannula problems, overdose intent and smoking status were recorded to assess their contribution to delays. RESULTS From 263 cases identified, 198 met the study inclusion criteria. The median time between the start of infusions 1 and 3 was delayed from the intended 5 h by a median (interquartile range) of 90 (50-163) min, with 135 (68%) cases delayed by more than 1 h. Significantly longer delays were observed in patients with anaphylactoid reactions [median delay 267 (217-413) min, n = 8] and accidental/supratherapeutic overdose [median delay 170 (95-260) min, n = 29]. There were no significant differences between smokers and nonsmokers, or for patients with intravenous cannula problems. CONCLUSION Long delays were identified during the three-infusion acetylcysteine regimen for the treatment of paracetamol overdose. These were of clinical significance and could lead to periods of subtherapeutic plasma acetylcysteine concentrations and potentially avoidable hepatotoxicity, as well as delaying hospital discharge.
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Affiliation(s)
- George P Bailey
- Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Emergency Department, St Mary's Hospital, Imperial College NHS Trust, London, UK
| | - Javad Najafi
- Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | | | - Simon H L Thomas
- Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Medical Toxicology Centre, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - John R H Archer
- Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - David M Wood
- Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust and King's Health Partners, London, UK. .,Faculty of Life Sciences and Medicine, King's College London, London, UK.
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Sanchez Cuervo M, Rojo Sanchis A, Pueyo Lopez C, Gomez de Salazar Lopez de Silanes E, Gramage Caro T, Bermejo Vicedo T. The impact of a computerized physician order entry system on medical errors with antineoplastic drugs 5 years after its implementation. J Clin Pharm Ther 2015; 40:550-554. [PMID: 26177870 DOI: 10.1111/jcpt.12305] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 06/09/2015] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Computerized physician order entry (CPOE) systems reduce medical errors (MEs). Nevertheless, a CPOE system may also lead to new types of errors, especially when it is first implemented. The objectives of this study were to determine the impact of a CPOE on the number of MEs and to identify the types of MEs in prescriptions issued by the Haematology Department 5 years after the implementation of the CPOE system. METHODS We conducted a prospective analytical study on the implementation of a CPOE system at the Pharmacy Department of the Hospital Ramon y Cajal (Madrid, Spain). The study comprised three phases: a pre-implementation phase, an implementation phase conducted in the Haematology Department and a post-implementation phase, which was conducted 5 years after the implementation of the CPOE system. One hundred and fifty prescriptions per pre- and post-implementation phase were consecutively included in the study. A previously described classification scheme was used to detect and classify MEs. RESULTS AND DISCUSSION The implementation of a CPOE system was associated with a large reduction in MEs. One hundred and fourteen patients (pre-implementation phase) were compared to 82 patients (post-implementation phase). The total number of MEs per 100 patients decreased from 236·8 (95% CI: 212·1-261·3) to 10·9 (95% CI: 5·8-19·6), with an absolute risk reduction of 36·2 (95% CI: 32·6-39·9). The percentage of prescriptions with an ME decreased from 37·5% to 1·2% (P < 0.001). In the pre-implementation phase, the drugs most frequently associated with MEs were rituximab (35·9%), cyclophosphamide (13%) and methotrexate (7%). In the post-implementation phase, 44·4% of prescription errors involved methotrexate. Five years after the implementation of the CPOE system, the majority of MEs were eliminated, the number of remaining errors (quantity, concentration and ambiguous prescription errors) decreased, and no new types of ME were detected. WHAT IS NEW AND CONCLUSION The CPOE system almost completely eliminated MEs with antineoplastic drugs in the Haematology Department. No new types of MEs were observed once physicians had become accustomed to using the system. However, some MEs were not eliminated. Constant diligence is needed to analyse and evaluate MEs associated with the CPOE system and their causes, such that the limitations of CPOE can be identified and overcome and the medication-use process associated with antineoplastic agents improved.
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Affiliation(s)
| | - A Rojo Sanchis
- Department of Pharmacy, Ramon y Cajal Hospital, Madrid, Spain
| | - C Pueyo Lopez
- Department of Pharmacy, Ramon y Cajal Hospital, Madrid, Spain
| | | | - T Gramage Caro
- Department of Pharmacy, Ramon y Cajal Hospital, Madrid, Spain
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Nygaard M, Hovgaard D, Schjødt IM, Andersen NS, Vindeløv L, Sengeløv H. Oral cyclosporine A treatment is feasible after myeloablative conditioning in allogeneic hematopoietic stem cell transplantation. J Clin Pharm Ther 2015; 40:358-61. [PMID: 25829023 DOI: 10.1111/jcpt.12266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 03/02/2015] [Indexed: 11/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE The target level and route of administration of cyclosporine A (CsA) differ between transplantation centres. It is unclear whether oral CsA is sufficient to maintain target level of CsA. CASE SUMMARY We retrospectively analysed data from 48 adult patients, who underwent myeloablative hematopoietic stem cell transplantation. Twenty-one patients (44%) tolerated CsA orally throughout the transplantation period without increased incidence of acute graft versus host disease(aGVHD). Low concentration of CsA in week 2 was associated with increased incidence of aGVHD. WHAT IS NEW AND CONCLUSION Oral administration of CsA is safe, less time-consuming and economically advantageous. Close monitoring of CsA concentration is important.
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Affiliation(s)
- M Nygaard
- Hematological department, National University Hospital Rigshospitalet, Copenhagen, Denmark
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36
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Abstract
BACKGROUND Alerts generated by intravenous (IV) infusion pump safety software prevent life-threatening situations that might otherwise go unnoticed. However, when alerts are often clinically insignificant, health care workers may become desensitized and discount their importance, resulting in potentially dangerous situations. Little research has been devoted to visual alert desensitization. METHOD This paper describes how the Carolinas HealthCare System decreased the number of nonclinically relevant infusion pump alerts by analyzing alert data that were formatted into scatter plots. This in turn enabled the identification of the medications associated with the most meaningful alerts and those associated with the least meaningful alerts. CONCLUSION By revising drug library limits for specific medications, it was possible to decrease the number of less clinically meaningful alerts, reduce alert fatigue, and thereby increase the effectiveness of the smart infusion pumps. This added another layer of safety to patient care.
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Affiliation(s)
- Jennifer Mansfield
- Smart Pump Liaison, Carolinas HealthCare System, Charlotte, North Carolina
| | - Steven Jarrett
- Medication Safety Officer, Carolinas HealthCare System, Charlotte, North Carolina
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37
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Abstract
Perioperative intravenous (IV) fluid management is controversial. Fluid therapy is guided by inaccurate algorithms and changes in the patient's vital signs that are nonspecific for changes to the patient's blood volume (BV). Anesthetic agents, patient comorbidities, and surgical techniques interact and further confound clinical assessment of volume status. Through adaptation of existing acute normovolemic hemodilution algorithms, it may be possible to predict patient's BV by measuring hematocrit (HcT) before and after hemodilution. Our proposed mathematical model requires the following four data points to estimate a patient's total BV: ideal BV, baseline HcT, a known fluid bolus (FB), and a second HcT following the FB. To test our method, we obtained 10 ideal and 10 actual subject BV data measures from 9 unique subjects derived from a commercially used Food and Drug Administration-approved, semi-automated, BV analyzer. With these data, we calculated the theoretical BV change following a FB. Using the four required data points, we predicted BVs (BVp) and compared our predictions with the actual BV (BVa) measures provided by the data set. The BVp calculated using our model highly correlated with the BVa provided by the BV analyzer data set (df = 8, r = .99). Our calculations suggest that, with accurate HcT measurement, this method shows promise for the identification of abnormal BV states such as hyper- and hypovolemia and may prove to be a reliable method for titrating IV fluid.
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Affiliation(s)
- Matthew D'Angelo
- Uniformed Services University of the Health Sciences, Daniel K. Inouye Graduate School of Nursing, Bethesda, MD, USA
| | - R Kyle Hodgen
- Uniformed Services University of the Health Sciences, Daniel K. Inouye Graduate School of Nursing, Bethesda, MD, USA
| | - Kenneth Wofford
- Uniformed Services University of the Health Sciences, Daniel K. Inouye Graduate School of Nursing, Bethesda, MD, USA
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38
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Abstract
BACKGROUND Safety software installed on intravenous (IV) infusion pumps has been shown to positively impact the quality of patient care through avoidance of medication errors. The data derived from the use of smart pumps are often overlooked, although these data provide helpful insight into the delivery of quality patient care. OBJECTIVE The objectives of this report are to describe the value of implementing IV infusion safety software and analyzing the data and reports generated by this system. CASE STUDY Based on experience at the Carolinas HealthCare System (CHS), executive score cards provide an aggregate view of compliance rate, number of alerts, overrides, and edits. The report of serious errors averted (ie, critical catches) supplies the location, date, and time of the critical catch, thereby enabling management to pinpoint the end-user for educational purposes. By examining the number of critical catches, a return on investment may be calculated. Assuming 3,328 of these events each year, an estimated cost avoidance would be $29,120,000 per year for CHS. Other reports allow benchmarking between institutions. CONCLUSION A review of the data about medication safety across CHS has helped garner support for a medication safety officer position with the goal of ultimately creating a safer environment for the patient.
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Affiliation(s)
| | - Steven Jarrett
- Medication Safety Officer, Carolinas HealthCare System, Charlotte, North Carolina. Corresponding author: Jennifer Mansfield, PharmD, Carolinas HealthCare System, 1000 Blythe Boulevard, Charlotte, NC 28203; phone: 704-355-2434; e-mail:
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39
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Christakis P. The birth of chemotherapy at Yale. Bicentennial lecture series: Surgery Grand Round. Yale J Biol Med 2011; 84:169-72. [PMID: 21698052 PMCID: PMC3117414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Chemotherapy, one of the mainstays of cancer treatment today, was pioneered at Yale during World War II. Last year, two Yale surgeons, Drs. John Fenn and Robert Udelsman, sought to unearth the mystery surrounding the discovery of chemotherapy and its first use at Yale. The first chemotherapy patient is known only as JD in the literature, and without a name, date of birth, or medical record number, a search for his record seemed futile. However, persistence coupled with sheer fortune led them to JD's chart, where they found information that differed from previous accounts. The riveting personal story of JD, an immigrant patient with lymphosarcoma, was revealed for the first time by Drs. Fenn and Udelsman on January 19, 2011, at a special Surgical Grand Rounds celebrating the bicentennial of Yale School of Medicine.
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Twelves CJ, Cassidy J. Which endpoints should we use in evaluating the use of novel fluoropyrimidine regimens in colorectal cancer? Br J Cancer 2002; 86:1670-6. [PMID: 12087448 PMCID: PMC2375398 DOI: 10.1038/sj.bjc.6600341] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2001] [Revised: 03/21/2002] [Accepted: 03/27/2002] [Indexed: 02/04/2023] Open
Abstract
Although significant advances have been made in the treatment of advanced/metastatic colorectal cancer, 5-fluorouracil (5-FU) still forms the basis of chemotherapy. Recently, new 5-FU schedules and novel fluoropyrimidines have been developed, but there are no trials directly comparing these regimens. The current review describes the mechanisms of action, pre-clinical and phase I/II studies of two oral fluoropyrimidine therapies, capecitabine and uracil with tegafur plus leucovorin. It also compares the phase III studies of these agents with those of the two most popular infusional 5-FU-based regimens: de Gramont and German AIO (The Association of Medical Oncology (AIO) of the German Cancer Society). Both oral and infusional regimens demonstrated similar survival to the Mayo Clinic regimen, a standard treatment for colorectal cancer. Therefore, other endpoints must be examined to decide optimum therapy, including response rates, time to disease progression, tolerability and patients' convenience. All four new therapies demonstrated superior safety profiles compared with the Mayo Clinic regimen. However the uracil with tegafur plus leucovorin regimen was associated with severe diarrhoea and capecitabine with hand-foot syndrome. Patients will not sacrifice efficacy for the convenience of oral therapy alone, therefore the fact that capecitabine achieved superior response rates and equivalent time to disease progression compared with the Mayo Clinic regimen, while uracil with tegafur plus leucovorin produced lower response rates and significantly inferior time to disease progression, is highly relevant in choosing treatment.
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Affiliation(s)
- C J Twelves
- Cancer Research UK Department of Medical Oncology, Alexander Stone Building, Garscube Estate, Switchback Road, Bearsden, Glasgow G61 1BD, Scotland, UK.
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