Assessment and Impact of Intravenous Medication Fluid Administration in Critically Ill Patients With Acute Respiratory Failure.

BACKGROUND: Positive fluid balance early in critical illness is associated with poor outcomes. Reducing intravenous medication volume may mitigate volume overload. Objective: Assessment of fluid and medication administration and clinical outcomes in acute respiratory failure. METHODS: Single-center, prospective observational study of hemodynamically stable adult patients in a medical intensive care unit (MICU) with acute respiratory failure. RESULTS: Median cumulative total intake volume was 12 890 (interquartile range [IQR] = 8654-22 221) mL (n = 27), and median cumulative intravenous medication volume was 3563 (IQR = 2371-9412) mL over the first 7 days. Medication volume accounted for 27.6% of aggregate fluid volume. Median daily intravenous medication volume administered was 591 (IQR = 339-1082) mL. Cumulative fluid volume was associated with reduced ventilator-free days (r2 = -0.393; P = 0.043), and cumulative fluid volumes during the first 3 and 7 days were associated with increased MICU length of stay (LOS ± standard error 0.73 ± 0.35 d/L, P = 0.047, and 0.38 ± 0.16 d/L, P = 0.021, respectively). Cumulative medication volume administered significantly reduced the likelihood of mechanical ventilator liberation (hazard ratio [HR] = 0.917; 95% CI: 0.854, 0.984; P = 0.016) and MICU discharge (HR = 0.911; 95% CI: 0.843, 0.985; P = 0.019). Small-volume infusion may decrease cumulative intravenous medication volume by 38%. CONCLUSION AND RELEVANCE: Intravenous medication diluent contributes substantially to total fluid intake in patients with acute respiratory failure and is associated with poor outcomes. Reduction of intravenous medication fluid volume to improve clinical outcomes should be further investigated.

Reducing Intermittent Infusion Syringe Pump Errors via Weight-Based Safety Parameters.

UNLABELLED: Historically, smart infusion pumps with dose error reduction software were implemented to improve safety associated with programming of continuous infusion modes on large-volume infusion pumps. Much of the published literature related to smart infusion pumps and safety alerts is focused on continuous medication infusions, with little available information related to their use with intermittent infusions. As a result of the focus on continuous infusions, an impression exists that intermittent infusions are less prone to programming errors and/or do not require comparably rigorous safety parameters, such as use of weight-based medication programming. METHODS: A retrospective study was conducted with data from 10 pediatric inpatient hospitals, all of which used syringe infusion pumps for intermittent medications, to describe the impact of weight-based safety parameters on the occurrence of potential programming errors. The data were analyzed based on recorded safety alerts and alert triggers for weight-based (dose/kilogram/time) and non-weight-based (volume-over-time [VOT]) intermittent infusions. RESULTS: Data from a total of 4,162 pumps, 943,448 total infusions, and 810,359 intermittent infusions between January 1 and December 31, 2013, were reviewed. Weight-based infusions had a greater percentage of safety alerts (83.3%) compared with VOT infusions (16.7%). CONCLUSION: Weight-based intermittent infusion modes can prevent programming errors and, compared with non-weight-based intermittent infusion modes, can be used to improve safety in the pediatric population. Additional research should be conducted to confirm a decrease in adverse drug events resulting from implementation of weight-based safety parameters.

Clinical performance of a new blood control peripheral intravenous catheter: A prospective, randomized, controlled study.

INTRODUCTION: The performance of a new safety peripheral intravenous catheter (PIVC) that contains a blood control feature in the hub (blood control) was compared against the current hospital standard without blood control (standard). METHODS: In this prospective, non-blinded trial, patients were randomized 1:1 to receive either device. Insertions were performed and rated by emergency room nurses. Primary endpoints included clinical acceptability, incidence of blood leakage, and risk of blood exposure. Secondary endpoints were digital compression, insertion success, and usability. RESULTS: 15 clinicians performed 152 PIVC insertions (73 blood control, 79 standard). Clinical acceptability of the blood control device (100%) was non-inferior to the standard (98.7%) (p < 0.0001). The blood control device had a lower incidence of blood leakage (14.1% vs 68.4%), was superior in eliminating the risk of blood exposure (93.9% vs 19.1%) and the need for digital compression (95.3% vs 19.1%), while maintaining non-inferior insertion success rates (95.9% vs 93.7%) and usability ratings (p < 0.0001). DISCUSSION: In comparison with the hospital-standard, the new safety PIVC with integrated blood control valve had similar clinical acceptability ratings yet demonstrated superior advantages to both clinicians and patients to decrease blood leakage and the clinician's risk of blood exposure, during the insertion process.

The costs of fluid overload in the adult intensive care unit: is a small-volume infusion model a proactive solution?

PURPOSE: Fluid overload (FO) in critically ill patients remains a challenging clinical dilemma, and many continuous intravenous (IV) medications in the US are being delivered as a dilute solution, adding significantly to a patient's daily intake. This study describes the costs and outcomes of FO in patients receiving multiple continuous infusions. MATERIALS AND METHODS: A retrospective study was conducted using a hospital administrative database covering >500 US hospitals. An FO cohort included adult intensive care unit (ICU) patients with a central line receiving IV loop diuretics and 2+ continuous IV infusions on 50%+ of their ICU days; a directly matched non-FO cohort included patients without IV diuretic use. The primary outcome of the study was total hospitalization costs per visit. Additional outcomes were ICU costs, mortality, total and ICU length of stay (LOS), 30-day readmission rates, and ventilator use. Unadjusted descriptive analysis was performed using chi-squared or paired t-tests to compare outcomes between the two cohorts. RESULTS: A total of 63,974 patients were identified in each cohort. The total hospitalization cost per visit for the FO cohort was US$15,344 higher than the non-FO cohort (US$42,386 vs US$27,042), and the ICU cost for the FO cohort was US$5,243 higher than the non-FO cohort (US$10,902 vs US$5,659). FO patients had higher mortality (20% vs 16.8%), prolonged LOS (11.5 vs 8.0 days), longer ICU LOS (6.2 vs 3.6 days), higher risk of 30-day readmission (21.8% vs 21.3%), and ventilator usage (47.7% vs 28.3%) than the non-FO cohort (all P<0.05). CONCLUSION: In patients receiving multiple continuous infusions, FO is associated with increased health care resources and costs. Maximally concentrating medications and proactively providing continuous medications in small-volume infusions (SVI) could be a potential solution to prevent iatrogenic FO in critically ill patients. Further prospective research is warranted to assess the impact of the SVI dispensing model on patient outcomes and health care costs.

Demonstration of compatibility of multiple arterial blood gas syringes with current multi-parameter analyzers.

OBJECTIVE: Since there is a lack of current evidence to support the compatibility of the most commonly used arterial blood gas syringes with the latest multi-parameter analyzers, the objective of this study was to assess the agreement of analyte values between three heparinized arterial blood gas syringes using three different analyzers. METHODS: Venous blood from 25 healthy volunteers was drawn into the study syringes (BD Drihep A-Line, PICO50, and Portex Line Draw Plus) by four clinician volunteers in a random order (441 total) and immediately (<15 minutes) analyzed (ABL800 FLEX, RAPIDPoint 500, i-STAT System) in a randomized order. The Bland-Altman method was used to assess agreement of analyte values between the syringes for each analyzer. The results by analyte and analyzer were compared across syringes using one-way ANOVA, and Tukey's approach was used to identify statistically significant differences between pairs of syringes. RESULTS: Comparison of the syringes' mean differences and standard deviations showed close agreement for all three analyzers. There were no statistically significant differences between syringes in 14 of the analytes for any of the analyzers (p > 0.05). For RAPIDPoint and i-STAT, the Ca(2+) value was significantly less for A-Line than for the other syringes. The value for Na(+) was significantly greater for the PICO50 than the A-Line and Line Draw syringes with the i-STAT. Both results were within two standard deviations of the mean of the other two syringes and are not considered clinically significant; however, comparisons were not made between the values from the different analyzers. CONCLUSIONS: Dry-balanced lithium heparin ABG syringes used for blood draws should provide reliable results, regardless of syringe type, provided that the clinicians use proper pre-analytical techniques.