Intravenous therapy

One fifth of drips ‘are dangerous’

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Nurse attending to drip

A fifth of patients on an intravenous drip develop complications because they are given the wrong levels of fluid, according to a review of guidance in England and Wales.

Too much fluid can cause heart failure and too little leads to kidney problems.

The National Institute for Health and Care Excellence (NICE) said doctors and nurses needed better drip training.

Patients’ groups said the scale of the problem was “staggering”.

Thousands of people each year need a drip in hospital. But NICE warns that staff are putting lives in danger due to a lack of education in managing intravenous drips.

It has developed new guidelines for the NHS in England and Wales.

Dr Mike Stroud, a gastroenterology consultant at Southampton University Hospitals NHS Trust, who developed the guidelines, said: “Doctors and other health professionals are not well educated in terms of what a patient needs and that is astonishing really.

“This needs to change.”

Drip chief

Hospitals will also be expected to appoint an “intravenous fluid champion” and patients’ drips will need to be managed and monitored more closely.

Katie Scales, a consultant nurse at Imperial College Healthcare NHS Trust, said: “The majority of patients who receive intravenous fluids do so without complications but this is not the case for every patient.

“This NICE guideline is an important lever for improvement and may ultimately help to save lives.”

Katherine Murphy, the chief executive of the Patients’ Association, said the guidelines were “very welcome” due to the “staggering” figure of one in five patients developing complications.

“It’s essential that all staff receive support and training in the administration of IV fluids and hospitals should ensure time is dedicated to this,” she added.

Dr Mike Durkin, director of patient safety at NHS England, said: “I welcome this new guidance.

“Hospitals across the country need to ensure that the recommendations are implemented as routine practice so that the clinical effectiveness of infusion fluids are maximised and any risks are minimised.”

Severe Sepsis Strategy Significantly Reduces Mortality.

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Patients with severe sepsis or septic shock triaged and managed using 4 clinical goals were significantly less likely to die in hospital than patients who did not meet all 4 objectives, a new prospective study shows.

The take-home message is “simple saves,” said Jason D’Amore, MD, from North Shore University Hospital and Long Island Jewish Medical Center in Manhasset, New York.

He explained that the strategy his team developed is easier than targeting specific physiologic goals for patients with sepsis. The work, known as the Early Sepsis Prophylaxis Study, is in contrast to other efforts over the past decade, which manage sepsis using early physiologic-directed therapy.

Here at the American College of Emergency Physicians 2013 Scientific Assembly, Dr. D’Amore reported that his team evaluated all-cause in-hospital mortality using registry data from a healthcare system that include 11 acute care facilities, 3 tertiary centers, and 700,000 emergency department visits per year.

They assessed the impact of goal compliance in 5787 adults who either presented to the emergency department with severe sepsis or septic shock or developed these conditions during hospitalization.

Their sepsis bundle consists of 4 clinical goals:

  • blood cultures before antibiotics
  • lactate before 90 min
  • intravenous (IV) antibiotics before 180 min
  • 30 cc/kg of IV fluids before 180 min

In-hospital all-cause mortality was significantly lower when the goals were used than when they were not (22.6% vs 26.5%; P = .0005).

The strategy was fully implemented in January 2012. Mean in-hospital mortality for this patient population dropped from 30% in the first quarter of 2012 to 23% in the fourth quarter of 2012.

Table. Performance of the Sepsis Management Strategy

Measure

First Quarter

Last Quarter

Patients in full goal compliance (%)

32.4

57.1

Mean time

 

 

   To antibiotic administration (min)

140

102

   To fluid bolus (min)

96

71

   From lactate order to result (min)

45

54

 

On multivariate regression analysis, complete compliance with the goals was associated with a survival odds ratio of 1.194 (1.04 – 1.37; P = .013), even after adjustment for factors such as age, admission to the intensive care unit, vasopressor initiation, central venous catheter insertion, and monitoring of central venous pressure and central venous oxygen saturation.

The overall absolute risk reduction for in-hospital mortality was 3.9% (1.7% – 6.0%).

 

We’re not asking people to do anything other than take a good hard look at a patient, give timely antibiotics, timely fluids, and then remain vigilant.

 

On the basis of these figures, the team calculated the number of patients needed to treat to see a survival benefit. “Every 26 times we complete a bundle, we think we have an opportunity to save a life. That’s meaningful,” Dr. D’Amore said.

“We’re not asking people to do anything other than take a good hard look at a patient, give timely antibiotics, timely fluids, and then remain vigilant about decompensation,” he explained.

This study “certainly shows that the bundle improved care, relative to historic outcomes. We still don’t know if there’s an opportunity to improve this even more,” said session moderator Alan Heffner, MD, from the Carolinas Healthcare System in Charlotte, North Carolina.

Future research could evaluate whether the strategy combined with physiologic parameters or goal-directed therapy improves outcomes in patient with severe sepsis, Dr. Heffner added.

Source: American College of Emergency Physicians (ACEP)

N-Acetylcysteine Plus Intravenous Fluids Versus Intravenous Fluids Alone to Prevent Contrast-Induced Nephropathy in Emergency Computed Tomography.

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Abstract

STUDY OBJECTIVE:

We test the hypothesis that N-acetylcysteine plus normal saline solution is more effective than normal saline solution alone in the prevention of contrast-induced nephropathy.

METHODS:

The design was a randomized, double blind, 2-center, placebo-controlled interventional trial. Inclusion criteria were patients undergoing chest, abdominal, or pelvic computed tomography (CT) scan with intravenous contrast, older than 18 years, and at least one contrast-induced nephropathy risk factor. Exclusion criteria were end-stage renal disease, pregnancy, N-acetylcysteine allergy, or clinical instability. Intervention for the treatment group was N-acetylcysteine 3 g in 500 mL normal saline solution as an intravenous bolus and then 200 mg/hour (67 mL/hour) for up to 24 hours; and for the placebo group was 500 mL normal saline solution and then 67 mL/hour for up to 24 hours. The primary outcome was contrast-induced nephropathy, defined as an increase in creatinine level of 25% or 0.5 mg/dL, measured 48 to 72 hours after CT.

RESULTS:

The data safety and monitoring board terminated the study early for futility. Of 399 patients enrolled, 357 (89%) completed follow-up and were included. The N-acetylcysteine plus saline solution group contrast-induced nephropathy rate was 14 of 185 (7.6%) versus 12 of 172 (7.0%) in the normal saline solution only group (absolute risk difference 0.6%; 95% confidence interval -4.8% to 6.0%). The contrast-induced nephropathy rate in patients receiving less than 1 L intravenous fluids in the emergency department (ED) was 19 of 147 (12.9%) versus 7 of 210 (3.3%) for greater than 1 L intravenous fluids (difference 9.6%; 95% confidence interval 3.7% to 15.5%), a 69% risk reduction (odds ratio 0.41; 95% confidence interval 0.21 to 0.80) per liter of intravenous fluids.

CONCLUSION:

We did not find evidence of a benefit for N-acetylcysteine administration to our ED patients undergoing contrast-enhanced CT. However, we did find a significant association between volume of intravenous fluids administered and reduction in contrast-induced nephropathy.

Source: Pubmed

 

N-Acetylcysteine Plus Intravenous Fluids Versus Intravenous Fluids Alone to Prevent Contrast-Induced Nephropathy in Emergency Computed Tomography..

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Abstract

STUDY OBJECTIVE:

We test the hypothesis that N-acetylcysteine plus normal saline solution is more effective than normal saline solution alone in the prevention of contrast-induced nephropathy.

METHODS:

The design was a randomized, double blind, 2-center, placebo-controlled interventional trial. Inclusion criteria were patients undergoing chest, abdominal, or pelvic computed tomography (CT) scan with intravenous contrast, older than 18 years, and at least one contrast-induced nephropathy risk factor. Exclusion criteria were end-stage renal disease, pregnancy, N-acetylcysteine allergy, or clinical instability. Intervention for the treatment group was N-acetylcysteine 3 g in 500 mL normal saline solution as an intravenous bolus and then 200 mg/hour (67 mL/hour) for up to 24 hours; and for the placebo group was 500 mL normal saline solution and then 67 mL/hour for up to 24 hours. The primary outcome was contrast-induced nephropathy, defined as an increase in creatinine level of 25% or 0.5 mg/dL, measured 48 to 72 hours after CT.

RESULTS:

The data safety and monitoring board terminated the study early for futility. Of 399 patients enrolled, 357 (89%) completed follow-up and were included. The N-acetylcysteine plus saline solution group contrast-induced nephropathy rate was 14 of 185 (7.6%) versus 12 of 172 (7.0%) in the normal saline solution only group (absolute risk difference 0.6%; 95% confidence interval -4.8% to 6.0%). The contrast-induced nephropathy rate in patients receiving less than 1 L intravenous fluids in the emergency department (ED) was 19 of 147 (12.9%) versus 7 of 210 (3.3%) for greater than 1 L intravenous fluids (difference 9.6%; 95% confidence interval 3.7% to 15.5%), a 69% risk reduction (odds ratio 0.41; 95% confidence interval 0.21 to 0.80) per liter of intravenous fluids.

CONCLUSION:

We did not find evidence of a benefit for N-acetylcysteine administration to our ED patients undergoing contrast-enhanced CT. However, we did find a significant association between volume of intravenous fluids administered and reduction in contrast-induced nephropathy.

Source: Pubmed

 

 

Intravenous or nebulised magnesium sulphate versus standard therapy for severe acute asthma (3Mg trial): a double-blind, randomised controlled trial.

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Background

Previous studies suggested intravenous or nebulised magnesium sulphate (MgSO4) might improve respiratory function in patients with acute asthma. We aimed to determine whether intravenous or nebulised MgSO4 improve symptoms of breathlessness and reduce the need for hospital admission in adults with severe acute asthma.

Methods

In our double-blind, placebo-controlled trial, we enrolled adults (aged ≥16 years) with severe acute asthma at emergency departments of 34 hospitals in the UK. We excluded patients with life-threatening features or contraindication to study drugs. We used a central randomisation system to allocate participants to intravenous MgSO4 (2 g in 20 min) or nebulised MgSO4 (three 500 mg doses in 1 h) alongside standard therapy including salbutamol, or placebo control plus standard therapy alone. We assessed two primary outcome measures in all eligible participants who started treatment, according to assigned treatment group: the proportion of patients admitted to hospital within 7 days and breathlessness measured on a 100 mm visual analogue scale (VAS) in the 2 h after initiation of treatment. We adjusted for multiple testing using Simes’s method. The trial stopped before recruitment was completed because funding expired. This study is registered, number ISRCTN04417063.

Findings

Between July 30, 2008, and June 30, 2012, we recruited 1109 (92%) of 1200 patients proposed by the power calculation. 261 (79%) of 332 patients allocated nebulised MgSO4 were admitted to hospital before 7 days, as were 285 (72%) of 394 patients allocated intravenous MgSO4 and 281 (78%) of 358 controls. Breathlessness was assessed in 296 (89%) patients allocated nebulised MgSO4, 357 (91%) patients allocated intravenous MgSO4, and 323 (90%) controls. Rates of hospital admission did not differ between patients treated with either form of MgSO4 compared with controls or between those treated with nebulised MgSO4 and intravenous MgSO4. Change in VAS breathlessness did not differ between active treatments and control, but change in VAS was greater for patients in the intravenous MgSO4 group than it was in the nebulised MgSO4 group (5·1 mm, 0·8 to 9·4; p=0·019). Intravenous or nebulised MgSO4 did not significantly decrease rates of hospital admission and breathlessness compared with placebo: intravenous MgSO4 was associated with an odds ratio of 0·73 (95% CI 0·51 to 1·04; p=0·083) for hospital admission and a change in VAS breathlessness of 2·6 mm (—1·6 to 6·8; p=0·231) compared with placebo; nebulised MgSO4 was associated with an odds ratio of 0·96 (0·65 to 1·40; p=0·819) for hospital admission and a change in VAS breathlessness of −2·6 mm (—7·0 to 1·8; p=0·253) compared with placebo.

Source: lancet

 

 

Ondansetron (Zofran) 32 mg, Single Intravenous (IV) Dose: Updated Safety Communication – Product Removal due to Potential For Serious Cardiac Risks

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AUDIENCE: Oncology, Surgery, Health Professional

ISSUE: FDA is notifying health care professionals that the 32 mg, single intravenous (IV) dose of the anti-nausea drug Zofran (ondansetron hydrochloride) will no longer be marketed because of the potential for serious cardiac risks.

BACKGROUND: The 32 mg, single IV dose of Zofran had been used to prevent chemotherapy-induced nausea and vomiting. A previous Drug Safety Communication (DSC), issued on June 29, 2012, communicated that the 32 mg, single IV dose should be avoided due to the risk of a specific type of irregular heart rhythm called QT interval prolongation, which can lead to Torsades de Pointes, an abnormal, potentially fatal heart rhythm.  These drugs are sold pre-mixed in solutions of either dextrose or sodium chloride in plastic containers.

FDA anticipates these products will be removed from the market through early 2013.  FDA does not anticipate that removal of the 32 mg intravenous dose of ondansetron currently sold as pre-mixed injections will contribute to a drug shortage of IV ondansetron, as the 32 mg dose makes up a very small percentage of the current market

RECOMMENDATION: FDA continues to recommend the intravenous regimen of 0.15 mg/kg administered every 4 hours for three doses to prevent chemotherapy-induced nausea and vomiting. Oral dosing of Ondansetron remains effective for the prevention of chemotherapy-induced nausea and vomiting. At this time, there is not enough information available for FDA to recommend an alternative single IV dose regimen.

Replacing IV Catheters Only When Clinically Indicated Seems Safe .

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Replacing peripheral intravenous catheters only when clinically indicated (for example, after accidental removal or infiltration) causes no more complications than replacing them according to standard time-based schedules, according to a Lancet study.

Researchers randomized some 3300 adult patients to have their intravenous catheters replaced every third day or only as clinically indicated. The rate of phlebitis, the primary outcome, was identical in the two groups, at 7%. Secondary outcomes, such as rates of catheter colonization and all-cause bloodstream infections, were also similar between groups.

The authors calculate that, on average, clinically indicated replacement would extend catheter use by a single day, and that one in every five patients would avoid an unnecessary procedure. They estimate that the reduction in staff time and other costs could save the U.S. $60 million in healthcare costs annually.

Source: Lancet