ABSTRACT
Introducción: No se ha establecido cuál es el aporte óptimo para mejorar el metabolismo proteico sin producir efectos adversos en lactantes gravemente enfermos. Nuestro objetivo fue analizar si un mayor aporte proteico a través de la nutrición enteral se relaciona con una mejoría en el balance proteico en lactantes críticamente enfermos. Material y métodos: Se diseñó un estudio multicéntrico, prospectivo, aleatorizado y controlado (diciembre de 2016 a junio de 2019). Se incluyeron lactantes críticamente enfermos con nutrición enteral, asignándose aleatoriamente a tres dietas con diferente contenido proteico: estándar (1,7g/100ml), hiperproteica (2,7g/100ml) e hiperproteica suplementada (5,1g/100ml). Se realizaron análisis de sangre y orina y se calculó el balance nitrogenado en el momento basal y tras 3-5días de nutrición. Se analizó la variación del balance nitrogenado y de las proteínas séricas (proteínas totales, albúmina, transferrina, prealbúmina y proteína ligada al retinol) a lo largo del periodo de estudio. Resultados: Noventa y nueve lactantes (33 por grupo) completaron el estudio. No se encontraron diferencias entre grupos en características demográficas, puntuaciones de gravedad y otros tratamientos recibidos, salvo corticoides, administrados en una mayor proporción de pacientes del tercer grupo. Tuvo lugar un aumento significativo de los niveles de prealbúmina y proteína ligada al retinol en los grupos con nutrición hiperproteica e hiperproteica suplementada. El balance nitrogenado aumentó en todos los grupos, pero este incremento no fue significativo en el grupo de nutrición hiperproteica suplementada. No se encontraron diferencias en cuanto a tolerancia gastrointestinal. Los pacientes con nutrición hiperproteica suplementada presentaron niveles superiores de urea sérica y mayor incidencia de hiperuremia. (AU)
Introduction: The optimal intake to improve protein metabolism without producing adverse effects in seriously ill infants has yet to be established. The aim of our study was to analyse whether an increased protein intake delivered through enteral nutrition would be associated with an improvement in nitrogen balance and serum protein levels in critically ill infants. Material and methods: We conducted a multicentre, prospective randomized controlled trial (December 2016-June 2019). The sample consisted of critically ill infants receiving enteral nutrition assigned randomly to 3 protein content groups: standard diet (1.7g/dL), protein-enriched diet (2.7g/dL) and high protein-enriched diet (5.1g/dL). Blood and urine tests were performed, and we assessed nitrogen balance at baseline and at 3 to 5days of the diet. We analysed variations in nitrogen balance and serum protein levels (total protein, albumin, transferrin, prealbumin, and retinol-binding protein) throughout the study period. Results: Ninety-nine infants (33 per group) completed the study. We did not find any differences were between groups in demographic characteristics, severity scores or prescribed medications, except for corticosteroids, administered in a higher proportion of patients in the third group. We observed significant increases in prealbumin and retinol-binding protein levels in patients receiving the protein-enriched and high protein-enriched diets at 3 to 5days compared to baseline. The nitrogen balance increased in all groups, but the differences were not significant in the high protein-enriched group. There were no differences in gastrointestinal tolerance. Patients fed high protein-enriched formula had higher levels of serum urea, with a higher incidence of hyperuraemia in this group. (AU)
Subject(s)
Humans , Male , Female , Infant , Enteral Nutrition/adverse effects , Proteins/metabolism , Prospective Studies , Intensive Care Units, Pediatric , Nutritional Requirements , Critical IllnessABSTRACT
INTRODUCTION: The optimal intake to improve protein metabolism without producing adverse effects in seriously ill infants has yet to be established. The aim of our study was to analyse whether an increased protein intake delivered through enteral nutrition would be associated with an improvement in nitrogen balance and serum protein levels in critically ill infants. METHODS: We conducted a multicentre, prospective randomized controlled trial (December 2016-June 2019). The sample consisted of critically ill infants receiving enteral nutrition assigned randomly to 3 protein content groups: standard diet (1.7â¯g/dL), protein-enriched diet (2.7â¯g/dL) and high protein-enriched diet (5.1â¯g/dL). Blood and urine tests were performed, and we assessed nitrogen balance at baseline and at 3-5 days of the diet. We analysed variations in nitrogen balance and serum protein levels (total protein, albumin, transferrin, prealbumin, and retinol-binding protein) throughout the study period. RESULTS: Ninety-nine infants (33 per group) completed the study. We did not find any differences were between groups in demographic characteristics, severity scores or prescribed medications, except for corticosteroids, administered in a higher proportion of patients in the third group. We observed significant increases in prealbumin and retinol-binding protein levels in patients receiving the protein-enriched and high protein-enriched diets at 3-5 days compared to baseline. The nitrogen balance increased in all groups, but the differences were not significant in the high protein-enriched group. There were no differences in gastrointestinal tolerance. Patients fed high protein-enriched formula had higher levels of serum urea, with a higher incidence of hyperuraemia in this group. CONCLUSION: Enteral administration of higher amounts of protein improves serum protein levels in critically ill children. A protein intake of 2.2â¯g/kg/day is generally safe and well tolerated, whereas an intake of 3.4â¯g/kg/day may produce hyperuraemia in some patients.
Subject(s)
Critical Illness , Prealbumin , Child , Humans , Infant , Prealbumin/metabolism , Critical Illness/therapy , Prospective Studies , Blood Proteins/metabolism , Diet , Retinol-Binding Proteins , Nitrogen/metabolismABSTRACT
La parada cardiorrespiratoria (PCR) se puede presentar en cualquier lugar y en cualquier momento y por ello todos los centros sanitarios y los servicios de urgencias extrahospitalarias deben disponer de personal y material adecuado para realizar una reanimación cardiopulmonar (RCP). Estas recomendaciones son el consenso de expertos del Grupo Español de Reanimación Cardiopulmonar Pediátrica y Neonatal sobre el material y medicación de RCP pediátrica y neonatal y su distribución y utilización. Los carros y mochilas de RCP deben tener el material y la medicación para llevar a cabo de forma rápida y eficiente una RCP pediátrica. Debe existir al menos un carro de RCP accesible en cada centro de atención primaria, unidad de cuidados intensivos pediátricos, unidad de cuidados intensivos neonatales, servicio de urgencias, servicio de urgencias extrahospitalarias, planta de pediatría, área de consultas y zona de radiología. El carro de RCP debe contener solo el material y la medicación imprescindibles para realizar una RCP y atender a las urgencias vitales. El material debe ser conocido por el personal, incluir los repuestos necesarios y ser revisado y repuesto periódicamente. La estandarización y unificación del contenido (material y medicación) de los carros y mochilas de RCP pediátrica, así como el entrenamiento del personal en su utilización, son una parte esencial de la organización asistencial de la RCP pediátrica (AU)
Cardio-respiratory arrest (CPA) is infrequent in children, but it can occur in any place and at any time. This fact means that every health care facility must always have the staff and material ready to resuscitate a child. These recommendations are the consensus of experts of the Spanish Paediatric and Neonatal Resuscitation Group on the material and medication for paediatric and neonatal resuscitation and their distribution and use. CPR trolleys and backpacks must include the essential material to quickly and efficiently perform a paediatric CPR. At least one CPR trolley must be available in every Primary Care facility, Paediatric Intensive Care Unit, Emergency Department, and Pre-hospital Emergency Areas, as well as in paediatric wards, paediatric ambulatory areas, and radiology suites. This trolley must be easily accessible and exclusively include the essential items to perform a CPR and to assist children (from newborns to adolescents) who present with a life-threatening event. Such material must be familiar to all healthcare staff and also include the needed spare parts, as well as enough drug doses. It must also be re-checked periodically. The standardisation and unification of the material and medication of paediatric CPR carts, trolleys, and backpacks, as well as the training of the personnel in their use are an essential part of the paediatric CPR (AU)
Subject(s)
Humans , Male , Female , Infant, Newborn , Child , Cardiopulmonary Resuscitation , Material Resources in Health/classification , Hospital Rapid Response Team , Health ResourcesABSTRACT
Cardio-respiratory arrest (CPA) is infrequent in children, but it can occur in any place and at any time. This fact means that every health care facility must always have the staff and material ready to resuscitate a child. These recommendations are the consensus of experts of the Spanish Paediatric and Neonatal Resuscitation Group on the material and medication for paediatric and neonatal resuscitation and their distribution and use. CPR trolleys and backpacks must include the essential material to quickly and efficiently perform a paediatric CPR. At least one CPR trolley must be available in every Primary Care facility, Paediatric Intensive Care Unit, Emergency Department, and Pre-hospital Emergency Areas, as well as in paediatric wards, paediatric ambulatory areas, and radiology suites. This trolley must be easily accessible and exclusively include the essential items to perform a CPR and to assist children (from newborns to adolescents) who present with a life-threatening event. Such material must be familiar to all healthcare staff and also include the needed spare parts, as well as enough drug doses. It must also be re-checked periodically. The standardisation and unification of the material and medication of paediatric CPR carts, trolleys, and backpacks, as well as the training of the personnel in their use are an essential part of the paediatric CPR.
Subject(s)
Cardiopulmonary Resuscitation/instrumentation , Equipment and Supplies, Hospital/standards , Child , Humans , Infant, NewbornABSTRACT
Patient safety is a matter of major concern that involves every health professional. Nowadays, emerging technologies such as smart pumps can diminish medication errors as well as standardise and improve clinical practice with the subsequent benefits for patients. The aim of this paper was to describe the smart pump implementation process in a paediatric intensive care unit (PICU) and to present the most relevant infusion-related programming errors that were prevented. This was a comparative study between CareFusion Alaris Guardrails(®) and Hospira MedNet(®) systems, as well as a prospective and intervention study with analytical components carried out in the PICU of Gregorio Marañón General and Teaching Hospital. All intravenous infusions programmed with a pump in the eleven beds of the unit were analyzed. A drug library was developed and subsequently loaded into CareFusion and Hospira pumps that were used during a three month period each. The most suitable system for implementation was selected according to their differences in features and users' acceptance. Data stored in the pumps were analyzed to assess user compliance with the technology, health care setting and type of errors intercepted. The implementation process was carried out with CareFusion systems. Compliance with the technology was 92% and user acceptance was high. Vacation substitution and drug administration periods were significantly associated with a greater number of infusion-related programming errors. High risk drugs were involved in 48% of intercepted errors. Based on these results we can conclude that implementation of smart pumps proved effective in intercepting infusion-related programming errors from reaching patients. User awareness of the importance of programming infusions with the drug library is the key to succeed in the implementation process.
Subject(s)
Drug Delivery Systems/standards , Equipment Safety/nursing , Infusion Pumps/statistics & numerical data , Intensive Care Units, Pediatric/trends , Medication Errors/prevention & control , Technology Assessment, Biomedical , Drug Delivery Systems/statistics & numerical data , Humans , Infusion Pumps/standards , Infusion Pumps/trends , Prospective StudiesABSTRACT
OBJECTIVES: The aim of this study was to identify risk points in the different stages of the smart infusion pump implementation process to prioritize improvement measures. METHODS: Failure modes and effects analysis (FMEA) in the pediatric intensive care unit (PICU) of a General and Teaching Hospital. A multidisciplinary team was comprised of two intensive care pediatricians, two clinical pharmacists and the PICU nurse manager. FMEA was carried out before implementing CareFusion infusion smart pumps and eighteen months after to identify risk points during three different stages of the implementation process: creating a drug library; using the technology during clinical practice and analyzing the data stored using Guardrails® CQI v4.1 Event Reporter software. RESULTS: Several actions for improvement were taken. These included carrying out periodical reviews of the drug library, developing support documents, and including a training profile in the system so that alarms set off by real programming errors could be distinguished from those caused by incorrect use of the system. Eighteen months after the implementation, these measures had helped to reduce the likelihood of each risk point occurring and increase the likelihood of their detection. CONCLUSIONS: Carrying out an FMEA made it possible to detect risk points in the use of smart pumps, take action to improve the tool, and adapt it to the PICU. Providing user training and support tools and continuously monitoring results helped to improve the usefulness of the drug library, increased users' compliance with the drug library, and decreased the number of unnecessary alarms.
Subject(s)
Equipment Failure Analysis , Infusion Pumps/standards , Patient Safety , Intensive Care Units, Pediatric , Interdisciplinary Communication , Risk Assessment/methodsABSTRACT
Drug administration is one of the main sources of errors in pediatric intensive care units (PICUs). An available guide for intravenous drug administration might be useful. The aim of this article is to present the methodology and results for the development of a guide for intravenous drug administration in a PICU. A total of 116 drugs were included. Standard concentrations, diluents, technique for reconstitution and dilution, stability, rate of administration, and relevant observations were defined for each drug according to a review of the most commonly used literature resources. The main unique feature of this article is that it includes standard concentrations for each drug.
Subject(s)
Infusions, Intravenous , Intensive Care Units, Pediatric , Child , HumansABSTRACT
OBJECTIVE: To analyze the cost effectiveness of implementing smart infusion pump technology in a pediatric intensive care unit (PICU). MATERIAL AND METHODS: An observational, prospective, intervention study with analytical components was carried out. A drug library was developed and integrated into the Carefusion Alaris Guardrails® infusion systems. A systematic analysis of all the data stored on the devices during use was performed by the data processing program Guardrails® CQI v4.1 Event Reporter. Intercepted errors were classified in terms of their potential severity and probability of causing an adverse effect (PAE) had they reached the patient. Knowing the estimated cost of a preventable adverse effect (AE), we analyzed costs saved and the profit/cost ratio resulting from the implementation process. RESULTS: Compliance with the drug library was 92% and during the study period 92 infusion-related programming errors were intercepted, leading to a saving of 172,279 euros by preventing AEs. This means that 2.15 euros would be obtained for each euro invested in hiring a pharmacist to implement this technology. DISCUSSION: The high percentage of use of safety software in our study compared to others allowed for the interception of 92 errors. The estimation of the potential impact of these errors is based on clinical judgment. The cost saved might be underestimated because the cost of an AE is usually higher in pediatrics, indirect and intangible costs were not considered and pharmacists involved do not spend the whole day on this task. CONCLUSIONS: Smart pumps have shown to be profitable in a PICU because they have the ability to intercept potentially serious medication errors and reduce costs associated with such errors.
Subject(s)
Cost-Benefit Analysis , Infusion Pumps/statistics & numerical data , Intensive Care Units, Pediatric , Child , Humans , Infusion Pumps/economicsABSTRACT
PURPOSE: The impact of smart infusion pumps on the interception of errors in the programming of i.v. drug administrations on a pediatric intensive care unit (PICU) is investigated. METHODS: A prospective observational intervention study was conducted in the PICU of a hospital in Madrid, Spain, to estimate the patient safety benefits resulting from the implementation of smart pump technology (Alaris System, CareFusion, San Diego, CA). A systematic analysis of data stored by the devices during the designated study period (January 2010-June 2011) was conducted using the system software (Guardrails CQI Event Reporter, CareFusion). The severity of intercepted errors was independently classified by a group of four clinical pharmacists and a group of four intensive care pediatricians; analyses of intragroup and intergroup agreement in perceptions of severity were performed. RESULTS: During the 17-month study period, the overall rate of user compliance with the safety software was 78%. The use of smart pump technology resulted in the interception of 92 programming errors, 84% of which involved analgesics, antiinfectives, inotropes, and sedatives. About 97% of the errors resulted from user programming of doses or infusion rates above the hard limits defined in the smart pump drug library. The potential consequences of the intercepted errors were considered to be of moderate, serious, or catastrophic severity in 49% of cases. CONCLUSION: The use of smart pumps in a PICU improved patient safety by enabling the interception of infusion programming errors that posed the potential for severe injury to pediatric patients.
Subject(s)
Infusion Pumps , Medication Errors/prevention & control , Pharmaceutical Preparations/administration & dosage , Software , Child , Guideline Adherence , Humans , Infusions, Intravenous , Intensive Care Units, Pediatric , Medication Errors/statistics & numerical data , Pilot Projects , Prospective Studies , Severity of Illness Index , SpainABSTRACT
BACKGROUND: The most serious medication errors occur during intravenous administration. The potential consequences are more serious the more critical and younger the patient. Smart pumps can help to prevent infusion-related programming errors, thanks to associated dose-limiting software known as "drug library". Drug libraries alert the user if pre-determined high dosage limits are exceeded or if entry is below pre-determined low dosage limits. OBJECTIVE: To describe the process for developing a specific drug library for a pediatric intensive care unit (PICU) and the key factors for preventing programming errors. METHODS AND MATERIALS: The study was performed by a multidisciplinary team consisting of a clinical pharmacist, a PICU pediatrician, and the chief nurse of the unit. The process of developing the drug library lasted seven months. A literature review was carried out to determine standard concentrations and accurate limits for intravenous administration of high-risk drugs. Alaris(®) syringe pumps and Guardrails(®) CQI v4.1 Event Reporter software were used. RESULTS: Several manufacturers offer smart pump technology. Users should be aware of differences in features, such as definition of parameters and associations between them, definition of safety limits, organization of the drug library, and data use. Our infusion pump technology covered 108 drugs. Compliance with the drug library was 85% and nurses' acceptance of the drug library was high as 94% would recommend implementation of this technology in other units. After nine months of implementation, several potentially harmful infusion-related programming errors were intercepted. CONCLUSIONS: Drug libraries are specifically designed for a particular hospital unit, and may condition the success in implementing this technology. Implementation of smart pumps proved effective in intercepting infusion-related programming errors after nine months of implementation in a PICU.
Subject(s)
Drug Therapy/instrumentation , Infusion Pumps , Intensive Care Units, Pediatric , Medication Errors/prevention & control , Child , Humans , Infusions, Intravenous/instrumentation , SoftwareABSTRACT
INTRODUCTION: The implementation of smart pump technology can reduce the incidence of errors in the administration of intravenous drugs. This approach involves developing drug libraries for specific units and setting hard and soft limits for each drug. If a programming error occurs and these limits are exceeded, an alarm sounds and the infusion can be blocked. A detailed analysis of these alarms is essential in order not to bias the results in favor of a positive impact of this technology. PURPOSE: To evaluate the results of the first analysis of the use of smart infusion pumps and to assess the significance and practical implications of the alarms sounded. METHODS: The study was performed by a multidisciplinary team that consisted of a clinical pharmacist, a pediatrician from the pediatric intensive care unit (PICU), and the chief nurse of the unit. A library of 108 drugs was developed over a 7-month period and introduced into 40 syringe pumps and 12 volumetric pumps (Alaris(®) with Plus software) before being applied in 6 of the 11 beds in the PICU. After four month's use, data were analyzed using the Guardrails(®) CQI v4.1 Event Reporter program. RESULTS: Following the first four months of implementation, compliance with the drug library was 87%. By analyzing the alerts triggered, we were able to detect problems such as the need to increase user training, readjust limits that did not correspond to clinical practice, correct errors in the editing of the drug library and including a training profile. CONCLUSION: It is difficult to obtain accurate data on the true impact of this technology in the early stages of its implementation. This preliminary analysis allowed us to identify improvement measures to distinguish, in future evaluations, the alarms triggered by a real programming error from those caused by incorrect use.
Subject(s)
Decision Support Systems, Clinical , Drug Therapy, Computer-Assisted , Drug Therapy/instrumentation , Infusion Pumps , Infusions, Intravenous/instrumentation , Intensive Care Units, Pediatric , Medication Errors/prevention & control , Child , Equipment Safety , Humans , Risk Management , SoftwareABSTRACT
OBJECTIVE: To study the postoperative factors associated with prolonged mechanical ventilation after cardiac surgery in children. DESIGN: Prospective observational study. SETTING: Pediatric intensive care unit (PICU). PATIENTS: 59 children aged between 2 months and 14 years after cardiac surgery. VARIABLES OF INTEREST: We analyzed postoperative parameters associated to mechanical ventilation lasting more than 3 and more than 7 days. We performed a stepwise multiple logistic regression analysis to study the influence of each factor on prolonged mechanical ventilation. RESULTS: Mechanical ventilation lasted more than 3 days in 19 (32%) children and more than 7 days in 12 (20%). Predictive factors at PICU admission and 24 hours after admission associated with mechanical ventilation at 3 and 7 days were age less than 12 months, weight less than 7 kg, extrapulmonary complications (hypotension, arrhythmias, postoperative bleeding, delayed sternal closure, and airway complications), nitric oxide treatment, midazolam perfusion more than 4 microg/kg/min or fentanyl perfusion more than 4 microg/kg/h, and continuous muscle relaxant treatment. In the logistic multiple regression study, weight less than 7 kg and extrapulmonary complications predicted 82.8% of children with mechanical ventilation more than 3 days and 87.9% with mechanical ventilation more than 7 days. CONCLUSIONS: Weight less than 7 kg and extrapulmonary complications are the most important factors associated with prolonged mechanical ventilation after cardiac surgery in children.
Subject(s)
Cardiac Surgical Procedures , Respiration, Artificial/statistics & numerical data , Adolescent , Child , Child, Preschool , Female , Humans , Infant , Male , Postoperative Care , Prospective Studies , Risk Factors , Time FactorsABSTRACT
Objetivo. Estudiar los factores postoperatorios que influyen en la prolongación de la ventilación mecánica en niños sometidos a cirugía cardíaca. Diseño. Estudio prospectivo observacional. Ámbito. Unidad de cuidados intensivos pediátricos (UCIP). Pacientes. Cincuenta y nueve niños de edades entre 2 meses y 14 años sometidos a cirugía cardíaca. Variables de interés. Se estudiaron los factores postoperatorios que se relacionaron con la duración de ventilación mecánica > 3 y > 7 días. Se realizó un estudio de regresión logística multivariable paso a paso para analizar la influencia de cada factor en la ventilación mecánica prolongada. Resultados. Precisaron ventilación mecánica más de 3 días 19 (32%) niños y más de 7 días, 12 (20%). Los factores al ingreso y a las 24 h en la UCIP que se relacionaron con una duración de la ventilación > 3 y > 7 días fueron la edad < 12 meses, el peso < 7 kg, la presencia de complicaciones extrapulmonares (hipotensión, arritmias, sangrado postoperatorio, tórax abierto y alteraciones de la vía aérea), la necesidad de administrar óxido nítrico, la sedación con midazolam > 4 μg/kg/min o fentanilo > 4 μg/kg/h y la relajación muscular. En el estudio de regresión logística, el peso < 7 kg más la presencia de complicaciones extrapulmonares al ingreso en la UCIP predijeron el 82,8% de los niños con ventilación mecánica > 3 días y el 87,9%, > 7 días. Conclusiones. El peso < 7 kg y la presencia de complicaciones extrapulmonares son los factores más importantes de los relacionados con la necesidad de ventilación mecánica prolongada en el postoperatorio de cirugía cardíaca en niños
Objective. To study the postoperative factors associated with prolonged mechanical ventilation after cardiac surgery in children. Design. Prospective observational study. Setting. Pediatric intensive care unit (PICU). Patients. 59 children aged between 2 months and 14 years after cardiac surgery. Variables of interest. We analyzed postoperative parameters associated to mechanical ventilation lasting more than 3 and more than 7 days. We performed a step wise multiple logistic regression analysis to study the influence of each factor on prolonged mechanical ventilation. Results. Mechanical ventilation lasted morethan 3 days in 19 (32%) children and more than 7days in 12 (20%). Predictive factors at PICU admission and 24 hours after admission associated with mechanical ventilation at 3 and 7 days were age less than 12 months, weight less than 7 kg, extrapulmonary complications (hypotension, arrhythmias, postoperative bleeding, delayed sternal closure, and airway complications), nitric oxidetreatment, midazolam perfusion more than 4 g/kg/min or fentanyl perfusion more than 4 g/kg/h, and continuous muscle relaxant treatment. In the logistic multiple regression study, weight less than 7 kg and extrapulmonary complications predicted 82.8% of children with mechanical ventilation more than 3 days and 87.9% with mechanical ventilation more than 7 days. Conclusions. Weight less than 7 kg and extrapulmonary complications are the most important factors associated with prolonged mechanical ventilation after cardiac surgery in children
