Implementation and evaluation of a nurse-centered computerized potassium regulation protocol in the intensive care unit - a before and after analysis

<p>Abstract</p> <p>Background</p> <p>Potassium disorders can cause major complications and must be avoided in critically ill patients. Regulation of potassium in the intensive care unit (ICU) requires potassium administration with frequent blood potassium measurements and subsequent adjustments of the amount of potassium administrated. The use of a potassium replacement protocol can improve potassium regulation. For safety and efficiency, computerized protocols appear to be superior over paper protocols. The aim of this study was to evaluate if a computerized potassium regulation protocol in the ICU improved potassium regulation.</p> <p>Methods</p> <p>In our surgical ICU (12 beds) and cardiothoracic ICU (14 beds) at a tertiary academic center, we implemented a nurse-centered computerized potassium protocol integrated with the pre-existent glucose control program called GRIP (Glucose Regulation in Intensive Care patients). Before implementation of the computerized protocol, potassium replacement was physician-driven. Potassium was delivered continuously either by central venous catheter or by gastric, duodenal or jejunal tube. After every potassium measurement, nurses received a recommendation for the potassium administration rate and the time to the next measurement. In this before-after study we evaluated potassium regulation with GRIP. The attitude of the nursing staff towards potassium regulation with computer support was measured with questionnaires.</p> <p>Results</p> <p>The patient cohort consisted of 775 patients before and 1435 after the implementation of computerized potassium control. The number of patients with hypokalemia (<3.5 mmol/L) and hyperkalemia (>5.0 mmol/L) were recorded, as well as the time course of potassium levels after ICU admission. The incidence of hypokalemia and hyperkalemia was calculated. Median potassium-levels were similar in both study periods, but the level of potassium control improved: the incidence of hypokalemia decreased from 2.4% to 1.7% (P < 0.001) and hyperkalemia from 7.4% to 4.8% (P < 0.001). Nurses indicated that they considered computerized potassium control an improvement over previous practice.</p> <p>Conclusions</p> <p>Computerized potassium control, integrated with the nurse-centered GRIP program for glucose regulation, is effective and reduces the prevalence of hypo- and hyperkalemia in the ICU compared with physician-driven potassium regulation.</p

Long-term changes in dysnatremia incidence in the ICU: a shift from hyponatremia to hypernatremia

Background: Dysnatremia is associated with adverse outcome in critically ill patients. Changes in patients or treatment strategies may have affected the incidence of dysnatremia over time. We investigated long-term changes in the incidence of dysnatremia and analyzed its association with mortality. Methods: Over a 21-year period (1992–2012), all serum sodium measurements were analyzed retrospectively in two university hospital ICUs, up to day 28 of ICU admission for the presence of dysnatremia. The study period was divided into five periods. All serum sodium measurements were collected from the electronic databases of both ICUs. Serum sodium was measured at the clinical chemistry departments using standard methods. All sodium measurements were categorized in the following categories: 160 mmol/L. Mortality was determined at 90 days after ICU admission. Results: In 80,571 ICU patients, 913,272 serum sodium measurements were analyzed. A striking shift in the pattern of ICU-acquired dysnatremias was observed: The incidence of hyponatremia almost halved (47–25 %, p  155 mmol/L) increased dramatically over the years. On ICU day 10 this incidence was 0.7 % in the 1992–1996 period, compared to 6.3 % in the 2009–2012 period (p < 0.001). More severe dysnatremia was associated with significantly higher mortality throughout the 21-year study period (p < 0.001). Conclusions: In two large Dutch cohorts, we observed a marked shift in the incidence of dysnatremia from hyponatremia to hypernatremia over two decades. As hypernatremia was mostly ICU acquired, this strongly suggests changes in treatment as underlying causes. This shift may be related to the increased use of sodium-containing infusions, diuretics, and hydrocortisone. As ICU-acquired hypernatremia is largely iatrogenic, it should be—to an important extent—preventable, and its incidence may be considered as an indicator of quality of care. Strategies to prevent hypernatremia deserve more emphasis; therefore, we recommend that further study should be focused on interventions to prevent the occurrence of dysnatremias during ICU stay

Association between potassium concentrations, variability and supplementation, and in‑hospital mortality in ICU patients: a retrospective analysis

BACKGROUND: Serum potassium concentrations are commonly between 3.5 and 5.0 mmol/l. Standardised protocols for potassium range and supplementation in the ICU are lacking. The purpose of this retrospective analysis of ICU patients was to investigate potassium concentrations, variability and supplementation, and their association with in-hospital mortality. METHODS: ICU patients ≥ 18 years, with ≥ 2 serum potassium values, treated at the Charité - Universitätsmedizin Berlin between 2006 and 2018 were eligible for inclusion. We categorised into groups of mean potassium concentrations:  3.5-4.0, > 4.0-4.5, > 4.5-5.0, > 5.0-5.5, > 5.5 mmol/l and potassium variability: 1st, 2nd and ≥ 3rd standard deviation (SD). We analysed the association between the particular groups and in-hospital mortality and performed binary logistic regression analysis. Survival curves were performed according to Kaplan-Meier and tested by Log-Rank. In a subanalysis, the association between potassium supplementation and in-hospital mortality was investigated. RESULTS: In 53,248 ICU patients with 1,337,742 potassium values, the lowest mortality (3.7%) was observed in patients with mean potassium concentrations between > 3.5 and 4.0 mmol/l and a low potassium variability within the 1st SD. Binary logistic regression confirmed these results. In a subanalysis of 22,406 ICU patients (ICU admission: 2013-2018), 12,892 (57.5%) received oral and/or intravenous potassium supplementation. Potassium supplementation was associated with an increase in in-hospital mortality in potassium categories from > 3.5 to 4.5 mmol/l and in the 1st, 2nd and ≥ 3rd SD (p < 0.001 each). CONCLUSIONS: ICU patients may benefit from a target range between 3.5 and 4.0 mmol/l and a minimal potassium variability. Clear potassium target ranges have to be determined. Criteria for widely applied potassium supplementation should be critically discussed. Trial registration German Clinical Trials Register, DRKS00016411. Retrospectively registered 11 January 2019, http://www.drks.de/DRKS00016411

Correction Factor Calculation by Comparison of Electrolyte Values done by Blood-Gas Analyzer and Laboratory Serum Autoanalyzer

BACKGROUND: Arterial blood gas (ABG) analyzers and laboratory serum auto analyzers (AA) both can measure serum electrolytes sodium and potassium. In Intensive Care Unit (ICU) setups, physician mostly uses the point-of-care analysis of electrolytes by ABG analyzer. It prevents time delay and early treatment for the patient. Minimum 2 hours needed to get laboratory report for serum electrolytes measured by auto analyzer in most of the tertiary care hospitals in developing countries. The ABG analyzer and laboratory AA uses ion-sensing electrode technology to assay electrolytes. This method is used in many tertiary care hospitals. OBJECTIVES: To evaluate sodium and potassium values measured by using arterial blood gas analyzers (ABG) and laboratory serum auto-analyzers (AA) are may be equivalent and correlating the values. Calculate a correction factor for sodium and potassium; to minimize the difference between two methods. MATERIALS AND METHODS: Patients in study group are tested for ABG electrolytes and compared with Laboratory Auto Analyzer serum electrolytes and analysed in med calc software. RESULTS: The test results of ABG and AA are not equivalent. Correlation between ABG and AA should be obtained by adding correction factor. Higher difference between two methods is 10.7 mEq/L for sodium; lower difference is 1.8 mEq/L. Mean ± standard deviation: 6.2 mEq/L ± 1.96 mEq/L. Correction factor: current difference = 6.2. Higher difference between two methods is 0.72 mEq/L for potassium; lower difference is 0.08 mEq/L. Mean ± standard deviation: 0.40 mEq/L ± 1.96 mEq/L. Correction factor: current difference = 0.40. CONCLUSION: The results obtained by using ABG analyzer and Laboratory AA differ significantly. After adding correction factor with ABG value, there will be no significance difference between corrected ABG value and Laboratory AA value

Erforderliche Frequenz der Blutgasanalysen in einem geregelten System

Die arterielle Blutgasanalyse ist eine der am häufigsten diagnostischen Methoden auf der Intensivstation. Doch gibt es bis heute keine klinische Richtlinie, um die Indikation für die Notwendigkeit zu stellen. Um Komplikationen und Kosten für unnötige Laboruntersuchungen zu reduzieren, war es Ziel dieser Arbeit, die Notwendigkeit einer BGA aufgrund vorhandener Ausgangswerte zu bestimmen. Um dem größer werdenden Mangel an Ärzten und Pflegekräften auf Intensivstationen zu begegnen war es zudem Ziel dieser Arbeit die Machbarkeit aber auch den Nutzen einer automatisierten Steuerung zu evaluieren. Zur Datenerhebung wurden gesunde Schweine der deutschen Landrasse unter druckkontrollierter Beatmung 72h in Narkose gehalten und intensivmedizinisch überwacht. Die Homöostase wurde mittels Automation und einer stündlichen BGA aufrechterhalten (Versuchsreihe AP). Zur Evaluierung der Automatisierung wurden bestehende Rohdaten aus einer Studie zum akuten Leberversagen durch Paracetamolintoxikation (Versuchsreihe NAP) im Vergleich ausgewertet. Im direkten Vergleich der Versuchsreihen zeigten sich signifikante Unterschiede in der Dauer, bis die Werte aus der Norm liefen. Bei der Versuchsreihe NAP waren im Mittel Messungen alle 4 - 6 Stunden nötig, dies deckt sich gut mit der gängigen Praxis von einer BGA pro Schicht. Unter automatisierter Steuerung genügte eine BGA alle 11 - 20 Stunden. Als Modell der Zukunft ermöglicht es seltenere Blutgasanalysen mit konstanteren Werten im Referenzbereich. Mittels Darstellung in Entscheidungsbäumen lässt sich einfach bestimmen, wann die nächste BGA sinnvoll ist und damit unnötige Messungen vermeiden. Inzwischen haben Computer in allen Lebensbereichen Einzug gehalten. Wie es zu den Anfängen der Intensivmedizin lange bis zum flächendeckenden Ausbau dauerte, braucht es auch bei der Verbreitung der Automatisierung. Mit der bewiesenen Machbarkeit und den gezeigten Vorteilen ist der erste Schritt getan. Denn auch auf der Intensivstation wird die Zukunft der Steuerung mehr und mehr beim Autopiloten liegen

A pessoa em situação crítica e a aquisição de competências para o seu cuidar

O presente relatório surge na sequência do 1º Curso de Mestrado em enfermagem à Pessoa em Situação crítica, da Escola Superior de Saúde – Instituto Politécnico de Leiria. Encontra-se aqui sistematizado o percurso desenvolvido durante este período na aquisição de Competências Comuns e Específicas do Enfermeiro Especialista em Enfermagem à Pessoa em Situação Crítica. Durante este período de aprendizagem, para além das diferentes unidades curriculares teóricas, houve oportunidade de realização de 3 ensinos clínicos, que tiveram lugar no Centro Hospitalar de Leiria - Hospital de Santo André. Estes tiverem um contributo fulcral no desenvolvimento destas competências. O Serviço de Urgência Médico- Cirúrgica, o Serviço de Medicina Intensiva e a Unidade de Cuidados Intensivos de Cardiologia foram os serviços que me acolheram durante este período de aprendizagem. A reflexão acerca das competências comuns e especificas, que se encontra aqui descrita, demonstrou ser muito construtiva e enriquecedora, contribuindo para a consciencialização das minhas capacidades enquanto futura Enfermeira Especialista, bem como dos domínios que carecem de maior investimento no futuro. Na segunda parte deste relatório tem lugar uma Revisão Sistemática da Literatura, um trabalho de investigação secundário, que pretende compreender os benefícios da realização da passagem de turno junto ao doente. Este modelo de passagem de turno tem demonstrado ser vantajoso tanto para o doente como para o enfermeiro, pelo que foram analisados alguns estudos neste âmbito