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Purpose: Immunoglobulin (Ig) replacement therapy is an important life-saving treatment modality for patients with primary antibody immune deficiency disorders (PAD). IVIG and SCIg are suitable alternatives to treat patients with PAD but vary in key ways. Existing evidence on patient preferences for Ig treatments given the complexities associated with IVIG and SCIg treatment is limited and fails to account for variations in preferences across patients. For this reason, we sought to evaluate PAD patient preferences for features of IVIG and SCIg across different patient characteristics., Materials and Methods: 119 PAD patients completed a discrete-choice experiment (DCE) survey. The DCE asked respondents to make choices between carefully constructed treatment alternatives described in terms of generic treatment features. Choices from the DCE were analyzed to determine the relative influence of attribute changes on treatment preferences. We used subgroup analysis to evaluate systematic variations in preferences by patients' age, gender, time since diagnosis, and treatment experience., Results: Patients were primarily concerned about the duration of treatment side effects, but preferences were heterogeneous. This was particularly true around administration features. Time since diagnosis was associated with an increase in patients' concerns with the number of needles required per infusion. Also, patients appear to prefer the kind of therapy they are currently using which could be the result of properly aligned patient preferences or evidence of patient adaptive behavior., Conclusions: Heterogeneity in preferences for Ig replacement treatments suggests that a formal shared decision making process could have an important role in improving patient care., Competing Interests: MB has been a consultant and speaker for Grifols SSNA and Green Cross DSMB. MB is also a consultant and advisor to the Immune Deficiency Foundation. Also, MCR is currently an employee of Grifols. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Gonzalez, Ballow, Fairchild and Runken.)

Background and Objectives: Status epilepticus as a pediatric emergency requires rapid seizure control in order to prevent subsequent disabilities. Therefore, the present study was conducted to compare the efficacy and side effects of continuous intravenous infusion of sodium valproate versus midazolam as a third-line treatment of status epilepticus in children., Methodology: This randomized clinical trial study included all children with convulsive and non-convulsive status epilepticus admitted to the pediatric intensive care unit (PICU) of the Bu-Ali Sina Hospital in Sari City (Mazandaran Province, Iran) who had not responded to first-line treatment with diazepam and second-line treatment with phenytoin or phenobarbital. They were consequently treated with continuous intravenous infusion of sodium valproate or midazolam to control persistent seizures., Results: The study comprised 70 patients who were randomly assigned to two equal groups of sodium valproate or midazolam treatment. The mean age of patients in group A (sodium valproate) and group B (midazolam) was 3.97 ± 3.33 and 3.84 ± 2.93 years, respectively. In the present study, the most common etiology of status epilepticus was remote symptomatic, accounting for 35% of cases in the two groups. Sodium valproate was effective in controlling status epilepticus in 91.4% of patients, while midazolam was found to be effective in 85.7% of patients (p > 0.05). Patients who received sodium valproate had shorter seizure duration after administration of the drug compared to those who received midazolam (p = 0.01). Eight patients in the midazolam group and two patients in the sodium valproate group were intubated (p = 0.023). The mean duration of stay in the PICU was 3.2 ± 1.4 and 5.6 ± 2.8 days in groups A and B, respectively, showing a significant difference (p = 0.001)., Conclusion: According to our findings, intravenous infusion of sodium valproate can be used as an effective and relatively safe treatment in children with all types of status epilepticus, especially in challenging situations such as lack of intensive care units or respiratory problems., Competing Interests: Declaration of Competing Interest None, (Copyright © 2021 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.)

Background: Geriatric trauma populations respond differently than younger trauma populations. Critical care ultrasound (CCUS) can guide resuscitation, and it has been shown to decrease intravenous fluid (IVF), lower time until operation, and lower mortality in trauma. Critical care ultrasound-guided resuscitation has not yet been studied in geriatric trauma. We hypothesized that incorporation of CCUS would decrease amount of IVF administered, decrease time to initiation of vasopressors, and decrease end organ dysfunction., Methods: A PRE-CCUS geriatric trauma group between January 2015 and October 2016 was resuscitated per standard practice. A POST-CCUS group between January 2017 and December 2018 was resuscitated based on CCUS performed by trained intensivist upon admission to the intensive care unit and 6 hours after initial ultrasound. The PRE-CCUS and POST-CCUS groups underwent propensity score matching, yielding 60 enrollees in each arm. Retrospective review was conducted for demographics, clinical outcomes, and primary endpoints, including amount of IVF in the first 48 hours, duration to initiation of vasopressor use, and end organ dysfunction. Wilcoxon two-sample, χ2 tests, and κ statistics were performed to check associations between groups., Results: There was no statistical difference between PRE-CCUS and POST-CCUS demographics and Injury Severity Scores. Intravenous fluid within 48 hours decreased from median [interquartile range] of 4941 mL [4019 mL] in the PRE-CCUS to 2633 mL [3671 mL] in the POST-CCUS (p = 0.0003). There was no significant difference between the two groups in time to initiation of vasopressors, vasopressor duration, lactate clearance, intensive care unit length of stay, or hospital length of stay. There was a significant decrease in ventilator days, with 26.7% PRE-CCUS with ventilation longer than 2 days, and only 6.7% POST-CCUS requiring ventilation longer than 2 days (p = 0.0033)., Conclusion: Critical care ultrasound can be a useful addition to geriatric resuscitation. The POST-CCUS received less IV fluid and had decreased ventilator days. While mortality, lactate clearance, complications, and hospital stay were not statistically different, there was a perception that CCUS was a useful adjunct for assessing volume status and cardiac function., Level of Evidence: Therapeutic, level II., (Copyright © 2021 American Association for the Surgery of Trauma.)

Introduction: Daratumumab is an anti-CD38 monoclonal antibody widely used for treating patients with newly diagnosed or relapsed/refractory multiple myeloma. The subcutaneous formulation of daratumumab was developed with the purpose of minimizing the treatment burden (to patients and health care system) associated with intravenous daratumumab. Given its recent approval, there is a knowledge gap regarding the best practices that should be instituted for safe administration of subcutaneous daratumumab., Methods: A retrospective chart review was performed from August 2020 until November 2020 to identify patients either switched to or treated upfront (daratumumab naive) with any subcutaneous daratumumab-based treatment regimen. All patients received appropriate premedications per institutional standards of care. The study end points were to report real-world data regarding administration-related reaction rates (at or following discharge from infusion center), as well as compare their incidence rates to those noted in the COLUMBA study (historical cohort)., Results: The study included 58 patients, of whom 38% (n = 22) were daratumumab naive. The majority (84%, n = 49) received subcutaneous daratumumab in combination with various antimyeloma regimens. There were no cases of administration-related reactions at infusion center or after discharge irrespective of previous exposure to intravenous daratumumab. None of the patients included herein required rescue home medications or visited the emergency department within 24 to 48 hours after subcutaneous daratumumab administration. These translated into a significant difference in incidence of administration-related reactions compared with historical cohort (0% vs. 13%, P = .003)., Conclusion: Subcutaneous daratumumab was extremely well tolerated and could be safely administered without need for monitoring or rescue home medications., (Copyright © 2021. Published by Elsevier Inc.)

Importance: Infusion reactions occur in 7% to 20% of patients receiving biologics. Home infusions are convenient and incur lower costs but may be associated with more adverse events; the safety of receiving biologic infusions for immune-mediated diseases at home remains unclear., Objective: To assess whether patients receiving home biologic infusions have increased adverse events requiring emergency department (ED) or hospital admission compared with patients receiving facility infusions., Design, Setting, and Participants: This retrospective cohort study used administrative claims data from a large national insurer for adult patients who received biologic infusions for immune-mediated disease between January 2007 and December 2017. Patients with hematologic malignant neoplasms or bone marrow transplantation were excluded. Data were analyzed from August 2019 to October 2020., Main Outcomes and Measures: ED or hospital admission on the same or next day after administration of a biologic infusion at home vs at a facility; secondary outcomes included discontinuation of the biologic after an ED or hospital admission and postinfusion mortality., Results: Of a total of 57 220 patients (mean [SD] age, 50.1 [14.8] years; 512 314 [68.1%] women) who received 752 150 biologic infusions (34 078 home infusions [4.5%] to 3954 patients and 718 072 facility infusions [95.5%] to 54 770 patients), patients who received home infusions were younger (mean [SD] age, 43.2 [13.2] vs 51.3 [14.8] years), more likely to be men (14 031 [41.2%] vs 225 668 [31.4%]), and had a lower Charlson comorbidity score compared with patients who received facility infusions (mean [SD] score, 0.5 [1.0] vs 1.1 [1.3]). Home infusions were associated with 25% increased odds of ED or hospital admission on the same or next day after the infusion (odds ratio [OR], 1.25; 95% CI, 1.09-1.44; P = .002) and 28% increased odds of discontinuation of the biologic after the ED or hospital admission (OR, 1.28; 95% CI, 1.08-1.51; P = .005). There was no difference in postinfusion mortality between home or facility infusions. The rates of adverse events were highest with home infusions of tocilizumab (48 of 481 infusions [10.0%]), vedolizumab (150 of 2681 infusions [5.6%]), and infliximab (1085 of 20 653 infusions [5.3%]), although the number of tocilizumab and vedolizumab infusions was low., Conclusions and Relevance: In this study, biologic infusions administered at home, compared with those administered at a facility, were associated with increased adverse events requiring escalation of care. Because the number of home infusions has increased and is expected to continue to rise, the safety implications of administering biologic infusions at home needs to be further assessed.

Abstract: This retrospective study investigated the preventive effect of intravenous esomeprazole (IVEO) in the prevention of nonvarices upper gastrointestinal bleeding (NUGIB).This study enrolled 130 patients with NUGIB and all of them underwent successful endoscopic hemostasis, of which 65 cases received routine management and IVEO (Group A) and the other 65 cases received routine management alone (Group B). The primary outcome (recurrent bleeding rate within 72-hour, 7-day, and 30-day), and secondary outcomes ((all-cause mortality, bleeding-related mortality, blood transfused, hospital stay (day), and incidence of adverse events)) were compared between 2 groups.Patients in the group A showed lower recurrent bleeding rate within 72-hour(P < .05), 7-day (P < .05), and 30-day (P < .05), than that of patients in the group B. However, no significant differences were identified in all-cause mortality(P = .26), bleeding-related mortality (P = .57), blood transfused (P = .33), and hospital stay (P = .74) between 2 groups. In addition, both groups had similar safety profile.This study found that routine management and IVEO was superior to the routine management alone for preventing the recurrent bleeding rate after successful endoscopic hemostasis in patients with NUGIB., Competing Interests: The authors have no conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Hyperkalemia is a rare life-threatening complication of red blood cell (RBC) transfusion. Stored RBCs leak intracellular potassium (K+) into the supernatant; irradiation potentiates the K+ leak. As the characteristics of patients and implicated RBCs have not been studied systematically, a multicenter study of transfusion-associated hyperkalemia (TAH) in the pediatric population was conducted through the AABB Pediatric Transfusion Medicine Subsection., Study Design: The medical records of patients <18 years old were retrospectively queried for hyperkalemia occurrence during or ≤12 h after the completion of RBC transfusion in a 1-year period. Collected data included patient demographics, diagnosis, medical history, timing of hyperkalemia and transfusion, mortality, and RBC unit characteristics., Results/findings: A total of 3777 patients received 19,649 RBC units during the study period in four facilities. TAH was found in 35 patients (0.93%) in 37 occurrences. The patient median age and weight were 1.28 years and 9.80 kg, respectively. All patients had multiple serious comorbidities. There were 79 RBC units transfused in the TAH events; 62% were irradiated, and the median age of the units was 10 days. The median total RBC volume transfused ≤12 h before TAH was 24% of patient estimated total blood volume, and the median infusion rate (IR) was19.6 ml/kg/h. Mortality rate within 1 day after the TAH event was 20%., Conclusions: The prevalence of TAH in children was low; however, the 1-day mortality rate was 20%. Patients with multiple comorbidities may be at higher risk for TAH. The IR was higher for patients who had TAH than the IR threshold for safe transfusion., (© 2021 AABB.)

Human infection with Angiostrongyloides cantonensis , or rat lungworm disease, manifests most commonly with neurologic symptoms that often include severe diffuse pain. While pain is reported by the majority of patients with rat lungworm disease, there are presently no published guidelines on the approach to pain management for these patients. Here we report a case of rat lungworm disease where severe refractory pain was the most prominent symptom and an intravenous lidocaine infusion was used as a successful treatment modality. Intravenous lidocaine has been shown to be safe and effective in neuropathic pain, refractory cancer pain, and peri-operative pain management. To our knowledge, this is the first case report on the use of lidocaine infusion for the management of refractory pain from rat lungworm disease, and among the first reports of any approach, to pain management for rat lungworm disease. We suggest that a lidocaine infusion protocol be considered when pain from rat lungworm disease fails to respond to first-line analgesics., (©Copyright 2020 by University Health Partners of Hawai‘i (UHP Hawai‘i).)

Purpose: To evaluate the impact on cost, time, resource use, and clinic workflow of converting the route of drug administration from a neurokinin-1 receptor antagonist (NK-1 RA) 30-min intravenous (IV) infusion to aprepitant IV, and more specifically to IV push, within a multicenter community oncology practice., Methods: This was a retrospective, multicenter time, motion, and resource/cost evaluation study. Conversion to aprepitant IV was determined by calculating number of doses of aprepitant IV versus fosaprepitant administered in patients receiving moderately or highly emetogenic chemotherapy regimens. Operational advantages (i.e., supply costs, time saved) of switching from fosaprepitant IV infusion to aprepitant administered as a 2-min IV push were assessed., Results: A total of 12,908 doses of aprepitant IV 130 mg were administered at 13 Rocky Mountain Cancer Centers clinics over an 18-month period. Conversion from fosaprepitant to aprepitant IV reached 90% after 9 months of aprepitant IV initiation. Supply costs per administration were reduced ($2.51 to $0.52) when aprepitant was prepared as an IV push versus an NK-1 RA infusion. The overall time savings per administration of aprepitant was reduced by 90% (from 36.5 to 3.5 min, 33 min saved) as an IV push rather than an infusion. Most of the time saved per administration (30 min) pertained to the infusion nurse, and 3 min was saved by the pharmacy technician., Conclusion: Successful conversion to aprepitant, and specifically to a 2-min IV push, provides time, cost, and resource savings, improves operational efficiency, and avoids the negative impact of potential future IV fluid shortages.

Background: Natalizumab (NTZ) is a humanized monoclonal antibody used in the treatment of relapsing remitting multiple sclerosis. Although NTZ is usually well-tolerated, infusion-related reactions (IRRs) may occur, and the patients have to be monitored during the infusion and for one hour afterwards., Objective: To identify frequency and severity of IRRs during NTZ infusions and one-hour post-infusion observation period in a clinical practice setting., Methods: Multicenter, observational study involving three Swiss (Lugano, St. Gallen and Luzern) and two Italian (Milano and Napoli) tertiary MS centers. Predisposing factors to IRRs were investigated using multivariate Cox regression models., Results: A total of 11'133 infusions received by 302 MS patients were analyzed (68.9% females, median age 33.6 years, median EDSS 2.5). IRRs occurred in 24 (8%) patients during NTZ infusions and in 7 (2%) during one-hour post-infusion. Only 8 patients needed pharmacological treatment, of whom 7 during NTZ infusion. Age, sex and history of allergies were not associated with risks for IRR. The frequency of post infusion IRRs after the fifth cycle was low compared to that during the first four infusions (0.83% vs 0.06%)., Conclusion: In our cohort, NTZ associated IRR mainly occurred during the infusion period compared to the one-hour observational period. Also, the first IRR exclusively occurred within the first 4 NTZ administrations. However, further multi-center studies with a larger sample size are needed to capture rare and serious events that could emerge during the observational period and to make clinical recommendations., Competing Interests: Declaration of Competing Interest Zecca C, Gobbi C received financial support for scientific activity, congress participation and speaking bureau from Almirall, Biogen, Bayer, CelleGene, Genzyme, Merck-Serono, Novartis, Roche, Teva Pharma. Sacco R, Disanto G, Maraffi I, Candrian U and Schwegler G declare that they have no conflict of interest Kamm CP has received honoraria for lectures as well as research support from Biogen, Novartis, Almirall, Bayer Schweiz AG, Teva, Merck, Sanofi Genzyme, Roche, Celgene and the Swiss MS Society (SMSG). Rossi S acted as an Advisory Board member of Biogen, Bayer Schering, Merck, Teva, Novartis, Genzyme, Mylan and received travel funding from Biogen, Merck, Teva, Novartis, Bayer Schering, Genzyme, Almirall, and received honoraria for consultancy, speaking or writing from Biogen, Merck, Teva, Novartis, Bayer Schering, Genzyme, Roche. She received support for research projects by Teva, Merck and Bayer Schering and is involved as principal investigator in clinical trials for Teva, Novartis, Biogen and Roche. Gallo A received honoraria for speaking and travel grants from Biogen, Sanofi-Aventis, Merck, Genzyme, Teva, and Novartis., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Purpose: Standard dosing and intermittent bolus application (IB) are important risk factors for pharmacokinetic (PK) target non-attainment during empirical treatment with β-lactams in critically ill patients, particularly in those with sepsis and septic shock. We assessed the effect of therapeutic drug monitoring-guided (TDM), continuous infusion (CI) and individual dosing of piperacillin/tazobactam (PIP) on PK-target attainment in critically ill patients., Methods: This is a retrospective, single-center analysis of a database including 484 patients [933 serum concentrations (SC)] with severe infections, sepsis and septic shock who received TDM-guided CI of PIP in the intensive care unit (ICU) of an academic teaching hospital. The PK-target was defined as a PIP SC between 33 and 64 mg/L [fT > 2-4 times the epidemiological cutoff value (ECOFF) of Pseudomonas aeruginosa (PSA)]., Results: PK-target attainment with standard dosing (initial dose) was observed in 166 patients (34.3%), whereas only 49 patients (10.1%) demonstrated target non-attainment. The minimum PK-target of ≥ 33 mg/L was overall realized in 89.9% (n = 435/484) of patients after the first PIP dose including 146 patients (30.2%) with potentially harmful SCs ≥ 100 mg/L. Subsequent TDM-guided dose adjustments significantly enhanced PK-target attainment to 280 patients (62.4%) and significantly reduced the fraction of potentially overdosed (≥ 100 mg/L) patients to 4.5% (n = 20/449). Renal replacement therapy (RRT) resulted in a relevant reduction of PIP clearance (CL PIP ): no RRT CL PIP 6.8/6.3 L/h (median/IQR) [SCs n = 752, patients n = 405], continuous veno-venous hemodialysis (CVVHD) CL PIP 4.3/2.6 L/h [SCs n = 160, n = 71 patients], intermittent hemodialysis (iHD) CL PIP 2.6/2.3 L/h [SCs n = 21, n = 8 patients]). A body mass index (BMI) of > 40 kg/m 2 significantly increased CL PIP 9.6/7.7 L/h [SC n = 43, n = 18 patients] in these patients. Age was significantly associated with supratherapeutic PIP concentrations (p < 0.0005), whereas high CrCL led to non-target attainment (p < 0.0005). Patients with target attainment (33-64 mg/L) within the first 24 h exhibited the lowest hospital mortality rates (13.9% [n = 23/166], p < 0.005). Those with target non-attainment demonstrated higher mortality rates (≤ 32 mg/L; 20.8% [n = 10/49] ≥ 64 mg/L; 29.4% [n = 79/269])., Conclusion: TDM-guided CI of PIP is safe in critically ill patients and improves PK-target attainment. Exposure to defined PK-targets impacts patient mortality while lower and higher than intended SCs may influence the outcome of critically ill patients. Renal function and renal replacement therapy are main determinants of PK-target attainment. These results are only valid for CI of PIP and not for prolonged or intermittent bolus administration of PIP.

Purpose: Intravenous immune globulin (IVIG) is a high-cost medication used in a diverse range of settings. At many institutions, IVIG is dosed using total body weight (TBW). Recent evidence suggests that alternative dosing weights reduce waste without compromising clinical outcomes. The objective of this study was to quantify the waste reduction potential generated through the use of alternative IVIG dosing weights., Methods: We performed a retrospective analysis of all IVIG doses administered from January 2011 through January 2016 to adults (≥18 years). TBW and height at the time of administration were used to calculate prescribed dose (g/kg), ideal body weight (IBW), and adjusted body weight (AdjBW). Three dosing methods were analyzed, as follows: use of AdjBW if TBW is >120% IBW (method 1), AdjBW for all doses (method 2), and IBW for all doses (method 3). Outcomes included potential IVIG use averted, direct drug cost savings, and reductions in outpatient infusion times for each method., Results: A total of 9,918 doses were administered to 2,564 patients over 5 years, representing an average usage of 75,994 g/year. If dosing methods 1, 2, and 3 had been used, the annual use of IVIG would have decreased by 21.9% (16,658 g/year, p < 0.001), 24.2% (18,371 g/year, p < 0.001), and 35.9% (27,252 g/year, p < 0.001), respectively. This translates into average annual cost differences of $2.37 million, $2.62 million, and $3.89 million and average annual outpatient infusion time savings of 841 hours, 920 hours, and 1,366 hours, respectively., Conclusion: IVIG dosing optimization through use of alternative dosing weights represents a significant source of waste reduction and cost reduction., (© American Society of Health-System Pharmacists 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Patients with primary immunodeficiency disease (PIDD) and antibody deficiency require lifelong immunoglobulin replacement therapy. While both subcutaneous immunoglobulin (SCIG) and intravenous immunoglobulin (IVIG) replacement therapy are effective in preventing infection, patients with PIDD still experience worse health-related quality of life (hrQOL) outcomes., Objective: Assess differences in hrQOL for PIDD patients receiving home SCIG versus IVIG., Methods: SF-36 surveys were administered by a specialty pharmacy to 630 PIDD patients receiving home SCIG and IVIG at baseline and then every 3 months between 2014 and 2016. Results were analyzed using two-sample t tests and linear mixed effects model. Analysis was repeated for different age categories and trended over time., Results: Patients receiving SCIG reported statistically significant higher energy fatigue scores (+ 9 points, p < 0.001) but lower perceived role limitations due to physical health scores (- 14 points, p < 0.001). These differences were only observed in patients > 36 years of age. There were no differences in the composite SF-36 score for patients receiving SCIG versus IVIG (+ 1, p = 0.66). Immunoglobulin-naïve patients all improved their hrQOL, but a larger improvement was seen in those initiating SCIG versus IVIG., Conclusion: Patients with PIDD on home IVIG versus SCIG have similar composite hrQOL scores as measured by the SF-36. In the adult population, initiating immunoglobulin replacement with SCIG may result in more hrQOL improvement compared with IVIG, although personal preferences should also be considered., Clinical Implications: Patients with PIDD on home IVIG versus SCIG have similar composite health-related quality of life scores as measured by the SF-36. Patients with primary immune-deficiency on home IVIG versus SCIG have similar composite health-related quality of life scores as measured by the SF-36. Personal preferences are important in deciding whether to treat with IVIG or SCIG.

Compared with a 5% intravenous immunoglobulin, a 10% intravenous immunoglobulin as the first-line treatment of Kawasaki disease significantly reduced the fever duration (10 vs 13 hours, P = .022) among the responders, and the interval to adjunctive therapy for nonresponders (47 vs 49 hours, P = .035). There were no severe adverse events., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: To determine the effects of the sodium content of maintenance fluid therapy on cumulative fluid balance and electrolyte disorders., Methods: We performed a randomized controlled trial of adults undergoing major thoracic surgery, randomly assigned (1:1) to receive maintenance fluids containing 154 mmol/L (Na154) or 54 mmol/L (Na54) of sodium from the start of surgery until their discharge from the ICU, the occurrence of a serious adverse event or the third postoperative day at the latest. Investigators, caregivers and patients were blinded to the treatment. Primary outcome was cumulative fluid balance. Electrolyte disturbances were assessed as secondary endpoints, different adverse events and physiological markers as safety and exploratory endpoints., Findings: We randomly assigned 70 patients; primary outcome data were available for 33 and 34 patients in the Na54 and Na154 treatment arms, respectively. Estimated cumulative fluid balance at 72 h was 1369 mL (95% CI 601-2137) more positive in the Na154 arm (p < 0.001), despite comparable non-study fluid sources. Hyponatremia < 135 mmol/L was encountered in four patients (11.8%) under Na54 compared to none under Na154 (p = 0.04), but there was no significantly more hyponatremia < 130 mmol/L (1 versus 0; p = 0.31). There was more hyperchloremia > 109 mmol/L under Na154 (24/35 patients, 68.6%) than under Na54 (4/34 patients, 11.8%) (p < 0.001). The treating clinicians discontinued the study due to clinical or radiographic fluid overload in six patients receiving Na154 compared to one patient under Na54 (excess risk 14.2%; 95% CI - 0.2-30.4%, p = 0.05)., Conclusions: In adult surgical patients, sodium-rich maintenance solutions were associated with a more positive cumulative fluid balance and hyperchloremia; hypotonic fluids were associated with mild and asymptomatic hyponatremia.

Purpose: The present study aimed to evaluate the impact of warming on physiological indices of patients undergoing laparoscopic cholecystectomy., Design: The study was a three-group randomized controlled clinical trial., Methods: In the present study, 96 patients were assigned to three groups: forced-air warming system group; warmed intravenous fluid group; and control group. The intervention was performed immediately after the anesthesia induction. Physiological indices (core body temperature, blood pressure, and heart rate) were evaluated at 15-minute intervals, and postoperative shivering was also recorded., Findings: The mean systolic blood pressure and the mean heart rate were significantly different in each warming group before, during, and after surgery, but the three groups had no significant differences in terms of physiological indices at any time (P > .05). Postoperative shivering was not seen in any group., Conclusions: Both interventions had similar effects on physiological indices. Therefore, the recommendation is to use the warming method according to patient's other conditions., (Copyright © 2018 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.)

This article reviews the current status of the overuse of intravenous (IV) infusions in China and implications to patient safety, and analyzes factors associated with the overuse. Although many factors contribute to the overuse of IV infusions in China, we focus on the construction of an IV infusion management system and tackling cultural problems as the first step to address issues of IV therapy in this commentary.

Background: Dehydration, mainly due to diarrheal illnesses, is a leading cause of childhood mortality worldwide. Intravenous (IV) therapy is the standard of care for patients who were unable to tolerate oral rehydration; however, placing IVs in fragile, dehydrated veins can be challenging. Studies in resource-rich settings comparing hyaluronidase-assisted subcutaneous rehydration with standard IV rehydration in children have demonstrated several benefits of subcutaneous rehydration, including time and success of line placement, ease of use, satisfaction, and cost-effectiveness., Methods: A single-arm trial assessing the feasibility of hyaluronidase-assisted subcutaneous resuscitation for the treatment of moderately to severely dehydrated individuals in western Kenya was conducted. Children aged 2 months or older who presented with moderately to severely dehydration clinically warranting parenteral rehydration and had at least 2 failed IV attempts were eligible. Study staff received training on standard dehydration management and hyaluronidase infusion processes. Children received all other standards of care. They were monitored from presentation and through discharge, with a 1-week phone follow-up. Predischarge surveys were completed by caregivers, and semistructured interviews with providers were performed., Results: A total of 51 children were enrolled (median age, 13.0 months; interquartile range of 18 months). Fifty-one patients (100%) had severe dehydration. The median length of subcutaneous infusion was 3.0 hours (interquartile range [IQR], 2.95). The median total subcutaneous infusion was 700.0 mL (IQR, 420 mL). Median time to resolution of moderate to severe dehydration symptoms was 3.0 hours (IQR, 2.95 hours). There were no significant complications., Conclusions: Hyaluronidase-assisted subcutaneous resuscitation is a feasible alternative to IV hydration in moderately to severely dehydrated children with difficult to obtain IV access in resource-limited areas.

Avoiding excess fluid administration is necessary when managing critically ill surgical patients. The aim of this study was to delineate the current practices of IV electrolyte (IVE) replacement in a surgical ICU and quantify their contribution to the fluid balance (FB) status. Patients admitted to the surgical ICU over a six-month period were reviewed. Patients undergoing dialysis and those with ICU stay <72 hours were excluded. A total of 248 patients were included. The median age was 60 years, and 57 per cent were male. Overall, 1131 patient ICU days were analyzed. The median daily FB was 672 mL. IVEs were administered in 62 per cent of ICU days. In days that IVEs were used, negative FB was significantly less likely to be achieved (62% vs 69%, P = 0.02). The most commonly administered IVE was calcium (32% of ICU days); however, the largest volume of IVE was administered in the form of phosphorus (median 225 mL). Diuretics were administered in 17 per cent of ICU days. Patients who received diuretics were significantly more likely to receive IVE (70% vs 61%, P = 0.02). Administration of IVE may contribute to the daily positive FB of surgical ICU patients. Implementation of practices that can ameliorate this effect is encouraged.

Infusion-associated medication errors have the potential to cause the greatest patient harm. A 21-year review of errors and near-miss reports from a national medication error-reporting program found that infusion-associated medication errors resulted in the identification of numerous best practices that support patient safety. A content analysis revealed that most errors involved improper dosage, mistaken drug choice, knowledge-based mistakes, skill-based slips, and memory lapses. The multifaceted nature of administering medications via infusions was highlighted. Opportunities for improvements include best practices such as developing learning cultures and reinforcing the independent double-check process on medications. Staff will likely benefit from education on specific medications, prescription details, and smart pump technology.

Background: Optimal infusion rate of colloids in patients with suspected hypovolemia is unknown, and the primary objective of the present study was to test if plasma volume expansion by 5% albumin is greater if fluid is administered slowly rather than rapidly., Methods: Patients with signs of hypoperfusion after major abdominal surgery were randomized to intravenous infusion of 5% albumin at a dose of 10 ml/kg (ideal body weight) either rapidly (30 min) or slowly (180 min). Plasma volume was measured using radiolabeled albumin at baseline, at 30 min, and at 180 min after the start of infusion. Primary outcome was change in plasma volume from the start of infusion to 180 min after the start of infusion. Secondary outcomes included the change in the area under the plasma volume curve and transcapillary escape rate (TER) for albumin from 180 to 240 min after the start of albumin infusion., Results: A total of 33 and 31 patients were included in the analysis in the slow and rapid groups, respectively. The change in plasma volume from the start of infusion to 180 min did not differ between the slow and rapid infusion groups (7.4 ± 2.6 vs. 6.5 ± 4.1 ml/kg; absolute difference, 0.9 ml/kg [95%CI, - 0.8 to 2.6], P = 0.301). Change in the area under the plasma volume curve was smaller in the slow than in the rapid infusion group and was 866 ± 341 and 1226 ± 419 min ml/kg, respectively, P < 0.001. TER for albumin did not differ and was 5.3 ± 3.1%/h and 5.4 ± 3%/h in the slow and in the rapid infusion groups, respectively, P = 0.931., Conclusions: This study does not support our hypothesis that a slow infusion of colloid results in a greater plasma volume expansion than a rapid infusion. Instead, our result of a smaller change in the area under the plasma volume curve indicates that a slow infusion results in a less efficient plasma volume expansion, but further studies are required to confirm this finding. A rapid infusion has no effect on vascular leak as measured after completion of the infusion., Trial Registration: EudraCT2013-004446-42 registered December 23, 2014.

We experimentally investigated the fluid warming performances of three warmers with different technology, according to flow rates and distances. We used the following intravenous fluid warmers: Mega Acer Kit (Group M, n = 8), Ranger (group R, n = 8), and ThermoSens (group T, n = 8). Fluids that had been stored in the operating room over the previous 24 h were delivered at sequent flow rates of from 440 mL/h up to 2500 mL/h through preheated warming devices. The fluid temperatures were recorded at the inlet point, 76-cm proximal (P out1 ) and 166-cm distal outlet points (P out2 ) every 1 min for 10 min. We repeated each test eight times. The delivered fluid temperature [mean (95% confidence interval)] was significantly higher in group M than group R and T at flow rates up to 650 mL/h with the highest value at 440 mL/h [34.30 (33.35-35.24)°C] (P < 0.001), and was higher in group T and R at flow rates over 1140 mL/h at P out1 [36.67 (36.62-36.73)°C and 37.85 (37.52-38.17)°C at 2500 mL/h, respectively] (P < 0.001). It was significantly higher at the P out1 than the P out2 at all flow rates for each device (P < 0.001). Mega Acer Kit can warm fluid more effectively compared with ThermoSens and Ranger at the low flow rate whereas the ThermoSens and the Ranger are suitable at higher flow rates. Furthermore, the device performance is more effective with shorter extension lines.

Objective: To assess the accuracy of multiple Intravenous Infusion Flow Regulators (IIFRs) at infusion rates and hanging heights common to the prehospital setting., Methods: Five different manufacturer's IIFRs were tested over a range of infusion rates while hanging at heights equivalent to the gurney pole, ambulance ceiling hook, and manufacturer's recommended height (if available). Each IIFR was run over a 15-minute period at each infusion rate and height three times. Drip effluent was collected and measured for comparison of volumes. Intra- and inter-device accuracy at different infusion rates and heights was calculated., Results: All devices deviated from the expected infusion volume regardless of infusion rate or height. There was inter-device variability across all IIFRs with some having reproducible though inaccurate volumes. Volumes were consistently below expected at lower heights and above expected at increased heights. Manufacturer recommended height guidelines provided slight improvements in accuracy., Conclusions: Significant deviations from expected IIFR volume were observed across all devices, flow rates, and heights in a static, laboratory environment. These findings would lend caution to the use of IIFRs as they could lead to inaccurate medication dosing (both over- or under-dosing) in the prehospital environment.

With an estimated 90% of all hospitalized patients receiving intravenous medications via infusion pumps, intravenous infusion pump systems are among the most frequently used technologies in health care. This article reviews important issues regarding clinical usability, intravenous medication administration error, and patient safety related to the use of intravenous smart pumps. Although it is possible to address some of the issues with changes in clinical processes, the most fundamental challenges need to be addressed through innovation and the development of new technologies using a human factors approach., (Copyright © 2018 The Author. Published by Elsevier Inc. All rights reserved.)

Background: Children with chronic rheumatic disease often require intravenous (IV) therapy. Our center has instituted standardized protocols for use of IV medications in rheumatology patients. Herein, we introduce the therapeutic protocols and report on their short-term safety., Methods: This was an institutional review board (IRB) approved retrospective chart review of all patients who had received IV infusions between the years 2012 and 2015 at a single center, prescribed by a pediatric rheumatologist. Infusion medications included abatacept, belimumab, cyclophosphamide, immune globulin, infliximab, methylprednisolone, N-acetylcysteine, pamidronate disodium, rituximab, and tocilizumab. For calendar year 2015, all adverse infusions reactions were recorded along with treatment strategies used to manage them, and outcomes. Rates of adverse events were calculated per infusion medication., Results: During calendar years 2012-2015, 7585 IV infusions were administered to 398 unique patients. In the year 2015, 2187 infusions were administered to 224 patients, with 34 patients experiencing 41 infusion reactions (1.9% of all infusions). Rituximab had the highest rate of adverse drug reactions with 10 patients experiencing reactions during 106 infusions (9.4%). None of the reactions were life-threatening, and only 6 resulted in discontinuation of therapy., Conclusions: In a recent 4-year span, the UAB Pediatric Rheumatology Infusion Center has given thousands of IV infusions with minimal adverse reactions over a one-year reporting period. The combination of standard infusion protocols, experience of and communication between physicians and nurses who staff the center, and safety of the medications themselves, allows for safe IV administration of a variety of therapies for pediatric rheumatology patients., Trial Registration: Not applicable; this was a retrospective study.

Introduction: Atrial fibrillation (AF) is a common diagnosis of patients presenting to the emergency department (ED). Intravenous (IV) diltiazem bolus is often the initial drug of choice for acute management of AF with rapid ventricular response (RVR). The route of diltiazem after the initial IV loading dose may influence the disposition of the patient from the ED. However, no studies exist comparing oral (PO) immediate release and IV continuous infusion diltiazem in the emergency setting. The objective of this study was to compare the incidence of treatment failure, defined as a heart rate (HR) of >110 beats/min at four hours or conversion to another agent, between PO immediate release and IV continuous infusion diltiazem after an initial IV diltiazem loading dose in patients in AF with RVR., Methods: This was a single-center, observational, retrospective study conducted at a tertiary academic medical center. The study population included patients ≥18 years old who presented to the ED in AF with a HR > 110 beats/min and received an initial IV diltiazem loading dose. We used multivariate logistic regression to assess the association between routes of administration and treatment failure., Results: A total of 111 patients were included in this study. Twenty-seven percent (11/41) of the patients in the PO immediate-release group had treatment failure compared to 46% (32/70) in the IV continuous-infusion group. The unadjusted odds ratio (OR) of treatment failure with PO was less than IV at 0.4 (95% confidence interval [CI] [0.18, 0.99], p = 0.046). When we performed a multivariate analysis adjusted for race and initial HR, PO was still less likely to be associated with treatment failure than IV with an OR of 0.4 (95% CI [0.15, 0.94], p = 0.041). The median dose of PO diltiazem and IV continuous infusion diltiazem at four hours was 30 mg and 10 mg/h, respectively., Conclusion: After a loading dose of IV diltiazem, PO immediate-release diltiazem was associated with a lower rate of treatment failure at four hours than IV continuous infusion in patients with AF with RVR., Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. Statistical analysis provided through CTSA award No. UL1TR000058 from the National Center for Advancing Translational Sciences. This publication was supported by NIH/NCRR Colorado CTSI Grant Number UL1 RR025780. Its contents are the authors’ sole responsibility and do not necessarily represent official NIH views.

Objectives: Current literature estimates the error rate associated with the preparation and administration of all intravenous (IV) medications to be 9.4% to 97.7% worldwide. This study aims to compare the number of observed medication preparation and administration errors between the only commercially available ready-to-administer product (Simplist) and IV push traditional practice, including a cartridge-based syringe system (Carpuject) and vials and syringes., Methods: A prospective, multisite, observational study was conducted in 3 health systems in various states within the United States between December 2015 and March 2016 to observe IV push medication preparation and administration. Researchers observed a ready-to-administer product and IV push traditional practice using a validated observational method and a modified data collection sheet. All observations were reconciled to the original medication order to determine if any errors occurred., Results: Researchers collected 329 observations (ready to administer = 102; traditional practice = 227) and observed 260 errors (ready to administer = 25; traditional practice = 235). The overall observed error rate for ready-to-administer products was 2.5%, and the observed error rate for IV push traditional practice was 10.4%., Conclusions: The ready-to-administer group demonstrated a statistically significant lower observed error rate, suggesting that use of this product is associated with fewer observed preparation and administration errors in the clinical setting. Future studies should be completed to determine the potential for patient harm associated with these errors and improve clinical practice because it relates to the safe administration of IV push medications.

Background: There is growing evidence that online resources used to develop clinical skills among students in the healthcare professions can produce equivalent learning outcomes to traditional face-to-face training methods. Whether clinical competence is retained equally well for online and face-to-face training methods is not yet established., Objectives: The objective of the study was to compare retention of competence in using an IV infusion pump among nursing students trained in its use using three different protocols., Design: A quasi-experimental design was used., Setting: The study was conducted in the School of Nursing and Midwifery at a regional university in Queensland, Australia., Participants: Participants were 102 first year nursing students (female=89, male=13) enrolled in a medications course, ranging in age from 18 to 44years., Methods: Three groups of participants were trained in the use of an IV infusion pump and competence was assessed following a 26-week period of no access to the pump. Group 1 participants (ONL; n=34) were trained online using an Intravenous Pump Emulator (IVPE); Group 2 participants (ONC; n=38) were trained on campus using an actual IV pump in a traditional face-to-face setting; Group 3 participants (ONL+ONC; n=30) were trained both on campus using the actual IV pump and online using the IVPE., Results: As hypothesised, no significant differences in learning outcomes, measured by assessment scores out of 80 points, were found between the ONL (M=68.7±5.9) and ONC (M=65.5±11.5; p>0.05) groups. The ONL+ONC group recorded the highest mean assessment score (M=70.0±5.0) and completed the assessment task significantly faster (p<0.001) than the other two groups., Conclusions: This study suggests that nursing students retained clinical competence in preparing and administrating IV infusions better when face-to-face and online learning were combined., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Purpose: To evaluate the frequency of concurrent drug administration and drug-drug incompatibility of concurrently administered drugs in critically ill children based on available references., Materials and Methods: We retrospectively evaluated concurrent intravenous drug administration in children admitted to a single centre. Eligible patients included those admitted to the critical care unit for at least 6-hours in the ten-year period ending 30 July 2015 and received two or more IV drug administrations. Compatibilities were classified using local reference documents., Results: The 16,863 eligible patients were admitted to ICU for 2,212,326h and received 3,664,667 concurrent administrations. Concurrent infusions ran for 6,263,600h. There were 2,284,066 (62%) concurrent administrations; 334,144 (9%) were compatible, 293,856 (8%) were incompatible, 293,856 (8%) required pharmacist consultation, and 752,601 (21%) had 'unknown' compatibility. Individual patients received a median (IQR) of 33 (10-132) concurrent administrations, comprised of 7 (1-30) concurrent injections 1 (0-5) concurrent infusions and 13 (0-74) concurrently administered injections and infusions., Conclusions: Concurrent IV-drug administration is frequent in critically ill children. Known incompatible concurrent administration occurs, however the compatibilities of many drug-drug pairs were unknown - adding complexity to routine bedside management and identifying information gaps for future research., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Intravenous medication errors persist despite the use of smart pumps. This suggests the need for a standardised methodology for measuring errors and highlights the importance of identifying issues around smart pump medication administration in order to improve patient safety., Objectives: We conducted a multisite study to investigate the types and frequency of intravenous medication errors associated with smart pumps in the USA., Methods: 10 hospitals of various sizes using smart pumps from a range of vendors participated. Data were collected using a prospective point prevalence approach to capture errors associated with medications administered via smart pumps and evaluate their potential for harm., Results: A total of 478 patients and 1164 medication administrations were assessed. Of the observed infusions, 699 (60%) had one or more errors associated with their administration. Identified errors such as labelling errors and bypassing the smart pump and the drug library were predominantly associated with violations of hospital policy. These types of errors can result in medication errors. Errors were classified according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). 1 error of category E (0.1%), 4 of category D (0.3%) and 492 of category C (excluding deviations of hospital policy) (42%) were identified. Of these, unauthorised medication, bypassing the smart pump and wrong rate were the most frequent errors., Conclusion: We identified a high rate of error in the administration of intravenous medications despite the use of smart pumps. However, relatively few errors were potentially harmful. The results of this study will be useful in developing interventions to eliminate errors in the intravenous medication administration process., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Authors of recent meta-analyses have reported that prolonged glucocorticoid treatment is associated with significant improvements in patients with severe pneumonia or acute respiratory distress syndrome (ARDS) of multifactorial etiology. A prospective randomized trial limited to patients with sepsis-associated ARDS is lacking. The objective of our study was to evaluate the efficacy of hydrocortisone treatment in sepsis-associated ARDS., Methods: In this double-blind, single-center (Siriraj Hospital, Bangkok), randomized, placebo-controlled trial, we recruited adult patients with severe sepsis within 12 h of their meeting ARDS criteria. Patients were randomly assigned (1:1 ratio) to receive either hydrocortisone 50 mg every 6 h or placebo. The primary endpoint was 28-day all-cause mortality; secondary endpoints included survival without organ support on day 28., Results: Over the course of 4 years, 197 patients were randomized to either hydrocortisone (n = 98) or placebo (n = 99) and were included in this intention-to-treat analysis. The treatment group had significant improvement in the ratio of partial pressure of oxygen in arterial blood to fraction of inspired oxygen and lung injury score (p = 0.01), and similar timing to removal of vital organ support (HR 0.74, 95 % CI 0.51-1.07; p = 0.107). After adjustment for significant covariates, day 28 survival was similar for the whole group (HR 0.80, 95 % CI 0.46-1.41; p = 0.44) and for the larger subgroup (n = 126) with Acute Physiology and Chronic Health Evaluation II score <25 (HR 0.57, 95 % CI 0.24-1.36; p = 0.20). With the exception of hyperglycemia (80.6 % vs. 67.7 %; p = 0.04), the rate of adverse events was similar. Hyperglycemia had no impact on outcome., Conclusions: In sepsis-associated ARDS, hydrocortisone treatment was associated with a significant improvement in pulmonary physiology, but without a significant survival benefit., Trial Registration: ClinicalTrials.gov identifier NCT01284452 . Registered on 18 January 2011.

Unlabelled: This study aims to describe the pediatric physician-staffed EMS missions at a national level and to compare the pediatric and the adult EMS missions. Using a national database, we analyzed 254,812 interventions including 15,294 (6 %) pediatric emergencies. Less children than adults received an intravenous infusion (52.7 versus 77.1 %, p < 0.001), but the intra-osseous access was used more frequently in children (1.3 versus 0.8 %, p < 0.001). More children than adults benefited from a therapeutic immobilization (16.3 versus 13.2 %, p < 0.001). Endotracheal intubation was rare in children (2.1 %) as well as cardiopulmonary resuscitation (1.2 %). Children were more likely than adults to suffer from a neurological problem (32.4 versus 21.3 %, p < 0.001) or from a trauma (27.1 versus 16.8 %, p < 0.001). The prevalence of the pediatric diagnoses showed an age dependency: the respiratory problems were more prevalent in infants (40.3 % of the 0-12-months old), 52.1 % of the 1-4-year-old children suffered from a neurological problem, and the prevalence of trauma raised from 14.8 % of the infants to 47.1 % of the 11-15 year olds., Conclusion: Pre-hospital pediatric EMS missions are not frequent and differ from the adult interventions. The pediatric characteristics highlighted in this study should help EMS teams to be better prepared to deal with sick children in the pre-hospital setting., What Is Known: • Pediatric and adult emergencies differ. • Pediatric life-threatening emergencies are not frequent. What is New: • This study is the first to describe a European national cohort of pediatric physician-staffed EMS missions and to compare the pediatric and the adult missions at a national level. • This large cohort study confirms scarce regional data indicating that pediatric pre-hospital emergencies are not frequent and mostly non-life-threatening.

Objective: Compared with conventional intravenous platinum and taxane-based chemotherapy for ovarian cancer, both intraperitoneal chemotherapy and more frequent dose-dense intravenous chemotherapy have been associated with improved survival in some studies. We examined the utilization and toxicity of these three methods of chemotherapy delivery in women with ovarian cancer., Methods: We performed a population-based study and analyzed data on women with ovarian cancer who underwent primary surgery followed by platinum and taxane-based chemotherapy from 2009 to 2013 who were recorded in the MarketScan database. Adjuvant chemotherapy was classified as: intraperitoneal chemotherapy, dose-dense chemotherapy (weekly administration of chemotherapy), or standard chemotherapy (every 3 weeks). Hospitalizations and emergency department visits for chemotherapy-associated complications and costs were recorded and compared using χ tests., Results: A total of 5,892 patients, including 4,135 (70.2%) who received standard chemotherapy, 859 (14.6%) who received intraperitoneal chemotherapy, and 898 (15.2%) treated with dose-dense chemotherapy, were identified. From 2009 to 2013, use of intraperitoneal chemotherapy remained constant (16.3-16.3%), whereas use of dose-dense therapy increased (8.7-18.1%) (P<.001). Hospitalizations for chemotherapy-associated complications occurred in 21.3% of women receiving standard chemotherapy, 34.7% of patients treated with intraperitoneal therapy, and in 25.2% of those receiving dose-dense treatment (P<.001); emergency department visits occurred in 18.3%, 26.3%, and 20.3%, respectively (P<.001). The largest differences in hospitalizations and emergency department visits were seen for gastrointestinal toxicities and electrolyte disorders. The per-patient costs of hospitalization were higher for intraperitoneal chemotherapy than other treatment modalities., Conclusion: Intraperitoneal chemotherapy was used in less than 15% of women with ovarian cancer, whereas use of dose-dense chemotherapy is increasing. Although we did not examine survival, intraperitoneal chemotherapy is significantly more toxic than the other methods of treatment.

The increasing prevalence of antibiotic-resistant bacteria challenges a clinician's ability to fight life-threatening infections. Administering beta-lactams via extended infusion may improve patient outcomes. This article discusses the underlying principles of this therapeutic approach and when it may be appropriate.

Background: Most intravenous medication errors occur during administration. Smart pumps can reduce the incidence of dose or rate errors using soft and hard limits. However, industry standard dose error reduction software misses errors that occur during titration. The dose change alert was developed to detect errors during titration., Purpose: To evaluate the safety implications of the dose change alert in the SIGMA Spectrum Infusion System on the administration of high-alert medications at The Ottawa Hospital., Method: This retrospective analysis included all titratable high-alert medication infusions administered between May 1 and October 31, 2014 (inclusive). Analysis of continuous quality improvement reports included drug library compliance, dose change alerts, soft limit confirmations and cancellations, and hard limit pull-back reports for each high-alert medication and care area., Findings: Compliance with using the drug library was 96.8%. The percentage of dose change alert confirmations and cancellations within the soft limits were 48.1% and 1.9%, respectively. The titration of vasopressors resulted in the highest percentage (75%) of dose change alert confirmations. The titration of anticoagulants resulted in the highest percentage (12%) of dose change alert cancellations. Titration within the soft limits accounted for 65% of the alerts., Conclusions: This study provided insight into the safety implications of the dose change alert on the titration of high-alert medications. Key-press errors during titration of high-alert medications can cause patient harm, even within the soft limits. Nurses can be involved in customizing the percentage dose change limit for individual drugs within each care area to provide an additional safety check during titration.

Background: Magnesium sulphate, administered by the intravenous (i.v.) or inhaled (nebulised) route, has been proposed as a treatment for adults with acute severe asthma. Existing trials show mixed results and uncertain evidence of benefit., Objectives: We aimed to determine whether i.v. or nebulised magnesium sulphate improves symptoms of breathlessness and reduces the need for hospital admission in adults with acute severe asthma., Design: Multicentre, double-blind, placebo-controlled, three-arm, randomised trial., Setting: The emergency departments of 34 acute hospitals in the UK., Participants: We recruited 1109 adults (age >16 years) with acute severe asthma [peak expiratory flow rate (PEFR) <50% of best/predicted, respiratory rate >25 breaths per minute, heart rate >110 beats per minute or inability to complete sentences in one breath]. Patients with life-threatening features or a contraindication to either nebulised or intravenous magnesium sulphate were excluded., Interventions: Participants were randomly allocated to i.v. magnesium sulphate (2 g over 20 minutes) or nebulised magnesium sulphate (3 × 500 mg over 1 hour) or standard therapy alone., Main Outcome Measures: The primary outcome was the proportion of patients admitted to hospital (either after emergency department treatment or at any time over the subsequent 7 days) and breathlessness measured on a 100-mm visual analogue scale (VAS) over 2 hours after initiation of treatment., Results: We randomised 406 patients to i.v. magnesium sulphate, 339 to nebulised magnesium sulphate and 364 to placebo. Hospital admission was recorded for 394, 332 and 358 patients, respectively, and VAS breathlessness for 357, 296 and 323 patients respectively. Mean age was 36.1 years and 763 out of 1084 (70%) patients were female. Intravenous magnesium sulphate was associated with an odds ratio (OR) of 0.73 [95% confidence interval (CI) 0.51 to 1.04; p=0.083] for hospital admission, an improvement in VAS breathlessness that was 2.6 mm (95% CI -1.6 to 6.8 mm; p=0.231) greater than that associated with placebo and an improvement in PEFR that was 2.4 l/minute (95% CI -8.8 to 13.6 l/minute; p=0.680) greater than that associated with placebo. Nebulised magnesium sulphate was associated with an OR of 0.96 (95% CI 0.65 to 1.40; p=0.819) for hospital admission, an improvement in VAS breathlessness that was 2.6 mm (95% CI -1.8 mm to 7.0 mm; p=0.253) less than that associated with placebo and an improvement in PEFR that was 2.6 l/minute (95% CI -9.2 to 14.5 l/minute; p=0.644) less than that associated with placebo. There were no significant differences between i.v. or nebulised magnesium sulphate and placebo for any other outcomes. The number (%) of patients reporting any side effect was 61 (15.5%) in the i.v. group, 52 (15.7%) in the nebuliser group and 36 (10.1%) in the placebo group. The ORs for suffering any side effect were 1.68 (95% CI 1.07 to 2.63; p=0.025) for i.v. compared with placebo and 1.67 (95% CI 1.05 to 2.66; p=0.031) for nebuliser compared with placebo., Conclusions: We were unable to demonstrate a clinically worthwhile benefit from magnesium sulphate in acute severe asthma. There was some weak evidence of an effect of i.v. magnesium sulphate on hospital admission, but no evidence of an effect on VAS breathlessness or PEFR compared with placebo. We found no evidence that nebulised magnesium sulphate was more effective than placebo., Trial Registration: Current Controlled Trials ISRCTN04417063.

Background: Drug handling in paediatric intensive care units (PICU) is prone to medication errors. We aimed to identify type and prevalence of those errors and to assess preventative interventions., Methods: Prospective intervention study investigating a 3-step intervention for preventing errors in drug handling in a 10-bed PICU of a university hospital. Nurses' drug handling was monitored in daily routine to identify the number of patients affected by errors and overall prevalence and types of errors in drug handling. We implemented a comprehensive intervention consisting of an information handout, a training course, and a 76-page reference book tailored to reduce the prevalence., Results: The prevalence of errors in drug handling decreased from 83 % (555 errors/668 processes)to 63 % (554/883; p < 0.001) after the intervention. The number of affected patients remained unchanged (95 % vs. 89 %, p = 0.370).Peroral (PO) drugs (1.33 errors/process) were more error-prone than intravenous (IV) drugs(0.64), despite being used less frequently (27 % vs.73 % of all processes, p < 0.001). The interventions decreased the prevalence to 0.77 errors/process(p < 0.001) in PO and to 0.52 in IV drugs (p = 0.025)., Conclusion: Errors in drug handling were alarmingly frequent. PO drugs were frequently subject to errors, even though being used less frequently. The implementation of a comprehensive intervention succeeded in reducing the prevalence of errors. Yet further refinements are necessary to decrease also the number of affected patients., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Nasogastric rehydration therapy (NGRT) is the recommended therapy in moderately dehydrated children with gastroenteritis and refusal to drink, since it is supposed to be as effective if not better than intravenous rehydration therapy (IVRT). However, in clinical practice IVRT is often favored. We conducted a clinical trial to determine whether IVRT is not inferior to NGRT., Patients and Methods: Children 3 months to 6 years of age with moderate dehydration and refusal to drink secondary to gastroenteritis were recruited. After clinical assessment of the degree of dehydration, patients were assigned randomly to receive either IVRT or NGRT over 6 h on the hospital ward., Results: Recruitment did not yield the estimated number of patients. Mainly, non-enrollment was due to failure to obtain parental consent because IVRT was expected. 97 patients were enrolled in the study, 46 were randomized to NGRT and 51 to IVRT. There was no difference between IVRT and NGRT groups concerning length of hospital stay (2.2±1.1 days vs. 2.4±1.1 days), success of rehydration (78 vs. 76%) and adverse events., Discussion: Since we had to terminate the study ahead of schedule due to a low recruiting rate, our results are not reliable. However, data from the literature shows that the widespread described superiority of NGRT over IVRT is seriously influenced by studies from developing countries questioning the applicability of the results to a setting available in high-income countries nowadays., Conclusion: Our study demonstrates the difficulties performing such a study in a high-income country to come to an objective and clearly evident final conclusion., (© Georg Thieme Verlag KG Stuttgart · New York.)

Multi-lumen extensions used to infuse multiple fluids via a single intravenous cannula might increase resistance and so limit the flow that can be achieved. We constructed low-pressure and high-pressure models and compared the effect of two different multi-lumen extensions on flow rate. Both multi-lumen extensions reduced flows by up to 76% (p < 0.001). The effect was greatest with large cannulae and in the high-pressure model, with the longer and narrower extension most impeding flow. Multi-lumen extensions can therefore significantly impede fluid flow, and should be avoided or removed when rapid infusion is required. These effects are less important in paediatric anaesthesia where smaller cannulae are used. Manufacturers should include internal diameter or flow effects on the packaging of these extensions to assist clinicians in making such decisions., (© 2013 The Association of Anaesthetists of Great Britain and Ireland.)

Background: Intravenous amiodarone is an important treatment for arrhythmias, but peripheral infusion is associated with direct irritation of vessel walls and phlebitis rates of 8% to 55%. Objectives To determine the incidence and factors contributing to the development of amiodarone-induced phlebitis in the coronary care unit in an academic medical center and to refine the current practice protocol., Methods: Medical records from all adult patients during an 18-month period who received intravenous amiodarone while in the critical care unit were reviewed retrospectively. Route of administration, location, concentration, and duration of amiodarone therapy and factors associated with occurrence of phlebitis were examined. Descriptive statistics and regression methods were used to identify incidence and phlebitis factors., Results: In the final sample of 105 patients, incidence of phlebitis was 40%, with a 50% recurrence rate. All cases of phlebitis occurred in patients given a total dose of 3 g via a peripheral catheter, and one-quarter of these cases (n = 10) developed at dosages less than 1 g. Pain, redness, and warmth were the most common indications of phlebitis. Total dosage given via a peripheral catheter, duration of infusion, and number of catheters were significantly associated with phlebitis., Conclusions: Amiodarone-induced phlebitis occurred in 40% of this sample at higher drug dosages. A new practice protocol resulted from this study. An outcome study is in progress.

Objective: To determine the frequency of pregame intravenous fluid hyperhydration (PIVFH) usage, administration protocols, indications, complications, and perceived efficacy by National Collegiate Athletic Association Football Bowl Subdivision (NCAA-FBS) teams., Design: Cross-sectional survey study., Setting: National Collegiate Athletic Association Football Bowl Subdivision., Participants: Head athletic trainers from NCAA-FBS institutions., Intervention: Voluntary, anonymous 15-item validated online survey instrument., Main Outcome Measures: Number of teams reporting use of PIVFH., Results: The survey response rate was 64% (77 of 120). Thirty percent of respondents reported the utilization of PIVFH, administered to an average of 2 to 3 players. The most common reasons cited for using PIVFH were to prevent muscle cramps (95%), heat illness (79%), and dehydration (68%). Additionally, 47% of programs used PIVFH to improve player exercise tolerance and 47% per player request. Twenty-four percent of programs that used PIVFH reported the occurrence of associated complications. Only 15% of respondents believed that PIVFH improved their teams' overall performance., Conclusions: PIVFH is a common practice among NCAA-FBS teams. PIVFH is used most often to prevent muscle cramps, dehydration, and heat illness. The relatively few numbers of players per team who receive PIVFH suggest that higher risk individuals were targeted for administration.