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February 9, 2016
It was just a matter of time...
It was just a matter of time… In response to the serious problem of alarm fatigue across the nation, many hospitals have put in place sophisticated IT systems linking alarms to paging or messaging systems in attempt to get prompt responses by responsible staff to alarms. But a recent incident at a California hospital illustrates how wrong things can go in spite of (or because of) such systems.
The case (CDPH 2015) involved a patient with hypercarbic respiratory failure who was admitted to an ICU and put on a ventilator. As we see in most incidents resulting in patient harm, a series of events rather than a single event led to the untoward outcome.
The alarm management system at that hospital assigns a pager ID to a nurse and a respiratory therapist (RT) who have primary responsibility to respond to alarms/pages for each individual patient. But on the evening of the incident the patient expressed her desire to have a female respiratory therapist so the RT responsibilities were switched to another RT. But there was no change made in the alarm management system to indicate this switch in responsibility.
Around 3:00 AM a section of the patient’s ventilator circuit became disconnected from a Y-connector. Heart rate and oxygen alarms went off and a series of pages/messages were sent to an LVN (licensed vocational nurse) and an RT (respiratory therapist). Unfortunately, the RT with responsibility for the patient never received any such pages/messages and the RT to whom pages/messages were erroneously sent did not respond since he did not think he had any responsibility for this patient.
Though the patient’s room was only 13 feet from the nurses’ station and two nurses, including the charge nurse and the RN with primary responsibility for the patient, heard the loud audible alarm but none responded.
Statement from the RN with primary responsibility for the patient (who was at the nurses’ station and heard the audible alarm): “It was just the vent alarm, it’s not like it was the oxygen saturation alarm, so I didn’t think anything of it”. She saw the LVN go into the room. The LVN came out of the patient’s room and called the RN for help. They found the patient unresponsive and cyanotic and called the Rapid Response Team. Another respiratory therapist arrived with the Rapid Response Team and found the expiratory limb of the ventilator circuit had become disconnected from the Y-connector. It was determined that the ventilator had alarmed for 12 minutes due to oxygen desaturation before there was a response. The patient suffered anoxic brain damage and subsequently died.
The charge nurse, who was also at the nurses’ station, recalled hearing multiple alarms and did not respond to any because she was “distracted” by the report she was receiving from another nurse. The charge nurse did see the LVN enter the patient’s room and also recalled getting a phone call (just prior to the Rapid Response Team call) from the technician at the alarm center that was sending out the pages/messages stating that the patient was desaturating.
And there was another telling quote from the respiratory therapist to whom the alarm messages/pages were erroneously sent. While he denied receiving any pages at all, he said “It didn’t matter if I don’t get a page on that patient, the nurses get the pages too and they should have responded.”
Review of the central alarm system logs showed that 23 pages/messages had been sent to the RT who had not been assigned this patient and 24 were sent to the LVN. The pages had been sent because of both a rising heart rate and oxygen desaturation. In addition, the alarm center technician made 3 phone calls to the nurses’ station. The first was unanswered. The second was answered by the nurse with primary responsibility for the patient and she was told of the oxygen desaturation. The third was answered by the charge nurse who was informed of continued oxygen desaturation. The Rapid Response Team announcement went out shortly after that third call.
This unfortunate incident, of course, points out some of the key vulnerabilities of alarm management systems.
Firstly, it points out that the hi-tech systems are only as good as the data input to them. The computerized system appropriately sent out messages/pages to the personnel for whom it was programmed. But it was human error and system error that led to the failure to change the recipients after the change in assignment of RT responsibility had occurred.
Secondly, it points out blatantly what happens when more than one person is designated as responsible for the patient. Each assumes the other will respond and then no one responds. And even the nurses who were almost within arm’s length of this patient failed to respond because they expected someone else to respond. We’ve talked about this “dual responsibility” issue before. In our October 13, 2009 Patient Safety Tip of the Week “Slipping Through the Cracks” we cited a paper (Singh et al 2009) on radiology reports that demonstrated dual alerts (those sent to both the referring physician and the primary care physician) were twice as likely to go unacknowledged. In the current case multiple parties all assumed someone else would respond.
There apparently was no system for escalation. A good system would escalate the messaging after a certain time elapses without a response from the individual with primary responsibility. In this incident the alarm system technician did escalate in that she made phone calls to the nurses’ station when the oxygen desaturation alarm continued. But apparently there was no formal escalation procedure in their policy and procedure for alarm management. Perhaps the system might have sent an initial page/message to the LVN, then a second page to both the LVN and RN if there was no response within 1 minute, and so on. The report also does not mention whether the RN who had primary responsibility for the patient was even in the messaging loop (the RN was paired with the LVN because of limited scope of practice for the LVN so both were responsible for the patient). Would it not have been appropriate for the system to escalate the pages/messages to that RN when others had not responded?
Note also it is not clear how this alarm management system recognizes whether someone has responded to the patient. Presumably the central technician would continue sending out pages/messages until the alarms stopped alarming. The technician would not know whether appropriate responders were already at the bedside attending to the patient.
The policies and procedures were deficient in that they did not clearly delegate responsibilities for responding to alarm messages/pages. Their policies and procedures for assignment of patient responsibilities was also deficient and there was no guidance for conveying changes in responsibility.
The hospital also had not been tracking response times as part of their quality improvement/patient safety monitoring. In our July 2, 2013 Patient Safety Tip of the Week “Issues in Alarm Management” we noted one hospital found it took on average 9.5 minutes before a clinician responded to high priority alarms. Had the hospital in the current incident been tracking such response times before the event they might have identified and fixed problems in the system and avoided this unfortunate outcome.
We also wonder whether there was a knowledge deficit. The quoted comment above from the nurse who said it was only a ventilator alarm, not an oxygen desaturation alarm, probably had a poor understanding of respiratory physiology. This patient was admitted with hypercarbic respiratory failure. That means the patient might have progressive respiratory depression with hypercarbia which would occur before significant oxygen desaturation occurred, particularly if the patient was receiving supplemental oxygen. Perhaps other staff need re-education on all facets of hypercarbic respiratory failure as well.
How did the hospital respond?
1) They implemented daily ventilator alarm response drills
2) They implemented daily ventilator alarm checks
3) They developed a pager assignment verification process (each shift the supervisors for Respiratory Therapy and Nursing are to verify pager assignment for their respective staffs)
4) A multi-disciplinary Clinical Alarms Task Force was convened
5) A FMEA (Failure Modes and Effects Analysis) was completed
6) 3 individuals were terminated (see below)
7) Performance benchmarks were set for expected response times to ventilator alarms
8) Policy and procedure were revised to include “ventilator circuit connections shall be checked by staff after repositioning, bathing, and provision of care at the bedside”
9) The central alarm system policy and procedure was revised to include pager verification process steps to follow if they receive a page on a patient not assigned to them
10) Pager verifications to be reviewed daily
11) Several clinical indicators to be monitored were added including: staff response to ventilator alarms in <1 minute, pager assignment verification, internal ventilator alarm function test, and external ventilator alarm function test
The hospital’s Plan of Correction (POC) indicated that 3 individuals had been terminated (the RN and LVN with primary responsibility for this patient, and the RT to whom the alarm messages/pages had been erroneously sent). Should the 3 really have been fired? That is always a dual-edged sword. Who are the 3 individuals most likely to never make those mistakes again? Yes, the 3 individuals you just fired! And if during one of your ventilator alarm drills several other individuals do not respond promptly, would you fire them? We often make the mistake of taking one action based on the outcome of an incident and a different one when the outcome was benign even though the same mistakes were made in both circumstances. It may well be that other issues (eg. attitude, honesty, previous problems, etc.) played into their decision to terminate individuals. But it is very important to root out what was part of a problem with the safety culture of the unit as opposed to bad actions solely accountable to individuals. Could the same thing have happened had 3 different individuals been in those roles that evening? We obviously don’t know those answers. But there were certainly many upstream system defects that put those individuals in a position to make fatal errors.
There are several other considerations if you are using alarm management systems linking alarms to messaging/paging capabilities. One of these has to do with battery life. In our February 4, 2014 Patient Safety Tip of the Week “But What If the Battery Runs Low?” we recommended that if you are using cell phones or pagers for alerting staff to various alarms, consider doing a FMEA (failure mode and effects analysis) and ask not only what would happen if the primary responder’s battery is low but also what would happen if more than one responders’ battery is low. You also need to consider that there may well be “dead zones” in your facilities where transmission to a cell phone or other device may be blocked or otherwise unavailable. And you’ve never misplaced your smartphone even temporarily? Unlike anachronistic pagers that you kept attached to your belt except to look at what number to call, today’s smartphones or similar devices are typically used for much more than responding to pages/messages. The more frequently you remove that smartphone from its holster, the higher the likelihood that at some point you will put it down somewhere and lose it.
When we do RCA’s or review RCA’s we always also try to recognize things that were done well in addition to those not done well. In this case the hospital did several things well immediately after the incident:
So do we think such centralized alarm management systems linking alarms to messaging/paging capabilities are a bad idea? No. They have the potential to add valuable defenses in combating alarm fatigue. Yet the current incident provides many lessons learned that other hospitals need to consider:
And we refer you back to our July 2, 2013 Patient Safety Tip of the Week “Issues in Alarm Management” for numerous other recommendations for your alarm management program.
Prior Patient Safety Tips of the Week pertaining to alarm-related issues:
CDPH (California Department of Public Health). Statement of Deficiencies/Plan of Correction. CDPH Complaint Intake Number CA00397517. 2015
Singh H, Thomas EJ, Mani S, et al. Timely Follow-up of Abnormal Diagnostic Imaging Test Results in an Outpatient Setting. Arch Intern Med. 2009; 169(17): 1578-1586.
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We’ve done several columns on problems with methotrexate (see our What’s New in the Patient Safety World columns of July 2010 “Methotrexate Overdose Due to Prescribing Error” and July 2011 “More Problems With Methotrexate”). But most of the issues have focused on the erroneous prescription and administration of daily doses of methotrexate (as are used for oncological indications) instead of once weekly doses that are used for rheumatoid arthritis (RA) or other autoimmune diseases.
There are actually several other dangers associated with low-dose methotrexate, as outlined by a recent ISMP Canada Safety Bulletin (ISMP Canada 2015). They provide details of 3 incidents of methotrexate toxicity in patients with RA or other autoimmune diseases.
In the first incident a patient with RA and renal dysfunction and hypoalbuminemia doubled his weekly methotrexate dose (without his prescriber’s knowledge). This coincided with a course of amoxicillin and initiation of leflunomide therapy. The patient developed severe pancytopenia and died. The severe methotrexate toxicity was attributed to the doubled dose, the underlying risk factors (renal disease and hypoalbuminemia), and the drug interactions with amoxicillin and leflunomide.
In the second incident a patient on weekly methotrexate for RA was hospitalized with a fracture and was begun on diclofenac. Renal failure, pancytopenia, and death followed.
In the third incident a patient with an autoimmune disorder was prescribed a once weekly dose of methotrexate but the pharmacy dispensed a 3-month supply with instructions to take the medication daily. The patient developed severe harm necessitating prolonged hospitalization.
The ISMP Canada safety bulletin notes risk factors for methotrexate toxicity as renal dysfunction, hypoalbuminemia, and certain concomitant medications (like NSAID’s and proton pump inhibitors). They stress the importance of careful monitoring if one of these medications must be used. They also note that folate supplementation be considered to reduce GI and hepatic side effects.
The ISMP Canada article has several very practical recommendations for IT systems, prescribers, and pharmacists.
On the IT side, it recommends that CPOE and pharmacy IT systems should default to a weekly dose. If a daily dose is ordered there should be a hard stop requiring input of the indication and duration of treatment. It recommends provision of an alert about potential serious adverse effects of daily dosing, particularly in patients with some of the above risk factors or taking any of the interacting medications, with suggestions for monitoring. It also suggests linking lab results to order entry for methotrexate (eg. CBC, LFT’s, albumin, creatinine) so the prescriber and pharmacist can be reminded to check for risk factors and be reminded of parameters they may need to monitor.
It also recommends a robust drug-drug and drug-disease interaction module for methotrexate. That one is the most problematic. We already know that drug-drug and drug-disease and drug-food alerts are among the alerts most often ignored by prescribers. Many EHR’s and CPOE or e-prescribing systems allow for configuration of alerts to allow only certain more serious alerts to be shown. But some do not allow selective enabling of these alerts (i.e. allowing drug-drug or drug-disease alerts for just high alert medications as opposed to all medications).
On the prescriber side it recommends baseline values for parameters that may need to be monitored during therapy (eg. CBC, LFT’s, creatinine) and notes that a good order entry system could prompt the provider to order these at the time methotrexate is being ordered. It also has recommendations for frequency of monitoring these parameters, screening for hepatitis B and C and HIV prior to initiating therapy, and considering folate supplementation.
It has 2 excellent recommendations to avoid the error of patients getting daily methotrexate rather than intended once weekly methotrexate:
It also reminds the prescriber to ask the patient about specific prescription and any OTC medications they may be taking that could increase the likelihood of methotrexate toxicity.
On the pharmacist side it recommends a forcing function be developed to ensure that every prescription of methotrexate is reviewed with the patient (or caregiver). The patient should be counselled and given written information about methotrexate and stress the importance of adhering to the prescribed dose and monitoring. If folate supplementation has not been prescribed the pharmacist should contact the prescriber. The pharmacist should follow up on any drug interaction alerts that may appear and discuss with the prescriber and patient. Specific discussion about OTC medications or other medications known to interact with methotrexate should occur. And, again, the supply dispensed should only be for 4 weeks.
Most of the same recommendations appear in a recent article in the rheumatology literature (Blank 2015). This article has a couple more practical recommendations. It notes that use of a “dose pack” may help guide patients to take the proper weekly dose for non-oncologic indications. When reviewing the dosing schedule with patients it is important to explain that taking extra doses is dangerous and discuss that the medication is not to be used “as needed” for symptom control. Have the patient repeat back the instructions to validate that he or she understands the dosing schedule and toxicities of the medication if taken more frequently than prescribed.
In our July 2011 What's New in the Patient Safety World column “More Problems With Methotrexate” we noted that the patient in a long-term care facility may be especially vulnerable. In such cases, the original order for methotrexate is usually written by a specialist. The patient is then followed in the LTC facility typically by a primary care physician who may be less knowledgeable about the particular use of methotrexate for that condition. Also, the LTC patient may not be seen by a physician for periods as long as a month. And many LTC patients have cognitive impairments that might prevent them from understanding issues about their medications. So if a medication reconciliation error has occurred and a patient intended for once weekly dosing is now on daily dosing, the opportunity for toxicity is greatly increased. So LTC facilities should take steps to ensure that any of their residents taking methotrexate get the same level of supervision and protections that non-LTC patients would get.
Methotrexate can be a very effective drug for RA and other autoimmune diseases and is usually well tolerated. But, as the above examples demonstrate, even low-dose methotrexate can be associated with severe toxicity in certain circumstances. It is thus for good reasons that ISMP (US) includes methotrexate on its list of high alert medications. ISMP also provides a great consumer leaflet with safety tips for patients taking methotrexate.
ISMP Canada. Severe Harm and Deaths Associated with Incidents Involving Low-Dose Methotrexate. ISMP Canada Safety Bulletin 2015; 15(9): 1-5
Blank C. 10 Ways to Avoid Fatal Methotrexate Errors. Rheumatology Network 2015; December 2, 2015
ISMP (Institute for Safe Medication Practices). ISMP List of High-Alert Medications in Community/Ambulatory Healthcare.
ISMP (Institute for Safe Medication Practices). Consumer Leaflet with Safety Tips for Methotrexate. 2013
AORN (Association of periOperative Registered Nurses) has updated its guideline to prevent retained surgical items (Putnam 2015). The updated guideline stresses the importance of creating a culture and environment that promotes safety and communication. It highly recommends formal training programs, such as TeamSTEPPS™, that improve teamwork, promote respect and recognition of the role everyone in the OR plays, standardize communication, promote hearback, and break down hierarchical barriers so that all team members feel free to speak up at any time. The update also stresses the importance of limiting distractions to ensure accurate counting. Doing the initial count before the patient enters the OR is a start at avoiding distractions but it is important to create “no-interruption” zones when counts are being done, eliminating non-essential conversations and background noise and ensuring everyone’s attention is focused on the task at hand, akin to the “sterile cockpit” concept in aviation.
The guideline outlines best practices for counting using methods that are consistent and standardized. It recommends that the RN circulator and the scrub person perform the counts (with the same individuals performing the initial count and all subsequent counts). Both individuals should view the items (one separates and points out each item and counts audibly).
Counts should occur:
Putnam notes the scrub person should discard all surgical soft goods into a kick bucket immediately after use and the RN circulator should organize them in a pocketed sponge bag or similar system, which helps separate the items from one another and increase visibility for counting. Sponge pocketing systems are widely used now, with transparent units typically with 5 rows of 2 pockets so there is a total of 10 sponges per unit.
Count sheets and count boards should be used to avoid miscommunication and make sure all OR participants understand the status of the count(s). The sequence of the count should follow the order in which they are listed on the sheets and boards (standardization usually follows a proximal to distal sequence, e.g. first the surgical field, then Mayo stand, back table, and soft goods that have been discarded into a kick bucket).
Putnam also stresses the importance of perioperative personnel immediately inspecting on their removal from the surgical site all instruments and any attached labels for signs of damage or fragmentation. Small retained fragments from these may be particularly difficult to find because they often do not show up on X-rays.
Verna Gibbs, MD, one of the founders of the No Thing Left Behind campaign recently had some practical advice in Outpatient Surgery Magazine on preventing RSI’s (Gibbs 2015). In discussing the factors associated with RSI’s Gibbs, whose work we have highlighted in most of our previous columns on RSI’s listed below, categorizes 3 separate clinical scenarios:
The first type, Gibbs says, is most commonly seen in the obstetrical environment. She notes that perinatal birthing rooms often use gauze sponges that lack radiopaque markers and often do not have formal sponge management practices. That probably accounts for why the vagina is the second commonest site for RSI’s (after the abdomen). But she notes those same factors often occur in cardiac cath labs and sponges may be left behind after pacemaker implantations. This category accounts for about 10% of RSI cases. The second type (correct-count retention cases) accounts for about 70% of all retention cases. And the third type, incorrect-count retention cases, accounts for about 20% of cases.
One problem we’ve seen over and over occurs when there is a discrepant count and the sponge is later found. This gives rise to many surgeons complacently dismissing discrepant counts with statements like “The count was off in our last case and we found the sponge later”. We’ve seen near misses when that occurs and the staff speak up and insist an X-ray be performed, which finds the missing sponge in the patient.
Gibbs also points out one of what we’ll call an unintended consequence of teamwork: relegation of individual accountability to the team. She notes that “people often downplay the importance of their own roles when they know that more than one person has to slip up for a mistake to happen”. When we do team training and discuss the fact that an error cascade is usually necessary to breach the “swiss cheese” model of defenses, we stress that in most incidents with adverse outcomes avoiding any single one of the errors in the cascade could have prevented the ultimate adverse outcome. (Note that we see this same phenomenon in double checks, such as those used in medication safety, that are done incorrectly. We know that the error rate for someone supervising someone else’s work in any industry may approach 10% but there is probably also an increase in errors of the original work when someone thinks a second person will catch any errors they make. That is why double checks need to be done truly independently. See our October 16, 2012 Patient Safety Tip of the Week “What is the Evidence on Double Checks?”.)
Gibbs goes on to describe that the sponge accounting system needs to account for all sponges opened rather than sponges used. Transparent sponge holders, as noted above, typically with 5 rows of 2 pockets so there is a total of 10 sponges per unit. As sponges are used and thrown into a kick bucket they should be put into the sponge holder, one to a pocket, so they can easily be seen and counted. At the end of the case all sponges, including any unused ones, should be in the sponge holder. There should also be an erasable white board that everyone can see which keeps a count of the sponges. Before closing, surgeons must always do a methodical wound search (MWS) regardless of whether the count is correct or discrepant. And before leaving the OR the surgeon and circulating nurse must look at the sponge holder to make sure no pockets are empty. This is referred to as the “show me” step and can be included on your surgical safety checklist or your debriefing checklist. Gibbs advises that an “incorrect-count checklist” be posted in each OR so that everyone knows what to do when there is a discrepant count. If the sponge cannot be found, X-rays should be done and a radiologist (not just the surgeon) must call back the report before the patient is allowed to leave the OR.
While sponge accounting systems are at the top of everyone’s list because surgical sponges are far and away the most commonly retained surgical items, our previous columns warn you not to lose sight of the fact that all sorts of other RSI’s have been appearing more and more (blue towels, Kerlix, cautery tips, Glassman viscera container, KOH cup, instrument labeling tape, Jackson Pratt drain bulbs, Rainey clips, and others). Even the newest radiofrequency identification and tracking systems would miss most of those items.
An article in Anesthesiology News (Frei 2016) reviewed a poster presentation by Van Doren et al. at the 2015 annual meeting of the International Society for Pharmacoeconomics and Outcomes Research that pegged the cost of $6,412 per foreign object left behind during total joint arthroplasties. The poster authors also calculated that the rate of RSIs was one per 6,878 primary total hip arthroplasties and one per 11,961 primary total knee arthroplasties, for an overall rate was one per 11,948 procedures. The Frei article includes comments from Robert Cima, MD, who notes true costs are largely hidden and that this estimate significantly underestimates the cost of RSI’s, noting that indirect costs, litigation costs, meeting costs, etc. lead to a much higher financial toll. In our November 5, 2013 Patient Safety Tip of the Week “Joint Commission Sentinel Event Alert: Unintended Retained Foreign Objects” the Joint Commission sentinel event alert (TJC 2013) noted that 95% of the incidents result in additional care or extended hospital stay and additional costs (citing a Pennsylvania Patient Safety Authority estimate of $166,000 average cost for an RSI or “URFO” as the Joint Commission now apparently prefers to call them).
Whatever the financial cost of RSI’s might be, it pales in contrast to the human cost suffered by the patients affected and the reputation cost to the surgeons, teams and hospitals where such events occur.
Our prior columns on retained surgical items/retained foreign objects (RSI’s/RFO’s):
Putnam K. Guideline First Look. Guideline for prevention of retained surgical items. Periop Briefing 2015; 102(6): P11-P13
Gibbs V. A Better Way to Eliminate Retained Surgical Items. Accounting, not counting, will ensure no sponges are left behind. Outpatient Surgery Magazine 2015
Frei R. Cost Calculated for Each Retained Surgical Item in Total Knee, Hip Arthroplasty. Anesthesiology News 2016; January 1, 2016
Commenting on: Van Doren B, Odum S, et al. 2015 annual meeting of the International Society for Pharmacoeconomics and Outcomes Research (abstract PM58)
TJC (The Joint Commission). Sentinel Event Alert. Preventing unintended retained foreign objects. Issue 51 October 17, 2013
Several recent articles about contrast-induced nephropathy (CIN) prompted us to search our now nearly 1000 columns to see what we have written about CIN. Much to our surprise we only found one (see our June 2011 What's New in the Patient Safety World column “Reducing the Risk of Contrast-Related Damage from Imaging Studies”) and that one dealt as much with other contrast-related injuries as it did with CIN.
The study that attracted our attention was one that looked at long-term outcomes in patients who developed CIN (Mitchell 2015). They followed 633 emergency department patients undergoing contrast-enhanced CT, of whom 11% developed acute kidney injury consistent with contrast-induced nephropathy. Within one year 15% experienced at least 1 major adverse event (defined as the combined outcome of death of any cause, renal failure, myocardial infarction, and stroke or other arterial vascular events, in any anatomic territory, requiring invention), including 7% who died. After adjustment for a number of clinical variables the rate of these adverse events was almost 2 and a half times that of patients who did not develop CIN.
Our 2011 column noted many of the risk factors for CIN and mentioned a risk stratification nomogram for predicting CIN in patients undergoing contrast enhanced abdominal CT scans in the emergency room (Kim 2011). But another new study was a systematic review of predictive models that identified patients at risk of contrast induced nephropathy among adults undergoing a diagnostic or interventional procedure using conventional radiocontrast media (media used for computed tomography or angiography, and not gadolinium based contrast) (Silver 2015). Those authors found a total of 12 prediction models but found that ability to predict CIN was modest at best and really only relevant to patients receiving contrast for coronary angiography. The authors conclude that further research is needed to develop models that can better inform patient centered decision making, as well as improve the use of prevention strategies for contrast induced nephropathy.
Pertinent to management, a new study (Qian 2016) addressed prevention of CIN in a particularly high risk group – those patients with chronic kidney disease (CKD) and congestive heart failure (CHF). The incidence of CIN in this group of patients is more than 20%. So the Chinese investigators compared those patients managed with CVP-guided fluid administration vs. those without CVP monitoring in a randomized controlled trial. The incidence of CIN was 15.9% in the group managed with CVP-guided fluid administration vs. 29.5% in the group without CVP monitoring. The former group overall had a higher volume of fluid replacement and higher urinary output. The occurrence of acute heart failure did not differ between the two groups. Since hydration is the cornerstone for prevention of CIN, this study shows that our fears of precipitating acute heart failure or pulmonary edema may be keeping us from optimal fluid management in such patients receiving contrast. It demonstrates that use of CVP monitoring allows for more aggressive fluid management in this high risk group and helps avoid CIN.
While a CVP might allow for more aggressive fluid management, we’ll again note that a simple bedside maneuver may obviate the need for such catheters. Ever since our residency days we’d take great pride in showing our colleagues how a passive leg raise or equivalent can help with decisions about fluid/hemodynamic status in patients, avoiding the need for invasive monitoring.
The Royal College of Physicians also recently made available a toolkit on acute kidney injury and intravenous fluid therapy that includes advice on managing AKI and issues related to contrast (Royal College of Physicians 2015).
Mitchell AM, Kline JA, Jones AE, Tumlin JA. Major Adverse Events One Year after Acute Kidney Injury After Contrast-Enhanced Computed Tomography. Ann Emerg Med 2015; 66(3): p267-274.e4; Published online: May 21 2015
Kim KS, Kim K, Hwang SK, et al. Risk stratification nomogram for nephropathy after abdominal contrast-enhanced computed tomography. The American Journal of Emergency Medicine 2011; 29: 412-417
Silver SA, Shah PM, Chertow GM, et al. Risk prediction models for contrast induced nephropathy: systematic review. BMJ 2015; 351: h4395
Qian G, Fu Z, Guo J, et al. Prevention of Contrast-Induced Nephropathy by Central Venous Pressure–Guided Fluid Administration in Chronic Kidney Disease and Congestive Heart Failure Patients. J Am Coll Cardiol Intv 2016; 9(1): 89-96
Royal College of Physicians. Acute care toolkit 12: Acute kidney injury and intravenous fluid therapy. September 2015
The ACCP (American College of Chest Physicians) has issued its new antithrombotic guideline update for treatment of venous thromboembolism (VTE) (ACCP 2016). This is the 10th edition, updating the 9th edition that was published in 2012. Since the 9th edition the clinical trials of several novel oral anticoagulants (NOAC’s) have been completed and published and the new 10th addition acknowledges the place of these in the management of VTE.
According to the press release from the ACCP the key changes to recommendations in the 9th edition to the 10th edition include:
For VTE and no cancer, as long-term anticoagulant therapy, the new guideline suggests NOAC’s (dabigatran, rivaroxaban, apixaban, or edoxaban) over vitamin K antagonist (VKA) therapy and suggests VKA therapy over LMWH. However, for VTE and cancer it suggests LMWH over VKA or the NOAC’s.
Importantly, of 54 recommendations included in the total 30 statements, 20 were strong and none was based on high quality evidence. This highlights the need for further research.
The full guideline is available in CHEST (Kearon 2016).
ACCP (American College of Chest Physicians). CHEST issues new antithrombotic guideline update for treatment of VTE disease. Press release January 7, 2016
Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline. Chest 2016; January 2016
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