Effects of different sedatives/analgesics on stress responses in patients undergoing craniotomy and bone flap decompression

Objective To explore the effects of sedation and analgesia with dexmedetomidine and other drugs on the stress response in patients with cerebral hemorrhage after craniotomy hematoma removal and bone flap decompression and insertion of an indwelling endotracheal catheter. Methods A total of 180 patients with cerebral hemorrhage with consciousness disturbance who underwent emergency surgery were included in this study. They were divided into six groups treated with propofol, dexmedetomidine, lidocaine, sufentanil, dezocine, and remifentanil, respectively. Intravenous medication was given after recovery of spontaneous respiration, and stress responses were compared among the group. Results Serum concentrations of norepinephrine, epinephrine, and cortisol and systolic blood pressure were significantly correlated with drug treatment. Serum norepinephrine concentrations differed significantly among the groups, except between the sufentanil and propofol groups. There were significant differences in serum epinephrine concentrations among all groups, and significant differences in serum cortisol concentrations among all groups, except the propofol, dexmedetomidine, and lidocaine groups. Conclusion Dexmedetomidine can reduce the stress response in patients with intracerebral hemorrhage undergoing emergency craniotomy and bone flap decompression, and can reduce adverse events from an indwelling endotracheal catheter 3 hours post-operation.

Novel rhythm conversion approach in unsuccessful electric cardioversion of persistent atrial fibrillation

The average effectiveness of electrical cardioversion in persistent atrial fibrillation (AF) is considered about 90%. The success is limited by arrhythmia longevity, essential heart pathology, excessive body mass, concomitant deceases. A novel developed in Russia class III intravenous medication “Refralon” (4-nitro-N-(1RS)-1(4-fluorophenyl)-2-(1-ethylpiperidin-4-ethyl) benzamide hydrochloride) seems to be promising in sinus rhythm restoration in such patients. The aim of the study was to assess the effectiveness of a novel class III intravenous medication “Refralon” in conversion to sinus rhythm in patients with permanent AF in whom electrical cardioversion was unsuccessful. Materials and methods 19 patients were included: 16 male and 3 female aged from 45 to 68 years old (59,9±5,84 (M±SD)). Left atrial size was 47±3,2 × 59±2,8 mm, BMI 38,5±7,0 kg/m2, arrhythmia duration from 2 to 21 months (6,7±4,99). Refralon was injected according to the approved manual in ICU; heart rhythm and rate, blood pressure, SpO2 were monitored. Dynamic assessment of QT and QRS duration was performed. Results In 17 of 19 patients (89,4%) sinus rhythm was restored. In 7 patients (41%) sinus rhythm was restored before 10 min, in 4 patients (24%) before one hour, in 4 patients (24%) before two hours, in 2 patients (11%) before six hours. In two patients sinus rhythm was not restored. In both target dose was not infused due to non-sustained ventricular tachycardia in one case, and QT prolongation in another. Conclusion In a small pilot study Refralon was highly effective in patients with persistent atrial fibrillation when electrical cardioversion was ineffective. All the patients had significantly increased BMI. The results may suggest the indication for Refralon usage in obese patients. FUNDunding Acknowledgement Type of funding sources: None.

Assessment and Impact of Intravenous Medication Fluid Administration in Critically Ill Patients With Acute Respiratory Failure

Background: Positive fluid balance early in critical illness is associated with poor outcomes. Reducing intravenous medication volume may mitigate volume overload. Objective: Assessment of fluid and medication administration and clinical outcomes in acute respiratory failure. Methods: Single-center, prospective observational study of hemodynamically stable adult patients in a medical intensive care unit (MICU) with acute respiratory failure. Results: Median cumulative total intake volume was 12 890 (interquartile range [IQR] = 8654-22 221) mL (n = 27), and median cumulative intravenous medication volume was 3563 (IQR = 2371-9412) mL over the first 7 days. Medication volume accounted for 27.6% of aggregate fluid volume. Median daily intravenous medication volume administered was 591 (IQR = 339-1082) mL. Cumulative fluid volume was associated with reduced ventilator-free days ( r2 = −0.393; P = 0.043), and cumulative fluid volumes during the first 3 and 7 days were associated with increased MICU length of stay (LOS ± standard error 0.73 ± 0.35 d/L, P = 0.047, and 0.38 ± 0.16 d/L, P = 0.021, respectively). Cumulative medication volume administered significantly reduced the likelihood of mechanical ventilator liberation (hazard ratio [HR] = 0.917; 95% CI: 0.854, 0.984; P = 0.016) and MICU discharge (HR = 0.911; 95% CI: 0.843, 0.985; P = 0.019). Small-volume infusion may decrease cumulative intravenous medication volume by 38%. Conclusion and Relevance: Intravenous medication diluent contributes substantially to total fluid intake in patients with acute respiratory failure and is associated with poor outcomes. Reduction of intravenous medication fluid volume to improve clinical outcomes should be further investigated.

Comparison of a Metronome-guided Prehospital Medication Infusion Technique with Manual Calculation: A Simulated Randomized, Controlled, Cross-over Study

BackgroundLimited research regarding administration of timed medication infusions in the prehospital environment has identified wide variability with accuracy, timing, and overall feasibility. This study was a pragmatic, randomized, controlled, crossover study comparing two different techniques for medication infusion administration. We hypothesized that the use of a metronome-based technique would decrease medication dosage errors and reduce time to administration for intravenous medication infusions. Methods Forty-two nationally registered paramedics were randomized to either a metronome-based technique versus a standard stopwatch-based technique. Each subject served as a control. Subjects were asked to establish an infusion of amiodarone at a dose of 150 mg administered over 10 minutes, simulating treatment of a hemodynamically stable patient with sustained monomorphic ventricular tachycardia. Descriptive statistics and multiple linear regression were used for data analysis. Results When compared to a standard stopwatch-based technique, a metronome-based technique was associated with faster time to goal, fewer mid-infusion adjustments, and greater ease of use. Conclusions Use of a metronome technique for establishing medication infusion rates may help prehospital clinicians provide safer and more precise medication delivery.

P113 How has COVID-19 affected the treatment of osteoporosis? The answers from a global survey

Background/Aims The COVID-19 pandemic has had profound effects on the health of the global population both directly, via the sequelae of the infection, and indirectly, including the relative neglect of chronic disease management. Together the International Osteoporosis Federation and National Osteoporosis Foundation sought to ascertain the impact on osteoporosis management. Methods Questionnaires were electronically circulated to a sample of members of both learned bodies and included information regarding the location and specialty of respondents, current extent of face to face consultations, alterations in osteoporosis risk assessment, telemedicine experience, alterations to medication ascertainment and delivery, and electronic health record (EHR) utilisation. Responses were collected, quantitative data analysed, and qualitative data assessed for recurring themes. Results Responses were received from 209 healthcare workers from 53 countries, including 28% from Europe, 24% from North America, 19% from the Asia Pacific region, 17% from the Middle East, and 12% from Latin America. Most respondents were physicians (85%) with physician assistants, physical therapists and nurses/nurse practitioners represented in the sample. The main three specialties represented included rheumatology (40%), endocrinology (22%) and orthopaedics (15%).In terms of the type of patient contact, 33% of respondents conducted telephone consultations and 21% video consultations. Bone mineral density assessment by dual-energy x-ray absorptiometry (DXA) usage was affected with only 29% able to obtain a scan as recommended. The majority of clinicians (60%) had systems in place to identify patients receiving subcutaneous or intravenous medication, and 43% of clinicians reported difficulty in arranging appropriate osteoporosis medications during the COVID-19 crisis. Conclusion To conclude through surveying a global sample of osteoporosis healthcare professionals, we have observed an increase in telemedicine consultations, delays in DXA scanning, interrupted supply of medications and reductions in intravenous medication delivery. Disclosure N.R. Fuggle: None. A. Singer: None. N. Harvey: None. J. Reginster: None. C. Cooper: None. S. Greenspan: None.

Extending tubing to place intravenous smart pumps outside of patient rooms during COVID-19: an innovation that increases medication dead volume and risk to patients

The COVID-19 pandemic has stretched hospitals to capacity with highly contagious patients. Acute care hospitals around the world have needed to develop ways to conserve dwindling supplies of personal protective equipment (PPE) while front-line clinicians struggle to reduce risk of exposure. By placing intravenous smart pumps (IVSP) outside patient rooms, nurses can more quickly attend to alarms, rate adjustments and bag changes with reduced personal risk and without the delay of donning necessary PPE to enter the room. The lengthy tubing required to place IVSP outside of patient rooms comes with important clinical implications which increase the risk to patient safety for the already error-prone intravenous medication administration process. This article focuses on the implications of increasing medication dead volume as intravenous tubing lengths increase. The use of extended intravenous tubing will lead to higher medication volumes held in the tubing which comes with significant safety implications related to unintended alterations in drug delivery. Safe intravenous medication administration is a collaborative responsibility across the team of nurses, pharmacists and ordering providers. This article discusses the importance and safety implications for each role when dead volume is increased due to IVSP placement outside of patient rooms during the COVID-19 pandemic.

Analysis of drug compatibility in Y in intravenous therapy: preparation of a preventive tool for a university hospital in Petrolina – PE

Objectives: To elaborate instruments for the analysis of the compatibility of intrave-nous medications, in order to assist in the conduct and routines of the assistance teams of the Federal University of the São Francisco’s Valley (HU-Univasf) Methods: Injectable drugs were initially selected, which belong to the HU-Univasf stand-ardization list. Information on the pH of medicines, compatibilities and incompatibili-ties, were extracted from the databases: Lexi-comp® Inc, Micromedex IV Compatibil-ity, Internet website Stabilis and King Guide to Parenteral Admixtures®. This work was carried out in two stages: (1) Creation of a tool to analyze the compatibility of injectable medications used in the hospital in a guide format; (2) Elaboration of the cross-table for quick consultation of the compatibility of the most prevalent medica-tions in the Intensive and Semi-Intensive Care Unit (UCISIN), in the parenteral dos-age form for intravenous administration (IV). Results: The Guide for analysis of Y compatibility in intravenous drug administration for a University Hospital in Petroli-na-Pe, was published with ISBN (International Standard Book Number): 978-85-92656-19-5 and it is available on the HU-Univas institutional website for free ac-cess. This material suited as the basis for the construction of the drug compatibility chart that contains the 50 most distributed items from the pharmacy to UCISIN. From this table, 1,225 pairs of drugs were obtained, of which 36% (N = 444) corresponded to compatible pairs and 20% (N = 241) to incompatible pairs. It should be noted that a higher value of pairs was observed with the indefinite compatibility 44% (N = 540), that is, without data in the consulted literature. Conclusions: It was possible to prepare the Guide for Analysis of Y Compatibility in Intravenous Medication Administra-tion and the HU-Univasf Y-Drug Incompatibility Cross-Table Graph, already availa-ble for the entire team. Therefore, it is expected that these instruments facilitate the access of the multiprofessional team to quality information, expanding the role of the pharmacist in the care of critical patients, improving patient safety in the use of intra-venous medications in the hospital.