Pediatric Critical Care Medicine 2015


1. Pediatr Crit Care Med. 2015 Sep;16(7):e224-30. doi: 10.1097/PCC.0000000000000497.

Comparatively Evaluating Medication Preparation Sequences for Treatment of
Hyperkalemia in Pediatric Cardiac Arrest: A Prospective, Randomized,
Simulation-Based Study.

Arnholt AM(1), Duval-Arnould JM, McNamara LM, Rosen MA, Singh K, Hunt EA.

Author information: 
(1)1Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD.
2Department of Anesthesia and Critical Care Medicine, The Johns Hopkins
University School of Medicine, Baltimore, MD. 3Division of Health Science
Informatics, The Johns Hopkins University School of Medicine, Baltimore, MD.
4Department of Pediatrics, The Johns Hopkins University School of Medicine,
Baltimore, MD.

OBJECTIVES: To determine whether time to prepare IV medications for hyperkalemia
varied by 1) drug, 2) patient weight, 3) calcium salt, and 4) whether these data
support the Advanced Cardiac Life Support recommended sequence.
DESIGN: Prospective randomized simulation-based study.
SETTING: Single pediatric tertiary medical referral center.
SUBJECTS: Pediatric nurses and adult or pediatric pharmacists.
INTERVENTIONS: Subjects were randomized to prepare medication doses for one of
four medication sequences and stratified by one of three weight categories
representative of a neonate/infant, child, or adult-sized adolescent: 4, 20, and
50 kg. Using provided supplies and dosing references, subjects prepared doses of
calcium chloride, calcium gluconate, sodium bicarbonate, and regular insulin with
dextrose. Because insulin and dextrose are traditionally prepared and delivered
together, they were analyzed as one drug. Subjects preparing medications were
video-recorded for the purpose of extracting timing data.
MEASUREMENTS AND MAIN RESULTS: A total of 12 nurses and 12 pharmacists were
enrolled. The median (interquartile range) total preparation time for the three
drugs was 9.5 minutes (6.4-13.7 min). Drugs were prepared significantly faster
for larger children (50 kg, 6.8 min [5.6-9.1 min] vs 20 kg, 9.5 min [8.6-13.0
min] vs 4 kg, 16.3 min [12.7-18.9 min]; p = 0.001). Insulin with dextrose took
significantly longer to prepare than the other medications, and there was no
difference between the calcium salts: (sodium bicarbonate, 1.9 [0.8-2.6] vs
calcium chloride, 2.1 [1.2-3.1] vs calcium gluconate, 2.4 [2.1-3.0] vs insulin
with dextrose, 5.1 min [3.7-7.7 min], respectively; p < 0.001). Forty-two percent
of subjects (10/24) made at least one dosing error.
CONCLUSIONS: Medication preparation for hyperkalemia takes significantly longer
for smaller children and preparation of insulin with dextrose takes the longest. 
This study supports Pediatric Advanced Life Support guidelines to treat
hyperkalemia during pediatric cardiac arrest similar to those recommended per
Advanced Cardiac Life Support (i.e., first, calcium; second, sodium bicarbonate; 
and third, insulin with dextrose).

PMID: 26181299  [PubMed - in process]





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