Comparatively evaluating medication preparation sequences for treatment of hyperkalemia in pediatric cardiac arrest: A prospective, randomized, simulation-based study

Amy M. Arnholt, Jordan Duval-Arnould, LeAnn M. Mcnamara, Michael Rosen, Karambir Singh, Elizabeth Hunt

Research output: Contribution to journalArticle

Abstract

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).

Original languageEnglish (US)
Pages (from-to)e224-e230
JournalPediatric Critical Care Medicine
Volume16
Issue number7
DOIs
StatePublished - Sep 1 2015

Fingerprint

Hyperkalemia
Heart Arrest
Insulin
Pediatrics
Glucose
Sodium Bicarbonate
Advanced Cardiac Life Support
Calcium Gluconate
Calcium Chloride
Calcium
Pharmacists
Pharmaceutical Preparations
Therapeutics
Salts
Weights and Measures
Tertiary Care Centers
Nurses
Newborn Infant
Guidelines

Keywords

  • cardiac arrest
  • hyperkalemia
  • medication preparation
  • pediatric
  • sequence
  • simulation

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Critical Care and Intensive Care Medicine

Cite this

@article{7e361fbab140471e9119ebb01bff8826,
title = "Comparatively evaluating medication preparation sequences for treatment of hyperkalemia in pediatric cardiac arrest: A prospective, randomized, simulation-based study",
abstract = "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).",
keywords = "cardiac arrest, hyperkalemia, medication preparation, pediatric, sequence, simulation",
author = "Arnholt, {Amy M.} and Jordan Duval-Arnould and Mcnamara, {LeAnn M.} and Michael Rosen and Karambir Singh and Elizabeth Hunt",
year = "2015",
month = "9",
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doi = "10.1097/PCC.0000000000000497",
language = "English (US)",
volume = "16",
pages = "e224--e230",
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T1 - Comparatively evaluating medication preparation sequences for treatment of hyperkalemia in pediatric cardiac arrest

T2 - A prospective, randomized, simulation-based study

AU - Arnholt, Amy M.

AU - Duval-Arnould, Jordan

AU - Mcnamara, LeAnn M.

AU - Rosen, Michael

AU - Singh, Karambir

AU - Hunt, Elizabeth

PY - 2015/9/1

Y1 - 2015/9/1

N2 - 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).

AB - 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).

KW - cardiac arrest

KW - hyperkalemia

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KW - sequence

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