23.06.2016

Journal of pediatric intensive care medicine

Wagging tails brought a smiling face to 13-year-old Kaitlyn Stinebaugh as she made her way down the hall of the Pediatric Intensive Care Unit at Covenant Children’s hospital.
Sarah, Kaitlyn’s mother, said her child’s smile was a change from the usual expressions shown during regular extended visits in the past six months.
The expression meant Zoe, a yorkie-toy poodle mix, and Cass, a standard poodle, served their purpose.
The pets involved in local pet therapy programs have special certification to go into health care facilities with their owners. Before becoming a therapy pet team, the animals and owners must go through a training course where the animals are tested in different situations to make sure they keep a calm demeanor in a hospital setting. Susan Bailey, director of volunteer services at University Medical Center, said pets have a natural sense to heal. Philip Wischkaemper, Dakota’s owner, said his cat has been a therapy pet for about seven years and is the only therapy cat in Lubbock, to his knowledge. Critters for Christ is a pet therapy program with volunteers that visit the Covenant facilities. Hatler said she recommends pet owners becoming pet therapy teams only when owners have time to work with their animal.
As people call, dates are set for Row and Evans to review the rules and regulations of pet therapy. Aside from being a tester, Row said she has a miniature schnauzer named Sadi who regularly makes rounds at UMC. Driskill described an incident when Denver was present and helped distract a boy he said was about 11 or 12 years old as he was given an IV. Driskill said he and Denver were going to wait by the door of his room until the nurse called them in. Aim: To measure noise levels in a pediatric intensive care customer unit and discuss the consequences of such noise in relation to professional actions.
Method: This is an observational and correlational study, performed in the pediatric intensive care unit of a federal hospital in Rio de Janeiro. Discussion: The noise levels identified exceed recommendations of national and international organizations.
Conclusion: There is an urgent need to rethink this environment and establish educational strategies for noise reduction, making it safer and healthier. The pediatric intensive care unit (PICU) is prepared to assist children aged between 29 days and 18 years of age who are in a serious condition requiring immediate and specialized assistance, with the primary objective of saving lives, and returning the child to social conviviality with no, or the least number of possible, sequels.
Noise can cause changes in all body systems; it interferes with work, rest, sleep, and communication, in addition to damaging hearing and causing physiological and psychological reactions(3). Given the high noise interference in terms of the physical and psychological health of the child, the purpose of this research was to measure the noise levels of the inpatient unit in a Pediatric Intensive Care Sector and to discuss the consequences of environmental noise in terms of professional actions. This observational and correlational study was conducted in a six-bed PICU of a federal hospital, which is a benchmark in maternal care and childcare, and this study is aimed towards teaching and research and assistance. At PICU the doors have no locks and the floor is rubberized, suitable for a hospital, minimizing noise from the movement of people.
The multidisciplinary team of the unit is composed of nurses (staff, residents, trainees, and specialization trainees), nursing technicians (staff and trainees), doctors (staff and residents), and a physiotherapist, totaling in the sector, simultaneously, about 20 professionals during a day shift and seven during a night shift. To obtain the data and to avoid random errors, the research was performed using the standardization of the measurement method and involved the training of observers (two nurses belonging to the staff of the PICU). Samples were collected for five non-consecutive days in three hours during daytime (8am, 12pm, and 4pm) and in two hours during the night period (11pm and 4am), totaling 150 measures.
For the results to be always achieved in the same place, we established as a measurement point the intersection obtained at a distance of 30 cm from the patient's earlobe and 20 cm from the bed mattress. The collection period and the sequence with which it was held (non-consecutive days) was defined according to the availability of nurse observers and the little time available, due to previously scheduled work in the unit with an expected duration of one year, which impeded data collection.
After analyzing the data collected, a model for multiple linear regressions was adjusted, having the SPL as a variable response. To assess the multicollinearity we used the Variance Inflation Factor (VIF) in which values VIF>10 were considered multicollinear(5). The highest noise levels were observed in the units of patients 1, 2, 3, and 4, which are closest to the nursing station used by almost all of the multidisciplinary team, not only by the nursing staff.
Graphic 1 shows that patient units 5 and 6, used as insulation boxes, had the greatest value variation and the lowest median. In Graphic 2, we found that the SPL varied the time of collection, presenting higher or lower levels, which is believed to be related to the number of professionals at the PICU at the different times considered. It can be verified in Graphic 2 that the schedules that have the highest noise values are those between 8am and 4pm, which are the times when there are no pre-established routines in the sector in which professionals may or may not conduct some kind of activity in units containing patients. Based on the characteristics of the unit and the existence of variables, in which there may be some interference in the production of noise, researchers produced a grouping that has enumerated, among others, a variable called “professionals.” This variable was composed of the activities shown in Table 1. Using Graphic 3, we noted a relationship between the increase in the number of events related to professionals and the increase in noise median, exceeding 70 dBA, remaining highly concentrated at high levels.
The exploratory analysis allowed us to identify that the SPL is influenced by covariates: time, patient unit, and the professional activity (Graphics 1, 2, and 3), while modeling allowed the quantification of such influences. By visual inspection of the qq-plot of the residues and of the scatter graph between the adjusted values and residues (graphics not shown), it was considered that the assumptions of normality, homoscedasticity, and independence of errors were met.
It can be perceived that there is a significant difference among the hours considered, that is, the sound pressure level measured at 4am in the morning is different from the level observed at other times. The Environmental Protection Agency of the United States recommends hospital levels of 45 dBA during the daytime and 35 dBA during nighttime(2).
The data from the study indicates that the pediatric intensive care unit studied exceeded the maximum levels recommended by official national and international organizations, solely presenting an isolated measure smaller than 45 dBA, which occurred at 4am in the morning. Keeping the focus on the schedule, the data contradicted the expectations of researchers that the PICU’s routine hours (12pm and 11pm) would present higher noise levels due to the amount of activities that have to be performed. Data found in a study conducted in a general ICU of a private hospital, which evaluated the stressors for inpatients, identified nurses’ and physicians’ high tones of voice in conversations as one of the stressors(9). High noise levels during the night hamper a comfortable rest, causing sleep disturbances, psychological disorders, and even anxiety among most susceptible professionals(9), along with headaches(11), fatigue(11), mood changes(11), and psychiatric disorders(11), as well as influencing professional performance, possibly inducing the professional to distraction(7.9), error(6), and accidents(1).
The humanization of the PICU environment will involve some consideration of the environmental issues in order to achieve a degree of noise comfort.  However, this is still undervalued in the PICU, where the structural planning must combine technology, reception and respect for the patient.
An example of environmental imbalance caused by the physical destructuring of the unit can be demonstrated by Graphic 1, where patient units 1 and 2 were the ones that presented the highest median because they were less than 1 m away from the nursing station, the site of greatest professional concentration, beside the telephone and television, while the more distant units showed lower values. Reinforcing the premise that the physical structure of the PICU contributed to the increase in noise of the patient units closest to the station, meets its limitations in the almost nonexistent publications on the topic of noise in pediatric ICUs, which is a state of affairs that is much more relevant in terms of the neonatal NICUs.
On the other hand, the technology involved in ICU care should also be taken into account as a source of noise, since several studies point to a significant share of the equipment in the production of loud noise. It is agreed that the construction of healthy spaces includes the control and reduction of ambient noise(14), as well as the awareness of the staff that the health professionals and hospitalized children need to be protected from this adverse environmental hazard, which can irreversibly compromise their health. In line with the results found, relating the loud noise to the behavioral character of the multidisciplinary team, it is believed that health education would have a relevant impact on the reduction of ambient noise.
The sensitization and reeducation of the health team are fundamental for a change in behavior and an adjustment in behavior is essential in reducing noise(2,11,14). We suggest the implementation of a program of continuing education focused on this issue, with the inclusion of the various categories and auxiliary services operating in the PICU. The PICU studied exceeded the levels recommended by official national and international organizations. This website is archived for historical purposes and is no longer being maintained or updated.
Getting a flu vaccine reduces a child's risk of flu-related intensive care hospitalization by 74 percent, according to a CDC study published today in the Journal of Infectious Diseases. The study is the first to estimate vaccine effectiveness (VE) against flu admissions to pediatric intensive care units (PICU).
Children younger than 5 years and children of any age with certain chronic medical conditions like asthma, diabetes or developmental delays, are at high risk of serious flu complications.
Fry's team analyzed the medical records of 216 children age 6 months through 17 years admitted to 21 PICUs in the United States during the 2010-2011 and 2011-2012 flu seasons. Though flu vaccination was associated with a significant reduction in risk of PICU admission, flu vaccine coverage was relatively low among the children in this study: only 18 percent of flu cases admitted to the ICU had been fully vaccinated. More than half (55 percent) of cases had at least one underlying chronic medical condition that placed them at higher risk of serious flu-related complications. CDC usually measures flu VE against a€?medically attended flu illnessa€? a€“ that is, how well it protects against having to go to the doctor for flu symptoms. Symptoms of flu may include fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills, and sometimes diarrhea and vomiting. Flu causes hospitalizations in children each season, but how many children are affected varies, depending on the severity of the season.
Implementation of electrolyte repletion protocols to facilitate and ensure the safety of electrolyte control is common practice in intensive care units (ICUs). To evaluate the effectiveness and safety of an electrolyte repletion protocol in a large, homogeneous group of postoperative patients.
A retrospective study of patients admitted to the surgical ICU following coronary artery bypass grafting or heart valve replacement was undertaken at the Centre hospitalier universitaire de Sherbrooke, a 682-bed tertiary care hospital in Sherbrooke, Quebec.
In total, 627 patients were included in the study: 312 in the control group and 315 in the protocol group.
The electrolyte repletion protocol was more efficacious than traditional electrolyte repletion in maintaining normal serum potassium concentration and was safe. La mise en place de protocoles de recharge electrolytique favorisant le controle prudent des electrolytes est une pratique courante dans les unites de soins intensifs. Evaluer l'efficacite et l’innocuite d’un protocole de recharge electrolytique dans un important groupe homogene de patients en phase postoperatoire. On a mene une etude retrospective de patients admis a une unite de soins intensifs chirurgicaux par suite d’un pontage aortocoronarien ou d’un remplacement d’une valvule cardiaque au Centre hospitalier universitaire de Sherbrooke, un centre de soins tertiaires de 682 lits a Sherbrooke, au Quebec. En tout, 627 patients ont ete admis a l’etude : 312 dans le groupe temoin et 315 dans le groupe protocole.
Le protocole de recharge electrolytique etait plus efficace que la methode de remplacement electrolytique classique pour maintenir un taux serique normal de potassium et s’est revele sur. This retrospective study was conducted in the surgical intensive care unit (ICU) at the Centre hospitalier universitaire de Sherbrooke, a 682-bed tertiary care university hospital in Sherbrooke, Quebec.


To reduce the risk of bias, the current study focused on patients who underwent cardiac surgery, a homogenous group for whom postoperative care did not change after implementation of the protocol.
The protocol was developed as a preprinted order sheet with predetermined IV replacement doses that varied according to plasma electrolyte concentrations.
The primary objective was to evaluate the efficacy of the electrolyte repletion protocol by comparing the proportion of measured values of serum potassium concentration within the desired range before and after implementation of the protocol. For some patients included in the protocol group, the standard electrolyte order sheet was not used, even though they were treated after implementation of the protocol.
The sample size calculation was based on an initial analysis of serum potassium concentration for 92 patients who had undergone cardiac surgery and were admitted to the ICU between April and August 2006. For the 2 study periods, a total of 710 patients were eligible for inclusion, and 325 patients were selected from each period. The proportion of morning serum potassium values within the desired range was not significantly different between the control and protocol groups (Table 2). Patients undergoing cardiac surgical procedures are at high risk for electrolyte depletion.
The strengths of this study included the large sample size and the homogeneous patient population. The implementation of protocols in the ICU is increasingly being used to enhance patient care. We thank Julie Perron, BPharm, MSc, Hugues Blain, BPharm, MSc, and Benoit Cossette, BPharm, MSc, for helping with conception of the study.
Julie and Tommy Combs bring Zoe and their other dog Cass to the hospital as a pet therapy program.
They visit some local hospitals and nursing homes with a mission to help patients feel better, if only for a moment. Melinda Hatler, a Critters for Christ volunteer, trains pet therapy teams for certification.
We measured the noise level by decibel DEC-460 for five non-consecutive days and nights at five different hours.
The linear regression found that 44% of the variability of the noise is explained by the covariables.
For the success of this assistance, modern monitoring equipment and life support are necessary, as well as a multidisciplinary team(1) responsible for a high number of professionals and numerous stimuli.
High noise levels are especially harmful to children, infants, and newborns who are at greater risk of developing stress-related behavioral disorders(3).
The unit is composed of several pieces of equipment necessary for the provision of care of critical patients and use of a multidisciplinary team, which, although important, are sources that produce noise. It is worth mentioning the presence of other professionals who are not continually present, such as an occupational therapist, speech therapist, psychologist, radiology technicians and various experts, as well as the presence of relatives and visitors of patients. The sound pressure levels (SPL) were obtained with a DEC-460 decibel meter model with measurements in weighted decibels (dBA), calibrated and manufactured according to the specifications of the International Electrotechnical Commission (IEC) number 60651. The hours were predetermined in order to measure sound pressure levels at times of different activities (peak hours for routine activities versus observation time), in order to obtain as much data as possible. All significant variables at the 10% level in the univariate model were included in the multivariate model. As a result of the adjustment of the regression model we presented estimates, the standard error that measures the uncertainty of these estimates and the p-value that indicates the significance of the covariate. It is worth mentioning that this study is part of the ongoing investigation projects of two authors from the Master’s Course in Nursing and the Doctorate in Nursing and Biosciences, both from the Federal University of the State of Rio de Janeiro. The noise peak occurred at 4pm, in the unit of patient 1 (located next to the nursing station), with 82.5 dBA measured during the presence of four professionals who provided assistance.
The nursing station is used for the preparation of medications and houses the notes of medical and nursing staff (and other professionals when necessary). These are the most physically distant boxes from the nursing station and accommodate, in most cases, the patients with lower clinical complexity due to little space.
However, the medians remain above 60 dBA, demonstrating that the PICU, as a physical space, has a high noise level, easing up only during late night hours (4am), which showed an average of 56.12 dBA.
It can still be observed that, even in the absence of events related to this variable, the patient unit reached high sound pressure levels, reaching heights of almost 80 dBA.
Furthermore, the VIF showed all values smaller than 10, concluding that there is no multicollinearity. Furthermore, all the estimates of these parameters (8am, 12pm, 4pm, and 11pm) are positive, meaning that there is an increase in the sound pressure at those times. It is also evident that there is the influence of the patient unit and it can be concluded that units 2, 3, and 4 are not significantly different from unit 1, but units 5 and 6 are.
The Brazilian Association of Technical Norms (NBR10152) agrees, suggesting 35 to 45 dBA as acceptable levels for different hospital environments, in which case the first is the desirable level and the second the acceptable limit(4).
The relationship between the time and the increase or reduction of noise is due to the activities performed and the number of professionals moving around the PICU. This data reinforces the idea that conversations are important sources of noise in the unit, as also identified in this study and demonstrated in Graphic 3. This fact must be known and recognized by the active health team in the PICU in its search for strategies to reduce noise, whether structural, behavioral, or technological. The physical structure of the PICU needs to share a favorable workspace for the technical exercise and fulfillment of professionals and patients(7).
Several studies on nursing and medical workers’ health claim the need to give greater attention to occupational hazards, among which excessive noise is included(15).
Despite the fact that technology contributes to the studied event, it cannot be held responsible for unexpected issues caused to the patient; rather, the human beings who are responsible for its misuse or excessive use are responsible for the misuse of the equipment(16). As auxiliary measures, we propose the installation of a continuous sound pressure level measurer, in order to alert the team when levels are exceeded, enabling immediate action, a critical analysis of the physical structure, with discussions aimed at improving the structure focusing on sound comfort and the assessment of the equipments’ noise levels prior to purchase. It is believed that the implementation of a strategic plan based on behavioral changes can positively impact on the control and reduction of ambient noise, making it safer and healthier for everyone working in the pediatric intensive care scenario. Sampaio Neto RA, Mesquita FOS, Paiva Junior MDS, Ramos FF, Andrade FMD, Correia Junior MAV. It illustrates the important protection flu vaccine can provide to children against more serious flu outcomes. They found that flu vaccination reduced a child's risk of ending up in the pediatric intensive care unit for flu by an estimated 74 percent.
During the 2010-2011 and 2011-2012 seasons, the midpoint VE estimates against medically attended illness were 60 percent and 47 percent respectively.
CDC estimates that 20,000 children younger than 5 years are hospitalized on average each year. The proportion of measured values for serum potassium concentration that were within the desired range was compared between patients treated according to the electrolyte repletion protocol and those treated with the traditional approach to electrolyte repletion. The proportions of serum electrolyte values above the normal range were similar between the 2 groups, and there was no difference in the incidence of cardiac arrhythmias.
On a compare la proportion des valeurs mesurees pour le taux serique de potassium qui etaient dans la plage des valeurs desirees chez les patients traites selon le protocole de recharge electrolytique a celle chez ceux traites selon la methode de remplacement electrolytique classique. Les proportions de taux seriques d’electrolytes au-dessus de la plage des valeurs normales etaient similaires dans les deux groupes et on n’a observe aucune difference dans l’incidence des arythmies cardiaques.
The objective of the current study was to evaluate the efficacy and safety of an electrolyte repletion protocol in a large homogenous group of postoperative cardiac surgery patients.
Until the end of 2006, electrolyte repletion for ICU patients was performed by medical staff during rounds or during patient visits.
Patients aged 18 years or older who were admitted to the surgical ICU following surgery for coronary artery bypass grafting or heart valve replacement between November 2005 and October 2006 (control group) and between April 2007 and March 2008 (protocol group) were eligible for inclusion.
The protocol also suggested standard electrolyte monitoring, with specific recommendations regarding the timing of monitoring in relation to administration of replacement doses (6 h after potassium repletion and 24 h after magnesium, phosphate, or calcium repletion). Potassium was chosen for the primary end point because it is the electrolyte for which repletion is most often performed in the ICU, and potassium abnormalities are associated with worse outcomes than occur with abnormalities of other electrolytes. Therefore, we first analyzed data for all patients included for this period and then analyzed data for the subgroup of patients who received care according to the protocol (per-protocol group).
It was determined that a sample size of 250 patients per group was needed to show a 7.5% difference in the mean proportion of daily morning serum potassium values in the established target range, given an ? error of 5% and a ? error of 80%. Dichotomous variables and the proportions of daily electrolyte concentration values within the target range are presented as frequencies and percentages and were compared with the ?2 test (or Fisher exact test if the frequency was less than 5).
After application of the exclusion criteria, 312 patients remained in the control group and 315 in the protocol group. In addition, there was a significantly greater proportion of serum potassium values above the desired range in the control group than in the per-protocol group (Table 2). Some clinical variables and medications seemed unbalanced between the groups (Table 1), but the final effect on serum potassium concentration seemed balanced. The electrolyte repletion protocol described here was efficacious in maintaining normal serum potassium concentration. Severe electrolyte disorders following cardiac surgery: a prospective controlled observational study. Preoperative serum potassium levels and perioperative outcomes in cardiac surgery patients.
Correction of ionized plasma magnesium during cardiopulmonary bypass reduces the risk of postoperative cardiac arrhythmia. A randomized trial of protocol-directed sedation management for mechanical ventilation in an Australian intensive care unit. Intravenous phosphate in the intensive care unit: more aggressive repletion regimens for moderate and severe hypophosphatemia. Implementation and evaluation of a nurse-centered computerized potassium regulation protocol in the intensive care unit--a before and after analysis. Evaluation of an electrolyte replacement protocol in an adult intensive care unit: a retrospective before and after analysis.
Implementing and assessing an evidence-based electrolyte dosing order form in the medical ICU.
Acute renal failure—definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group.
Comparison of calcium phosphate product values using measurement of plasma total calcium and serum ionized calcium.


Multicenter validation of a risk index for mortality, intensive care unit stay, and overall hospital length of stay after cardiac surgery. Matthew Driskill, Denver’s owner and senior clinical department administration for the Department of Ophthalmology & Visual Sciences at the Texas Tech Health Sciences Center, said pet therapy has had measurable influence on patient health.
He said he was told the patient had been unresponsive until Dakota was placed on her chest, where he began to purr. Though this environment has shown benefits in restoring the health of the child, it also has its negative effects of a physical and psychological nature.
The psychological effects are linked to the nature of the sound; however, loud noises can affect the child's personality and reduce their capacity for coping with their diseases or traumas(3). The unit used to measure the data has an area of 77.17 m2 and presents mixed characteristics, that is, it is composed of four beds in a common area, with washable partitions (curtains) and two beds in a closed area (boxes) with glass panels.
This reference is adopted by NBR 10152(4) of the Brazilian Association of Technical Standards (ABNT, in Portuguese). Numerical data (dBA), the activities performed by professionals and sources (equipment, actions and interactions of people) that produced noise at the time of collection were recorded in a field diary built by researchers.
This bed, whose measurement was performed at 11pm, was also the one that presented the second highest SPL (78.8 dBA). This fact generates some difficulty for the use of many types of equipment in tandem with the presence of the multidisciplinary team that needs to get around the units to provide assistance. Moreover, since the estimates of units 5 and 6 are negative, there is a decrease in the sound pressure level if compared to unit 1.
The recognition of noise as a stressor agent for the child and the professional is the beginning of the germination of a healthy and safe environment(12).
The recognition of this dual dimension fosters respect for the therapeutic nature of the unit, facilitates the action of the staff, and, above all, does not make it iatrogenic for the patient(13). Nursing has a decisive role in this process, as it is represented in a greater number inside the unit and as an important element in the formulation of strategies for improving environmental quality, understanding it as an integral part of the dimension of human care. Noise in the intensive care unit: quantification and perception by healthcare professionals. Risks to health of intensive care unit nursing staff: proposal of integral approach of health. Factors that cause stress for physicians and nurses working in a pediatric and neonatal intensive care unit: bibliographic review. CDC recommends annual flu vaccination for everyone 6 months and older and especially for children at high risk of serious flu-related complications. These findings show that while vaccination may not always prevent flu illness, it protects against more serious outcomes. For children younger than 18 years, published studies suggest an annual range of flu-related hospitalization rates of between one child and seven children per 10,000 children.
On a egalement compare la prise en charge de l’equilibre en magnesium, en phosphore et en calcium ionise.
The physician had the option of choosing which electrolyte would be replaced in the case of a low value (potassium, magnesium, phosphate, or calcium) during the ICU stay.
Secondary end points included proportion of serum concentration values within the desired range for magnesium, phosphorus, and ionized calcium. Multivariate logistic regression was used to evaluate independent factors associated with optimal potassium control, defined as 100% of the morning serum potassium concentration values within the desired range. Patients were excluded because of continuous renal replacement therapy (11 control patients and 9 patients in the protocol group) and death during surgery (2 control patients and 1 patient in the protocol group). The results of this study showed that this electrolyte repletion protocol was safe and led to better control of daily serum potassium concentration. To become a pet therapy team through Critters for Christ, Hatler said a handler and the pet are required to attend classes once a week for eight weeks. This group of factors combined with the complexity inherent in the unit generates stress for patients, families, and professionals, in which case high levels of noise is one of its causes(1,2). In addition, excessive noise has direct interference on sleep, generating insomnia, which is related to immunosuppression, impaired protein synthesis, confusion, irritability, disorientation, lack of control, and anxiety, thus consuming the energy needed for the process of restoration of health(3). Of these boxes, one has no door and on the other, the door would be kept closed only in case of respiratory isolation. Furthermore, the unit features infusion pumps, oxygen transport bullet, litter, scale, gas meter appliances, an X-ray machine, and cleaning equipment such as a washer and floor polisher, in addition to handsets of the professionals working in the sector. Because of the inability to position the decibel meter in the center of the rooms and at a distance of 1 m from the ceiling (as recommended by the literature)(4) due to the large influx of professionals and the specific routine of the service and physical arrangement of the area, we opted for individualized assessment in the six beds, that is, in each patient unit. In an extra measurement, during the admission of a child in a gastric transposition postoperative condition, the value of 79 dBA was obtained, due to communication between professionals, furniture being dragged, and equipments alarming.
With the reduction of the patient's clinical complexity and the amount of equipment used in such patient units, it is found that the number of procedures and actions performed by the multidisciplinary team is lower than in other patient units. More specifically, the average sound pressure level is increased by 8.669 dBA when passing from 4am to 8am. The incidence of cardiac arrhythmias was documented, and the safety of the electrolyte repletion protocol was evaluated by determining and comparing proportions of values for serum electrolyte concentration that were above the desired range.
On a constate l’incidence des arythmies cardiaques et on a evalue l’innocuite du protocole de recharge electrolytique en determinant et en comparant les proportions des valeurs du taux serique d’electrolyte qui etaient au-dessus de la plage des valeurs desirees. Patients requiring renal replacement therapy, those with a diagnosis of diabetic ketoacidosis, those weighing less than 45 kg, and those who died during surgery or during the ICU stay were excluded. Bedside nurses were responsible for following the protocol and for preparing and administering the electrolyte replacement doses. Morning serum concentration was chosen as a proxy for daily serum concentrations within the desired range because morning values were systematically available for all patients, and their measurement was not affected by implementation of the protocol.
No differences in the proportions of serum magnesium, phosphorus, and calcium values within the normal range were observed, despite the fact that more patients in the protocol group received magnesium and phosphorus supplementation (Figure 1).
Given that supplementation by other routes was similar between groups, it is unlikely that these electrolytes influenced the results. The use of this protocol seemed safe, as it did not cause above-normal serum concentration of potassium, magnesium, phosphorus, or calcium. The glass panels facilitate the visualization of children and, consequently, increase the capacity of observation and supervision.
The measurement was performed in a non-concurrent way due to the existence of only one decibel meter.
This value was not part of the statistical analysis because it was measured at that time only for comparison with other values. With this, there is also a reduction in the median of SPL of these units compared to others, which raises reflection on the influence of noise coming from the professionals during daily care activities. Estabelece o Regulamento Tecnico para o Funcionamento dos Servicos de Tratamento Intensivo e sua respectiva classificacao de acordo com o grau de complexidade, capacidade de atendimento e grau de risco inerente ao tipo de atendimento prestado.
For patients with multiple ICU admissions during the study period, only the first admission was considered.
Samples were drawn and electrolyte concentrations measured by the hospital’s laboratory according to the same methods throughout the study. The ethics committee for health research in humans of the Centre hospitalier universitaire de Sherbrooke and Universite de Sherbrooke approved the study.
In both groups, coronary artery bypass grafting was the main indication for surgery, and the majority of patients underwent extracorporeal circulation.
The study was limited by its retrospective design and the comparison of only daily serum electrolyte concentrations. A more aggressive dosing strategy may be warranted to improve the effectiveness of the protocol with regard to magnesium and phosphorus. The selection of measurement sites was performed from the physical plant of the unit, obtained by the researchers. Yet the previously mentioned units are influenced by external noise since both have windows, which, although they remain closed, allow the entry of noise from the corridor of the hospital to the patient's unit. During the 2-year study period, the medical staff was stable, with no new ICU attending physicians or cardiac surgeons added to the team. The duration of cardiopulmonary bypass was longer in the control group than in the protocol group (135 versus 124 min). We noticed that, in many cases, a single supplementary dose of the electrolytes, as suggested by the protocol, was insufficient to normalize serum concentrations. Although morning sampling does not necessarily reflect the electrolyte concentrations throughout the day, these values were chosen because they were systematically available for all patients and were not affected by implementation of the protocol. It has no central monitoring for preventing equipment alarms to be programmed to a milder sound level. The incidence of cardiac arrhythmias (atrial fibrillation, cardiac arrest, ventricular fibrillation, ventricular tachycardia, or torsades de pointe) during the hospital stay (ICU and ward) was also compared.
Safety analyses were limited to evaluation of serum electrolyte concentrations and arrhythmias. Finally, education of the nursing staff is required to enhance the measurement of serum electrolyte concentration following potassium repletion. Adherence to monitoring guidelines set out in the protocol was evaluated by documenting the proportion of serum potassium concentration measurements ordered within 6 ± 2 h after repletion, as required by the electrolyte protocol. The safety of the protocol was evaluated by comparing the mean proportion of morning serum electrolyte concentration values above the desired range and the proportion of calcium–phosphate product values greater than 2.2 mmol2\L2. As such, calcium repletion could be eliminated from the electrolyte repletion protocol to limit the costs associated with monitoring serum calcium concentration.
Finally, the study focused on patients undergoing cardiac surgery, and potential extrapolation of effectiveness and safety to other patient populations is therefore limited. Finally, follow-up measurement of serum potassium concentration 6 ± 2 h after a supplemental dose was performed only 49.6% of the time.
No conclusions can be drawn concerning the lower trend for calcium–phosphate product in the protocol group, as the clinical implications of this effect are unknown in the acute care setting.



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