Double Pumping Vasoactive Drugs

A significant number of our critical care patients are dependent on vasoactive drugs, so it is worth reviewing the process for managing these infusions during inter-hospital transfers.

pastedgraphic-2

The priming volume of the distal lumen of a central line is 0.44mls. Therefore an infusion running at 10mls / hour could take approximately 3 minutes to reach the patient if started de novo. The half-life of inotropes such as adrenaline and noradrenaline is short, approximately 1 minute. This leaves the patient vulnerable to a period of hypotension. Corrective bolusing of vasoactive drugs is not recommended as it can lead to large, and potentially detrimental, swings in blood pressure. Therefore a smooth transition between syringe pumps is recommended to maintain haemodynamic stability.

There are a number of different methods for double pumping but one suggested protocol is as follows:

  1. Leave infusion number 1 running at its current rate (100%)
  2. Commence infusion number 2 at 50% of the rate of infusion number 1
  3. Wait for a small kick in blood pressure to indicate that the second infusion is reaching the patient. This can be up to but should not exceed SBP 20mmHg
  4. Immediately increase infusion number 2 to 100% (the current rate of infusion 1) and reduce infusion number 1 back to 50%.
  5. Reduce infusion 1 back to zero incrementally over a few minutes ensuring that BP doesn’t drop.

Tips and tricks

  1. Avoid the use of a 3-way tap if you have enough ports to manage without. Three-way taps increase the complexity of the process and the likelihood of an error. No matter how intelligent you think you are, 3-way taps have a habit of embarrassing you. If you really must use a 3-way tap make sure both taps are “on” to the patient during the process and then make sure the correct tap is left “on” at the end.
  2. Dedicate a member of the HEMS team to the double pumping process and avoid being interrupted during it.
  3. Use a dedicated line for vasoactive drugs to prevent inadvertent bolusing
  4. Label the line and the syringe driver clearly to prevent confusing the vasoactive drug with sedation (which can be, and often is, bolused)
  5. If you are about to embark on a long transfer you may want to replace a single strength vasoactive drug with double strength. Take this into account when double pumping. If infusion 2 is double strength it will need to be started at 25% of infusion 1 and then increased to 50% once the BP kick is seen.
  6. Be patient. Depending on the infusion rate and the dead space in the catheter lumen, the process can take several minutes. It is worth taking the time to do it smoothly rather than trying to speed it up by increasing infusion rates or bolusing.

Further reading:

Practical considerations in the administration of i ntravenous vasoactive drugs in the critical care set ting the double pumping or piggyback technique–part oneIntensive and Critical C

An in vitro evaluation of infusion methods using a syringe pump to improve noradrenaline administrationActa Anaesthesiologica Scandinavica 2014 GENAY

Practical considerations in the administration of intravenous vasoactive drugs in the critical care settingIntensive and Critical Care Nursing 2004 Morrice

Management of the changeover of inotrope infusions in childrenIntensive and Critical Care Nursing 2004 ArinoChangeovers of vasoactive drug infusion pumps impact of a quality improvement programCritical Care 2007 Argaud

Posted in General PH&RM | Leave a comment

Clinical Governance & Education Day – 7th March

Slide1

Here is a link to the paper that will be discussed at Journal Club

Crewdson et al(1)

Posted in General PH&RM | Leave a comment

Blue Sky Trauma from Umbara Base Hospital Part Two

The following learning points are collated from Regional and Rural hospitals of NSW, Australia, represented here by a single fictional institution – Umbara Base Hospital.  Cases are amalgamated and anonymised (including alteration of patient demographics) such that similarity to real patients is coincidental. 

Below are some high-yield learning points collated from the Umbara Hospital trauma case review meeting.

Beware distracting injury

Patients with blunt trauma with significant orthopaedic injury may have other significant other injuries that are difficult to assess on history and examination and easy to miss.

Here’s a good article on this.

Anchoring bias may also occur, particularly in inter-hospital transfers. These are higher risk patients for missed/delayed diagnosis. Reassess the patient from the start.

Rib injuries in the elderly

Elderly patients (>65) who sustain blunt chest trauma with rib fractures have twice the mortality and thoracic morbidity of younger patients with similar injuries. For each additional rib fracture in the elderly, mortality increases by 19% and the risk of pneumonia by 27%.

CXR is inaccurate in diagnosing the presence and number of rib fractures – hence we should have a low threshold for CT to further assess. Current best practice is the ChIP protocol.

Angioembolisation

Angioembolisation in renal trauma is effective in selected patients.

Trauma CT: Blue arrow is contrast ‘blush’=active bleeding point. Red arrow is perinephric haematoma.

Angioembolisation. Red arrow=coils in arcuate artery of kidney which has stopped the bleeding.

When transferring these patients from smaller hospitals to larger centres, consider whether initial destination should be the ED for rapid re-assessment prior to entering IR suite.

Stab Heart

Anterior and posterior ‘cardiac box’

Penetrating trauma to the ‘cardiac box’ may result in cardiac injury and pericardial effusion leading to tamponade. A permissive hypotension strategy is followed where practical.

Diagnosis may be made by eFAST, bedside formal echo or by CT depending on clinical stability.

Axial CT showing anterior pericardial effusion (blood) from trauma (blue arrow)

Pericardial fat stranding caused by pericardial blood (red arrow)

The key operative finding at the tertiary trauma centre was right ventricle laceration, which was successfully repaired.

Posted in Cases, Trauma | Tagged , , , | Leave a comment

Clinical Governance Day, 24th January 2018

Slide1Guidelines for the management of tracheal intubation in critically ill adults

 

Image | Posted on by | Leave a comment

Education Day – Wednesday 10th January

Education Day 10th Jan

Image | Posted on by | Leave a comment

Blue Sky Trauma from Umbara Base Hospital

The following learning points are collated from Regional and Rural hospitals of NSW, Australia, represented here by a single fictional institution – Umbara Base Hospital.  Cases are amalgamated and anonymised (including alteration of patient demographics) such that similarity to real patients is coincidental. 

Below are some high-yield learning points collated from the Umbara Hospital trauma case review meeting.

Chest drains

Always check the chest drain with a CXR – particularly check for the drain’s position and for complications such as kinking, as can be seen in this left sided CXR.

Pneumothorax is often associated with subcutaneous emphysema (free air in the tissues under the skin). It feels like bubble-wrap and looks like this on CT. Don’t press too hard though – it’s likely there are rib fractures underlying the air and they are extremely painful!

Elderly trauma

Trauma in older patients is increasing with our ageing population here in Umbara – ever improving management of chronic health conditions means people are living longer. It is difficult to predict mortality in elderly trauma and hence some scoring systems exist.

Geriatric Trauma Outcome: Age + (2.5x ISS) + 22 (if PRBCs administered)

Mortality: 205=75%, 233=90%, %, 252= 95%, 310=99%.

These scoring systems may help guide discussions with patients and their families in the future.

Non-accidental Injury in Children

Data from the UK Trauma Audit and Research Network (TARN) showed that 2.5% of children in their database had suspected child abuse underlying their injuries. 97.7% of these children were aged <5yrs; 76.3% were aged <1yr. Injury severity score (ISS) was also greater in patients with suspected child abuse: they were 1.7x as likely to have an ISS score >15.

You can read more in this free-to-access paper.

What can we do?

IDENTIFY risk factors through history, examination, observation.

LISTEN and watch parent-child interaction

CONSIDER the possibility

DON’T DISMISS non-accidental injury as a possibility due to lack of physical findings

DOCUMENT carefully, clearly and contemporaneously

PREVENT  by linking with services

KNOW your legal requirements for reporting

Risk Factors for NAI

Although non-accidental injury can occur in the absence of these factors, there are several factors which have associations with non-accidental injury.

In the child:

  • Chronic illness, disability or developmental problem
  • Prematurity
  •  Age of child
  • “Difficult” behaviour

Parent/Family:

  • Unwanted pregnancy
  • Young parents
  • Single parent family
  • Relationship problems
  • Exposure to drug and alcohol abuse and/or family violence
  • Low socioeconomic status
  • Social isolation
  • Physical or mental illness in a parent

Other concerning features:

  • Poor hygiene
  • Dirty clothes
  • Missing a lot of school
  • Previous contact with FACS / CPU

Clinical/Attendance features:

  • Delay in presentation
  • Injury not explained by story
  • Inconsistent with developmental ability (know developmental milestones! Here’s a quick reminder)
  • Inconsistencies in history and changes over time
  • Unexplained or unwitnessed fall with neglect
  • Previous suspicious injuries
  • Unusual parent – child interaction
  • Failure To Thrive (FTT)
  • Resuscitation efforts caused injuries
  • Patterned bruise/burns; certain distribution
  • Spiral/transverse long bone fractures, particularly in non-mobile children

Child Protection Courses: http://www.heti.nsw.gov.au/Courses/Child-Protection/

Non-accidental injury blog & podcast: http://stemlynsblog.org/child-protection/

From the Horse’s Mouth

When Umbara Base Hospital’s own Dr Tallie fell from her horse earlier this month and ended up being treated in her own Emergency Department, she was in a unique position in being able to provide constructive feedback around her own care with a full understanding of the processes of the hospital.

This month we invited her to share her thoughts at the trauma case review meeting and were delighted to learn the following.

  • Prehospital methoxyflurane is an excellent analgesic and she was very grateful for it
  • She found the experience had increased her trust: she was happy to put her life in hands of the staff of Umbara Base Hospital and has a renewed appreciation for them all as a result
  • She particularly noted that nurses are awesome (both during her ED and ICU stays): she added,  “it’s the ‘little things’ that make all the difference”.
  • Having experienced both, she found regional block much better in the pain management of her rib fractures than drugs.
  • Overall she was dismayed to realise just how long bones take to heal.

Huge thanks to Dr Tallie for her insights – we wish her well on her recovery.

Posted in Cases, Trauma | Tagged , , , | Leave a comment

Difficult Missions: The Hospital Primary

Drs Natalie May, Geoff Healy, and Cliff Reid discuss missions in which the prehospital medical team is diverted to a hospital because their patient has been moved from scene to a (non-major) hospital.

While one might expect these missions to be easier from the point of view of having the hospital environment and resources to hand, they can in fact be more complicated and take longer than typical prehospital (primary) and interhospital (secondary) missions.

There are a number of reasons for this:

  • Timing – the retrieval team (RT) usually arrives shortly after the patient, disrupting the hospital team (HT)’s initial assessment and management
  • Clash of goals – RT focuses on rapid management of essentials and extrication of the patient to a trauma centre. HT often focused on more traditional ATLS management
  • Assumptions – RT uniform and appearance may make the HT assume the RT are the paramedics who brought the patient in, and dismiss their attempts to offer advanced interventions and leadership
  • Crowd control – large number of good people keen to do things, can paradoxically make interventions much longer to perform compared with a small well rehearsed RT working to mutually understood operating procedures.

Nat, Geoff and Cliff discuss these challenges and how to tackle them, including how to introduce yourself, what language to use, how to integrate yourself into the team and offer support and if necessary leadership, the importance of a collaborative approach, and the critical contribution of the RT paramedic in making all this happen smoothly.

Resources referred to in the podcast

Prehospital Advanced Non-Technical Skills Handout (PANTS) Handout

Graded Assertiveness in the TeamSTEPPS® program

101 Reflective Lessons from a Year with Sydney HEMS

Part One: Education

Part Two: Human Factors

Part Three: Clinical

Part Four: More Clinical

Part Five: Leadership

Part Six: Self Care

Part Seven: Life Lessons

 

Posted in General PH&RM, Podcasts | Tagged ,