A3 Rapid Fire: Managing the Medication Danger Zone - R Carr, T Northway and K Thibault
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Transcript of A3 Rapid Fire: Managing the Medication Danger Zone - R Carr, T Northway and K Thibault
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March 2012
Standard Concentrations for Continuous Infusions
And Improving Opioid Safety in
Critically Ill ChildrenRoxane Carr PharmD, BCPS, FCSHP
Supervisor, Clinical Pharmacy Critical Care Program&
Tracie Northway, RN, MSN, CNCCP(C)Project Manager, Strategic Implementation, BC Children’s & Sunny Hill
&Kris Thibault RN, BScN
Quality & Safety Leader Critical Care Program
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*Note: Patient weight range of 2 -157 kg
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Pediatric Critical Care
•Delivery of “high risk” continuous infusion medications occurs commonly–Opioids–Benzodiazepines–Vasopressors/inotropes
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Rule of Six Mixing:
•6 X pt weight (kg) = X mg•Put X mg into 100 mL of fluids(6 mg/kg/100 ml IV fluid)
•1 ml/hr delivers 1 mcg/kg/minute
•Concentration different for each patient but rate the same
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Practice makes perfect?
Order reads: Norepinephrine at 0.1 mcg/kg/min
What you need to know…–J.M. weighs 26 kg –Norepinephrine comes as 1 mg/ml–Mix 0.6 mg/kg in 100 ml of D5W–1 ml/hr delivers 0.1 mcg/kg/minute
How much drug do you need to make the infusion?What is your final concentration?
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Practice makes perfect?
Now calculate it based on a 50 mL volume.
Do the math:• 0.6 mg/kg x 26 kg = 15.6 mg•15.6 mg / Norepinephrine 1 mg/mL = 15.6 mL•D5W 100 mL. Remove 15.6 mL and add norepinephrine. Final concentration is 15.6 mg/100mL = 0.156 mg/mL
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Standard Concentration
Order reads: Norepinephrine at 0.1 mcg/kg/minWhat you need to know…
J.M. weighs 26 kg
Norepinephrine standard concentrations:•Neonatal: 25 mcg/mL•Child: 50 mcg/mL•> 30 kg or fluid restricted: 200 mcg/mL
Which one do you select?
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Selection Guidelines
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Standard Concentrations
Mixing recipe:
•50 mcg/mL
•To make 50 mL of 50 mcg/mL
•Draw up 2.5mL of 1 mg/mL norepinephrine
•Add to 47.5 mL D5W
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Standard Concentrations
Programming pump
•Calculate infusion rate:Rate (mL/hr) = dosage (mcg/kg/min) X 60 min/hr X pt wt (kg)
Concentration (mcg/mL)
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1.561.872.182.502.813.126.249.36
12.4815.60
26
DOSE(mcg/kg/
min)0.050.060.070.080.090.100.200.300.400.50
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Standard Concentrations
Program pump
•Enter patient weight
•Select drug and concentration from drug library in pump
(or scan barcode)
•Enter dosage (mcg/kg/min)
•Pump calculates infusion rate
•Confirm using equation
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•Advantages:– Set rate for dose–Minimized fluid volume issues
•Disadvantages:–Different mixing–Errors in calculation –At time exceeded recommended safe concentrations for infusion–Not always rule of “6”
ComparisonWeight Based Concentration Standard Concentrations
•Advantages:–Standardized approach–Concentration always same–Decrease calculation & compounding errors
•Disadvantages:–Visual rate to dose identification difficult– Wrong concentration pick
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Timeline
2006 – Dopamine vial shortage Switch to premade standard conc 2007 – Standard concentrations: epinephrine & milrinone - Smart pumps- Standard concentrations for all IV medications determined - Drug library created
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Timeline
2008 - Standard concentrations: morphine & midazolam-Secured storage
2010 - Barcoding capabilities
2011/12 – Ongoing review of standards (number and concentrations)
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Implementation strategies
• Collaborative effort between PICU and pharmacy
• Communication & interprofessional education for emergency, PICU & surgical suites
• Clinical support• Prompts & reminders• Responsive to feedback
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Opioids
•Standard concentrations–Morphine (pre-mixed by pharmacy)–Hydromorphone–Fentanyl
•Bolus from continuous infusion syringe via pumps
•Education
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Results
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Results
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Results
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Summary
•Multipronged approach to improve safety•Standard concentrations decrease mixing errors•Smart pumps decrease pump programming errors•Bar coding decrease pump programming errors and drug selection errors
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Summary - Opioids
•Multiple small changes to system over 1-2 yrs•Addressed variety of aspects
– Mixing– Administration– Monitoring
•Sustainable: – With each change review & reinforce previous
practice changes
Successful large sustained practice change