Automatic versus manual changeovers of norepinephrine infusion pumps in critically ill adults: a prospective controlled study

Abstract

BackgroundNorepinephrine is a key drug for treating shock but has a short half-life that requires continuous intravenous administration to maintain the constant plasma concentration needed to obtain a stable blood pressure. The small volume of the syringes used in power infusion pumps requires frequent changeovers, which can lead to norepinephrine flow interruptions responsible for hemodynamic instability. Changeovers from the nearly empty to the full syringe can be performed manually using the quick change technique (QC) or automatically using smart infusion pumps (SIP) that link two syringes. The purpose of our study was to evaluate the hypothesis that, compared to QC, SIP for norepinephrine changeovers was associated with less hemodynamic instability.MethodsAfter information of the patient or next of kin, patients receiving norepinephrine for shock were allocated to QC or SIP changeovers. QC changeovers were performed by a nurse, who started a new loaded pump when the previous syringe was nearly empty. SIP changeovers were managed automatically by SIP workstations. The primary outcome was the proportion of changeovers followed by a ≥20 % drop in mean arterial pressure (MAP).Results411 changeovers were performed, 193 in the 18 patients allocated to QC and 218 in the 32 patients allocated to SIP. Baseline patient characteristics were similar in both groups. The proportion of changeovers followed by an MAP drop ≥20 % was 12.4 % (24/193) with QC and 5.5 % (12/218) with SIP (P = 0.01). By multivariate analysis, two factors were independently associated with a significantly decreased risk of ≥20 % MAP drops during changeovers, namely, SIP (odds ratio, 0.47; 95 % confidence interval, 0.22–0.98) and norepinephrine dosage >0.5 μg/kg/min (odds ratio, 0.39; 95 % confidence interval, 0.19–0.81).ConclusionsThe risk of MAP drops ≥20 % during changeovers can be significantly diminished using SIPs instead of the QC method.Trial registration: Clinicaltrial.gov NCT 01127152

Predictors of haemodynamic instability during the changeover of norepinephrine infusion pumps

“…This result agrees with the few studies published on this topic in which the frequency of haemodynamic incidents related to vasoactive infusion pump changeovers varied from 5 to 38 % [ 2 – 7 , 10 , 11 ]. Obviously, the frequency of these incidents depends on the definition of CNIP-induced haemodynamic instability, which is not consensual [ 2 – 7 , 10 , 11 ]. We chose to define haemodynamic instability as a relative change in MAP rather than an absolute change in MAP.…”

“…low flow rates, entrapped air in the perfusion line, vertical displacements of syringe pumps) [ 2 , 12 – 14 ]. Above all, we used the safest available method to perform CNIP [ 5 , 7 , 8 ]. Indeed, both recent basic evidence and clinical evidence have suggested that the automation of a CNIP method without overlapping the perfusions (i.e.…”

“…Indeed, both recent basic evidence and clinical evidence have suggested that the automation of a CNIP method without overlapping the perfusions (i.e. “quick change”), using smart pumps, better maintains the delivered norepinephrine doses and further improves blood pressure stability during the syringe changeovers [ 5 , 7 , 8 ].…”

“…factors related to the syringe changeover) and random effects (i.e. related to the patient) [ 5 , 7 , 9 ]. The outcome was CNIP-related haemodynamic instability, as defined above.…”

“…60 ml for adults), changeovers of the norepinephrine infusion pumps (CNIPs) generally occur several times a day in an intensive care unit (ICU). Maintaining a constant flow rate during CNIP is challenging, and haemodynamic instability has been reported in up to one-third of vasoactive infusion pump relays [ 2 – 7 ].…”