Assessment and Impact of Intravenous Medication Fluid Administration in Critically Ill Patients With Acute Respiratory Failure

Abstract

Background: Positive fluid balance early in critical illness is associated with poor outcomes. Reducing intravenous medication volume may mitigate volume overload. Objective: Assessment of fluid and medication administration and clinical outcomes in acute respiratory failure. Methods: Single-center, prospective observational study of hemodynamically stable adult patients in a medical intensive care unit (MICU) with acute respiratory failure. Results: Median cumulative total intake volume was 12 890 (interquartile range [IQR] = 8654-22 221) mL (n = 27), and median cumulative intravenous medication volume was 3563 (IQR = 2371-9412) mL over the first 7 days. Medication volume accounted for 27.6% of aggregate fluid volume. Median daily intravenous medication volume administered was 591 (IQR = 339-1082) mL. Cumulative fluid volume was associated with reduced ventilator-free days ( r2 = −0.393; P = 0.043), and cumulative fluid volumes during the first 3 and 7 days were associated with increased MICU length of stay (LOS ± standard error 0.73 ± 0.35 d/L, P = 0.047, and 0.38 ± 0.16 d/L, P = 0.021, respectively). Cumulative medication volume administered significantly reduced the likelihood of mechanical ventilator liberation (hazard ratio [HR] = 0.917; 95% CI: 0.854, 0.984; P = 0.016) and MICU discharge (HR = 0.911; 95% CI: 0.843, 0.985; P = 0.019). Small-volume infusion may decrease cumulative intravenous medication volume by 38%. Conclusion and Relevance: Intravenous medication diluent contributes substantially to total fluid intake in patients with acute respiratory failure and is associated with poor outcomes. Reduction of intravenous medication fluid volume to improve clinical outcomes should be further investigated.

Impact of a Pharmacist-Driven Medication Diluent Volume Optimization Protocol on Fluid Balance and Outcomes in Critically Ill Patients

“…The authors estimated a 38% reduction in cumulative IV medication diluent volume with the implementation of SVI and found cumulative fluid volume was associated with ventilator-free days and medical ICU length of stay. 16 The present study found a reduction of 29.9% and 29.6% in cumulative vasopressor and antimicrobial diluent volumes, respectively. These findings align with those estimated in the aforementioned study; however, not all vasopressor and antimicrobial medication diluent volumes were able to be optimized with the current study protocol due to operational and logistical limitations (Supplemental Table 1).…”

“…27 One prior study by Gonzales et al investigated the impact of medication diluent volume optimization and was a noninterventional study of IV medication fluid administration in critically ill patients with acute respiratory failure. 16 This study found antimicrobial, electrolyte, sedative, and analgesic medications contributed the most to medication diluent volume. The authors estimated a 38% reduction in cumulative IV medication diluent volume with the implementation of SVI and found cumulative fluid volume was associated with ventilator-free days and medical ICU length of stay.…”

“…16 Lastly, prior studies investigating medication diluent volume optimization have been observational and non-interventional, only estimating potential volume savings. 16 Therefore, operational limitations and impact of patient admission source were not considered and may overestimate the true ability of broad SVI changes to spare medication diluent volumes. The limited literature available and inconclusive findings highlight the need for further research on medication diluent optimization as an approach to fluid stewardship and curbing VO.…”

“…Additionally, previous studies have implicated vasopressor and antimicrobial-associated diluent volumes as significant contributors to volume status. 10,16 These specific vasopressor and antimicrobial agents were selected as part of the protocol based on these prior studies, their frequency of use within general critically ill populations, and feasibility related to our institution's pharmacy operations and medication distribution logistics. Vasopressors were concentrated at time of initiation and antimicrobials were transitioned to small volume infusions upon study inclusion based on available safety and stability evidence.…”

“…[11][12][13][14][15] Recently, Gonzales et al conducted a prospective, observational study estimating the impact of utilizing small-volume infusions (SVI) for intermittent IV medications. 16 They found IV medication volume accounted for 27.6% of aggregate fluid volume, and cumulative fluid volume was associated with negative clinical outcomes. Furthermore, they estimated transitioning to SVI would result in a 38% reduction in cumulative IV medication volume.…”