Early lactate-guided therapy in cardiac surgery patients: a randomized controlled trial

Abstract

Introduction We aimed to audit the prescribing practice on a busy 14-bedd general ICU, and develop standardised practices and tools to improve safety. Prescribing errors occur as commonly as in 10% of UK hospital admissions, costing 8.5 extra bed days per admission, and costing the National Health Service an estimated £1 billion per annum [1]. The majority of these mistakes are avoidable [2]. Methods We audited the daily infusion charts of all patients in three separate spot checks, over 1 week. We assessed all aspects of prescriptions that make them legal and valid, in accordance with national guidance [3]. New procedures were introduced, which included a standardised prescription sticker, with common, preprinted, infusion prescriptions on (noradrenaline, propofol, and so forth), and education on using the new prescription stickers. A month later the audit process was repeated. Results We assessed 129 prescriptions in the fi rst round, and 111 after intervention, demonstrating a 70% improvement in safe prescribing. Only 24% of prescriptions initially fulfi lled best practice criteria, improving to 94% afterwards. We also reduced the number of infusions running without prescription, 7 (6%) versus 24 (19%). See Figures 1 and 2. Conclusion Our audit supports the need for standardised prescribing practices within critical care, especially when dealing with potentially harmful vasoactive/sedative drugs. With a small, cost-eff ective intervention (£20 for 6,200 stickers), we improved prescribing accuracy, and thus patient safety in intensive care. Introduction The theft and tampering of controlled drugs (CDs) remains a prevalent patient safety issue. Sadly there are numerous reports of critical care staff stealing CDs for personal use or fi nancial gain and notably there have been some cases where CDs have been substituted for other medications in order to delay detection of the theft. This creates both the hazard of medication errors and potentially exposes patients to opioid intoxicated healthcare workers. As most critical care staff have access to CDs, when drugs are found to be missing it can be diffi cult to identify the perpetrators. Therefore the implementation of a deterrent which also improves the methods of detection is warranted. ReferencesMethods The Limpet, a device which incorporates a proximity sensor and a camera unit, was installed within the CD cupboard of the critical care unit. Whenever the cupboard was accessed the date and time were recorded and a photograph was taken to identify the staff member. Mock thefts were subsequently undertaken by a designated staff member at random times. This allowed testing of the product to determine the number of times the 'thief' was correctly identifi ed. Publication of this supplement has been supported by ISICEM. M E E T I N G A B S T R AC T SFigure 1 (abstract P1). Accuracy of prescriptions before intervention. Figure 2 (abstract P1). Accuracy of prescriptions after intervention.Critical Care 2014, Volume 18 Suppl 1 http://ccforum.com/supplements/18/S1 © 2014...

Severe Impairment of Microcirculatory Perfused Vessel Density Is Associated With Postoperative Lactate and Acute Organ Injury After Cardiac Surgery

“…42 The cause for postcardiopulmonary bypass lactic acidosis remains unclear, with a number of contributing etiologies that include tissue hypoxia, hyperglycemia, exposure to catecholamines, cardiopulmonary bypass, and mitochondrial dysfunction. [43][44][45] Elevated lactate levels have been previously associated with changes in microcirculatory function, although this cohort appeared to have lactate levels that were much higher than those in previous studies, 3,8,46 Lactate levels were inversely related to PVD, with the highest lactate levels found in patients with the most significantly impaired capillary blood flow (Fig 4). While this study did not allow for a causal relationship to be made, perfusion impairments can clearly result in hypoxic hyperlactatemia.…”