Evaluation of an Electrolyte Repletion Protocol for Cardiac Surgery Intensive Care Patients

Couture, J.; Létourneau, Anne; Dubuc, Annie

doi:10.4212/cjhp.v66i2.1231

Cited by 13 publications

(25 citation statements)

References 25 publications

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“…Studies of standardized potassium repletion protocols have not demonstrated a reduction in atrial tachyarrhythmias (14, 15), while multiple trials of magnesium supplementation for POAF prophylaxis have demonstrated no clear benefit (16, 17, 24). Our findings help to explain the lack of efficacy of potassium and magnesium supplementation in these other reports, in that the maintenance of near-normal electrolyte levels was not sufficient to reduce the rate of POAF.…”

Section: Commentmentioning

confidence: 99%

“…The few existing studies of intensive care unit (ICU) electrolyte repletion protocols have demonstrated tighter control of postoperative potassium levels but no effect on the occurrence of POAF (14, 15). Intraoperative and postoperative magnesium administration has also been evaluated as an AF prophylaxis agent in many small and heterogeneous studies, with conflicting but overall limited efficacy (16, 17).…”

mentioning

confidence: 99%

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Potassium and Magnesium Supplementation Do Not Protect Against Atrial Fibrillation After Cardiac Operation: A Time-Matched Analysis

Lancaster

Schill

Greenberg

et al. 2016

The Annals of Thoracic Surgery

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Introduction Despite a lack of demonstrated efficacy, potassium and magnesium supplementation are commonly thought to prevent postoperative atrial fibrillation (POAF) after cardiac surgery. Our aim was to evaluate the natural time course of electrolyte level changes after cardiac surgery and their relationship to POAF occurrence. Methods Data were reviewed from 2041 adult patients without preoperative AF who underwent CABG and/or valve surgery between 2009 and 2013. In patients with postoperative AF, the plasma potassium and magnesium levels nearest to the first AF onset time were compared to time-matched electrolyte levels in patients without AF. Results POAF occurred in 752 patients (36.8%). At the time of AF onset or the matched time point, patients with POAF had higher potassium (4.30 vs. 4.21 mmol/L, p<0.001) and magnesium (2.33 vs. 2.16 mg/dL, p<0.001) levels than controls. A stepwise increase in AF risk occurred with increasing potassium or magnesium quintile (p<0.001). On multivariate logistic regression analysis, magnesium level was an independent predictor of POAF (OR 4.26, p<0.001), in addition to age, Caucasian race, preoperative beta blocker use, valve surgery, and postoperative pneumonia. Prophylactic potassium supplementation did not reduce the POAF rate (37 vs. 37%, p=0.813), while magnesium supplementation was associated with increased POAF (47 vs. 36%, p=0.005). Conclusion Higher serum potassium and magnesium levels were associated with increased risk for POAF after cardiac surgery. Potassium supplementation was not protective against POAF, while magnesium supplementation was even associated with increased POAF risk. These findings help explain the poor efficacy of electrolyte supplementation in POAF prophylaxis.

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Section: Commentmentioning

confidence: 99%

mentioning

confidence: 99%

Potassium and Magnesium Supplementation Do Not Protect Against Atrial Fibrillation After Cardiac Operation: A Time-Matched Analysis

Lancaster

Schill

Greenberg

et al. 2016

The Annals of Thoracic Surgery

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“…The small percentage (23.2% overall and 35% when rule-of-thumb estimation was provided) of potassium replacements in our study that resulted in attainment of the target serum concentration is within the range reported for other cohorts of critically ill patients in whom replacement was determined by using or not using a replacement protocol. [4][5][6][7][8][9] Before beginning use of a nurseinitiated, evidence-based order form in an MICU, Owen et al 5 observed achievement of the target serum potassium concentration in 18% of cases. After implementation, the percentage of target attainment increased to 72%.…”

Section: Discussionmentioning

confidence: 99%

“…Laboratory tests to determine serum potassium concentration after potassium replacement were part of the protocol in studies in which a protocol was used. [4][5][6]8 Hoekstra et al 4 reported that use of a nurse-centered, computerized potassium replacement protocol was associated with reduced rates of hyperkalemia and hypokalemia and ensured that all patients had serum levels of potassium determined after potassium replacement. Serum potassium concentrations should be monitored at least every 4 hours after potassium replacement if indications of abnormal potassium levels are present and every day or other day if patients are asymptomatic.…”

Section: Discussionmentioning

confidence: 99%

Effectiveness and Safety of Potassium Replacement in Critically Ill Patients: A Retrospective Cohort Study

Hammond

King

Kathe

et al. 2019

Critical Care Nurse

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Background Rules of thumb for potassium replacement are used in intensive care units despite minimal empirical validation. Objective To evaluate the effectiveness and safety of rule-of-thumb potassium replacement in critically ill patients with mild and moderate hypokalemia. Methods A retrospective, observational study was done of patients with mild (potassium, 3-3.9 mEq/L) and moderate (potassium, 2-2.9 mEq/L) hypokalemia admitted to a medical intensive care unit who received potassium replacement. Expected and actual frequencies of replacement that achieved target potassium concentrations (≥ 4 mEq/L) were compared by using a c 2 test. Logistic regression analysis was used to assess whether rule-of-thumb administration affected the probability of target attainment within 24 hours of replacement. Results Serum potassium concentrations were checked within 24 hours after potassium replacement on 354 of 577 days (61.4%) when replacement was provided. Concentrations were within target range in 82 instances (23.2%). Of 62 episodes of replacement expected to achieve the target according to the rule-ofthumb estimation, 22 did (35%). Rule-of-thumb administration was associated with greater likelihood of target attainment (odds ratio, 2.12; 95% CI, 1.18-3.85; P = .01). This difference in likelihood remained significant after adjustment for covariates (odds ratio, 2.18; 95% CI, 1.04-4.56; P = .04). Conclusion In critically ill patients given potassium replacement without regard to a formal protocol, the target serum potassium concentration was achieved more often than expected according to the rule-of-thumb estimation but less than one-third of the time. (Critical Care Nurse. 2019;39[1]:e13-e18)

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“…76 Electrolyte panels account for the highest frequency and volume of samples 77 despite evidence that correction of certain electrolyte abnormalities has no effect on patient outcome. 78 Statistically, as the number of tests performed increases, the number of falsepositive results will also increase. Thus, monitoring patients without clinical suspicion for a laboratory abnormality may lead to erroneous results and inappropriate interventions, compounding iatrogenic injury.…”

Section: Eq 1: Domentioning

confidence: 99%

Less Is More in the ICU: Resuscitation, Oxygenation and Routine Tests

Gopalratnam

Forde

O'Connor

et al. 2016

Semin Respir Crit Care Med

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The intensive care unit (ICU) was initially developed in the 1950s to treat patients who required invasive respiratory support and hemodynamic resuscitation. Since the beginning, ICU medicine has focused on maintaining sufficient arterial blood flow and oxygenation to provide adequate tissue oxygen delivery to forestall or reverse organ failure. Over time, ICU medicine became more intensive, with the administration of many diagnostic tests and monitors, invasive procedures, and treatments, often with scant evidence of benefit associated with them. An alternative perspective holds that ICU patients may represent a group of patients that is especially vulnerable to iatrogenic harm. We outline a case that presents common ICU dilemmas and discusses current data that propose that "less is more" when making key diagnostic or therapeutic choices in the ICU. Further, we assert that providers should skeptically consider common ICU interventions, trying to account for the potential unintended consequences of interventions. Finally, we suggest that the guiding principle of ICU medicine should be primum non nocere: in delicate situations, it may be better not to do something, or even to do nothing, rather than risk causing harm.

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Evaluation of an Electrolyte Repletion Protocol for Cardiac Surgery Intensive Care Patients

Abstract: Background: Implementation of electrolyte repletion protocols to facilitate and ensure the safety of electrolyte control is common practice in intensive care units (ICUs). However, few protocols have been evaluated and validated.

Cited by 13 publications

References 25 publications

Potassium and Magnesium Supplementation Do Not Protect Against Atrial Fibrillation After Cardiac Operation: A Time-Matched Analysis

Potassium and Magnesium Supplementation Do Not Protect Against Atrial Fibrillation After Cardiac Operation: A Time-Matched Analysis

Effectiveness and Safety of Potassium Replacement in Critically Ill Patients: A Retrospective Cohort Study

Less Is More in the ICU: Resuscitation, Oxygenation and Routine Tests

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