Minimising haemodynamic lability during changeover of syringes infusing norepinephrine in adult critical care patients: a multicentre randomised controlled trial

Abstract

Background: Arterial pressure lability is common during the process of replacing syringes used for norepinephrine infusions in critically ill patients. It is unclear if there is an optimal approach to minimise arterial pressure instability during this procedures. We investigated whether 'double pumping' changeover (DPC) or automated changeover (AC) reduced blood pressure lability in critically ill adults compared with quick syringe changeover (QC). Methods: Patients requiring a norepinephrine infusion syringe change were randomised in a non-blinded trial undertaken in six ICUs. Randomisation was minimised by norepinephrine flow rate at inclusion and centre. The primary outcome was the frequency of increased/decreased mean arterial pressure (defined by </>15 mm Hg from baseline measurements) within 15 min of switching the syringe compared with QC. Results: Patients (mean age: 64 (range:18e88)) yr were randomly assigned to QC (n¼95), DPC (n¼95), or AC (n¼96). Increased MAP was the commonest consequence of syringe changeovers. MAP variability was most frequent after DPC (89/224 changeovers; 39.7%) compared with 57/223 (25.6%) changeovers after quick syringe switch and 46/181 (25.4%) in patients randomised to receive automated changeover (P¼0.001). Fewer events occurred with QC compared with DPC (P¼0.002). Sensitivity analysis based on mixed models showed that performing several changeovers on a single patient had no impact. Both type of changeover and norepinephrine dose before syringe changeover were independently associated with MAP variations >15 mm Hg. Conclusions: Quick changeover of norepinephrine syringes was associated with less blood pressure lability compared with DPC. The prevalence of MAP variations was the same between AC and QC. Clinical trial registration: NCT02304939.

10 clinical tips for advancing patient safety when using syringe pump systems for microinfusion intravenous drug therapy

“…Recent clinical research has demonstrated that, independent of the changeover strategy used, at least 25% of critical haemodynamic events occurred around changeover when administering norepinephrine to critically ill adult patients. 21 Beside start-up delays, dead volume effects and pressure differences between the i.v. catheter and the newly connected syringe pump also seem to be responsible for the observed under or over infusion.…”

“…Microinfusions are run continuously and fresh infusions are required on a regular basis. Recent clinical research has demonstrated that, independent of the changeover strategy used, at least 25% of critical haemodynamic events occurred around changeover when administering norepinephrine to critically ill adult patients 21 . Beside start-up delays, dead volume effects and pressure differences between the i.v.…”

An analysis of the effect of syringe barrel volume on performance and user perception

“…Syringe is a medical device used to inject liquids into patients. [1][2][3][4][5] The syringe has 3 major components: the plunger, the barrel, and the needle. [6][7][8][9][10] The commonly used materials for the plunger and barrel are polypropylene [11][12][13] and materials for the needle are stainless, titanium, or other coated materials.…”

Effect of central venous pressure on fluid delivery during start‐up of syringe infusion pumps for microinfusion

“…However, this so called microinfusion strategy uses syringe infusion pumps that are associated with considerable start‐up delays of fluid delivery resulting in prolonged lag times of drug effect. This is of particular importance when initiating cardiovascular drugs in hemodynamically unstable patients or during syringe changeover 2,3 …”

“…This is of particular importance when initiating cardiovascular drugs in hemodynamically unstable patients or during syringe changeover. 2,3 In the last two decades researchers have studied different factors which affect the extent of start-up delays in syringe infusion pumps. These factors include flow rate, syringe size and architecture, syringe pump design, infusion line setup, administration of a…”