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Kim DW, Kim HJ, Kim JM, Jeon YH, Han M, Seong EY, Song SH. Effect of Phoxilium on prognostic predictors in patients undergoing continuous venovenous hemodiafiltration. Kidney Res Clin Pract 2021; 40:457-471. [PMID: 34370933 PMCID: PMC8476306 DOI: 10.23876/j.krcp.20.217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 05/11/2021] [Indexed: 11/04/2022] Open
Abstract
Background Phosphorus-containing dialysis solution is used to prevent hypophosphatemia in patients undergoing continuous venovenous hemodiafiltration (CVVHDF). This study evaluated the effect of phosphorus-containing dialysis solution on mortality in patients undergoing CVVHDF based on changes in phosphorus and red cell distribution width-coefficient of variation (RDW-CV) levels. Methods We included 272 patients with acute kidney injury (AKI) who underwent CVVHDF at the medical intensive care unit from 2017 to 2019 and classified them according to Phoxilium (Baxter Healthcare Ltd.), as a phosphorus-containing dialysis solution, use within 48 hours after CVVHDF initiation. Clinical data were collected at baseline and 48 hours after CVVHDF initiation. The primary outcome was all-cause mortality during the follow-up period. Results The non-Phoxilium (NP) group had higher phosphorus and lower RDW-CV levels than the Phoxilium (P) group (phosphorus, 7.3 ± 4.3 vs. 5.0 ± 2.8 mg/dL; RDW-CV, 14.6 ± 1.9 vs. 15.7 ± 2.6%; all p < 0.001). In the multivariable Cox proportional hazard regression of the NP group, an increase in phosphorus and RDW-CV at 48 hours of CVVHDF was associated with mortality (delta phosphorus: median, >0 mg/dL vs. <-2.0 mg/dL; hazard ratio [HR], 8.62; 95% confidence interval [CI], 2.10-35.32; p = 0.003/delta RDW-CV: median, >0% vs. <-0.2%; HR, 4.34; 95% CI, 1.49-13.18; p = 0.008). Meanwhile, in the P group, an increase in delta RDW-CV was associated with mortality (delta RDW-CV: >0% vs. >-0.2% and <0%; HR, 2.65; 95% CI, 1.12-6.24; p = 0.03), while an increase in delta phosphorus was not. Conclusion In patients with AKI undergoing CVVHDF, the risk factors for all-cause mortality differed according to the initial phosphorus levels and use of Phoxilium.
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Affiliation(s)
- Da Woon Kim
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Hyo Jin Kim
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Jin Mi Kim
- Department of Biostatistics, Clinical Trial Center, Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - You Hyun Jeon
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Miyeun Han
- Department of Internal Medicine, Hallym University Hangang Sacred Heart Hospital, Seoul, Republic of Korea
| | - Eun Young Seong
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Sang Heon Song
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
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Pistolesi V, Zeppilli L, Fiaccadori E, Regolisti G, Tritapepe L, Morabito S. Hypophosphatemia in critically ill patients with acute kidney injury on renal replacement therapies. J Nephrol 2019; 32:895-908. [PMID: 31515724 DOI: 10.1007/s40620-019-00648-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 09/06/2019] [Indexed: 02/08/2023]
Abstract
Hypophosphatemia is a common but often underestimated electrolyte derangement among intensive care unit (ICU) patients. Low phosphate levels can lead to cellular dysfunction with potentially relevant clinical manifestations (e.g., muscle weakness, respiratory failure, lethargy, confusion, arrhythmias). In critically ill patients with severe acute kidney injury (AKI) renal replacement therapies (RRTs) represent a well-known risk factor for hypophosphatemia, especially if the most intensive and prolonged modalities of RRT, such as continuous RRT or prolonged intermittent RRT, are used. Currently, no evidence-based specific guidelines are available for the treatment of hypophosphatemia in the critically ill; however, considering the potentially negative impact of hypophosphatemia on morbidity and mortality, strategies aimed at reducing its incidence and severity should be timely implemented in the ICUs. In the clinical setting of critically ill patients on RRT, the most appropriate strategy could be to anticipate the onset of RRT-related hypophosphatemia by implementing the use of phosphate-containing solutions for RRT through specifically designed protocols. The present review is aimed at summarizing the most relevant evidence concerning epidemiology, prognostic impact, prevention and treatment of hypophosphatemia in critically ill patients with AKI on RRT, with a specific focus on RRT-induced hypophosphatemia.
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Affiliation(s)
- Valentina Pistolesi
- UO Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università di Roma, Viale del Policlinico, 155, 00161, Rome, Italy.
| | - Laura Zeppilli
- UO Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università di Roma, Viale del Policlinico, 155, 00161, Rome, Italy.,UOC Nefrologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Enrico Fiaccadori
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Giuseppe Regolisti
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Luigi Tritapepe
- UO Anestesia e Terapia Intensiva in Cardiochirurgia, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università di Roma, Rome, Italy
| | - Santo Morabito
- UO Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università di Roma, Viale del Policlinico, 155, 00161, Rome, Italy
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Benfield CB, Brummond P, Lucarotti A, Villarreal M, Goodwin A, Wonnacott R, Talley C, Heung M. Applying lean principles to continuous renal replacement therapy processes. Am J Health Syst Pharm 2015; 72:218-23. [PMID: 25596606 DOI: 10.2146/ajhp140257] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The application of lean principles to continuous renal replacement therapy (CRRT) processes in an academic medical center is described. SUMMARY A manual audit over six consecutive weeks revealed that 133 5-L bags of CRRT solution were discarded after being dispensed from pharmacy but before clinical use. Lean principles were used to examine the workflow for CRRT preparation and develop and implement an intervention. An educational program was developed to encourage and enhance direct communication between nursing and pharmacy about changes in a patient's condition or CRRT order. It was through this education program that the reordering workflow shifted from nurses to pharmacy technicians. The primary outcome was the number of CRRT solution bags delivered in the preintervention and postintervention periods. Nurses and pharmacy technicians were surveyed to determine their satisfaction with the workflow change. After implementation of lean principles, the mean number of CRRT solution bags dispensed per day of CRRT decreased substantially. Respondents' overall satisfaction with the CRRT solution preparation process increased during the postintervention period, and the satisfaction scores for each individual component of the workflow after implementation of lean principles. The decreased solution waste resulted in projected annual cost savings exceeding $70,000 in product alone. CONCLUSION The use of lean principles to identify medication waste in the CRRT workflow and implementation of an intervention to shift the workload from intensive care unit nurses to pharmacy technicians led to reduced CRRT solution waste, improved efficiency of CRRT workflow, and increased satisfaction among staff.
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Affiliation(s)
- C Brett Benfield
- C. Brett Benfield, Pharm.D., is Postgraduate Year 1 Ambulatory Administrative Resident, Fairview Pharmacy Services, Minneapolis, MN; at the time of writing he was Student Pharmacist, University of Michigan College of Pharmacy (UMCP), Ann Arbor. Philip Brummond, Pharm.D., M.S., is Director of Pharmacy, Froedtert Hospital, Milwaukee, WI; at the time of writing he was Pharmacy Assistant Director, University of Michigan Health System (UMHS), Ann Arbor. Andrew Lucarotti, Pharm.D., is Pharmacist-Generalist UMHS, and Adjunct Clinical Instructor, UMCP. Maria Villarreal, CPhT, is Certified Pharmacy Technician; Adam Goodwin, CPhT, is Certified Pharmacy Technician; Rob Wonnacott, RN, is Critical Care Nurse; Cheryl Talley, RN, is Critical Care Nurse; and Michael Heung, M.D., M.S., is Medical Director, Inpatient Dialysis Programs, Department of Medicine, Division of Nephrology, UMHS.
| | - Philip Brummond
- C. Brett Benfield, Pharm.D., is Postgraduate Year 1 Ambulatory Administrative Resident, Fairview Pharmacy Services, Minneapolis, MN; at the time of writing he was Student Pharmacist, University of Michigan College of Pharmacy (UMCP), Ann Arbor. Philip Brummond, Pharm.D., M.S., is Director of Pharmacy, Froedtert Hospital, Milwaukee, WI; at the time of writing he was Pharmacy Assistant Director, University of Michigan Health System (UMHS), Ann Arbor. Andrew Lucarotti, Pharm.D., is Pharmacist-Generalist UMHS, and Adjunct Clinical Instructor, UMCP. Maria Villarreal, CPhT, is Certified Pharmacy Technician; Adam Goodwin, CPhT, is Certified Pharmacy Technician; Rob Wonnacott, RN, is Critical Care Nurse; Cheryl Talley, RN, is Critical Care Nurse; and Michael Heung, M.D., M.S., is Medical Director, Inpatient Dialysis Programs, Department of Medicine, Division of Nephrology, UMHS
| | - Andrew Lucarotti
- C. Brett Benfield, Pharm.D., is Postgraduate Year 1 Ambulatory Administrative Resident, Fairview Pharmacy Services, Minneapolis, MN; at the time of writing he was Student Pharmacist, University of Michigan College of Pharmacy (UMCP), Ann Arbor. Philip Brummond, Pharm.D., M.S., is Director of Pharmacy, Froedtert Hospital, Milwaukee, WI; at the time of writing he was Pharmacy Assistant Director, University of Michigan Health System (UMHS), Ann Arbor. Andrew Lucarotti, Pharm.D., is Pharmacist-Generalist UMHS, and Adjunct Clinical Instructor, UMCP. Maria Villarreal, CPhT, is Certified Pharmacy Technician; Adam Goodwin, CPhT, is Certified Pharmacy Technician; Rob Wonnacott, RN, is Critical Care Nurse; Cheryl Talley, RN, is Critical Care Nurse; and Michael Heung, M.D., M.S., is Medical Director, Inpatient Dialysis Programs, Department of Medicine, Division of Nephrology, UMHS
| | - Maria Villarreal
- C. Brett Benfield, Pharm.D., is Postgraduate Year 1 Ambulatory Administrative Resident, Fairview Pharmacy Services, Minneapolis, MN; at the time of writing he was Student Pharmacist, University of Michigan College of Pharmacy (UMCP), Ann Arbor. Philip Brummond, Pharm.D., M.S., is Director of Pharmacy, Froedtert Hospital, Milwaukee, WI; at the time of writing he was Pharmacy Assistant Director, University of Michigan Health System (UMHS), Ann Arbor. Andrew Lucarotti, Pharm.D., is Pharmacist-Generalist UMHS, and Adjunct Clinical Instructor, UMCP. Maria Villarreal, CPhT, is Certified Pharmacy Technician; Adam Goodwin, CPhT, is Certified Pharmacy Technician; Rob Wonnacott, RN, is Critical Care Nurse; Cheryl Talley, RN, is Critical Care Nurse; and Michael Heung, M.D., M.S., is Medical Director, Inpatient Dialysis Programs, Department of Medicine, Division of Nephrology, UMHS
| | - Adam Goodwin
- C. Brett Benfield, Pharm.D., is Postgraduate Year 1 Ambulatory Administrative Resident, Fairview Pharmacy Services, Minneapolis, MN; at the time of writing he was Student Pharmacist, University of Michigan College of Pharmacy (UMCP), Ann Arbor. Philip Brummond, Pharm.D., M.S., is Director of Pharmacy, Froedtert Hospital, Milwaukee, WI; at the time of writing he was Pharmacy Assistant Director, University of Michigan Health System (UMHS), Ann Arbor. Andrew Lucarotti, Pharm.D., is Pharmacist-Generalist UMHS, and Adjunct Clinical Instructor, UMCP. Maria Villarreal, CPhT, is Certified Pharmacy Technician; Adam Goodwin, CPhT, is Certified Pharmacy Technician; Rob Wonnacott, RN, is Critical Care Nurse; Cheryl Talley, RN, is Critical Care Nurse; and Michael Heung, M.D., M.S., is Medical Director, Inpatient Dialysis Programs, Department of Medicine, Division of Nephrology, UMHS
| | - Rob Wonnacott
- C. Brett Benfield, Pharm.D., is Postgraduate Year 1 Ambulatory Administrative Resident, Fairview Pharmacy Services, Minneapolis, MN; at the time of writing he was Student Pharmacist, University of Michigan College of Pharmacy (UMCP), Ann Arbor. Philip Brummond, Pharm.D., M.S., is Director of Pharmacy, Froedtert Hospital, Milwaukee, WI; at the time of writing he was Pharmacy Assistant Director, University of Michigan Health System (UMHS), Ann Arbor. Andrew Lucarotti, Pharm.D., is Pharmacist-Generalist UMHS, and Adjunct Clinical Instructor, UMCP. Maria Villarreal, CPhT, is Certified Pharmacy Technician; Adam Goodwin, CPhT, is Certified Pharmacy Technician; Rob Wonnacott, RN, is Critical Care Nurse; Cheryl Talley, RN, is Critical Care Nurse; and Michael Heung, M.D., M.S., is Medical Director, Inpatient Dialysis Programs, Department of Medicine, Division of Nephrology, UMHS
| | - Cheryl Talley
- C. Brett Benfield, Pharm.D., is Postgraduate Year 1 Ambulatory Administrative Resident, Fairview Pharmacy Services, Minneapolis, MN; at the time of writing he was Student Pharmacist, University of Michigan College of Pharmacy (UMCP), Ann Arbor. Philip Brummond, Pharm.D., M.S., is Director of Pharmacy, Froedtert Hospital, Milwaukee, WI; at the time of writing he was Pharmacy Assistant Director, University of Michigan Health System (UMHS), Ann Arbor. Andrew Lucarotti, Pharm.D., is Pharmacist-Generalist UMHS, and Adjunct Clinical Instructor, UMCP. Maria Villarreal, CPhT, is Certified Pharmacy Technician; Adam Goodwin, CPhT, is Certified Pharmacy Technician; Rob Wonnacott, RN, is Critical Care Nurse; Cheryl Talley, RN, is Critical Care Nurse; and Michael Heung, M.D., M.S., is Medical Director, Inpatient Dialysis Programs, Department of Medicine, Division of Nephrology, UMHS
| | - Michael Heung
- C. Brett Benfield, Pharm.D., is Postgraduate Year 1 Ambulatory Administrative Resident, Fairview Pharmacy Services, Minneapolis, MN; at the time of writing he was Student Pharmacist, University of Michigan College of Pharmacy (UMCP), Ann Arbor. Philip Brummond, Pharm.D., M.S., is Director of Pharmacy, Froedtert Hospital, Milwaukee, WI; at the time of writing he was Pharmacy Assistant Director, University of Michigan Health System (UMHS), Ann Arbor. Andrew Lucarotti, Pharm.D., is Pharmacist-Generalist UMHS, and Adjunct Clinical Instructor, UMCP. Maria Villarreal, CPhT, is Certified Pharmacy Technician; Adam Goodwin, CPhT, is Certified Pharmacy Technician; Rob Wonnacott, RN, is Critical Care Nurse; Cheryl Talley, RN, is Critical Care Nurse; and Michael Heung, M.D., M.S., is Medical Director, Inpatient Dialysis Programs, Department of Medicine, Division of Nephrology, UMHS
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