title: Comparatively Evaluating Medication Preparation Sequences for Treatment of Hyperkalemia in Pediatric Cardiac Arrest: A Prospective, Randomized, Simulation-Based Study.
abstract: OBJECTIVE
  To determine whether time to prepare IV medications for hyperkalemia varied by 1) drug, 2) patient weight, 3) calcium salt, and 4) whether these data support the Advanced Cardiac Life Support recommended sequence.
  
  
  METHODS
  Prospective randomized simulation-based study.
  
  
  METHODS
  Single pediatric tertiary medical referral center.
  
  
  METHODS
  Pediatric nurses and adult or pediatric pharmacists.
  
  
  METHODS
  Subjects were randomized to prepare medication doses for one of four medication sequences and stratified by one of three weight categories representative of a neonate/infant, child, or adult-sized adolescent: 4, 20, and 50 kg. Using provided supplies and dosing references, subjects prepared doses of calcium chloride, calcium gluconate, sodium bicarbonate, and regular insulin with dextrose. Because insulin and dextrose are traditionally prepared and delivered together, they were analyzed as one drug. Subjects preparing medications were video-recorded for the purpose of extracting timing data.
  
  
  RESULTS
  A total of 12 nurses and 12 pharmacists were enrolled. The median (interquartile range) total preparation time for the three drugs was 9.5 minutes (6.4-13.7 min). Drugs were prepared significantly faster for larger children (50 kg, 6.8 min [5.6-9.1 min] vs 20 kg, 9.5 min [8.6-13.0 min] vs 4 kg, 16.3 min [12.7-18.9 min]; p = 0.001). Insulin with dextrose took significantly longer to prepare than the other medications, and there was no difference between the calcium salts: (sodium bicarbonate, 1.9 [0.8-2.6] vs calcium chloride, 2.1 [1.2-3.1] vs calcium gluconate, 2.4 [2.1-3.0] vs insulin with dextrose, 5.1 min [3.7-7.7 min], respectively; p < 0.001). Forty-two percent of subjects (10/24) made at least one dosing error.
  
  
  CONCLUSIONS
  Medication preparation for hyperkalemia takes significantly longer for smaller children and preparation of insulin with dextrose takes the longest. This study supports Pediatric Advanced Life Support guidelines to treat hyperkalemia during pediatric cardiac arrest similar to those recommended per Advanced Cardiac Life Support (i.e., first, calcium; second, sodium bicarbonate; and third, insulin with dextrose).
authors.affiliation: 1Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD. 2Department of Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD. 3Division of Health Science Informatics, The Johns Hopkins University School of Medicine, Baltimore, MD. 4Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Amy M
authors.initials: AM
authors.lastname: Arnholt
authors.forename: Jordan M
authors.initials: JM
authors.lastname: Duval-Arnould
authors.forename: LeAnn M
authors.initials: LM
authors.lastname: McNamara
authors.forename: Michael A
authors.initials: MA
authors.lastname: Rosen
authors.forename: Karambir
authors.initials: K
authors.lastname: Singh
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Hunt
mesh_terms: D000293:Adolescent; D022561:Advanced Cardiac Life Support; D001835:Body Weight; D002122:Calcium Chloride / Q000008:administration & dosage / Q000737:chemistry; D002125:Calcium Gluconate / Q000008:administration & dosage / Q000737:chemistry; D002648:Child; D002675:Child, Preschool; D003422:Critical Care / Q000379:methods; D004339:Drug Compounding / Q000706:statistics & numerical data*; D005260:Female; D005947:Glucose / Q000008:administration & dosage / Q000737:chemistry; D006323:Heart Arrest / Q000188:drug therapy* / Q000209:etiology; D006801:Humans; D006947:Hyperkalemia / Q000150:complications / Q000188:drug therapy*; D007223:Infant; D007231:Infant, Newborn; D007328:Insulin / Q000008:administration & dosage / Q000737:chemistry; D008297:Male; D011446:Prospective Studies; D017693:Sodium Bicarbonate / Q000008:administration & dosage / Q000737:chemistry; D013997:Time Factors; D014882:Water-Electrolyte Balance
chemical_list: D007328:Insulin; D017693:Sodium Bicarbonate; D005947:Glucose; D002122:Calcium Chloride; D002125:Calcium Gluconate