title: Automatic versus manual changeovers of norepinephrine infusion pumps in critically ill adults: a prospective controlled study.
abstract: BACKGROUND
  Norepinephrine is a key drug for treating shock but has a short half-life that requires continuous intravenous administration to maintain the constant plasma concentration needed to obtain a stable blood pressure. The small volume of the syringes used in power infusion pumps requires frequent changeovers, which can lead to norepinephrine flow interruptions responsible for hemodynamic instability. Changeovers from the nearly empty to the full syringe can be performed manually using the quick change technique (QC) or automatically using smart infusion pumps (SIP) that link two syringes. The purpose of our study was to evaluate the hypothesis that, compared to QC, SIP for norepinephrine changeovers was associated with less hemodynamic instability.
  
  
  METHODS
  After information of the patient or next of kin, patients receiving norepinephrine for shock were allocated to QC or SIP changeovers. QC changeovers were performed by a nurse, who started a new loaded pump when the previous syringe was nearly empty. SIP changeovers were managed automatically by SIP workstations. The primary outcome was the proportion of changeovers followed by a ≥20 % drop in mean arterial pressure (MAP).
  
  
  RESULTS
  411 changeovers were performed, 193 in the 18 patients allocated to QC and 218 in the 32 patients allocated to SIP. Baseline patient characteristics were similar in both groups. The proportion of changeovers followed by an MAP drop ≥20 % was 12.4 % (24/193) with QC and 5.5 % (12/218) with SIP (P = 0.01). By multivariate analysis, two factors were independently associated with a significantly decreased risk of ≥20 % MAP drops during changeovers, namely, SIP (odds ratio, 0.47; 95 % confidence interval, 0.22-0.98) and norepinephrine dosage >0.5 μg/kg/min (odds ratio, 0.39; 95 % confidence interval, 0.19-0.81).
  
  
  CONCLUSIONS
  The risk of MAP drops ≥20 % during changeovers can be significantly diminished using SIPs instead of the QC method.
  
  
  BACKGROUND
  Clinicaltrial.gov NCT 01127152.
authors.affiliation: Medical-Surgical Intensive Care Unit, District Hospital Center, La Roche-sur-Yon, France. emilie.greau@chd-vendee.fr.
authors.forename: Emilie
authors.initials: E
authors.lastname: Greau
authors.affiliation: Medical-Surgical Intensive Care Unit, District Hospital Center, La Roche-sur-Yon, France. jean-baptiste.lascarrou@chd-vendee.fr.
authors.forename: Jean-Baptiste
authors.initials: JB
authors.lastname: Lascarrou
authors.affiliation: Clinical Research Unit, District Hospital Center, La Roche-sur-Yon, France. aurelie.le.thuaut@chu-nantes.fr.|Délégation à la Recherche Clinique et à l'Innovation, CHU Hôtel Dieu, 44093, Nantes Cedex, France. aurelie.le.thuaut@chu-nantes.fr.
authors.forename: Aurélie
authors.initials: A
authors.lastname: Le Thuaut
authors.affiliation: Medical-Surgical Intensive Care Unit, District Hospital Center, La Roche-sur-Yon, France. nathalie.maquigneau@chd-vendee.fr.
authors.forename: Nathalie
authors.initials: N
authors.lastname: Maquigneau
authors.affiliation: Medical-Surgical Intensive Care Unit, District Hospital Center, La Roche-sur-Yon, France. yolaine.alcourt@chd-vendee.fr.
authors.forename: Yolaine
authors.initials: Y
authors.lastname: Alcourt
authors.affiliation: Medical-Surgical Intensive Care Unit, District Hospital Center, La Roche-sur-Yon, France. anne.coutolleau@chd-vendee.fr.
authors.forename: Anne
authors.initials: A
authors.lastname: Coutolleau
authors.affiliation: Medical-Surgical Intensive Care Unit, District Hospital Center, La Roche-sur-Yon, France. cecile.rousseau@chd-vendee.fr.
authors.forename: Cécile
authors.initials: C
authors.lastname: Rousseau
authors.affiliation: Medical-Surgical Intensive Care Unit, District Hospital Center, La Roche-sur-Yon, France. vanessa.erragne@chd-vendee.fr.
authors.forename: Vanessa
authors.initials: V
authors.lastname: Erragne
authors.affiliation: Medical-Surgical Intensive Care Unit, District Hospital Center, La Roche-sur-Yon, France. jean.reignier@chu-nantes.fr.|UPRES EA-3826, Clinical and Experimental Therapies for Infections, University of Nantes, Nantes, France. jean.reignier@chu-nantes.fr.|Medical Intensive Care Unit, Nantes University Hospital, Nantes, France. jean.reignier@chu-nantes.fr.
authors.forename: Jean
authors.initials: J
authors.lastname: Reignier
keywords: Catecholamines; Changeover; Critically ill; Norepinephrine; Shock; Smart infusion pumps