Individualized parameterization of multiparametric monitors alarms in infarcted patients

Assis, Allan Peixoto de; Oliveira, Francimar Tinoco de; Camerini, Flávia Giron; Silva, Roberto Carlos Lyra da; Moraes, Camila Mendonça de

doi:10.1590/0034-7167-2018-0485

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ORIGINAL ARTICLE • Rev. Bras. Enferm. 72 (3) • May-Jun 2019 • https://doi.org/10.1590/0034-7167-2018-0485 copy

Individualized parameterization of multiparametric monitors alarms in infarcted patients

Parametrización individualizada de alarmas de monitores multiparamétricos en pacientes infartados

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To measure the magnitude of the effect of an individualized parameterization protocol for hemodynamic alarms in patients with acute myocardial infarction.

Method:

Pragmatic clinical trial, open label and single arm, whose intervention was performed through a protocol validated and tested in 32 patients using multiparametric monitors. The heart rate, blood pressure, respiratory rate, oxygen saturation and ST segment-monitoring were measured and classified for clinical consistency one hour before and after the intervention, for 64 hours.

Results:

The protocol obtained Content Validity Index of 0.92. Of the 460 registered alarms, 261 were considered inconsistent before the intervention and 47 after it. The Relative Risk of inconsistent alarms after the protocol was 0.32 (95% CI 0.23-0.43, p <0.0001).

Conclusion:

The protocol proved to be a protective factor to the appearance of inconsistent clinical alarms of multiparametric monitors.

Descriptors:
Clinical Alarms; Physiological Monitors; Parameters; Myocardial Infarction; Nursing Care

Steps of ProPIAM	Action	Level of evidence
1	Prepare the skin by cutting hairs and perform astringency with soap and water in the chosen places for adherence of the electrodes; dry the area with a towel or gauze.	B
2	Choose five-wire monitoring systems: Right Arm (RA), Left Arm (LA), Left Leg (LL), Right Leg (RL) and Chest (C).	E
3	Adhere the electrodes to the following anatomical references: RA - Right infraclavicular fossa; LA - Left infraclavicular fossa; LL - Below the left rib cage; RL - Below the right rib cage; C - In the desired precordial derivation (V1 to V6).	E
4	Adhere the electrodes considering the electrode C for the precordial derivation that showed a change in the ST segment on the electrocardiogram (ECG) of admission OR in the V3 derivation for patients with AMI without previous ST segment changes OR according to the obstructed artery in cardiac catheterization. V2 or V3 correspond to the injury of the anterior descending artery (ADA); V3R or V4R to the injury of the right coronary artery injury (RCA); and V1, V2 or V3 (where the mirror image is) to the posterior descending artery (PDA).	E
5	Consider electrode C in V1 for suspected right bundle branch block (RBBB) or left bundle branch block (LBBB) to confirm temporary transvenous pacemaker placement and distinguish between ventricular tachycardia and supraventricular tachycardia with aberrancy.	E
6	Choose the monitor with on-screen derivations using the same altered derivations for the ECG of admission. If there are no ECG changes, keep DIII and V3. If there is any arterial injury demonstrated in the cardiac catheterization with no ECG changes, maintain V2, V3 and/or V4 for ADA injury; DIII and V3R and/or V4R for RCA injury; DI, aVL and/or V5 for the Circumflex Artery (CA) injury; and V1, V2 and/or V3 (where the mirror is) for PDA injury.	E
7	Continuously measure non-invasive blood pressure using the oscillometric technique and a cuff that corresponds to 40% of arm circumference and 80% of its length. The cuff should be at the point which indicates the brachial artery, at 2.5 cm above the antecubital fossa. The patient should be lying down with the arm resting at the level of his/her heart.	B
8	Continuously monitor invasive blood pressure, with signal transduction system positioned at the level of the phlebostatic axis (4th intercostal space at the middle axillary line), with dynamic curve visualization and pressurized pocket at 300 mmHg.	E
9	Measure the pulse oximetry in a quantitative waveform through the plestimographic method, with signal recognition by light. The probe (transmitter sensor) should be located at distal ends such as ear lobes or fingertips. They must be in a contralateral limb, with a noninvasive blood pressure cuff. Any material that impedes the penetration of infrared radiation into the skin should be removed.	M
10	Set the Heart Rate alarms between 50 and 70.	B
11	Set ST segment alarms at roughly 1-2mm below the baseline or the ST segment pattern displayed by the patient on the ECG of admission up to 0.60s from the J point.	E
12	Adjust systolic blood pressure alarms between 90 and 140mmHg; diastolic blood pressure between 52 and 90mmHg; and mean arterial pressure between 65 and 105mmHg.	B
13	Set the Heart Rate alarms between 12 and 20 bpm.	E
14	Adjust the alarms of peripheral oxygen saturation between 90% and 97% in non-COPDs and without the use of O2; between 93% and 97% in non-COPD patients with the use of O2; between 88% and 97% in COPD patients without the use of O2; and between 90% and 97% in COPD patients with the use of O2.	B

Variables	Sample n(%)	Variables	Sample n(%)
Sex		Risk rating
Male	20 (62.5)	Killip Classification
Female	12 (37.5)	Killip I	23 (71,8)
Age		Killip II	7 (21,8)
<60 years old	13 (40.6)	Killip III	1 (3,2)
>60 years old	19 (59.4)	Killip IV	1(3,2)
Type of AMI		TIMI^ TIMI - Thrombolysis in Myocardial Infarction; GRACE - Global Registry of Acute Coronary Events. Risk
Supra-infarct	20 (62.5)	0-2	14 (43.8)
Non-supra infarct	12 (37.5)	3-4	12 (37.5)
AMI Extension		>4	6 (18.7)
Anterior wall	12 (37.5)	GRACE^ TIMI - Thrombolysis in Myocardial Infarction; GRACE - Global Registry of Acute Coronary Events. Risk
Inferior wall	7 (22)	<or=108	17 (53.2)
Lateral wall	4 (12.5)	109-140	9 (28.1)
Anteroseptal wall	4 (12.5)	>140	6 (18.7)
Anterolateral wall	1 (3.2)
No register^* * Representing the patients without indication of myocardial injury on the ECG.	4 (12.5)

Parametrization	Alarms	HR n(%)	BP n(%)	STS n(%)	RR n(%)	SpO2 n(%)
No	Consistent	17 (3.7)	11 (2.4)	3 (0.7)	0	5 (1.1)
No	Inconsistent	53 (11.5)	13 (2.8)	61 (13.2)	35 (7.6)	87 (18.9)
Yes	Consistent	43 (9.3)	36 (7.8)	6 (1.3)	3 (0.65)	23 (5)
Yes	Inconsistent	5 (1.1)	0	0	17 (3.7)	28 (6.1)

Parametrization	Inconsistent alarms n(%)	Consistent alarms n(%)	p-value	RR(CI 95%)	RRR
No	261 (88.5)	34 (11.5)	<0.0001	0.32 (0.23-0.43)	68%
Yes	47 (28.5)	118 (71.5)	<0.0001	0.32 (0.23-0.43)	68%

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[1] Corresponding Author: Allan Peixoto de Assis. E-mail: allanpeixoto@macae.ufrj.br