OBJECTIVES

Clinical pathways (CPs) ensure adherence to heart failure (HF) management guidelines. To optimize quality care in a low resource setting, an evidence-based care pathway for the management of acute HF was implemented at the emergency department (ED) of the Philippine General Hospital (PGH), the designated national tertiary hospital and referral center. This study aimed to describe the characteristics of adults with acute HF admitted at the ED and evaluate the quality of care they received, measured using physician adherence to the hospital’s acute heart failure CP.

METHODS

This was a retrospective, descriptive cohort study. We reviewed the inpatient charts of all adult patients with acute HF admitted to the ED of the PGH and referred to the Division of Cardiovascular Medicine between December 1, 2022 and May 31, 2023. Quality of care was assessed based on adherence to quality indicators adapted from routine and conditional order sets detailed in the pathway. Descriptive statistics was utilized to describe patient characteristics, quality of care, and outcomes.

RESULTS

Two hundred thirty-six (236) patients were included, with a mean age of 51.8 years. Majority were male (53.4%); hypertension (61.4%) and ischemic heart disease (53.8%) were the most common comorbidities, and infection the most common precipitant of decompensation (60.6%). There were optimal adherence rates to routine orders, which included referrals to Internal Medicine and Cardiology, baseline vital signs monitoring, fluid intake and output monitoring, chest radiograph, complete blood count, blood urea nitrogen, sodium, potassium, prothrombin time, partial thromboplastin time, arterial blood gas, urinalysis, and N-terminal pro b-type natriuretic peptide. Conditional orders, such as oxygen support, focused echocardiography, thyroid - stimulating hormone, and the use of vasopressors, diuretics, and venous thromboembolism prophylactic agents, were optimally performed when warranted. However, we noted suboptimal adherence to certain resource-intensive conditional orders, such as hourly monitoring of urine output (61.4%), hooking to cardiac monitor (53.8%), and performance of 12-lead ECG within 10 minutes (56.8%). Further, only 43.9% of patients were referred to the intensive care unit. Troponin I, calcium, magnesium, and albumin were ordered in excess.

CONCLUSION

Overall adherence rate of physicians to the hospital’s Acute Heart Failure Pathway was satisfactory. Work is needed to improve adherence to hourly urine output monitoring, consistent hooking to cardiac monitor, and timely performance of 12-lead ECG – an effort that begins with expanding in-hospital diagnostic equipment and human resource supply. We recommend continuous pathway implementation with periodic evaluation and stakeholder feedback to further improve quality of care.

Human ; Male ; Female ; Middle Aged: 45-64 Yrs Old ; Adult ; Albumins ; Blood ; Blood Urea Nitrogen ; Calcium ; Cardiology ; Chart ; Charts ; Cohort Studies ; Critical Care ; Critical Pathways ; Diagnostic Equipment ; Disease ; Diuretics ; Echocardiography ; Electrocardiography ; Emergencies ; Emergency Service, Hospital ; Equipment And Supplies ; Evaluation Studies As Topic ; Feedback ; Heart ; Heart Diseases ; Heart Failure ; Hormones ; Hospitals ; Hospitals, General ; Humans ; Hypertension ; Indicators And Reagents ; Infection ; Infections ; Inpatients ; Intensive Care Units ; Internal Medicine ; Lead ; Magnesium ; Male ; Medicine ; Myocardial Ischemia ; Natriuretic Peptide, Brain ; Natriuretic Peptides ; Nitrogen ; Overall ; Oxygen ; Partial Thromboplastin Time ; Patients ; Peptides ; Philippines ; Physicians ; Potassium ; Prothrombin ; Prothrombin Time ; Quality Of Health Care ; Referral And Consultation ; Sodium ; Statistics ; Tertiary Care Centers ; Thorax ; Thromboembolism ; Thromboplastin ; Thyroid Gland ; Time ; Troponin ; Troponin I ; Universities ; Urea ; Urinalysis ; Urine ; Venous Thromboembolism ; Vital Signs ; Work ; Workforce

Hypomagnesemia may arise from various disorders such as renal magnesium wasting, familial hypomagnesemia, inadequate intake and increased gastrointestinal loss. Hypomagnesemia and hypocalcemia were found in a month-old female patient with generalized tonic-clonic seizure. Twenty-four hour urine collection samples were used to assess renal magnesium wasting; fractional excretion of 24-hr urine magnesium was less than 1.45%, i.e., within the normal limits. The patient had no history of chronic diarrhea or failure to thrive, which supports the conclusion that intake was adequate. She had no family history of hypocalcemia, hypomagnesemia, or seizures. Here, we report a case of idiopathic hypomagnesemia.
Diarrhea ; Failure to Thrive ; Female ; Humans ; Hypocalcemia ; Magnesium ; Seizures ; Urine Specimen Collection

OBJECTIVE: To explore the objective evidence of the corpus biochemical changes in rabbits for postmortem diagnosis of potassium intoxication. METHODS: Rabbits were sacrificed by Infusion of 0.3% KCl at full speed push or 1% KCl at 100 drip/min, respectively, with normal rabbits used as control. Cardiac blood and urine samples were collected before and after potassium infusion to examine the concentrations of various electrolytes (K+, Na+, Ca2+, Mg2+, Cl-, and HCO3-) and to observe the antemortem and postmortem biochemical changes. RESULTS: The mean lethal infusion time in the 0.3%KCl group was longer than that in the 1% KCl group (P = 0.006). The serum concentration of K+ increased while the serum concentrations of Na+, Ca2+, Cl-, and HCO3- decreased after the infusion. There were no statistically significant differences in the whole blood concentration of K+ as well as the serum concentration of Mg2+ between the two groups (P = 0.062). There were statistically significant differences in the concentrations of whole blood K+, as well as serum Na+, Mg2+, and Cl-, but not in the serum K+, Ca2+, and HCO3-. There were no statistically significant differences seen in the urine volumes and the concentrations of all the urine electrolytes between the groups. CONCLUSION Examination of the concentrations of K+ both in the whole blood and serum, as well as Mg2+ in the serum may be helpful for postmortem diagnosis of potassium intoxication.
Animals ; Calcium/urine* ; Electrolytes/urine* ; Forensic Medicine/methods* ; Injections, Intravenous/methods* ; Magnesium/urine* ; Male ; Postmortem Changes ; Potassium/poisoning* ; Potassium Chloride/administration & dosage* ; Rabbits ; Sodium/urine*

OBJECTIVETo study the effect of different extracts of Alisma orientalis on urinary calcium oxalate stone formation in rats and to identify the effective constituents.

METHODDifferent extracts were administered through a stomach tube to rats of different groups with renal calcium oxalate stones induced by ethylene glycol (EG) and ammonium chloride (AC).

RESULTIn the rats administered with ethyl acetate elution of ethyl acetate extract, blood Cr, BUN, renal tissue calcium content, urinary calcium excretion and crystals deposition in renal tissue were significantly lower than those of the stone formation group.

CONCLUSIONThe ethyl acetate elution of ethyl acetate fraction extract of Alisma orientalis can significantly inhibit urinary calcium oxalate stone formation in rats and be the most effective constituent of Alisma orientalis.

Alisma ; chemistry ; Ammonium Chloride ; Animals ; Blood Urea Nitrogen ; Calcium ; metabolism ; Calcium Oxalate ; urine ; Creatinine ; blood ; Drugs, Chinese Herbal ; isolation & purification ; pharmacology ; Ethylene Glycol ; Kidney ; metabolism ; Kidney Calculi ; chemically induced ; metabolism ; prevention & control ; Magnesium ; metabolism ; urine ; Male ; Rats ; Rats, Wistar

Primary aldosteronism is defined as hypertension, hypokalemia, increased serum aldosteron, decreased serum renin activity. It has been known that prolonged hypokalemia, renal cyst formation and impairment of renal function. However, nephrocalcinosis associated with primary aldosteronism is rarely reported. A 31-year-old male was admitted to our hospital because of abdominal pain and uncontrolled hypertention which developed 2 years earlier. At admission, blood pressure 180/100 mmHg. Biochemical findings indicated sodium 146 mEq/L, potassium 2.3 mEq/L, BUN 8.2 mg/dL, creatinine 1.1 mg/dL, calcium 10.7 mg/dL, phosphate 5.7 mg/dL, magnesium 1.8 mg/dL. Twenty-four hour urine collection indicated sodium 108 mEq, potassium 32 mEq, calcium 75 mg, phosphate 72 mg, magnesium 8.0 mg. The hormone study revealed PTH 22.7 pg/mL (normal: 9~55 pg/mL), ACTH 8 pg/mL (normal: 6~56.7 pg/mL), aldosterone 51.0 ng/dL (normal: 1~16 ng/dL), plasma renin activity below 0.01 ng/mL/hr (normal: 0.15~233 ng/mL/hr). Abdominal sonography showed homogenous increased medullary echoes and multiple calcification. The abdomen CT showed adrenal mass (1 x 1 cm) consistent with adrenal tumor. Adrenalrectomy was performed on the 16th hospital day and clinical symptoms, blood pressure and hypokalemia improved shortly after operation.
Abdomen ; Abdominal Pain ; Adrenocorticotropic Hormone ; Adult ; Aldosterone ; Blood Pressure ; Calcium ; Creatinine ; Humans ; Hyperaldosteronism* ; Hypertension ; Hypokalemia ; Magnesium ; Male ; Nephrocalcinosis* ; Plasma ; Potassium ; Renin ; Sodium ; Urine Specimen Collection

A woman aged 45 years was presented with hypokalemic metabolic alkalosis and hypomagnesemia associated with renal potassium and magnesium wasting. Her 24-hour urinary calcium excretion was strikingly low despite normocalcemia and normal creatinine clearance, which is one of characteristic findings of Gitelman's syndrome (GS). She was evaluated for the responses following Mg supplementation for 10 days, which showed marked increments in serum potassium and magnesium as well as improvements of the degree of renal potassium wasting and hypocalciuria. This amelioration of abnormal biochemical pictures in this patient after Mg supplementation proposes that the hypokalemia with renal potassium wasting and hypocalciuria may be caused by abnormal Mg metabolism.
Bartter's Disease/urine ; Bartter's Disease/therapy* ; Bartter's Disease/blood ; Calcium/urine* ; Case Report ; Female ; Food, Fortified ; Human ; Hypokalemia/therapy* ; Magnesium/blood* ; Middle Age ; Syndrome