Intravenous Opioid Administration Research Articles

Timeliness of Opioid Administration for Pain in the Emergency Department for Adults with Sickle Cell Disease

Background: Individuals with sickle cell disease (SCD) often require emergent care to manage debilitating pain. The American Society of Hematology recommends individuals seeking care for the treatment of acute pain should have their pain assessed and medication administered within one hour of their arrival at the emergency department (ED). Data regarding guideline timeliness of pain treatment in adults are not well understood. We therefore sought to determine the timeliness of care for pain treatment in the ED for adults with SCD and factors associated with timeliness of care. We hypothesized that those using public insurance will have greater delays in receipt of intravenous opioids for pain. Methods: We leveraged the Center for Disease Control's Sickle Cell Data Collection Program in Wisconsin to identify individuals with SCD who received care in the ED associated with the adult SCD comprehensive clinic between 2017-2020. Individuals were identified as having SCD if confirmed via the state newborn screening program or if they had 3 or more visits/claims with a diagnosis of SCD in a five-year time frame. ED treat and release visits with 1) any diagnosis of pain or vaso-occlusive crises, and 2) receipt of an intravenous opioid were considered painful crises. The timeliness of ED pain treatment was determined by calculating the time between placement in an ED room and receipt of first intravenous opioid. All analyses were conducted at the visit level. A multivariable generalized linear model was used to determine if age, sex or insurance status were associated with time to opioid administration. Results: There were 382 individuals with SCD who contributed to 3400 ED treat and release visits; 1755 were for painful crises. The mean age of individuals was 31.8 (SD = 9.5) years and the majority of the visits were by females (64%). The primary payers included Medicaid (63.9%), Medicare (25.6%), private (5.7%), and other (4.7%). The median time to administration of intravenous opioids after being roomed was 57 minutes (IQR: 39 - 86 minutes). Intravenous opioids were not administered within 60 minutes of being roomed for 43% of the ED visits. The multivariable model demonstrated that females (as compared to males; 72.6 vs 55.4 minutes), and those on Medicaid and Medicare (70.4 and 72.6 minutes respectively as compared to private insurance 46 minutes) had a significantly longer time to receipt of first intravenous opioid (Table 1). Conclusion: Our data show that intravenous opioids were not given within 60 minutes of being roomed for more than 40% of ED visits for pain at an adult care facility . These analyses do not include the time in waiting room prior to being roomed, thus the problem of timely care is worse than reflected by these results. Females and those on public insurance have significantly longer time to receipt of pain treatment. Immediate work is needed to identify steps to ensure that adults with SCD seeking emergent care for pain receive guideline-adherent pain treatment.

MP65-14 PAIN IS THE MOST COMMON CLINICAL BARRIER TO SAME-DAY DISCHARGE AFTER PERCUTANEOUS NEPHROLITHOTOMY

You have accessJournal of UrologyStone Disease: Surgical Therapy V (MP65)1 Sep 2021MP65-14 PAIN IS THE MOST COMMON CLINICAL BARRIER TO SAME-DAY DISCHARGE AFTER PERCUTANEOUS NEPHROLITHOTOMY Heiko Yang, Jordan T Holler, Harry Lee, Greg Hosier, Rei Unno, Fadl Hamouche, Justin Ahn, David Bayne, Anobel Odisho, Marshall Stoller, and Thomas Chi Heiko YangHeiko Yang More articles by this author , Jordan T HollerJordan T Holler More articles by this author , Harry LeeHarry Lee More articles by this author , Greg HosierGreg Hosier More articles by this author , Rei UnnoRei Unno More articles by this author , Fadl HamoucheFadl Hamouche More articles by this author , Justin AhnJustin Ahn More articles by this author , David BayneDavid Bayne More articles by this author , Anobel OdishoAnobel Odisho More articles by this author , Marshall StollerMarshall Stoller More articles by this author , and Thomas ChiThomas Chi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002105.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The COVID-19 pandemic has provided an impetus to reconsider traditional urologic practices and adapt to the unprecedented healthcare burden. Reducing length of stay after minimally invasive procedures is now more important than ever. Using percutaneous nephrolithotomy (PCNL) as a model, we sought to evaluate clinical barriers to same-day discharge in order to better understand the feasibility of outpatient surgery. METHODS: Prospective data collected from 500 inpatient PCNLs performed at our institution between 2016 and 2020 was analyzed via the Registry for Surgery of the Kidney and Ureter (ReSKU). Preadmissions and aborted procedures were excluded. We analyzed clinical problems and complications that warranted postoperative admission. Major categories included infection, bleeding, and excessive pain, which was defined as either a documented pain complication or administration of intravenous opioids within 24 hours after discharge from the recovery room. Multivariate statistics were used to assess risk factors for each outcome. RESULTS: Excessive pain was the most common postoperative problem (40.9%). ASA score was inversely correlated with odds of having increased pain (OR 0.64, 95% CI 0.42-0.98) and was the only statistically significant predictor in our multivariate model that included dilated tract number, diameter, and location. The postoperative SIRS/sepsis rate within 7 days was 9.7%, and higher ASA score (OR 3.6, 95% CI 1.8-7.6) and incomplete stone clearance (OR 2.7, 95% CI 1.2-6.3) were significant predictors. Age, sex, body mass index (BMI), stone burden, and positive preoperative urine cultures were not associated with overall infection rate. In patients who had a postoperative infection, 34.1% of infections were detected intraoperatively or in the recovery room, and 48.8% were associated with the nephrostomy tube removal process on postoperative day 1. Patients who had a postoperative double-J stent rather than a nephrostomy tube had a lower overall infection rate (1.8%, p = 0.047). Finally, only 1.9% of patients had a bleeding complication, and 1.1% required a blood transfusion. CONCLUSIONS: Excessive pain is the most common clinical barrier to same-day discharge after PCNL and affects nearly half of all patients. Bleeding is infrequent, and most infections can be recognized perioperatively or avoided with alternative tube management strategies. Rigorous patient selection for same-day discharge does not appear to be necessary. Optimizing pain control may be the key to performing outpatient surgery on a large scale. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1125-e1125 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Heiko Yang More articles by this author Jordan T Holler More articles by this author Harry Lee More articles by this author Greg Hosier More articles by this author Rei Unno More articles by this author Fadl Hamouche More articles by this author Justin Ahn More articles by this author David Bayne More articles by this author Anobel Odisho More articles by this author Marshall Stoller More articles by this author Thomas Chi More articles by this author Expand All Advertisement Loading ...

Patient-controlled epidural analgesia, patient-controlled intravenous analgesia, and conventional intravenous opioids for gynecologic interstitial brachytherapy: A single-center retrospective study

PURPOSE Interstitial brachytherapy for gynecologic malignancies is stressful physically and mentally; however, optimal analgesic methods remain unclear. We investigated the effect of analgesic methods on pain and adverse events during interstitial brachytherapy for gynecologic malignancies.METHODS The data of 73 patients who underwent interstitial brachytherapy for gynecologic malignancies between April 2015 and March 2020 were retrospectively analyzed. Patient-controlled epidural analgesia (PCEA), patient-controlled intravenous analgesia (PCIA), and conventional intravenous opioid administration were used for analgesia during treatment. We compared the analgesic effects based on a numerical rating scale (NRS), the number of additional analgesics, and the adverse events associated with analgesia. The NRS score was calculated as an average value for every 12 h (NRS1: treatment on the 1st day from 12 to 24 o'clock; NRS2: treatment on the 2nd day from 0 to 12 o'clock; NRS3: treatment on the 2nd day from 12 to 24 o'clock). The mean NRS score differences between the methods were evaluated using mixed models for repeated-measures analyses.RESULTS The NRS score was significantly lower at all times for PCEA (NRS1: p = 0.003; NRS2: p = 0.011; NRS3: p < 0.001). NRS2 and NRS3 were significantly lower for PCIA (NRS2: p = 0.043; NRS3: p < 0.001) than for the conventional method. The NRS scores for PCEA and PCIA were not significantly different. Moreover, additional analgesics and adverse events did not differ between the three treatments.CONCLUSION PCEA and PCIA were superior to conventional intravenous opioids for analgesia in interstitial brachytherapy for gynecologic malignancies. However, adverse events associated with PCEA and PCIA were not reduced.

Continuous wound infusion with ropivacaine alone provides adequate analgesia following laparotomy

Although continuous wound infusion (CWI) with local anaesthetic has been used as an adjunct for pain relief following laparotomy, its use as the main modality has not been studied. This approach negates side effects related to intravenous opioid administration, therefore promoting enhanced recovery from surgery. We conducted this study to investigate the feasibility and efficacy of CWI following laparotomy. Consecutive patients who underwent laparotomy from June 2016 to December 2019 were analysed. All patients were given CWI with only oral supplementation. Pain was assessed based on the numeric rating scale (NRS). One hundred and three patients were analysed. Mean age was 61.1 (standard deviation 16.7). 47.6% of patients were operated for intestinal obstruction. Large bowel resection was the most common operation performed (49.5%). 69.9% of patients underwent emergency surgery, whilst 51.5% of patients had surgery for cancer. On postoperative day 0, NRS was 3.2 (standard deviation (sd) 2.6) which decreased to 1.5 (sd 1.9) on day 3, and 1.1 (sd 1.8) on day 5. Mean time to flatus was 2.3 (sd 1.4) days, whilst mean time to first bowel movement was 3.1 (sd 1.7) days. Patients were able to commence ambulation by 2.5 (sd 1.8) days. Patients could tolerate a normal diet on day 3.9 (sd 3.3), and IV drip was removed on day 3.5 (sd 3.0). Mean length of stay was 9.1 (sd 6.9) days. Only two patients suffered from respiratory depression (1.9%) whilst five patients suffered from hypotension (4.9%). No patients had pruritus. 23.3% of patients had nausea or vomiting. Only one patient had a catheter-related complication which was easily addressed. CWI provides adequate pain relief as the principle modality of analgesia after surgery, without opioid side effects.

Preoperative Implementation of Transverse Thoracic Muscle Plane Block and Rectus Sheath Block Combination for Pediatric Cardiac Surgery

Systemic intravenous administration of opioids is the main treatment strategy for intraoperative and postoperative pain management in patients undergoing cardiac surgery with sternotomy. However, using lower doses of opioids may achieve the well-established benefits of the fast-track approach, with minimal opioid-related side effects. Postoperative pain is coupled with a long stay in the intensive care unit. Although neuraxial anesthesia has some benefits, its use remains controversial due to the potential development of epidural hematoma after anticoagulation for cardiopulmonary bypass and coagulopathy after cardiac surgery. Therefore, there is a need for other effective postoperative analgesic strategies, such as peripheral nerve blocks other than neuraxial anesthesia, for cardiac surgery with sternotomy. The effects of real-time ultrasound-guided transverse thoracic muscle plane (TTP) block on postoperative pain after sternotomy have been reported; however, the pain and discomfort in the epigastric area caused by chest drainage tubes placed through the rectus abdominis muscle also are major postoperative problems after cardiac surgery. Herein, the authors report on a preoperative combination of TTP block and rectus sheath block (RSB) for postoperative pain management after cardiac surgery with sternotomy that addresses pain in both the chest and epigastric areas. Considering previous studies, it is presumed that preemptive analgesic effects can be expected via a combination of the TTP block and RSB, and indeed, the preemptive effect was observed in the present study's patients. In this article, the procedure and tips for combining the TTP block and RSB are introduced.

Subcutaneous sumatriptan for the treatment of postcraniotomy pain (SUPS trial): protocol for a randomised double-blinded placebo controlled trial

IntroductionPostcraniotomy pain protocols use opioids, which are considered suboptimal analgesia following this procedure. Multimodal analgesia components are sparse. Our null hypothesis states that sumatriptan is not different to placebo in...

Nurses’ beliefs and practices regarding intravenous opioid use for breakthrough cancer pain.

222 Background: Faster intravenous (IV) opioid administration speed is associated with increased adverse effects and subsequent increased opioid intake. Infusion rates ≥ 2 minutes are recommended. Data on nurse practices regarding IV opioid administration are limited. We assessed the frequency of nurse-reported speeds of IV opioid bolus infusion in the inpatient oncology units, and nurses’ beliefs and perceptions about opioids in cancer pain management. Methods: A cross-sectional survey among inpatient nurses working in the medical, surgical, intensive care unit (ICU), and emergency department (ED) work areas was conduceted. We defined fast IV opioid bolus infusion speed as &lt; 120 seconds(s). Results: The participant response rate was 60% (731/1234).57%, 55%, and 58% of all nurses administered morphine, hydromorphone, and fentanyl in &lt; 120s.Overall median (IQR) infusion speed of IV morphine, hydromorphone, and fentanyl were 60s (40-120), 90s (45-120), and 60s (30-120) respectively. Correlation between morphine, hydromorphone, and fentanyl infusion speeds were 0.93, 0.90, and 0.90 respectively (p &lt;0 .0001). Median infusion speed of morphine was 55s for ICU nurses, 60s for both surgical unit and emergency department nurses, and 85s for medical unit nurses (p=0.0002). The odds ratio for fast IV opioid infusion was 2.22 for ED nurses (p= 0.027), 2.67 for ICU nurses (p= 0.001), 0.27 and 0.18 for frequent (p=0.003) and very frequent(p=0.001) use a timing device respectively, and 0.86 for hydromorphone infusion compared with morphine (&lt; 0.0001). Fast infusion was also independently associated with perception that suboptimal pain control as the reason for increased patient opioid requests(p=0.009), clinician reluctance to prescribe opioids(p=0.008), lack of psychosocial support services (p= 0.03), and patient’s reluctance to take opiates (p=0.015). Conclusions: More than half the nurses working in the inpatient setting reported administering IV opioids at a faster speed than recommended. Nurses who frequently use a timing device are more likely to infuse at a more optimal speed. Further research is needed to standardize and improve safe intermittent infusion of parenteral opioids.

Subcutaneous or intravenous opioid administration by patient-controlled analgesia in cancer pain: a systematic literature review.

Opioids administered by various routes are a mainstay of tumour-related pain management. Subcutaneous or intravenous patient-controlled analgesia (PCA) with opioids is an appropriate and safe form of treatment for postoperative pain but studies on this form of administration are sparse in the setting of cancer pain despite widespread use. To evaluate the published studies on opioids administered by subcutaneous and intravenous patient-controlled analgesia for patients with cancer pain. Articles were identified from the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 7, 2016), PubMed (Medline; 1975 to 2016) and EMBASE (1974 to 2016). Additional reports were identified from the reference lists of retrieved papers. Studies based on original data with a focus on intravenous or subcutaneous PCA administration of opioids in patients suffering from cancer-related pain were selected. The language was restricted to Dutch, English or German. Predefined information was extracted depending on the topic. Fifty studies published since 1980 met the inclusion criteria. A wide range of study designs, study quality and research objectives were observed. The studies indicated use of standard or by proxy PCA in the inpatient and outpatient setting were safe and useful while significant adverse effects were rarely observed. This systematic review of the current evidence suggests PCA can be appropriately used in a wide range of clinical situations.

Intravenous versus oral paracetamol for acute pain in adults in the emergency department setting: a prospective, double-blind, double-dummy, randomised controlled trial

ObjectiveTo determine if intravenous paracetamol was superior to oral paracetamol as an adjunct to opioids in the management of moderate to severe pain in the ED setting.MethodsA prospective, randomised, double-blind,...

Comparative Effectiveness of Patient-Controlled Analgesia for Treating Acute Pain in the Emergency Department

We assess the effectiveness of patient-controlled analgesia in the emergency department (ED). We hypothesized that decline in pain intensity from 30 to 120 minutes after initial intravenous opioid administration is greater in patients receiving morphine by patient-controlled analgesia compared with usual care and would differ by a clinically significant amount. This was a pragmatic randomized controlled trial of patient-controlled analgesia and usual care (opioid and dose at physician's discretion) in 4 EDs. Entry criteria included age 18 to 65 years and acute pain requiring intravenous opioids. The primary outcome was decline in numeric rating scale pain score 30 to 120 minutes postbaseline. Secondary outcomes included satisfaction, time to analgesia, adverse events, and patient-controlled analgesia pump-related problems. We used a mixed-effects linear model to compare rate of decline in pain (slope) between groups. A clinically significant difference between groups was defined as a difference in slopes equivalent to 1.3 numeric rating scale units. Six hundred thirty-six patients were enrolled. The rate of decline in pain from 30 to 120 minutes was greater for patients receiving patient-controlled analgesia than usual care (difference=1.0 numeric rating scale unit; 95% confidence interval [CI] 0.6 to 1.5; P<.001) but did not reach the threshold for clinical significance. More patients receiving patient-controlled analgesia were satisfied with pain management (difference=9.3%; 95% CI 3.3% to 15.1%). Median time to initial analgesia was 15 minutes longer for patient-controlled analgesia than usual care (95% CI 11.4 to 18.6 minutes). There were 7 adverse events in the patient-controlled analgesia group and 1 in the usual care group (difference=2.0%; 95% CI 0.04% to 3.9%), and 11 pump-programming errors. The findings of this study do not favor patient-controlled analgesia over usual ED care for acute pain management.

The Role of Transversus Abdominis Plane Blocks in Enhanced Recovery After Surgery Pathways for Open and Laparoscopic Colorectal Surgery.

The concepts of Enhanced Recovery After Surgery (ERAS®) have steadily increased in usage, with benefits in patient outcomes and hospital length of stay. One important component of successful implementation of ERAS protocol is optimized pain control, via the multimodal approach, which includes neuraxial or regional anesthesia techniques and reduction of opioid use as the primary analgesic. Transversus abdominis plane (TAP) block is one such regional anesthesia technique, and it has been widely studied in abdominal surgery. We performed an extensive literature search in MEDLINE and PubMed. We review the benefits of TAP blocks for colorectal surgery, both laparoscopic and open. We organize the data by surgery type, by method of TAP block performance, and by a comparison of TAP block to alternative analgesic techniques or to placebo. We examine different endpoints, such as postoperative pain, analgesic use, return of bowel function, and length of stay. The majority of studies examined TAP blocks in the context of laparoscopic colorectal surgery, with many, but not all, demonstrating significantly less use of postoperative opioids in comparison to placebo, wound infiltration, and standard postoperative patient-controlled analgesia with intravenous opioid administration. There is evidence that use of liposomal bupivacaine may be more effective than conventional long-acting local anesthetics. Noninferiority of TAP infusions has been demonstrated, compared with continuous thoracic epidural infusions. TAP blocks are easily performed, cost-effective, and an opioid-sparing adjunct for laparoscopic colorectal surgery, with minimal procedure-related morbidity. The evidence is in concordance with several of the goals of ERAS pathways.

Effect of adjunctive dexmedetomidine on postoperative intravenous opioid administration in patients undergoing thyroidectomy in an ambulatory setting

Study ObjectiveTwo of the most feared complications for patients undergoing thyroid surgery are pain and postoperative nausea and vomiting. Thyroidectomy is considered high risk for postoperative nausea and vomiting, and recent studies have looked at adjuncts to treat pain, limit narcotic use, “fast-track” the surgical process, and enhance recovery without compromising the patient's safety. One such perioperative medication of interest is dexmedetomidine (Dex), a centrally acting α-2 agonist that has been associated with reducing pain and postoperative opioid consumption. Our aim was to examine the effectiveness of Dex as an adjunctive intraoperative medication to reduce postoperative narcotic requirements in patients undergoing outpatient thyroid surgery. Design, Setting, Patients and InterventionAfter obtaining approval from the Institutional Review Board at The University of Texas MD Anderson Cancer Center, we searched the electronic medical record for the period October 2013 to March 2015 to identify patients who had undergone thyroid surgery in the ambulatory setting under general anesthesia. Measurements and Main ResultsA total of 71 patients underwent thyroidectomy or thyroid lobectomy in the outpatient setting. Of the patients receiving adjunctive Dex, a lower proportion (50%, n=9) received postoperative intravenous opioids when compared with control patients (79%, n=42) (P=.017). One patient (5%) in the Dex group required rescue postoperative antiemetics as compared to 11 (21%) patients in the control group (P=.273). ConclusionsOur data suggest that intraoperative use of Dex reduced narcotic administration in the postoperative period among study population patients undergoing thyroidectomy.

Patient controlled opioid analgesia versus non-patient controlled opioid analgesia for postoperative pain.

This is an updated version of the original Cochrane review published in Issue 4, 2006. Patients may control postoperative pain by self administration of intravenous opioids using devices designed for this purpose (patient controlled analgesia or PCA). A 1992 meta-analysis by Ballantyne et al found a strong patient preference for PCA over non-patient controlled analgesia, but disclosed no differences in analgesic consumption or length of postoperative hospital stay. Although Ballantyne's meta-analysis found that PCA did have a small but statistically significant benefit upon pain intensity, a 2001 review by Walder et al did not find statistically significant differences in pain intensity or pain relief between PCA and groups treated with non-patient controlled analgesia. To evaluate the efficacy and safety of patient controlled intravenous opioid analgesia (termed PCA in this review) versus non-patient controlled opioid analgesia of as-needed opioid analgesia for postoperative pain relief. We ran the search for the previous review in November 2004. For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 12), MEDLINE (1966 to 28 January 2015), and EMBASE (1980 to 28 January 2015) for randomized controlled trials (RCTs) in any language, and reference lists of reviews and retrieved articles. We selected RCTs that assessed pain intensity as a primary or secondary outcome. These studies compared PCA without a continuous background infusion with non-patient controlled opioid analgesic regimens. We excluded studies that explicitly stated they involved patients with chronic pain. Two review authors independently extracted data, which included demographic variables, type of surgery, interventions, efficacy, and adverse events. We graded each included study for methodological quality by assessing risk of bias and employed the GRADE approach to assess the overall quality of the evidence. We performed meta-analysis of outcomes that included pain intensity assessed by a 0 to 100 visual analog scale (VAS), opioid consumption, patient satisfaction, length of stay, and adverse events. Forty-nine studies with 1725 participants receiving PCA and 1687 participants assigned to a control group met the inclusion criteria. The original review included 55 studies with 2023 patients receiving PCA and 1838 patients assigned to a control group. There were fewer included studies in our updated review due to the revised exclusion criteria. For the primary outcome, participants receiving PCA had lower VAS pain intensity scores versus non-patient controlled analgesia over most time intervals, e.g., scores over 0 to 24 hours were nine points lower (95% confidence interval (CI) -13 to -5, moderate quality evidence) and over 0 to 48 hours were 10 points lower (95% CI -12 to -7, low quality evidence). Among the secondary outcomes, participants were more satisfied with PCA (81% versus 61%, P value = 0.002) and consumed higher amounts of opioids than controls (0 to 24 hours, 7 mg more of intravenous morphine equivalents, 95% CI 1 mg to 13 mg). Those receiving PCA had a higher incidence of pruritus (15% versus 8%, P value = 0.01) but had a similar incidence of other adverse events. There was no difference in the length of hospital stay. Since the last version of this review, we have found new studies providing additional information. We reanalyzed the data but the results did not substantially alter any of our previously published conclusions. This review provides moderate to low quality evidence that PCA is an efficacious alternative to non-patient controlled systemic analgesia for postoperative pain control.

Bloqueo infraclavicular continuo guiado por ultrasonido para cirugía de mano. Reporte técnico de la posición del brazo para la colocación del catéter perineural

BackgroundContinuous perineural infusion of local anaesthetic provides better postoperative analgesia than intravenous administration of opioids or NSAIDs in upper limb surgery. The infraclavicular approach is a good option, due to the muscular stability to catheter; the abduction of the arm apparently makes the brachial plexus more superficial and which elevates the clavicle in the cephalic direction. AimThe aim of this study was to identify whether the abduction of the arm decreases the skin-plexus distance, making the perineural insertion of the catheter easier and for a better analgesia. This relationship between the arm and the insertion of catheter has not yet been established. Material and methodsThe study included 58 adult patients, undergoing forearm and hand surgery, initially divided into two groups, adduction and abduction. Ultrasound-guided infraclavicular block was performed, enabling the catheter tip to be positioned adjacent to the posterior cord. The group of patients with high technical difficulties were allowed to reposition the arm abduction. A record was made of the number of punctures, redirects, ease of insertion of the catheter, and skin-plexus distance. ResultsThe abduction of the arm moved the clavicle towards the cephalad and separated it from the linear transducer, this allowed to manoeuvre the needle right angle and redirect it. The skin-plexus distance did not decrease significantly with arm position. ConclusionsArm abduction allows better scanning, facilitates the infraclavicular puncture, and catheter introduction.

The Impact of an Acute Vaso-Occlusive Crisis on Patient Reported Outcomes: The Magic Study

▪Acute vaso-occlusive crises (VOC) are the most common complication in sickle cell disease (SCD) and frequently result in hospitalization. The impact of an acute VOC on patient reported outcomes (PROs) over time is not known. It is necessary to describe the patterns of change over time of these outcomes for future interventions that aim to optimize PROs. The objective of this study was to determine the impact over time of an acute VOC on the health-related quality of life (HRQL-a specific type of PRO) of children with SCD.A multi-center prospective trial was conducted within the setting of a randomized controlled trial (the Magnesium in Crisis or MAGiC trial) that recruited from eight United States Children’s hospitals. Eligibility criteria included children ages 5 to 21 years with hemoglobin SS disease or β0thalassemia who were admitted to the hospital for a VOC and required intravenous administration of opioids. The children were asked to complete the PedsQL SCD and Fatigue HRQL modules at four time points (T0= at time of admission to hospital, T1= 48 hours from admission, T2= approximately 7 days post discharge, T3= steady state – complete resolution of the acute event, one month or more from discharge). The primary outcomes were the SCD and Fatigue Total HRQL scores. Secondary analyses examined specific HRQL domain scores. HRQL scores range from 0-100 with higher scores representing better HRQL. HRQL scores of 60-80 represent intermediate functioning. Descriptive statistics including t-tests for paired differences in scores were performed and a multivariate analysis using a linear mixed effects model was used to determine significant differences. The following covariates were included in the model: hospital site, age, gender, hydroxyurea use, disease severity (ever had acute chest syndrome and/or hospitalized for 3 or more VOC in the prior 3 years), and steady state HRQL score.A total of 204 children participated in the trial. The mean age was 13.6 years and 51% were female. The mean SCD total HRQL scores over time were as follows: T0=48.5, T1=48.5, T2=59.5, and T3=60. The mean Fatigue HRQL total scores over time were as follows: T0=53.9, T1=50.8, T2=61.3, and T3=62.0.In the multivariate analysis, there was no significant change from T0 to T1 for the Total SCD HRQL score. There was a significant increase of 11.8 points (p<0.01) in the Total SCD HRQL score at T2. The same pattern was seen for the Total Fatigue HRQL scores with no significant change from T0 to T1 and an increase of 7.9 points (p<0.01) in the score at T2. Those with higher steady state (T3) HRQL scores had higher HRQL scores during crisis. None of the remaining covariates, hospital site, age ,gender hydroxyurea use, and disease severity were associated with significant differences in HRQL scores over time.In the multivariate analysis of the specific HRQL SCD domain scores, there was significant improvement in 8 of the 9 HRQL domains. The greatest improvement in scores (parameter estimates) were noted in the pain and hurt (16.9), pain impact (15.3), and pain management (13.4) domains, p<0.01. The only domain where significant improvement was not noted was the Communication I domain (3.4). There was significant improvement in scores in all of the specific Fatigue HRQL domains, the General Fatigue (9.3) and Sleep/Rest Fatigue (9.6), and Cognitive Fatigue domains (5.0), p<0.01.This prospective study demonstrates that children with SCD have significantly lower HRQL at presentation of an acute VOC that improves by nearly 12 points one week post discharge. This is maintained at the steady state visit. The rate of change is not affected by hospital site, age, gender, hydroxyurea use, and disease severity. These findings provide the necessary data to tailor future interventions that aim to optimize HRQL for these patients. DisclosuresNo relevant conflicts of interest to declare.

Real-time mobile detection of drug use with wearable biosensors: a pilot study.

While reliable detection of illicit drug use is paramount to the field of addiction, current methods involving self-report and urine drug screens have substantial limitations that hinder their utility. Wearable biosensors may fill a void by providing valuable objective data regarding the timing and contexts of drug use. This is a preliminary observational study of four emergency department patients receiving parenteral opioids and one individual using cocaine in a natural environment. A portable biosensor was placed on the inner wrist of each subject, to continuously measure electrodermal activity (EDA), skin temperature, and acceleration. Data were continuously recorded for at least 5 min prior to drug administration, during administration, and for at least 30 min afterward. Overall trends in biophysiometric parameters were assessed. Injection of opioids and cocaine use were associated with rises in EDA. Cocaine injection was also associated with a decrease in skin temperature. Opioid tolerance appeared to be associated with a blunted physiologic response as measured by the biosensor. Laterality may be an important factor, as magnitude of response varied between dominant and nondominant wrists in a single patient with bilateral wrist measurements. Changes in EDA and skin temperature are temporally associated with intravenous administration of opioids and cocaine; the intensity of response, however, may vary depending on history and extent of prior use.

CrossTalk opposing view: The pre‐Bötzinger complex is not essential for respiratory depression following systemic administration of opioid analgesics

Opioid receptors and enkephalinergic nerve terminals are widely distributed throughout respiratory-related regions of the brainstem and in the phrenic motor nucleus of the spinal cord (Xia & Haddad, 1991; Laferriere et al. 1999; Wang et al. 2002; Haji et al. 2003a; Lonergan et al. 2003a,b; Strornetta et al. 2003). Since opiate drugs given systemically will act on opioid receptors with conjoint selectivity in all respiratory regions, respiratory depression is unlikely to be dependent on actions at a single site. Therapeutic doses of opioids given to most mammalian species depress respiratory rate, minute ventilation, alveolar–arterial gas exchange and respiratory responsiveness to hypoxia and hypercapnia (Jaffe & Martin, 1990). Opioid-mediated depression of respiration is due at least in part to direct effects on the brainstem respiratory network, which includes several sites of action in medullary and pontine regions (reviewed by Pattison, 2008; Lalley, 2008). The degree of opioid-mediated respiratory depression depends on agonist dose, opioid receptor density and the subtypes of opioid receptor in various respiratory regions. Species variability and stage of development are also factors (Santiago & Edelman, 1985). In the paragraphs to follow, we review results of studies that indicate that the pre-Botzinger complex (preBotC) is not essential for respiratory depression by systemically administered opioid analgesics.

Effectiveness of Continuous Low Dose Local Anaesthetic Infusion in Transverses Abdominis Plane (TAP) for Renal Transplant Recipients: A Comparative Study of 157 Patients

Introduction: Renal transplant is becoming a gold standard treatment for patients with end stage renal failure. Perioperative management of transplant recipient has much improved over the last two decades. Many efforts have been put in to reduce post operative pain in renal transplant recipients. Currently intravenous opioid administration provides the mainstay of analgesia following renal transplantation. Other techniques including local anaesthetic wound infiltration, transverses abdominis plane (TAP) block and continuous wound infusions have been reported in the literature. This present study describes our experience in multimodal/ opioid sparing analgesia regime with effectiveness of TAP continuous infusion of local anaesthetic in renal transplant recipients and its effects on patient's outcome. Methods: We respectively analysed data of consecutive renal transplant recipients performed between 2009 and 2011. Patients were divided into three groups; Group I (TAP block with continuous TAP catheter infusion and Patient Controlled Analgesia {PCA}, n=43), Group II (Continuous TAP catheter infusion and PCA, n=53) and Group III (PCA only, n=61). Primary outcome was recorded as post-operative pain control. Secondary outcomes were total amount of fentanyl used; post operative wound infection, chest infection, deep venous thrombosis and length of stay in hospital. Medcal software was used for analysis. p < 0.05 was considered statistically significant. Results: Results are shown in Table 1Table: [Outcome analysis]Conclusion: Our results show that TAP continuous infusion of local anaesthetic is an effective method of controlling post-operative pain and minimising opioid use in renal transplant recipients. Although median hospital stay is dependent on many factors but better pain control and early mobility may contribute to the reduction in length of stay.

Epidural Analgesia for Labor and Delivery

A 30-year-old pregnant woman is undergoing induction of labor and is experiencing severe pain despite intravenous opioid administration. Epidural analgesia is recommended. Epidural analgesia involves the injection of a local anesthetic agent and an opioid analgesic agent into the lumbar epidural space. These agents diffuse across the dura and act on the spinal nerve roots. Rates of cesarean delivery are not increased with epidural analgesia.

Intravenous Opioids for Severe Acute Pain in the Emergency Department

To review clinical trials of intravenous opioids for severe acute pain in the emergency department (ED) and to provide an approach for optimization of therapy. Articles were identified through a search of Ovid/MEDLINE (1948-August 2010), PubMed (1950-August 2010), Cochrane Central Register of Controlled Trials (1991-August 2010), and Google Scholar (1900-August 2010). The search terms used were pain, opioid, and emergency department. The search was limited by age group to adults and by publication type to comparative studies. Studies comparing routes of administration other than intravenous or using non-opioid comparators were not included. Bibliographies of all retrieved articles were reviewed to obtain additional articles. The focus of the search was to identify original research that compared intravenous opioids used for treatment of severe acute pain for adults in the ED. At equipotent doses, randomized controlled trials have not shown clinically significant differences in analgesic response or adverse effects between opioids studied. Single opioid doses less than 0.1 mg/kg of intravenous morphine, 0.015 mg/kg of intravenous hydromorphone, or 1 μg/kg of intravenous fentanyl are likely to be inadequate for severe, acute pain and the need for additional doses should be anticipated. In none of the randomized controlled trials did patients develop respiratory depression requiring the use of naloxone. Future trials could investigate the safety and efficacy of higher doses of opioids. Implementation of nurse-initiated and patient-driven pain management protocols for opioids in the ED has shown improvements in timely provision of appropriate analgesics and has resulted in better pain reduction. Currently, intravenous administration of opioids for severe acute pain in the ED appears to be inadequate. Opioid doses in the ED should be high enough to provide adequate analgesia without additional risk to the patient. EDs could implement institution-specific protocols to standardize the management of pain.