Short-acting Opioids Research Articles

Multimodal opioid sparing onco-anesthesia: A consensus practice guideline from Society of Onco-Anesthesia and Perioperative Care (SOAPC).

Opioids are an indispensable part of perioperative pain management of cancer surgeries. Opioids do have some side effects and abuse potential, and some laboratory data suggest a possible association of cancer recurrence with perioperative opioid use. Opioid-free anesthesia and opioid-sparing anesthesia are emerging new concepts worldwide to safeguard patients from adverse effects of opioids and potential abuse. Opioid-free anesthesia could lead to ineffective pain management, leaving the perioperative physician with limited options, while opioid-sparing anesthesia may be a rational approach. This consensus guideline includes general considerations of the safe use of perioperative opioids along with concomitant use of central neuraxial or regional blockade and systematic nonopioid analgesics. Region-specific onco-surgeries with their specific recommendations and consensus statements for judicious use of opioids are suggested. Use of epidural analgesia or regional catheter during thoracic, abdominal, pelvic, and lower limb surgeries and use of regional nerve blocks/catheter in head neck, neuro, and upper limb onco-surgeries, wherever possible along with nonopioids analgesics, are suggested. Short-acting opioids in small aliquots may be allowed to control breakthrough pain for expedient control of pain. The purpose of this consensus practice guideline is to provide the practicing anesthesiologists with best practice evidence and consensus recommendations by the expert committee of the Society of Onco-Anesthesia and Perioperative Care for safe opioid use in onco-surgeries.

Do Formulation and Dose of Long-Term Opioid Therapy Contribute to Risk of Adverse Events among Older Adults?

Chronic non-cancer pain (CNCP) is highly prevalent in older adults and long-term opioid therapy (LTOT) has been used to manage chronic pain. However, the safety of LTOT among older adults with CNCP is not well-established and there is a need to identify therapy-related risk factors of opioid-related adverse events among older adults. To evaluate the relationship between opioid dose and formulation and the risk of opioid-related adverse events among Medicare-eligible older adults on LTOT. Nested case-control study. Older Medicare beneficiaries (N=35,189) who received > 3 opioid prescriptions with a total days-supply of >45 days within a 90-day period for CNCP between 2012 and 2016. This study utilized Medicare 5% medical and prescription claims data. Outcome measures included opioid-induced respiratory depression (OIRD), opioid overdose, all-cause mortality, and a composite outcome, defined as the first occurrence of any of the previous three events. Key independent variables were opioid formulation and opioid dose (measured in morphine milligram equivalents (MME)) prescribed during LTOT. Seventy-four OIRD, 133 overdose, 982 all-cause mortality, and 1122 composite outcome events were observed during follow-up. In unadjusted analyses, the use of combination opioids (OR: 4.52 [95%CI: 1.51-13.47]) was significantly associated with OIRD compared to short-acting (SA) opioids. In adjusted analyses, opioid-related adverse events were significantly associated with the use of LA (overdose OR: 13.00 [95%CI: 1.30-130.16] and combination opioids (overdose OR: 6.27 [95%CI: 1.91-20.55]; mortality OR: 2.75 [95%CI: 1.87-4.04]; composite OR: 2.82 [95%CI: 2.01-3.96]) when compared to SA opioids. When compared to an average dose of less than 20 MME, outcomes were significantly associated with doses of 20-50 MME (mortality OR: 1.61 [95%CI: 1.24-2.10]; composite OR: 1.59 [95%CI: 1.26-2.01]) and >50 MME (mortality OR: 1.99 [95%CI: 1.28-3.10]; composite OR: 2.09 [95%CI: 1.43-3.04]). Older adults receiving medically prescribed opioids at higher doses and those using LA and combination of LA and SA opioids are at increased risks for opioid-related adverse events, highlighting the need for close patient supervision.

Opioid Prescribing in United States Health Systems, 2015 to 2019

ObjectivesHealth systems (nonfederal hospitals and clinics) are the second major source for drug expenditure in the United States. Opioids prescribed in these healthcare settings are commonly short-acting opioids that can lead to persistent opioid use. Nevertheless, there are no national data that describe trends in opioid use and the associated expenditure in health systems. Therefore, the objective of this article was to describe opioid use and expenditures in US health systems from 2015 to 2019. MethodsWe used data from IQVIA National Sales Perspectives to describe prescription opioid expenditure and use in health systems (nonfederal hospitals and clinics). ResultsOver the 5-year study period, health systems dispensed a total of 6.55 billion units of opioids (26.88% decrease) with an associated expenditure of $3.33 billion (26.78% decrease). Relative to all opioid formulations in our study, oxycodone, hydrocodone, and fentanyl were the opioids with the highest use in US health systems. All opioid prescriptions decreased except fentanyl use, which increased by 29.80% in clinics. The use of abuse-deterrent formulations of opioids decreased by 51.00% over the study period, although the decrease seems to be driven mainly by long-acting oxycodone (brand name Oxycontin). ConclusionsOpioid use and expenditures in health systems have been decreasing following national trends from retail pharmacies. Nevertheless, fentanyl use increased in clinics and was prescribed at higher proportions in nonfederal hospitals than other opioids, which warrants further investigation.

Updates and controversies in anesthesia for advanced interventional pulmonology procedures.

Advanced bronchoscopic procedures continues to grow, and are now commonly used to diagnose and/or treat a variety of pulmonary conditions that required formal thoracic surgery in past decades. Pharmacologic developments have provided new therapeutic options, as have technical advances in both anesthesia and interventional pulmonology. This review discusses technical and clinical issues and advances in providing anesthesia for advanced bronchoscopic procedures. It also discusses some controversial issues that have yet to be fully resolved. We discuss anesthetic considerations for new procedures such as the new technology used in electromagnetic navigation bronchoscopy, and bronchoscopic cryotherapy. We also review new ventilation strategies as well as pharmacologic advances and recent trends in the utilization of anesthetic adjuvants, and the use of short-acting opioids like remifentanil, and alpha agonist sedatives such as dexmedetomidine. The anesthetic framework and the discussions presented here should help forge effective communication between the interventional pulmonologist and the anesthesiologist In the Bronchoscopy Suite nonoperating room anesthesia with the goal of enhancing patient safety.

Tracheal intubation with or without a neuromuscular blocking agent for a short surgical procedure in children: Prospective, randomized, double-blind trial.

Although a neuromuscular blocking agent during induction of anesthesia is the standard of care in adults, some pediatric anesthesiologists remain concerned about their use for several reasons. Therefore, propofol and short-acting opioids with a moderate concentration of sevoflurane have been used as alternatives to a neuromuscular blocking agent. This study compared propofol, alfentanil, and rocuronium to determine the optimal anesthetic agent for intubation conditions as well as emergence in a short pediatric procedure. In this prospective, randomized, double-blind study, 114 pediatric patients, aged 1-9years, were randomly assigned to one of three groups receiving either propofol 2mgkg-1 (propofol group), alfentanil 14mcgkg-1 (alfentanil group), or rocuronium 0.3mgkg-1 (rocuronium group). The primary outcome was intubating conditions, which were evaluated 90s after test drug administration. Vital signs were recorded during the intubation period. Complications during and after emergence, time to recovery, airway-related complications, and severity of emergence agitation were recorded. Compared with the propofol group (60%), significantly more excellent intubating conditions were observed in the alfentanil group (97%, percent difference -37, 95% confidence interval (CI) -54.4--21.0, p<.001) and the rocuronium group (87%, percent difference -27, 95% CI -46.5--8.2, p=.041). Hemodynamic responses were different between the rocuronium and alfentanil groups, although the incidence of adverse events was not different among the three groups. The emergence duration was only statistically different between the rocuronium group [9.9±3.2min] and the propofol group [11.7±2.2min] (difference 95% CI 0.667-3.583, p=.001), while that of the alfentanil group [10.9±2.4min] was comparable with the other groups. Both 0.3mgkg-1 rocuronium and 14µgkg-1 alfentanil are superior adjuncts for tracheal intubation in children undergoing frenulectomy in comparison with 2mgkg-1 propofol. Hemodynamic adverse events and recovery profiles were comparable among the three groups.

Day-to-day opioid withdrawal symptoms, psychological distress, and opioid craving in patients with chronic pain prescribed opioid therapy

BackgroundResearch has shown that opioid craving is one of the strongest determinants of opioid misuse in patients with chronic pain. To date, however, little is known on the factors that contribute to opioid craving in these patients. It is possible that patients’ physical dependence to opioids, manifested by opioid withdrawal symptoms in between daily opioid doses, contribute to opioid craving. Physical dependence symptoms might also lead to psychological distress, which in turn might contribute to opioid craving. The first objective of this study was to examine the day-to-day association between opioid withdrawal symptoms and opioid craving among patients with chronic pain. We also examined whether negative affect and catastrophic thinking mediated this association. MethodsIn this longitudinal study, chronic pain patients (n = 79) prescribed short-acting opioids completed daily diaries for 14 consecutive days. Diaries assessed a host of pain, psychological, and opioid-related variables. ResultsDay-to-day elevations in opioid withdrawal symptoms were associated with heightened opioid craving (p < .001). Results of a multilevel mediation analysis revealed that this association was mediated by patients’ daily levels of negative affect and catastrophizing (p < .001). ConclusionsOur study provides valuable new insights into our understanding of factors that may contribute to prescription opioid craving among patients with chronic pain.

Opioid prescribing and health outcomes in opioid-naive patients: Analysis of a statewide health information exchange

BackgroundWidespread use of prescription opioids is associated with adverse outcomes. ObjectiveTo identify factors associated with adverse health outcomes and health care use using a statewide health information exchange. MethodsThis is a retrospective cohort study using the Indiana Network for Patient Care. Adult opioid-naive patients who received an opioid prescription between January 2012 and December 2017 were included. The outcomes included (1) a composite outcome of any combination of opioid abuse, dependence, or overdose, (2) all-cause mortality, and (3) health care use. Independent variables included opioid dosage, dispensed amount, days supply, concurrent use of short-acting (SA) and long-acting (LA) opioids, and concurrent use with benzodiazepine or gabapentinoids. Additional variables included patients’ age, sex, race, modified Charlson Comorbidity Index score, mental health conditions, and medications for opioid use disorders. Factors associated with composite outcome and mortality were identified using Cox proportional hazards and reported as adjusted hazard ratio (aHR) and 95% CI. Factors associated with health care use were identified using Poisson regression and reported as adjusted incidence rate ratio (aIRR) and 95% CI. Results1,328,287 opioid prescriptions were identified for 341,722 patients. Opioid-related factors associated with the composite outcome, mortality, and hospitalizations, respectively, included opioid dosage (aHR 1.003 [95% CI 1.001–1.006]; aHR not applicable; aIRR 1.07 [1.06–1.08]), opioid days supply (aHR 1.03 [1.02–1.03]; aHR 1.009 [1.005–1.014]; aIRR 0.94 [0.92–0.96]), concurrent SA/LA opioids (aHR 2.12 [1.78–2.54]; aHR 1.40 [1.14–1.70]; aIRR 1.40 [1.37–1.42]), and use of benzodiazepines/gabapentinoids (aHR 1.68 [1.38–2.04]; aHR 1.23 [1.01–1.51]; aIRR 1.25 [1.23–1.27]). ConclusionMany factors are associated with poor health outcomes, especially concurrent use of SA and LA opioids and overlapping prescriptions of opioids with benzodiazepines or gabapentinoids. Identification of factors associated with adverse outcomes may help identify patients at risk for poor outcomes and could inform possible interventions.

Efficacy of Dexmedetomidine Infusion Without Loading Dose on Hemodynamic Variables and Recovery Time During Craniotomy: A Randomized Double-blinded Controlled Study.

BackgroundMaintaining hemodynamic stability during intracranial surgery is one of the most important tasks. There is no general agreement regarding which anesthetics are optimal for craniotomy. Propofol and short-acting opioids are usually used, but their use is not without side effects. Recently, dexmedetomidine has been considered a safe alternative in different surgeries.ObjectivesWe aimed to assess the efficacy of 0.5 µg/kg/h dexmedetomidine infusion without loading dose as an adjunct to general anesthesia for craniotomy.MethodsA prospective, randomized, double-blinded, parallel-group, placebo-controlled trial was conducted. Setting: Single university teaching hospital’s operating rooms and postoperative intensive care unit. Patients: A total of 50 patients scheduled for elective supratentorial craniotomy participated in this study. Interventions: Patients were randomly divided into either control group (group C) and Dexmedetomidine group (group D). Main outcome measure: Intraoperative hemodynamics measurements at specific timings.ResultsWe found that dexmedetomidine had significantly maintained mean arterial blood pressure and heart rate (P-value < 0.001); with lower intraoperative fentanyl and propofol consumption in group D (132 ± 35 µg and 14 ± 30 mg, respectively) when compared to group C (260 ± 38 µg and 534 ± 66 mg, respectively). Finally, a lesser sedation level was noticed in the dexmedetomidine group, together with a significantly lesser recovery time of 10.3 ± 4 min.ConclusionsDexmedetomidine infusion without loading dose could be an efficacious and safe agent in achieving hemodynamic stability with intraoperative opioid-sparing effect and lesser recovery time.

Impact of Electronic Prescribing of Controlled Substances on Opioid Prescribing: Evidence From I-STOP Program in New York.

New York's Internet System for Tracking Over-Prescribing (I-STOP) Act, requires prescribers in the state to electronically prescribe controlled substances (EPCS). We examine the effects of this mandate on prescribing patterns of opioids for Medicare Part D beneficiaries. Using 2014-2017 CMS Medicare Part D Prescriber Data, we apply a lagged dependent variable regression approach to identify the impact of I-STOP on the prescription of opioids. In the first year of implementation, the number of opioid prescriptions per prescriber decreased by 5.7 per year. The policy had a larger effect on the prescription of short-acting opioids and on prescribers prescribing medication for predominantly younger beneficiaries. Overall, I-STOP resulted in a reduction in the number of beneficiaries being prescribed opioids and in the number of opioid claims in the state of New York, suggesting positive implications for other states intending to curtail opioid overprescribing and misuse through the use of EPCS.

Managing Nonmedical Opioid Use Among Patients With Cancer Pain During the COVID-19 Pandemic Using the CHAT Model and Telehealth

Managing Nonmedical Opioid Use Among Patients With Cancer Pain During the COVID-19 Pandemic Using the CHAT Model and Telehealth

Management of Chronic Pain in Nursing Homes: Navigating Challenges to Improve Person-Centered Care

Despite the dynamic demands in the nursing home (NH), a definitive approach to managing chronic pain in older adults has yet to be established. Due to concerns for potential adverse pharmacologic effects, balancing appropriate pain management is a challenge among NH residents. The challenges encompass but are not limited to medical complexities, functional disabilities, and physical frailty. Barriers to the successful implementation of a comprehensive chronic pain management at the NH may include ambiguous directions on specific therapeutic interventions, insufficient guidance on treatment duration, and limited available treatment options. The Centers for Medicare and Medicaid Services’ reporting requirement of adequate pain control among NH residents coupled with widely variable clinician-prescribing habits highlights the difficulties in overcoming the preceding challenges and barriers. The Coronavirus Disease 2019 (COVID-19) pandemic has further complicated pain management due to its negative consequences on well-being of residents of NHs. Associated symptoms of psychosocial stress, anxiety and depression, and chronic pain symptoms can exacerbate during the COVID-19 pandemic, leading to increased requirement for pain medications including but not limited to opioids.Pain is a multidimensional symptom and requires a strategic multimodal approach for its management. Nonpharmacologic modalities are underutilized in the NH setting and are the preferred first steps for mild pain, and nonopioid pharmacological agents can be added as a second step for a synergistic effect for moderate to severe pain. Opioids should be used as a last resort. Short-acting opioids are preferred over extended-release/long-acting opioids for chronic pain. Clinicians are encouraged to engage residents in proactive strategies in managing their pain, and to set realistic expectations toward improving their quality of life, as complete elimination of pain is not feasible in most cases.This review article provides the interdisciplinary team with a contemporary perspective of the multitude of changes and challenges influencing the prescribing as well as deprescribing of various pain medications.

Postoperative opioid administration characteristics associated with opioid-induced respiratory depression: Results from the PRODIGY trial

Study objectiveOpioid administration for pain in general care floor patients remains common, and can lead to adverse outcomes, including respiratory compromise. The PRODIGY trial found that among ward patients receiving parenteral opioids, 46% experienced ≥1 respiratory depression episode. The objective of this analysis was to evaluate the geographic differences of opioid administration and examine the association between opioid administration characteristics and the occurrence of respiratory depression. DesignProspective observational trial. Setting16 general care medical and surgical wards in Asia, Europe, and the United States. Patients1335 patients receiving parenteral opioids. InterventionsBlinded, alarm-silenced continuous capnography and pulse oximetry monitoring. MeasurementsOpioid-induced respiratory depression, defined as respiratory rate ≤ 5 bpm, SpO2 ≤ 85%, or ETCO2 ≤ 15 or ≥ 60 mmHg for ≥3 min; apnea episode lasting >30 s; or any respiratory opioid-related adverse event. ResultsAcross all patients, 58% received only long-acting opioids, 16% received only short-acting (<3 h) opioids, and 21% received a combination of short- and long-acting (≥3 h) opioids. The type and median total morphine milligram equivalent (MME) of opioid administered varied significantly by region, with 31.5 (12.5–76.7) MME, 31.0 (6.2–99.0) MME, and 7.2 (1.7–18.7) MME in the United States, Europe, and Asia, respectively (p < 0.001). Considering only postoperative opioids, 54% (N = 119/220) and 45% (N = 347/779) of patients receiving only short-acting opioids or only long-acting opioids experienced ≥1 episode of opioid-induced respiratory depression, respectively. Multivariable analysis identified post-procedure tramadol (OR 0.62, 95% CI 0.424–0.905, p = 0.0133) and post-procedure epidural opioids (OR 0.485, 95% CI 0.322–0.731, p = 0.0005) being associated with a significant reduction in opioid-induced respiratory depression. ConclusionsDespite varying opioid administration characteristics between Asia, Europe, and the United States, opioid-induced respiratory depression remains a common global problem on general care medical and surgical wards. While the use of post-procedure tramadol or post-procedure epidural opioids may reduce the incidence of respiratory depression, continuous monitoring is also necessary to ensure patient safety when receiving postoperative opioids. Registration numberwww.clinicaltrials.gov, ID: NCT02811302

Perioperative Precedex: Whole New Ball Game or Whole New Ball of Wax?

Perioperative Precedex: Whole New Ball Game or Whole New Ball of Wax?

Sedation for bronchoscopy in children: A prospective randomized double-blinded trial.

In pediatric patients, flexible bronchoscopy requires deep sedation. Different sedation regimes are common, but only some of them include opioids. Due to their antitussive effect, the use of short-acting opioids may be beneficial for this particular indication, but additional respiratory depression may lead to an increase in adverse events. Here, we systematically compared sedation regimes in children undergoing flexible bronchoscopy with either propofol alone, or a combination of propofol and remifentanil. The primary outcome parameter was the frequency of coughing episodes during the intervention. Secondary outcome parameters were frequency and types of complications, patient satisfaction, examiner satisfaction, and recovery time after finishing the sedation. Fifty children aged 1-17 years undergoing flexible bronchoscopy under deep sedation with propofol were randomly assigned to two groups: PR receiving propofol and remifentanil and PP receiving propofol only. Sedation depth was predefined as Comfort Score 10-13. We found significantly less coughing episodes ([med (IQR)] PR: 0.73 (0.28-2.45)/min; PP: 1.98 (1.26-3.12)/min; p = .010) and shorter recovery time in Group PR (PR: 13.5 (8-17.5) min; PP: 21.0 (14-27) min; p = .011). Examiner's satisfaction was higher in Group PR (PR: 10 (8-10); PP: 9 (7-9); p = .012). The number of adverse events, patient satisfaction, and required propofol dose during the intervention did not differ between groups. We suggest the combination of propofol with remifentanil instead of using propofol alone in pediatric procedural sedation for flexible bronchoscopy.

Factors associated with success and failure of patient-controlled oral analgesia after total hip and knee arthroplasty: a historical comparative cohort study.

Patient-controlled oral analgesia (PCOA) is a novel method of oral opioid administration using set doses of short-acting oral opioids self-administered by patients with a "lockout" period as part of a multimodal regimen. Failure of PCOA can result in severe postoperative pain necessitating use of intravenous patient-controlled analgesia (IV-PCA) with its potential complications. This study evaluated factors related to success or failure of PCOA following total hip arthroplasty (THA) and total knee arthroplasty (TKA). We conducted a retrospective cohort study of all adults who underwent THA and TKA at our institution by extracting data from the proprietary database of our acute pain service. Patient, anesthetic, and surgical variables associated with PCOA failure defined as inadequate analgesia requiring conversion to IV-PCA within 24 hr following THA and TKA were evaluated. Univariable and multivariable logistic regression analyses were performed to identify predictors of PCOA failure. Of the 926 patients who underwent THA or TKA (n = 411 and 515, respectively), 147 (15.9%) patients (67 THA and 80 TKA patients) had PCOA failure with moderate-to-severe pain. Multivariable regression analysis showed that PCOA failure occurred in those with younger age (adjusted odds ratio [aOR] per year of age, 0.97; 99% CI, 0.95 to 0.99; P < 0.001), preoperative chronic use of controlled-release opioids (aOR, 3.45; 99% CI, 1.60 to 7.35; P < 0.001), and with the use of general anesthesia vs spinal anesthesia (aOR, 2.86; 99% CI, 1.20 to 6.84; P = 0.002). The use of PCOA provides adequate analgesia to a majority of patients undergoing THA and TKA. Factors predictive for PCOA failure should be considered when choosing the primary breakthrough analgesic modality following THA/TKA.

Effect of an Electronic Health Record \u201cNudge\u201d on Opioid Prescribing and Electronic Health Record Keystrokes in Ambulatory Care

BackgroundMultiple policy initiatives encourage more cautious prescribing of opioids in light of their risks. Electronic health record (EHR) redesign can influence prescriber choices, but some redesigns add to workload.ObjectiveTo estimate the effect of an EHR prescribing redesign on both opioid prescribing choices and keystrokes.DesignQuality improvement quasi-experiment, analyzed as interrupted time series.ParticipantsAdult patients of an academic multispecialty practice and a federally qualified health center (FQHC) who received new prescriptions for short-acting opioids, and their providers.InterventionIn the redesign, new prescriptions of short-acting opioids defaulted to the CDC-recommended minimum for opioid-naïve patients, with no alerts or hard stops, such that 9 keystrokes were required for a guideline-concordant prescription and 24 for a non-concordant prescription.Main MeasuresProportion of guideline-concordant prescriptions, defined as new prescriptions with a 3-day supply or less, calculated per 2-week period. Number of mouse clicks and keystrokes needed to place prescriptions.Key ResultsAcross the 2 sites, 22,113 patients received a new short-acting opioid prescription from 821 providers. Before the intervention, both settings showed secular trends toward smaller-quantity prescriptions. At the academic practice, the intervention was associated with an immediate increase in guideline-concordant prescriptions from an average of 12% to 31% of all prescriptions. At the FQHC, about 44% of prescriptions were concordant at the time of the intervention, which was not associated with an additional significant increase. However, total keystrokes needed to place the concordant prescriptions decreased 62.7% from 3552 in the 6 months before the intervention to 1323 in the 6 months afterwards.ConclusionsAutocompleting prescription forms with guideline-recommended values was associated with a large increase in guideline concordance in an organization where baseline concordance was low, but not in an organization where it was already high. The redesign markedly reduced the number of keystrokes needed to place orders, with important implications for EHR-related stress.Trial Registrationwww.ClinicalTrials.gov protocol 1710018646

Drug use evaluation of opioid analgesics in pain management among patients with hematopoietic stem cell transplantation

BackgroundHematopoietic stem cell transplantation (HSCT) patients usually experience mucositis, musculoskeletal pain associated with high-dose chemotherapy, radiation, post-HSCT infection, or graft-versus-host disease. Pain management is important for the patients’ quality of life. We evaluated appropriate opioid analgesic use in HSCT patients to propose effective pain management strategies.MethodsA retrospective analysis was conducted using electronic medical records of adult patients with HSCT treated with opioids for moderate to severe pain at Seoul National University Bundang Hospital. The numeric rating scale (NRS) was used in pain management. NRS scores of 4‒10 correspond to moderate to severe pain. Appropriate opioid analgesic use was evaluated following published cancer pain management guidelines.ResultsIn total, 119 cases were evaluated, including 369 episodes of moderate to severe pain. Mucositis-related, musculoskeletal, and headache pain occurred in 62.6%, 25.8%, and 6.0% of episodes, respectively. Frequently used opioids were intravenous tramadol (84.9%), fentanyl patch (73.9%), and intravenous morphine sulfate (68.9%). Intravenous and topical administrations were used for mucosal pain. In total, 95.0% of patients received appropriate short-acting opioids for initial pain management, 80.5% received appropriate doses of short-acting opioids, appropriate opioids dose adjustment was done after first assessment in 95.5% of patients, and 85.6% were converted to appropriate long-acting opioids.ConclusionShort-acting opioid analgesic use for initial pain management and dose adjustment after assessment were appropriate. However, initial and conversion dosages recommended by guidelines may be difficult to implement considering the severity of HSCT patients. Pain management guidelines specific for HSCT patients should be developed in the future.

Hospital Outcomes of Infants with Neonatal Opioid Withdrawal Syndrome at a Tertiary Care Hospital with High Rates of Concurrent Nonopioid (Polysubstance) Exposure.

Neonatal opioid withdrawal syndrome (NOWS) describes infants' withdrawal signs and symptoms after birth due to an interruption of prenatal opioid exposure. Many infants with NOWS are also exposed to nonopioids, however. This study was to determine hospital outcomes of infants exposed to opioids alone or coexposed with nonopioid substances (polysubstance). We reviewed infants of ≥34 weeks of gestation with prenatal opioid exposure from April 2015 to May 2018. We compared the median lengths of stay (LOS) and treatment (LOT) and the percentages of infants requiring pharmacologic and adjunctive treatment in infants exposed to opioids alone or polysubstance. We used Wilcoxon's test for continuous outcomes or Chi-squared test for categorical outcomes to determine statistical significance. We used multivariable regression model to calculate each drug category's estimates of adjusted mean ratios for LOS and LOT plus estimates of adjusted odds ratios for pharmacologic/adjunctive treatments. Of the 175 infants, 33 (19%) infants had opioid exposure alone. Opioid exposure included short- and/or long-acting opioids. A total of 142 (81%) had polysubstance exposure with 47% of mothers using nicotine products. We saw similar hospital outcomes between infants exposed to opioids alone or polysubstance; however, a higher percentage of infants with both short- and long-acting opioid exposure required pharmacologic treatment compared with either opioid alone. Focusing on individual drug categories, we detected differential hospital outcomes in which short-acting opioids decreased LOT, whereas long-acting opioids increased LOS, LOT, and need for pharmacologic and adjunctive treatment. Coexposure of opioids with stimulants decreased LOT and reduced need for adjunctive treatment. Coexposures with antidepressants increased LOT, while with antiepilepetics increased LOS. Because infants with NOWS often have coexposures to other nonopioid substances, appreciating the associated risks of individual or combination of drugs in modulating hospital outcomes may help counsel families on their infants' expected hospital course. · Hospital outcomes were similar between infants exposed to opioids alone or polysubstance including opioids.. · Infants with short- and long-acting opioids required pharmacologic treatment more often than either opioid alone.. · Differential hospital outcomes exist for various co-exposures of opioids with nonopioids..

What’s Your Motivation?

What’s Your Motivation?

Use of dexmedetomidine and opioids as the primary anesthetic in infants and young children: A retrospective cohort study.

Anesthetic regimens using dexmedetomidine and short-acting opioids have been suggested as potential alternatives to sevoflurane-based anesthesia in children. The primary aim of this study is to compare demographics, intraoperative characteristics, and complications of general anesthetics in which dexmedetomidine and opioids were used without sevoflurane, or in combination with a low sevoflurane concentration, in children 36months old and younger. The secondary aim is to evaluate intraoperative bispectral index (BIS) values when available in these patients. General anesthetics performed between January 1, 2017, and May 1, 2018, in children 2years and younger who received dexmedetomidine and remifentanil, with or without sevoflurane, were identified. Additional anesthetics performed during this time in children 36months and younger who received dexmedetomidine and opioids and had BIS monitoring were also identified. Charts were reviewed for demographic and intraoperative variables, including drug administration and hemodynamic data. A total of 244 patients were identified. All but 22 patients received remifentanil. Ninety-two patients received sevoflurane with a mean end-tidal concentration of 0.84% (SD 0.43). Compared to the sevoflurane group, the nonsevoflurane group received more remifentanil (median dose 0.4μg/kg/min vs 0.2μg/kg/min, difference of 0.1μg/kg/min, 95% CI 0.1-0.3, P<.001) and more dexmedetomidine (median dose 0.9μg/kg/h vs 0.3μg/kg/h, difference of 0.6μg/kg/h, 95% CI 0.4-0.8, P<.001), and had a higher mean arterial pressure (median 53mmHg vs 42mmHg, difference of 11mmHg, 95% CI 8.1-14.8, P<.001). Complications between the two groups were comparable. The median percent intraoperative time with BIS reading <60 was 71.6% (95% CI: 63.3%-79.8%). Dexmedetomidine and opioids can effectively be used in young children as an alternative total intravenous anesthesia technique with or without <1 minimum alveolar concentration of sevoflurane. Bispectral index monitoring reveals a likely sufficient depth of hypnosis.