Use Of Hydromorphone Research Articles

Liposomal bupivacaine plus intrathecal hydromorphone associated with shortened length of stay and decreased opioid use in pediatric patients following posterior spinal fusion surgery.

We aimed to determine if the use of intrathecal (IT) hydromorphone and/or liposomal bupivacaine (LB) decreased the amount of postoperative and post-discharge opioids for pediatric patients undergoing fusion (PSF) surgery to treat adolescent idiopathic scoliosis (AIS). A retrospective review of AIS patients undergoing PSF surgery was conducted. Hospital LOS, and inpatient and post-discharge opioid use were compared. Opioid use was reported as oral morphine equivalents (OMEs). Three groups were formed from 186 patients: the control (CG) (n = 39), the IT hydromorphone only (IT) (n = 58), and the liposomal bupivacaine with intrathecal hydromorphone (LB + IT) group (n = 89). The mean LOS were 4.8, 4.2, and 3.5 days for the CG, IT, and LB + IT groups, respectively, with the LB + IT group being shorter than both the CG (p < 0.001) and IT groups (p < 0.001). The mean inpatient OMEs were 106.3/day, 69.2/day, and 30.0/day for the CG, IT, and LB + IT groups, respectively, with each group being significantly different than each other (all pairwise comparisons, p < 0.001). The mean total OMEs that patients were prescribed post-discharge were 693.6 in the CG, 581.1 in the IT, and 359.4 in the LB + IT group (F(2,183) = 14.5, p < 0.001), with the LB + IT group being prescribed significantly less than both the IT (p = 0.003) and CG groups (p < 0.001). Both the use of IT hydromorphone and LB were associated with shortened LOS and fewer total and per day in-hospital OMEs; however, the group who received both IT and LB (LB + IT) had the greatest decrease in LOS, and both inpatient and post-discharge OME usage. Level III (retrospective comparative study).

Delayed gastric emptying after pancreatoduodenectomy: an analysis of risk factors

BackgroundDelayed gastric emptying (DGE) is a frequent complication after pancreatoduodenectomy. Preoperative factors are limited and controversial. This study aims to identify associated factors related to this complication in the Colombian population.MethodsA retrospective review of a prospectively collected database was conducted. All patients over 18 years of age who underwent pancreaticoduodenectomy were included. Associations with DGE syndrome were evaluated with logistic regression analysis, Odds ratio, and b-coefficient were provided when appropriate.Results205 patients were included. Male patients constituted 54.15% (n = 111). 53 patients (25.85%) were diagnosed with DGE syndrome. Smoking habit (OR 17.58 p 0.00 95% CI 7.62–40.51), hydromorphone use > 0.6 mg/daily (OR 11.04 p 0.03 95% CI 1.26–96.66), bilirubin levels > 6 mg/dL (OR 2.51 p 0.02 95% CI 1.12–5.61), and pancreatic fistula type B (OR 2.72 p 0.02 CI 1.74–10.00).DiscussionSmoking history, opioid use (hydromorphone > 0.6 mg/Daily), type B pancreatic fistula, and bilirubin levels > 6 mg/dL should be considered as risk factors for DGE.

The efficacy of nasal administration of esketamine in patients having moderate-to-severe pain after preoperative CT-guided needle localization: a randomized, double-blind, placebo-controlled trial.

Whether nasal administration of esketamine can provide effective analgesia is unclear in patients with acute pain after preoperative CT-guided needle localization. In this double-blind, randomized, placebo-controlled trial, patients were assigned to receive either nasal administration of esketamine (0.3 mg/kg or 0.5 mg/kg) or saline (identical in appearance to esketamine) when they had visual analog scale (VAS) pain scores >3/10 during deep breathing after preoperative CT-guided needle localization. The primary outcome was the percentage of patients with satisfactory pain relief, which was defined as VAS pain scores ≤3/10 measured 15 min after intranasal of esketamine or saline. Secondary outcomes included VAS measured following esketamine or saline, the incidence and cumulative dose of rescue hydromorphone use, and related adverse events. A total of 90 patients were included in the final analysis. Following intranasal treatment, the percentage of patients with satisfactory pain relief was 16.7% (5/30) in the saline group, 56.7% (17/30) in the 0.3 mg/kg esketamine group, and 53.3% (16/30) in the 0.5 mg/kg esketamine group (p = 0.002). The median VAS during deep breathing was less after the intranasal administration of esketamine {median (IQR), 3 (3, 5) in 0.3 mg/kg or 0.5 mg/kg esketamine compared to the saline group [5 (4, 6)], p = 0.009}. The incidence of rescue hydromorphone use was detected less in the esketamine group compared to the saline group (43.3% in the 0.3 mg/kg esketamine group, 36.7% in the 0.5 mg/kg esketamine group, and 73.3% in the saline group, p = 0.010). The adverse events were similar among the three groups (p > 0.05). Intranasal administration of esketamine is easier and more effective in alleviating acute pain in patients after preoperative CT-guided needle localization without significant adverse effects.

Effectiveness of Hydromorphone Hydrochloride Combined with Bupivacaine for Combined Spinal and Epidural Anaesthesia in Reducing Postpartum Urinary Retention: A Retrospective Study.

Postpartum urinary retention is a common complication following caesarean section, with significant implications for patient comfort and recovery. Combined spinal and epidural anaesthesia is frequently employed for caesarean section, but postpartum urinary retention remains a clinical concern despite its benefits. This study aimed to investigate the effectiveness of hydromorphone hydrochloride combined with bupivacaine for combined spinal and epidural anaesthesia in reducing postpartum urinary retention. A retrospective analysis was conducted on patients who received combined spinal and epidural anaesthesia for caesarean section. The control group received bupivacaine, whereas the hydromorphone hydrochloride combined with bupivacaine spinal-epidural anaesthesia (HB) group received hydromorphone hydrochloride combined with bupivacaine. Data on demographics, anaesthesia, operative characteristics, postoperative urinary retention and adverse events were collected and analysed. The study enrolled 105 patients, with a control group (n = 51) receiving bupivacaine spinal-epidural anaesthesia and an observation group (n = 54) receiving hydromorphone hydrochloride combined with bupivacaine spinal-epidural anaesthesia. The incidence of postoperative urinary retention was significantly lower in the HB group than in the control group (3.70% vs. 17.65%, p = 0.044). Furthermore, the HB group exhibited a shorter time to first voiding after anaesthesia (5.72 ± 1.26 h vs. 6.28 ± 1.35 h, p = 0.029), lower peak postvoid residual volume (168.57 ± 25.09 mL vs. 180.43 ± 30.21 mL, p = 0.032), decreased need for postoperative catheterisation (5.56% vs. 21.57%, p = 0.034) and shorter duration of urinary catheterisation (10.92 ± 2.61 h vs. 12.04 ± 2.87 h, p = 0.039) than the control group. Correlation analysis supported a negative correlation between hydromorphone supplementation and parameters related to postoperative urinary retention. Multivariate regression analysis demonstrated a significant association between the duration of urinary catheterisation and the use of hydromorphone with the occurrence of postoperative urinary retention, providing further insights into the multifactorial nature of this postoperative complication. The addition of hydromorphone hydrochloride to bupivacaine for combined spinal and epidural anaesthesia was associated with a reduced incidence of postpartum urinary retention and improved postoperative voiding parameters, without significantly increasing the risk of adverse events.

Morphine versus hydromorphone in pediatrics: a narrative review of latest indications and optimal use in neonates and children.

The management of pain in pediatrics is multimodal and includes non-pharmacologic and pharmacologic approaches. Opioids, and particularly morphine and hydromorphone, are frequently used to treat moderate-to-severe pain. The goals of this review are to describe the pharmacological characteristics of both drugs, to cover the latest evidence of their respective indications, and to promote their safe use in pediatrics. Morphine is the most studied opioid in children and is known to be safe and effective. Morphine and hydromorphone can be used to manage acute pain and are usually avoided when treating chronic non-cancer pain. Current evidence suggests that both opioids have a similar efficacy and adverse effect profile. Hydromorphone has not been studied in neonates but in some centers, it has been used instead of morphine for certain patients. In palliative care, the use of opioids is often indicated and their benefits extend beyond analgesia; indications include treatment of central neuropathic pain in children with severe neurologic impairment and treatment of respiratory distress in the imminently dying patients. The longstanding belief that the use of well-titrated opioids hastens death should be abandoned as robust evidence has shown the opposite. With the current opioid crisis, a responsible use of opioids should be promoted, including limiting the opioid prescription to the patient's anticipated needs, optimizing a multimodal analgesic plan including the use of non-pharmacological measures and non-opioid medications, and providing information on safe storage and disposal to patients and families. More data is needed to better guide the use of morphine and hydromorphone in children.

Opioid use and COVID-19: a secondary analysis of the impact of relaxation of methadone take-home dosing guidelines on use of illicit opioids

ABSTRACT Background: An exemption to existing U.S. regulation of methadone maintenance therapy after the onset of the COVID−19 pandemic permitted increased take-home doses beginning March 2020. Objectives: We assessed the impact of this exemption on opioid use. Methods: A pre/post study of 187 clients recruited from an OTP who completed a survey and consented to share their urine drug testing (UDT) data. Use of fentanyl, morphine, hydromorphone, codeine, and heroin was assessed via UDT. Receipt of take-home methadone doses was assessed from clinic records for 142 working days pre- and post-COVID exemption. Analysis was conducted using a linear regression model to assess the association between increased take-home doses and use of illicit opioids. Results: In the pre- vs. post-COVID−19 SAMHSA exemption periods, 26.2% vs. 36.3% of UDTs were positive for 6-acetylmorphine respectively, 32.6% vs. 40.6% positive for codeine, 34.2% vs 44.2% positive for hydromorphone, 39.5% vs. 48.1% positive for morphine, 8.0% vs. 14.4% positive for fentanyl (p-value < .001). However, in the unadjusted descriptive data, when grouped by change in substance use, those clients who experienced a decrease in the use of morphine, codeine, and heroin post-COVID−19 were given significantly more take-home doses than the groups that had no change or an increase in the use of these substances. In the adjusted model, there was no significant relationship between change in opioid use and increased receipt of take-home methadone doses. Conclusions: Although take-home doses post-COVID−19 nearly doubled, this increase was not associated with a significant change in use of illicit opioids.

Recent trends in the prescription of opioids in the emergency department in patients with urolithiasis.

Pain management is central in the treatment of urolithiasis. We aimed to estimate the impact of the 2017 Department of Health and Human Services declaration of an opioid crisis on prescribing patterns of opioids and NSAIDs in emergency department visits for urolithiasis. The National Health Ambulatory Medical Care Survey (NHAMCS) was queried for emergency department visits of adults with a diagnosis of urolithiasis. The association between urolithiasis and narcotic and NSAIDs prescription patterns was evaluated and compared at pre-declaration (2014-2016) to post-declaration (2017-2018) periods. Opioids were prescribed in about 211 million (41.1%) out of 513 million emergency department visits, over a 5-year period. Diagnosis of urolithiasis accounted for 1.9% of the visits (6.0 million). The use of opioids was higher in urolithiasis (82.7%) compared to non-urolithiasis diagnosis (40.3%), as well as the use of multiple opioids per visit (p < 0.01 for all). There was an overall decrease in opioid prescriptions in the post-declaration period, -4.3% for urolithiasis (p = 0.254) and -5.6% for non-urolithiasis visits (p < 0.05). A decrease in the use of hydromorphone (-47.5%. p < 0.001), an increase in the use of morphine (+ 59.7% p = 0.006), and an increase of 'other' opioids (+ 98.8%, p < 0.041), were observed. Opioids combined with NSAIDs comprised 72.6% of the opioid prescriptions and 62.3% of all analgesic prescriptions in visits with urolithiasis diagnosis. The use of opioids when managing urolithiasis decreased 4.3% after the crisis declaration; however, statistically are not different from pre-declaration numbers. Most often, opioids were prescribed with NSAIDs in urolithiasis patients.

Patient-Controlled Analgesia vs Intravenous Push Hydromorphone for Pain Management of Vaso-Occlusive Crisis Associated With Sickle Cell Disease

Patient-controlled analgesia (PCA) appears to be the preferred modality for treatment of pain associated with vaso-occlusive crisis (VOC) and is the current standard of therapy at most institutions. With limited data available, this study analyzed the effectiveness of PCA vs intravenous push (IVP) hydromorphone for pain management of VOC. The primary objective was to determine whether PCA or IVP hydromorphone is more effective in controlling VOC pain determined by a reduction in mean absolute difference pain intensity (MPI) from baseline to discharge. This retrospective single-center study evaluated differences in outcomes between patients treated with PCA vs those treated with IVP hydromorphone for VOC during hospital admission. Those 18 years or older admitted with one of the following International Classification of Diseases, Tenth Revision codes were included: D57.0 (Hb-SS disease with crisis), D57.2 (sickle cell/Hb-C disease), and D57.4 (sickle cell thalassemia), and administered PCA or IVP hydromorphone. The observed difference in absolute pain scores were not statistically significant (p = 0.753). The use of IVP hydromorphone resulted in a significant reduction in length of stay (LOS) and morphine milligram equivalent (MME) use compared to PCA, but was associated with a numerical increase in treatment failures. This study was limited by its retrospective nature, uneven distribution of groups, and only reviewed use of IVP and PCA hydromorphone at one institution.

Intraoperative opioid and analgesic adjuvant administration practice patterns following implementation of an enhanced recovery after surgery protocol for laparoscopic donor nephrectomy

Study objectiveThe primary aim of this study is to understand how intraoperative medication administration patterns change in response to ERAS® protocol implementation for patients who underwent laparoscopic donor nephrectomy. DesignSingle-center, retrospective analysis of laparoscopic donor nephrectomy patients. SettingLarge tertiary academic medical center. PatientsWe divided all cases of laparoscopic donor nephrectomies (n = 929) over seven years into three approximately equal time periods: Pre-ERAS 1 (n = 317), Pre-ERAS 2 (n = 297) and Post-ERAS (n = 315). MeasurementsWe examined patient demographics, intraoperative opioid and non-opioid pain adjuvant administration, Post Anesthesia Recovery Unit (PACU) pain scores and opioid use as well as PACU and hospital lengths of stay (LOS). Main resultsSegmented regression analysis of interrupted time series was utilized to evaluate the association of ERAS protocol implementation with the amount of intraoperative opioid and non-opioid pain adjuvant use. In adherence to our institutional ERAS protocol, there was a significant reduction in intraoperative fentanyl use after ERAS protocol of −70.2μg (95% CI -106.0, −34.2, p < 0.001) and a significant increase in intraoperative hydromorphone use of 0.47 mg (95% CI 0.284, 0.655, p < 0.001). However, in contrary to our ERAS protocol, we found no significant change in odds of receiving IV acetaminophen OR 1.31 (95% CI 0.450, 3.76, p = 0.613) or IV ketorolac OR 1.65 (95% CI 0.804, 3.41, p = 0.172) after ERAS protocol implementation. We found a significant reduction in PACU opioid use of −9.68 Morphine Milligram Equivalents (MME) (95% CI -17.1, −2.31, p = 0.010) but no significant change in PACU initial pain score, PACU LOS and hospital LOS. ConclusionsWe examined intraoperative practice pattern changes by anesthesiologists in response to ERAS protocol implementation for laparoscopic donor nephrectomies. Our results suggest that there was a variable uptake of recommendations from ERAS protocol. While ERAS protocols are often studied as a bundle of best practice recommendations, understanding the variability of provider adherence represents an important future research direction for the ERAS initiative.

Cost-Effectiveness and Guidelines for Opioid Substitution Treatment

&#x0D; There was evidence indicating that in the treatment of opioid use disorder, injectable hydromorphone, or injectable methadone provided more benefit at less cost compared with injectable diacetylmorphine over a 6-month time horizon.&#x0D; Evidence suggests that in the treatment of opioid use disorder, both injectable hydromorphone and injectable diacetylmorphine are likely to provide more benefit at less cost than methadone maintenance treatment. Treatment with injectable hydromorphone was more cost-effective than injectable diacetylmorphine in opioid use disorder patients who do not respond to or relapse from drug treatments.&#x0D; The evidence is limited because observed data were collected during a short-term follow-up, and long-term cost-effectiveness outcomes were based on extrapolations beyond data from the actual studies.&#x0D; One guideline provided a weak recommendation, supported by low-quality evidence, for using slow-release oral morphine in older adults with adequate renal function in whom buprenorphine and methadone maintenance have been ineffective to treat opioid use disorder or could not be tolerated. Another guideline recommends using injectable hydromorphone or injectable diacetylmorphine for individuals with severe opioid use disorders who relapsed previous treatments failed.&#x0D; No relevant cost-effectiveness evidence or guidelines with recommendations regarding the use of oral hydromorphone, fentanyl patches, or fentanyl buccal tablets for opioid use disorder treatment were identified; therefore, no summary can be provided.&#x0D;

Prevalence and duration of prescribed opioid use during pregnancy: a cohort study from the Quebec Pregnancy Cohort

BackgroundRecent studies show a rapid growth among pregnant women using high potency opioids for common pain management during their pregnancy. No study has examined the duration of treatment among strong opioid users and weak opioid users during pregnancy. We aimed to investigate the prevalence of prescribed opioid use during pregnancy, in Quebec; and to compare the duration of opioid treatment between strong opioid users and weak opioid users.MethodsUsing the Quebec Pregnancy Cohort (1998–2015), we included all pregnancies covered by the Quebec Public Prescription Drug Insurance Program. Opioid exposure was defined as filled at least one prescription for any opioid during pregnancy or before pregnancy but with a duration that overlapped the beginning of pregnancy. Prevalence of opioids use was calculated for all pregnancies, according to pregnancy outcome, trimester of exposure, and individual opioids. The duration of opioid use during pregnancy was analyzed according to 8 categories based on cumulative duration (< 90 days vs. ≥90 days), duration of action (short-acting vs. long-acting) and strength of the opioid (weak vs. strong).ResultsOf 442,079 eligible pregnancies, 20,921 (4.7%) were exposed to opioids. Among pregnancies ending with deliveries (n = 249,234), 5.4% were exposed to opioids; the prevalence increased by 40.3% from 3.9% in 1998 to 5.5% in 2015, more specifically a significant increase in the second and third trimesters of pregnancy. Weak opioid, codeine was the most commonly dispensed opioid (70% of all dispensed opioids), followed by strong opioid, hydromorphone (11%), morphine (10%), and oxycodone (5%). The prevalence of codeine use decreased by 47% from 4.3% in 2005 to 2.3% in 2015, accompanied by an increased use of strong opioid, morphine (0.029 to 1.41%), hydromorphone (0.115 to 1.08%) and oxycodone (0.022 to 0.44%), from 1998 to 2015. The average durations of opioid exposure were significantly longer among pregnancies exposed to strong opioid as compared to weak opioid regardless of the cumulative duration or duration of action (P < 0.05).ConclusionsGiven the differences in the safety profile between strong opioids and the major weak opioid codeine, the increased use of strong opioids during pregnancy with longer treatment duration raises public health concerns.

Randomized, blinded, controlled clinical trial to assess gastroesophageal reflux and regurgitation in dogs undergoing general anesthesia after hydromorphone premedication with or without acepromazine or dexmedetomidine.

To investigate whether premedication with hydromorphone alone or combined with acepromazine or dexmedetomidine affects the incidence of gastroesophageal reflux (GER) and regurgitation in dogs undergoing general anesthesia for elective orthopedic surgery. 39 healthy client-owned dogs undergoing general anesthesia for elective orthopedic surgery between November 2016 and November 2018. For this prospective, randomized, controlled, blinded clinical trial, dogs were randomly assigned to be premedicated with hydromorphone (0.1 mg/kg, IM) alone (group H [control group]) or with either acepromazine (0.05 mg/kg, IM; group AH) or dexmedetomidine (6 μg/kg, IM; group DH) before undergoing general anesthesia induced with propofol and maintained with isoflurane. A pH sensor-tipped probe was used to identify episodes of GER (esophageal pH < 4 or > 7.5 for ≥ 30 seconds). Results for GER, regurgitation, vomiting, propofol dose, and durations of food withholding and anesthesia were compiled and compared across groups. There were 13 dogs in each group, and no meaningful differences were detected in age, body weight, sex, breed, or durations of anesthesia or food withholding across groups. Overall, 16 of the 39 (41%) dogs developed GER: 9 in group H, 6 in group AH, and 1 in group DH. The incidence of GER was significantly lower for group DH versus group H. Six of the 39 (15%) dogs regurgitated: 4 in group H and 2 in group AH. The combined use of dexmedetomidine and hydromorphone as premedication may be a better choice to reduce GER in healthy dogs undergoing orthopedic surgery than would the use of hydromorphone with or without acepromazine. Additional research is warranted.

Hydromorphone for cancer pain.

Hydromorphone for cancer pain.

MO485PREVALENCE OF ANALGESICS USE AND ASSOCIATED ADVERSE OUTCOMES IN THE CHRONIC KIDNEY DISEASE POPULATION: A SYSTEMATIC REVIEW AND META-ANALYSIS*

Abstract Background and Aims Pain is one of the commonest symptoms in patients with chronic kidney disease (CKD), with a large proportion undertreated. Managing chronic pain in CKD patients is problematic due to the altered pharmacokinetic and pharmacodynamic related to the reduced renal clearance making it challenging for physicians to find appropriate pain management strategies. The aim of this systematic review was to estimate the overall prevalence of different types of analgesia in patients with CKD and investigate their safety. Method The population comprised of all adult patients with CKD defined as an estimated glomerular filtration rate (eGFR) less than 60mL/min/1.73m2 which included CKD-non dialysis (CKD-ND), kidney transplant recipients (KTR), patients undergoing dialysis and those receiving palliative care. Analgesics investigated included opioids, Nonsteroidal Anti-Inflammatory Drugs (NSAIDs), gabapentinoids and acetaminophen. All studies reporting a prevalence of analgesic use and/or exploring the association between analgesic consumption and adverse outcomes were included. Medline, Embase, CENTRAL, CINAHL and the grey literature were searched up to December 2020. Random-effect meta-analyses were conducted using a Generalised Linear Mixed Model approach to estimate the overall prevalence of analgesics use in the CKD population, displayed in forest-plots. Evidence gathered from studies investigating the adverse outcomes related to analgesics consumption was synthesised in ‘harvest plots’. Results Sixty-three studies reporting a prevalence of analgesic use in patients with CKD were included. The overall prevalence of analgesic consumption was 42% (95% CI, 35-50%) in the general CKD population and 70% (95% CI, 62-68%) among those experiencing chronic pain. Seventeen studies reported a prevalence of opioid use with 36% (95% CI, 23-51%) of patients with CKD receiving at least one opioid prescription while 16% (95% CI, 11-22%) were on chronic opioid therapy. The chronic use of oxycodone, tramadol, propoxyphene, fentanyl and hydromorphone were 3.6%, 2.0%, 1.3%, 1.1% and 0.05% respectively. NSAIDs usage was estimated to 20% (95% CI, 15-25%) among patients with CKD (ibuprofen 4.6%, diclofenac 1.7%) and 8% (95% CI, 5-12%) took NSAIDs chronically, with a higher prevalence among dialysis patients (17%) compared with CKD-ND (7%) and KTR (5%) (p&amp;lt;0.01). Prevalence of gabapentin and pregabalin use was estimated at 10% and 3.5% respectively, on pooling of 3 studies. Finally, five studies yielded an overall prevalence of 24% for acetaminophen use. Twenty studies assessing the association between analgesic use and adverse outcomes were included (Figure 1). Five of them demonstrated an association between opioid use and increased mortality, in all CKD subgroups; and three out of four studies reported more hospitalizations in opioid-users.Four studies highlighted an increased risk of gastro-intestinal bleeding associated with NSAIDs consumption and three studies found a significant association between gabapentin use and neurologic adverse events. Conclusion Only 70% of CKD patients experiencing chronic pain received an analgesic, suggesting that pain remains a significant public health burden. Despite limited evidence, opioids, NSAIDs and gabapentinoids seem to be associated with major adverse events. Their use requires cautious prescription, consideration of optimal dosage, and the development of therapeutic patient education to promote risk awareness. More evidence is warranted to better understand the adverse outcomes associated with long-term analgesic consumption and provide safe pain management strategies for patient with CKD.

Pattern of hydromorphone use in King Abdulaziz Medical City-Central Region (KAMC-CR)

Hydromorphone is a semi-synthetic opioid that acts mainly on the μ-opioid receptor. Hydromorphone has a fast onset of action, usually within 5 min, and its effectiveness peaks at approximately 20 min, which makes it favourable in the postoperative setting. It plays a role in the management of moderate to severe chronic pain. The most common adverse effects of hydromorphone are hypotension, bradycardia, and respiratory distress. The aim of this study was to determine the trend in the use of hydromorphone analgesics and to evaluate hydromorphone-related toxicity in King Abdulaziz Medical City-Central Region (KAMC-CR). A retrospective, cross-sectional study was carried out in KAMC-CR, and medical and pharmacological data were retrieved from electronic health records for adult patients who used hydromorphone between December 2014 and December 2015. The characteristics of the enrolled patients, including measured blood pressure, heart rate, respiration rate, oxygen saturation, and pain severity score, were collected. Moreover, we identified patients who received naloxone as a hydromorphone antidote. A total of 153 patients were included; 64.1% were male and 35.8% were female. The mean age of the included patients was 55.5 years old (+/− 18.6). Although the majority of patients reported an improvement in pain severity, 75 patients (49%) needed naloxone to overcome adverse effects of hydromorphone. The mean age of patients who received naloxone was 56.2 years old (+/− 20.5), their mean weight was 75.9 kg (+/− 17.2), and 61.3% of them were male (n = 46). Among those who received naloxone, 84% patients (n = 63) had received hydromorphone intravenously. The risk of respiratory depression was significantly higher in patients who received hydromorphone intravenously (IV) than in those who received it orally (p = 0.02). Hydromorphone can have adverse effect. Thus, we recommend evaluating cardiac parameters, oxygen saturation, respiration rate, and pain severity before administering hydromorphone, particularly in patients who have a high risk of cardiorespiratory adverse events, such as patients with cardiac disease, asthma, or chronic obstructive pulmonary disease. Additionally, we recommend the use of appropriate hydromorphone doses in cases of conversion from other opioid therapy or changes between oral and IV routes of the administration of hydromorphone. Moreover, we recommend establishing a policy to restrict the prescription of hydromorphone to avoid the overuse of hydromorphone and minimize the risk of adverse effects and medication errors.

Impact of Intrathecal Fentanyl on Hospital Outcomes for Patients Undergoing Primary Total Hip Arthroplasty With Neuraxial Anesthesia.

BackgroundIntrathecal opioids have been used to reduce pain after total joint arthroplasty; however, the utility of these drugs is disputed. We examined the impact of eliminating intrathecal fentanyl on outcomes for patients undergoing direct anterior approach total hip arthroplasty (THA).MethodsRetrospective review of 376 THA patients from a single institution was conducted. Univariate analysis was used to compare intraoperative medication usage and postoperative outcomes for THA patients receiving intrathecal fentanyl compared with those who did not receive intrathecal fentanyl.ResultsRecovery room pain scores were significantly lower for patients who received intrathecal fentanyl (intrathecal fentanyl 1.4 vs no 2.2, P = .001), but no difference in opioid consumption was observed (intrathecal fentanyl 9.3 milligram morphine equivalent vs no 10.5 milligram morphine equivalent, P = .200). Intraoperative use and dose of intravenous morphine, hydromorphone, and dexamethasone did not differ significantly between groups. There were no significant differences in length of stay between the groups (intrathecal fentanyl 1.1 days vs 1.1 days, P = .973), 90-day readmission, or recatherization rates between groups (readmission, intrathecal fentanyl 4.8% vs no 5.8%, P = .709; recatherization, intrathecal fentanyl 0% vs no 0.7%, P = 1.00).ConclusionThe administration of intrathecal fentanyl does not have a significant effect on early postoperative narcotic consumption, length of stay, 90-day readmissions, or recatheterization after THA with neuraxial anesthesia. Intrathecal fentanyl does not appear to improve outcomes and should not be included as a standard element of THA rapid recovery protocols.

Patterns of voiding following laparoscopic hysterectomy

ObjectiveClarify the normal patterns of voiding after minimally invasive hysterectomy. We also aim to identify perioperative factors associated with delayed time to void immediately following hysterectomy. DesignRetrospective cohort study SelectionWomen undergoing laparoscopic hysterectomy between September 2012 to October 2018 at a single academic university hospital. Results450 minimally invasive hysterectomies were included in the final analysis, 274 (60.9%) robotically-assisted, and 176 (39.1%) conventional laparoscopy. The overall median postoperative time-to-void following a retrograde bladder filling of 150 mL normal saline was 179 min. Based on the 50th percentile of the distribution of the time-to-void, two groups were created. Demographic characteristics between the groups were similar, except those who were above the 50th percentile were more likely to be older, have a reported history of previous myomectomy, and had a longer postoperative PACU stay compared to those below or equal to the 50th percentile. The mean time-to-void following conventional laparoscopic hysterectomy was less than that of robotic surgery (187.3 vs 200.5 min) however the difference was not statistically significant (p=.22). The use of hydromorphone intraoperatively and the combination of oxycodone-acetaminophen postoperatively were more likely to be associated with the group of patients above the 50th percentile but there was no significant difference in perioperative utilization of median morphine milliequivalents (MME) between the two groups. ConclusionsFollowing laparoscopic hysterectomy (either conventional or with robotic-assistance) with a retrograde bladder fill of 150 mL normal saline most patients will void within 4 h after surgery. This is consistent with historic data on normal voiding patterns facilitating safe same day discharge without prolonged time in the PACU.

Methadone and Ketamine: Boosting Benefits and Still More to Learn.

Methadone and Ketamine: Boosting Benefits and Still More to Learn.

Perioperative Methadone and Ketamine for Postoperative Pain Control in Spinal Surgical Patients: A Randomized, Double-blind, Placebo-controlled Trial.

Despite application of multimodal pain management strategies, patients undergoing spinal fusion surgery frequently report severe postoperative pain. Methadone and ketamine, which are N-methyl-d-aspartate receptor antagonists, have been documented to facilitate postoperative pain control. This study therefore tested the primary hypothesis that patients recovering from spinal fusion surgery who are given ketamine and methadone use less hydromorphone on the first postoperative day than those give methadone alone. In this randomized, double-blind, placebo-controlled trial, 130 spinal surgery patients were randomized to receive either methadone at 0.2 mg/kg (ideal body weight) intraoperatively and a 5% dextrose in water infusion for 48 h postoperatively (methadone group) or 0.2 mg/kg methadone intraoperatively and a ketamine infusion (0.3 mg · kg-1 · h-1 infusion [no bolus] intraoperatively and then 0.1 mg · kg-1 · h-1 for next 48 h [both medications dosed at ideal body weight]; methadone/ketamine group). Anesthetic care was standardized in all patients. Intravenous hydromorphone use on postoperative day 1 was the primary outcome. Pain scores, intravenous and oral opioid requirements, and patient satisfaction with pain management were assessed for the first 3 postoperative days. Median (interquartile range) intravenous hydromorphone requirements were lower in the methadone/ketamine group on postoperative day 1 (2.0 [1.0 to 3.0] vs. 4.6 [3.2 to 6.6] mg in the methadone group, median difference [95% CI] 2.5 [1.8 to 3.3] mg; P < 0.0001) and postoperative day 2. In addition, fewer oral opioid tablets were needed in the methadone/ketamine group on postoperative day 1 (2 [0 to 3] vs. 4 [0 to 8] in the methadone group; P = 0.001) and postoperative day 3. Pain scores at rest, with coughing, and with movement were lower in the methadone/ketamine group at 23 of the 24 assessment times. Patient-reported satisfaction scores were high in both study groups. Postoperative analgesia was enhanced by the combination of methadone and ketamine, which act on both N-methyl-d-aspartate and μ-opioid receptors. The combination could be considered in patients having spine surgery.

Implementation of Individualized Pain Care Plans Decreases Length of Stay and Hospital Admission Rates for High Utilizing Adults with Sickle Cell Disease.

Patients with sickle cell disease (SCD) face inconsistent effective analgesic management, leading to high inpatient healthcare utilization and significant financial burden for healthcare institutions. Current evidence does not provide guidance for inpatient management of acute pain in adults with sickle cell disease. We conducted a retrospective analysis of a longitudinal cohort quality improvement project to characterize the role of individualized care plans on improving patient care and reducing financial burden in high healthcare-utilizing patients with SCD-related pain. Individualized care plans were developed for patients with hospital admissions resulting from pain associated with sickle cell disease. A 2-year prospective longitudinal cohort quality improvement project was performed and retrospectively analyzed. Primary outcome measure was duration of hospitalization. Secondary outcome measures included: pain intensity; 7, 30, and 90-day readmission rates; cost per day; total admissions; total cost per year; analgesic regimen at index admission; and discharge disposition. Duration of hospitalization, the primary outcome, significantly decreased by 1.23 days with no worsening of pain intensity scores. Seven-day readmission decreased by 34%. Use of intravenous hydromorphone significantly decreased by 25%. The potential cost saving was $1,398,827 as a result of this quality initiative. Implementation of individualized care plans reduced both admission rate and financial burden of high utilizing patients. Importantly, pain outcomes were not diminished. Results suggest that individualized care plans are a promising strategy for managing acute pain crisis in adult sickle cell patients from both care-focused and utilization outcomes.