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Healthcare (Basel, Switzerland) Jun 2024The evolving landscape of opioid prescription practices necessitates a comprehensive understanding of emerging patterns, particularly among new opioid users discharged...
The evolving landscape of opioid prescription practices necessitates a comprehensive understanding of emerging patterns, particularly among new opioid users discharged from emergency departments. This study delves into the intricate realm of opioid utilization by elucidating the prevalence of their prescriptions. A retrospective analysis of electronic health records was conducted, including a cohort of 71 patients who received opioid prescriptions upon discharge from emergency departments from 1 January 2022 to 30 June 2022. Demographic characteristics and prescription details were systematically examined. This study illuminates tramadol's prominence, with 84% of prescriptions and a Defined Daily Dose (DDD) morphine equivalent of 60 mg, as the primary choice as a new opioid, a finding that draws attention due to the closely aligned dosages with morphine equivalents. This discovery prompts a critical reassessment of tramadol's therapeutic role, considering its multifaceted nature encompassing serotonergic effects and heightened fall risks. This study advocates for a nuanced and vigilant approach to tramadol prescription, cognizant of its potential risks and therapeutic implications, and highlights the imperative of optimizing data quality and traceability within electronic health records to enhance patient care and facilitate future research endeavors.
PubMed: 38891213
DOI: 10.3390/healthcare12111138 -
Journal of Cardiothoracic and Vascular... May 2024To assess the analgesic effect of erector spinae plane block in adults undergoing median sternotomy cardiac surgery. (Review)
Review
The Analgesic Effect of Ultrasound-guided Erector Spinae Plane Block in Median Sternotomy Cardiac Surgery in Adults: A Systematic Review and Meta-analysis of Randomized Controlled Trials.
OBJECTIVES
To assess the analgesic effect of erector spinae plane block in adults undergoing median sternotomy cardiac surgery.
DESIGN AND SETTING
The Cochrane, Embase, and PubMed databases from inception to January 2024 were searched. The study has been registered in the International Prospective Register of Systematic Reviews (CRD42023470375).
PARTICIPANTS
Eight randomized controlled trials involving 543 patients, comparing with no block or sham block, were included, whether it was a single injection or continuous.
MEASUREMENTS AND MAIN RESULTS
The primary outcomes were pain scores and opioid consumption. Erector spinae plane block reduced pain scores immediately after extubation (mean difference [MD], -1.19; 95% confidence interval [CI], -1.67 to -0.71; p for heterogeneity = 0.10), at 6 hours after extubation (MD, -1.96; 95% CI, -2.85 to -1.08; p for heterogeneity < 0.0001), and at 12 hours after extubation (MD, -0.98; 95% CI, -1.55 to -0.40; p for heterogeneity < 0.00001). The decrease in pain scores reached the minimal clinically important difference within 6 hours. Opioid consumption 24 hours after surgery decreased by 35.72 mg of oral morphine equivalents (95% CI, -50.88 to -20.57; p for heterogeneity < 0.0001). Sensitivity analysis confirmed the stability of results. The quality of primary outcomes was rated as very low to moderate.
CONCLUSIONS
Erector spinae plane block decreased pain scores within 12 hours after extubation, reached the minimal clinically important difference within 6 hours, and decreased opioid consumption 24 hours after surgery, based on data of very low to moderate quality. However, high-quality randomized controlled trials are necessary to validate these findings.
PubMed: 38890084
DOI: 10.1053/j.jvca.2024.05.019 -
The Journal of Pediatrics Jun 2024To determine whether an enteral, clonidine-based sedation strategy (CLON) during therapeutic hypothermia (TH) for hypoxic-ischemic encephalopathy (HIE) would decrease...
OBJECTIVE
To determine whether an enteral, clonidine-based sedation strategy (CLON) during therapeutic hypothermia (TH) for hypoxic-ischemic encephalopathy (HIE) would decrease opiate use, while maintaining similar short-term safety and efficacy profiles to a morphine-based strategy (MOR).
STUDY DESIGN
This was a single-center, observational study conducted at a level IV neonatal intensive care unit from January 1, 2017, to October 1, 2021. From April 13, 2020, to August 13, 2020, MOR was transitioning to CLON. Thus, patients receiving TH for HIE were grouped to MOR (before April 13, 2020) and CLON (after August 13, 2020). We calculated the total and rescue morphine milligram equivalent (MME)/ kg (primary outcome) and frequency of hemodynamic changes (secondary outcome) for both groups.
RESULTS
MOR and CLON groups (74 and 25 neonates, respectively) had similar baseline characteristics and need for rescue sedative intravenous infusion (21.6% MOR and 20% CLON). Both, MME/ kg and need for rescue opiates (combined bolus and infusions) were higher in MOR than CLON (p < 0.001). As days in TH advanced, a lower percentage of CLON patients needed rescue opiates (92% on day 1 to 68% on day 3). MOR patients received a higher cumulative dose of dopamine and more frequently required a second inotrope and hydrocortisone for hypotension. MOR had a lower respiratory rate during TH (p=0.01 vs. CLON).
CONCLUSIONS
Our CLON protocol is non-inferior to MOR, maintaining perceived effectiveness and hemodynamic safety, with an apparently reduced need for opiates and inotropes.
PubMed: 38889855
DOI: 10.1016/j.jpeds.2024.114158 -
Journal of Perianesthesia Nursing :... Jun 2024Emergence delirium (ED) after sevoflurane anesthesia remains a serious issue in children. We aimed to compare different ratios of propofol-ketamine combinations to...
PURPOSE
Emergence delirium (ED) after sevoflurane anesthesia remains a serious issue in children. We aimed to compare different ratios of propofol-ketamine combinations to determine a better option for preventing ED.
DESIGN
A prospective, randomized clinical trial.
METHODS
In this study, 112 children aged between 3 and 12 years who underwent adenoidectomy and tonsillectomy were recruited. Propofol 1 mg kg + ketamine 1 mg kg (1:1 ratio), propofol 1.5 mg kg + ketamine 0.75 mg kg (2:1 ratio), propofol 2 mg kg + ketamine 0.66 mg kg (3:1 ratio), and propofol 3 mg kg were applied at induction of anesthesia for Groups I, II, III, and IV, respectively. Fentanyl 1 mcg kg and rocuronium 0.6 mg kg were applied at induction, and anesthesia was maintained with sevoflurane and O/NO mixture for all participants. Intravenous morphine 0.1 mg kg was applied for postoperative analgesia in the last 10 minutes of surgery. ED was defined as a Watcha score of ≥3. Demographics, hemodynamics, extubation time, Watcha scores, the Face, Legs, Activity, Cry, and Consolability scores, length of stay in the postanesthesia care unit (PACU), rescue analgesic requirement, and postoperative complications were recorded.
FINDINGS
ED was significantly higher at 10 and 20 minutes in Group IV. Eighteen children experienced ED in PACU, (3, 2, 2, and 11 children in Groups I, II, III, and IV, respectively). Face, Legs, Activity, Cry, and Consolability scores were significantly different at all times. Rescue analgesics were required by 3 children (10.7%) in Group I, 2 (7.1%) in Group II, 2 (7.1%) in Group III, and 10 (35.7%) in Group IV (P = .012). The PACU stay was 21.9 ± 6.4 in Group I, 18.7 ± 6.3 in Group II, 16.7 ± 5.8 in Group III, and 17.4 ± 5.8 in Group IV. Nystagmus was observed in three children in Group I.
CONCLUSIONS
To addition of ketamine to propofol during the induction of sevoflurane anesthesia can reduce the ED and analgesic requirements in children. A propofol-to-ketamine ratio of 3:1 provided better postoperative recovery with less pain and ED, without prolonging the PACU length of stay.
PubMed: 38888523
DOI: 10.1016/j.jopan.2024.01.019 -
Equine Veterinary Journal Jun 2024Addition of morphine to the perfusate while performing intravenous regional limb perfusion (IVRLP) may be helpful in treating painful infectious orthopaedic conditions...
BACKGROUND
Addition of morphine to the perfusate while performing intravenous regional limb perfusion (IVRLP) may be helpful in treating painful infectious orthopaedic conditions of the distal limb.
OBJECTIVES
The main objective of this study was to determine synovial morphine concentrations following IVRLP with morphine alone or in combination with amikacin.
STUDY DESIGN
Randomised cross-over in vivo experiment.
METHODS
Six horses underwent IVRLP with 0.1 mg/kg morphine sulphate diluted to 60 mL using 0.9% NaCl (M group) or combined with 2 g amikacin and 0.9% NaCl (MA group) with a 2-week washout period between treatments. Synovial fluid was collected from the radiocarpal joint (RCJ) at 10, 20, 30, 120, 240, 480, 720 and 1440 min after IVRLP. The tourniquet was removed after the 30-min sample was collected. Synovial concentrations of morphine and major metabolites were measured using liquid chromatography-tandem mass spectrometry. Amikacin concentrations were quantified by a fluorescence polarisation immunoassay.
RESULTS
Measurable concentrations of morphine were apparent in the RCJ of all horses. Median C of morphine in the M group was 4753.1 (2115.7-14 934.5) ng/mL and 4477 (3434.3-7363) ng/mL in the MA group (p = 0.5). Median C of synovial amikacin was 322.6 (157.5-1371.6 μg/mL).
MAIN LIMITATIONS
Limitations include small sample size. Investigators were not blinded to the treatments and a third treatment group where amikacin alone was administered via IVRLP to the study population was not included.
CONCLUSIONS
IVRLP using morphine is a feasible technique and synovial morphine concentrations were measurable following IVRLP and were not affected when used concurrently with amikacin. Administration of morphine via IVRLP may be beneficial as an analgesic technique for orthopaedic conditions of the distal limb while limiting potential serious systemic side-effects.
PubMed: 38887833
DOI: 10.1111/evj.14114 -
Journal of Complementary & Integrative... Jun 2024The present study was aimed at investigating the antinociceptive and anti-inflammatory activities of the solvent fractions of the roots of Mesfin in rodent models of...
OBJECTIVE
The present study was aimed at investigating the antinociceptive and anti-inflammatory activities of the solvent fractions of the roots of Mesfin in rodent models of pain and inflammation.
METHODS
Successive maceration was used as a method of extraction using solvents of increasing polarity: methanol and water. Ethyl acetate, chloroform and distilled water were used as solvents of the fraction process. Swiss albino mice models were used in acetic acid induced writhing, hot plate, carrageenan induced paw edema and cotton pellet granuloma to assess the analgesic and anti-inflammatory activities. The test groups received different doses (100 mg/kg, 200 mg/kg and 400 mg/kg) of the three fractions (chloroform, ethyl acetate and aqueous). The positive control groups received ASA (150 mg/kg) for the writing test, morphine (10 mg/kg) for the hot plate method, diclofenac Na for carrageenan-induced paw edema, and dexamethasone (10 mg/kg) for granuloma, while the negative control group received distilled water.
RESULTS
EA fraction at all test doses employed (100 mg/kg, 200 mg/kg, and 400 mg/kg) showed statistically significant (p<0.05, p<0.01, p<0.001 respectively) analgesic and anti-inflammatory activities in a dose-dependent manner. The AQ fraction on the other hand produced statistically significant (p<0.05, p<0.012) analgesic and anti-inflammatory activities at the doses of 200 mg/kg and 400 mg/kg, while the CH fraction exhibited statistically significant (p<0.05) analgesic and anti-inflammatory activity at the dose of 400 mg/kg.
CONCLUSIONS
In general, the data obtained from the present study elucidated that the solvent fractions of the study plant possessed significant analgesic and anti-inflammatory activities and were recommended for further investigations.
PubMed: 38887090
DOI: 10.1515/jcim-2024-0133 -
Canadian Journal of Anaesthesia =... Jun 2024It is unclear if postoperative pain experience and opioid consumption differ in patients undergoing primary vs repeat Cesarean delivery (CD) as prior studies have...
PURPOSE
It is unclear if postoperative pain experience and opioid consumption differ in patients undergoing primary vs repeat Cesarean delivery (CD) as prior studies have yielded conflicting results and none used the same patients as their own controls. We sought to compare opioid consumption and pain scores in patients undergoing both a primary and a first repeat CD, using the same patients as their own controls.
METHODS
We conducted a single-centre historical cohort study of patients who underwent both a primary and a first repeat CD under neuraxial anesthesia between 1 January 2016 and 30 November 2022. The same standardized multimodal analgesic regimen was used for all patients. The primary outcome was opioid consumption in oral morphine equivalents (OME) at 48 hr after surgery. Secondary outcomes included area under the curve for pain scores at 24 and 48 hr, and opioid consumption at 24 hr.
RESULTS
We included 409 patients. In unadjusted analysis, there were no significant differences between primary and repeat CD in median [interquartile range] opioid consumption at 48 hr (45 [15-89] mg vs 45 [15-83] mg OME) or in any of the secondary outcomes. In the multivariable model adjusting for age, body mass index, anxiety, depression, priority, surgery duration, gestational age, receipt of postoperative ketorolac, and neuraxial type, repeat CD was still not associated with increased opioid consumption compared with primary CD (adjusted rate ratio, 1.20; 95% confidence interval, 0.95 to 1.51).
CONCLUSION
In this retrospective study, we found no differences in postoperative opioid consumption or reported pain scores in patients who underwent both a primary and a first repeat CD.
PubMed: 38886325
DOI: 10.1007/s12630-024-02786-2 -
The Journal of Pain Jun 2024µ-Opioid receptor agonists, the gold standard for analgesia, come with significant side effects when used chronically. Tolerance, defined as the decrease in analgesic...
µ-Opioid receptor agonists, the gold standard for analgesia, come with significant side effects when used chronically. Tolerance, defined as the decrease in analgesic activity after repeated use, remains a vital therapeutic obstacle as it increases the likelihood of dose escalation and potentially lethal side effects like respiratory depression. Previous experiments have indicated that the endomorphin-1 analog, ZH853, is a specific µ-opioid receptor agonist with reduced side effects like tolerance and glial activation following chronic central administration in pain-naïve animals. Here we investigated the effects of chronic, peripheral administration of µ-opioid receptor agonists following neuropathic injury. Though µ-opioids are effective at reducing neuropathic pain, they are not recommended for 1 line treatment due to negative side effects. Compared to chronic morphine, chronic ZH853 treatment led to decreased tolerance and reduced glial activation. Following twice daily intravenous injections, morphine was less potent and had a shorter duration of antinociception compared to ZH853. Chronic morphine, but not chronic ZH853, elevated markers of activation/inflammation of astrocytes (GFAP), microglia (Iba1), the proinflammatory cytokine TNFα and phosphorylated MAP kinase pp38. By contrast, chronic ZH853 reduced Iba1 and TNFα relative to both morphine and vehicle, suggesting anti-inflammatory properties with respect to these markers. GFAP and pp38 were not significantly different from vehicle but were significantly lower than morphine. This study demonstrates the effectiveness of chronic ZH853 for providing analgesia in a neuropathic pain state with reduced tolerance compared to morphine, potentially due to reductions in spinal glial activation. PERSPECTIVE: Neuropathic pain is generally undertreated, resistant to available medications, and opioid treatment is limited by side-effects. Here, we show that, compared to an equiantinociceptive dose of a stereotypical µ-opioid receptor agonist, morphine, chronic intravenous administration of endomorphin analog ZH853 led to prolonged antiallodynia, reduced tolerance, and inhibition of spinal cord neuroinflammation in male spared nerve-injured rats.
PubMed: 38885918
DOI: 10.1016/j.jpain.2024.104607 -
Journal of Oncology Pharmacy Practice :... Jun 2024Infusion reactions, characterized by symptoms such as rigors, fever, and hypotension, are common adverse events that occur during monoclonal antibody (MAB) therapy. The...
INTRODUCTION
Infusion reactions, characterized by symptoms such as rigors, fever, and hypotension, are common adverse events that occur during monoclonal antibody (MAB) therapy. The treatment of rigors often involves opioids, most commonly meperidine, despite limited evidence supporting use in the setting of MAB infusions. This study aims to compare the efficacy and safety of intravenous (IV) meperidine and morphine is treatment of MAB-related rigors, filling a significant gap in the literature.
METHODS
This was a single-center, retrospective cohort study which reviewed patients either inpatient or within outpatient infusion centers from January 2015 to January 2024. Patients receiving IV 2 mg morphine or 25 mg meperidine for MAB-related rigors were included. The primary outcome was defined as the number of opioid doses required for rigors ablation. Secondary outcomes included rates of naloxone administration and documented sedation.
RESULTS
A total of 1251 administration events were screened, of which 127 and 26 rigor events were in the meperidine and morphine cohorts, respectively, were included. A majority of both cohorts required only one dose of either agent for rigors ablation with <20% of either cohort requiring 2 or more doses (p = 0.539). Low rates of sedation were observed in both groups.
CONCLUSION
Both meperidine and morphine effectively manage MAB-related rigors within minimal safety concerns. These findings suggest that morphine is a suitable alternative to meperidine for this indication, which may influence future formulary decision, provide alternatives for drug shortage, and optimize supportive care for patients undergoing MAB therapy.
PubMed: 38884818
DOI: 10.1177/10781552241259986 -
Local and Regional Anesthesia 2024Acute postoperative pain is one of the major clinical problems that occurs in patients undergoing cesarean section with a prevalence of 89.8%. Postoperative pain causes...
OBJECTIVE
Acute postoperative pain is one of the major clinical problems that occurs in patients undergoing cesarean section with a prevalence of 89.8%. Postoperative pain causes discomfort and various complications for the mother. In addition, postoperative pain that is not handled properly can increase the risk of becoming chronic pain by 2.5 times. One of the methods recommended in the Enhanced Recovery After Caesarean Section (ERACS) protocol to prevent acute postoperative pain is the use of intrathecal long-acting opioids, with intrathecal morphine as the gold standard and Transversus Abdominis Plane (TAP) block. This study aims to assess the comparison of opioid needs as analgesic rescue between the administration of 0.1mg spinal morphine and TAP block with bupivacaine 0.2% 10mg in patients undergoing cesarean section.
METHODS
This study is an observational study in a single Tertiary Hospital in West Java - Indonesia. Patients were given patient-controlled anesthesia (PCA) with fentanyl as analgesic rescue. Statistical analysis of the numerical data used the unpaired -test and Chi-Square test for categorical data.
RESULTS
In the group that was given spinal morphine, the duration of additional opioids was longer (p < 0.05), and the total dose of additional opioids was less than the TAP block group (p < 0.05).
CONCLUSION
The spinal morphine requires fewer additional opioids than the TAP block.
PubMed: 38883999
DOI: 10.2147/LRA.S459530