Matched pilot study examining cannabis-based dronabinol for acute pain following traumatic injury

BackgroundTo determine whether adjunctive dronabinol, a licensed form of delta-9-tetrahydrocannabinol, reduces opioid consumption when used off-label for managing acute pain following traumatic injury.MethodsThis matched cohort study included patients who were admitted with a traumatic injury between 1 March 2017 and 30 October 2017. The hospital pharmacy database was used to identify patients who received dronabinol (cases), and they were matched 1:1 to patients who did not receive dronabinol (controls) using age, cause of injury and hospital length of stay. The primary outcome, change in opioid consumption, was calculated using morphine milligram equivalents (MME). The change in MME was calculated for cases as total MME over 48 hours with adjunctive dronabinol minus 48 hours prior to dronabinol, and for controls as total MME 48–96 hours from admission minus 0–48 hours from admission. Data are presented as mean and SE or median and IQR. Statistical analysis was performed using paired t-tests and McNemar’s tests.ResultsThere were 66 patients included: 33 cases and 33 matched controls. Dronabinol was initiated 55 (28–107) hours from admission. Cases and controls were well matched. Cases had a significant reduction in opioid consumption with adjunctive dronabinol (−79 (20) MME, p<0.001), while opioid consumption was unchanged for controls (−9 (20) MME, p=0.63). This resulted in a ninefold greater reduction in opioid consumption for cases versus controls that was statistically different between pairs (p=0.02). Nineteen (58%) cases reported using marijuana; in this subset, opioid consumption was reduced with adjunctive dronabinol (−97 (24) MME, p<0.001) versus a non-significant increase in opioid consumption in matched controls (11 (29) MME, p=0.70); difference between groups, p=0.01.ConclusionsThe results of this study suggest adjunctive dronabinol reduces opioid consumption following traumatic injury. The opioid-sparing effect of dronabinol may be greater in patients who are marijuana users.Level of evidenceIII.

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Association of an acute pain service with postoperative outcomes following pancreaticoduodenectomy

Journal of Perioperative Practice ◽

10.1177/1750458919874616 ◽

2019 ◽

Vol 30 (10) ◽

pp. 309-314

Author(s):

Engy T Said ◽

Jacklynn F Sztain ◽

Matthew W Swisher ◽

Erin I Martin ◽

Divya Sood ◽

...

Keyword(s):

Length Of Stay ◽

Epidural Analgesia ◽

Acute Pain ◽

Multimodal Analgesia ◽

Hospital Length ◽

Opioid Consumption ◽

Acute Pain Service ◽

Postoperative Outcomes ◽

Hospital Length Of Stay ◽

Thoracic Epidural

The aim of this retrospective study was to evaluate the effect of implementing the combination of thoracic epidural analgesia and multimodal analgesia by a dedicated acute pain service on opioid consumption and postoperative outcomes in patients undergoing pancreaticoduodenectomy. Opioid consumption during postoperative days 0–3 was compared in the acute pain service versus non-acute pain service cohort. Between matched cohorts, the median (quartiles) total opioid consumption during postoperative days 0–3 was 114mg morphine equivalents (54.7, 212.4mg morphine equivalents) in the non-acute pain service cohort and 47.4mg morphine equivalents (38.1, 100.8mg morphine equivalents) in the acute pain service cohort; the median difference was 44.8mg morphine equivalents (95% CI 14.2–90.2mg morphine equivalents, p = 0.002). The median difference in hospital length of stay was 2.0 days (95% confidence interval 0.8–4.0, p = 0.01), favouring the acute pain service cohort. A dedicated acute pain service implementing thoracic epidural analgesia in conjunction with multimodal analgesia was associated with decreased opioid consumption and hospital length of stay.

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Implementation of a patient-specific tapering protocol at discharge decreases total opioid dose prescribed for 6 weeks after elective primary spine surgery

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2020-101324 ◽

2020 ◽

Vol 45 (6) ◽

pp. 474-478

Author(s):

Sarah S Joo ◽

Oluwatobi O Hunter ◽

Mallika Tamboli ◽

Jody C Leng ◽

T Kyle Harrison ◽

...

Keyword(s):

Spine Surgery ◽

Joint Replacement ◽

Oral Morphine ◽

Hospital Length ◽

Opioid Consumption ◽

Hospital Length Of Stay ◽

Patient Specific ◽

Opioid Dose ◽

Before And After ◽

Primary Spine

Background and objectivesAt our institution, we developed an individualized discharge opioid prescribing and tapering protocol for joint replacement patients and implemented the same protocol for neurosurgical spine patients. We then tested the hypothesis that this protocol will decrease the oral morphine milligram equivalent (MME) dose of opioid prescribed postdischarge after elective primary spine surgery.MethodsIn this retrospective cohort study, we identified all consecutive elective primary spine surgery cases 1 year before and after introduction of the protocol. This protocol used the patient’s prior 24-hour inpatient opioid consumption to determine discharge opioid pill count and tapering schedule. The primary outcome was total opioid dose prescribed in oral MME from discharge through 6 weeks. Secondary outcomes included in-hospital opioid consumption in MME, hospital length of stay, MME prescribed at discharge, opioid refills, and rates of minor and major adverse events.ResultsEighty-three cases comprised the final sample (45 preintervention and 38 postintervention). There were no differences in baseline characteristics. The total oral MME (median (IQR)) from discharge through 6 weeks postoperatively was 900 (420–1440) preintervention compared with 300 (112–806) postintervention (p<0.01, Mann-Whitney U test), and opioid refill rates were not different between groups. There were no differences in other outcomes.ConclusionsThis patient-specific prescribing and tapering protocol effectively decreases the total opioid dose prescribed for 6 weeks postdischarge after elective primary spine surgery. Our experience also demonstrates the potential generalizability of this protocol, which was originally designed for joint replacement patients, to other surgical populations.

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Trauma resource pit stop: increasing efficiency in the evaluation of lower severity trauma patients

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2020-000670 ◽

2021 ◽

Vol 6 (1) ◽

pp. e000670

Author(s):

Imad S Dandan ◽

Gail T Tominaga ◽

Frank Z Zhao ◽

Kathryn B Schaffer ◽

Fady S Nasrallah ◽

...

Keyword(s):

Injury Severity ◽

Diagnostic Testing ◽

Trauma Team ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Trauma Patients ◽

Level Of Evidence ◽

Evaluation Time ◽

Retrospective Comparison ◽

Trauma Bay

BackgroundOvertriage of trauma patients is unavoidable and requires effective use of hospital resources. A ‘pit stop’ (PS) was added to our lowest tier trauma resource (TR) triage protocol where the patient stops in the trauma bay for immediate evaluation by the emergency department (ED) physician and trauma nursing. We hypothesized this would allow for faster diagnostic testing and disposition while decreasing cost.MethodsWe performed a before/after retrospective comparison after PS implementation. Patients not meeting trauma activation (TA) criteria but requiring trauma center evaluation were assigned as a TR for an expedited PS evaluation. A board-certified ED physician and trauma/ED nurse performed an immediate assessment in the trauma bay followed by performance of diagnostic studies. Trauma surgeons were readily available in case of upgrade to TA. We compared patient demographics, Injury Severity Score, time to physician evaluation, time to CT scan, hospital length of stay, and in-hospital mortality. Comparisons were made using 95% CI for variance and SD and unpaired t-tests for two-tailed p values, with statistical difference, p<0.05.ResultsThere were 994 TAs and 474 TRs in the first 9 months after implementation. TR’s preanalysis versus postanalysis of the TR group shows similar mean door to physician evaluation times (6.9 vs. 8.6 minutes, p=0.1084). Mean door to CT time significantly decreased (67.7 vs. 50 minutes, p<0.001). 346 (73%) TR patients were discharged from ED; 2 (0.4%) were upgraded on arrival. When admitted, TR patients were older (61.4 vs. 47.2 years, p<0.0001) and more often involved in a same-level fall (59.5% vs. 20.1%, p<0.0001). Undertriage was calculated using the Cribari matrix at 3.2%.DiscussionPS implementation allowed for faster door to CT time for trauma patients not meeting activation criteria without mobilizing trauma team resources. This approach is safe, feasible, and simultaneously decreases hospital cost while improving allocation of trauma team resources.Level of evidenceLevel II, economic/decision therapeutic/care management study.

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Older trauma patients are at high risk of delirium, especially those with underlying dementia or baseline frailty

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2020-000639 ◽

2021 ◽

Vol 6 (1) ◽

pp. e000639

Author(s):

Danielle Ní Chróinín ◽

Nevenka Francis ◽

Pearl Wong ◽

Yewon David Kim ◽

Susan Nham ◽

...

Keyword(s):

Older Patients ◽

Multivariable Analysis ◽

Primary Outcome Measure ◽

Hospital Length ◽

Assessment Tools ◽

Hospital Length Of Stay ◽

Trauma Patients ◽

Level Of Evidence ◽

Increased Risk ◽

History Of

BackgroundGiven the increasing numbers of older patients presenting with trauma, and the potential influence of delirium on outcomes, we sought to investigate the proportion of such patients who were diagnosed with delirium during their stay—and patient factors associated therewith—and the potential associations between delirium and hospital length of stay (LOS). We hypothesized that delirium would be common, associated with certain patient characteristics, and associated with long hospital LOS (highest quartile).MethodsWe conducted a retrospective observational cohort study of all trauma patients aged ≥65 years presenting in September to October 2019, interrogating medical records and the institutional trauma database. The primary outcome measure was occurrence of delirium.ResultsAmong 99 eligible patients, delirium was common, documented in 23% (23 of 99). On multivariable analysis, adjusting for age, frailty and history of dementia, frailty (OR 4.09, 95% CI 1.08 to 15.53, p=0.04) and dementia (OR 5.23, 95% CI 1.38 to 19.90, p=0.02) were independently associated with likelihood of delirium. Standardized assessment tools were underused, with only 34% (34 of 99) screened within 4 hours of arrival. On univariate logistic regression analysis, having an episode of delirium was associated with long LOS (highest quartile), OR of 5.29 (95% CI 1.92 to 14.56, p<0.001). In the final multivariable model, adjusting for any (non-delirium) in-hospital complication, delirium was independently associated with long LOS (≥16 days; OR 4.81, p=0.005).DiscussionIn this study, delirium was common. History of dementia and baseline frailty were associated with increased risk. Delirium was independently associated with long LOS. However, many patients did not undergo standardized screening at admission. Early identification and targeted management of older patients at risk of delirium may reduce incidence and improve care of this vulnerable cohort. These data are hypothesis generating, but support the need for initiatives which improve delirium care, acknowledging the complex interplay between frailty and other geriatric syndromes in the older trauma patients.Level of evidenceIII.

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562. Tocilizumab for the Treatment of Severe COVID-19: A Retrospective, Multi-Center, Case-Matched Series

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.756 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S346-S346

Author(s):

Sarah Norman ◽

Sara Jones ◽

David Reeves ◽

Christian Cheatham

Keyword(s):

Mechanical Ventilation ◽

Length Of Stay ◽

Hospital Mortality ◽

Primary Outcome ◽

Fungal Infections ◽

Hospital Length ◽

Hospitalized Patients ◽

Hospital Length Of Stay ◽

Matched Design ◽

Median Hospital

Abstract Background At the time of this writing, there is no FDA approved medication for the treatment of COVID-19. One medication currently under investigation for COVID-19 treatment is tocilizumab, an interleukin-6 (IL-6) inhibitor. It has been shown there are increased levels of cytokines including IL-6 in severe COVID-19 hospitalized patients attributed to cytokine release syndrome (CRS). Therefore, inhibition of IL-6 receptors may lead to a reduction in cytokines and prevent progression of CRS. The purpose of this retrospective study is to utilize a case-matched design to investigate clinical outcomes associated with the use of tocilizumab in severe COVID-19 hospitalized patients. Methods This was a retrospective, multi-center, case-matched series matched 1:1 on age, BMI, and days since symptom onset. Inclusion criteria included ≥ 18 years of age, laboratory confirmed positive SARS-CoV-2 result, admitted to a community hospital from March 1st – May 8th, 2020, and received tocilizumab while admitted. The primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay, total mechanical ventilation days, mechanical ventilation mortality, and incidence of secondary bacterial or fungal infections. Results The following results are presented as tocilizumab vs control respectively. The primary outcome of in-hospital mortality for tocilizumab (n=26) vs control (n=26) was 10 (38%) vs 11 (42%) patients, p=0.777. The median hospital length of stay for tocilizumab vs control was 14 vs 11 days, p=0.275. The median days of mechanical ventilation for tocilizumab (n=21) vs control (n=15) was 8 vs 7 days, p=0.139, and the mechanical ventilation mortality was 10 (48%) vs 9 (60%) patients, p=0.463. In the tocilizumab group, for those expired (n=10) vs alive (n=16), 10 (100%) vs 7 (50%) patients respectively had a peak ferritin > 600 ng/mL, and 6 (60%) vs 8 (50%) patients had a peak D-dimer > 2,000 ng/mL. The incidence of secondary bacterial or fungal infections within 7 days of tocilizumab administration occurred in 5 (19%) patients. Conclusion These findings suggest that tocilizumab may be a beneficial treatment modality for severe COVID-19 patients. Larger, prospective, placebo-controlled trials are needed to further validate results. Disclosures Christian Cheatham, PharmD, BCIDP, Antimicrobial Resistance Solutions (Shareholder)

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Cardiac Injuries at Estonian Major Trauma Facilities: A 23-year Perspective

Scandinavian Journal of Surgery ◽

10.1177/1457496918783726 ◽

2018 ◽

Vol 108 (2) ◽

pp. 159-163 ◽

Cited By ~ 1

Author(s):

M. Einberg ◽

S. Saar ◽

A. Seljanko ◽

A. Lomp ◽

U. Lepner ◽

...

Keyword(s):

Length Of Stay ◽

Primary Outcome ◽

Major Trauma ◽

Alcohol Intoxication ◽

Cardiac Injury ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Cardiac Trauma ◽

Icd 10 ◽

Overall Mortality

Background and Aims: Cardiac injuries are highly lethal lesions following trauma and most of the patients decease in pre-hospital settings. However, studies on cardiac trauma in Estonia are scarce. Thus, we set out to study cardiac injuries admitted to Estonian major trauma facilities during 23 years of Estonian independence. Materials and Methods: After the ethics review board approval, all consecutive patients with cardiac injuries per ICD-9 (861.0 and 861.1) and ICD-10 codes (S.26) admitted to the major trauma facilities between 1 January 1993 and 31 July 2016 were retrospectively reviewed. Cardiac contusions were excluded. Data collected included demographics, injury profile, and in-hospital outcomes. Primary outcome was mortality. Secondary outcomes were cardiac injury profile and hospital length of stay. Results: During the study period, 37 patients were included. Mean age was 33.1 ± 12.0 years and 92% were male. Penetrating and blunt trauma accounted for 89% and 11% of the cases, respectively. Thoracotomy and sternotomy rates for cardiac repair were 80% and 20%, respectively. Most frequently injured cardiac chamber was left ventricle at 49% followed by right ventricle, right atrium, and left atrium at 34%, 17%, and 3% of the patients, respectively. Multi-chamber injury was observed at 5% of the cases. Overall hospital length of stay was 13.5 ± 16.7 days. Overall mortality was 22% (n = 8) with uniformly fatal outcomes following left atrial and multi-chamber injuries. Conclusion: Overall, 37 patients with cardiac injuries were hospitalized to national major trauma facilities during the 23-year study period. The overall in-hospital mortality was 22% comparing favorably with previous reports. Risk factors for mortality were initial Glasgow Coma Scale < 9, pre-hospital cardiopulmonary resuscitation, and alcohol intoxication.

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Extended infusion compared to standard infusion cefepime as empiric treatment of febrile neutropenia

Journal of Oncology Pharmacy Practice ◽

10.1177/1078155216687151 ◽

2017 ◽

Vol 24 (3) ◽

pp. 170-175 ◽

Cited By ~ 7

Author(s):

Rebekah H Wrenn ◽

David Cluck ◽

LeAnne Kennedy ◽

Christopher Ohl ◽

John C Williamson

Keyword(s):

Febrile Neutropenia ◽

Creatinine Clearance ◽

Primary Outcome ◽

Clinical Success ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Secondary Outcome ◽

Cell Transplant ◽

To Receive ◽

Extended Infusion

Background Extended infusion (EI) dosing provides a longer time above the minimum inhibitory concentration, which is important for the clinical success of β-lactam antibiotics, especially for patients with impaired immunity. The aim of this study was to determine the feasibility and clinical impact of administering cefepime by EI as treatment of febrile neutropenia. Methods This was a prospective, randomized, comparative pilot study. All patients received cefepime 2 g IV every 8 h, with the first dose administered using a 30-min infusion. After the first dose, patients were randomized to receive cefepime over 30 min as a standard infusion (SI) or 3 h (EI). Patients were >18 years old with febrile neutropenia (neutrophil count <500 cells/mm3 and temperature >38.0ºC) and received chemotherapy or stem cell transplant as treatment for malignancy. Patients were excluded for the following: allergy to a cephalosporin, creatinine clearance (CrCl) < 50 mL/min, receipt of concurrent Gram-negative antimicrobial, sepsis, or solid tumor malignancy. The primary outcome was defervescence by 72 h. Secondary outcomes included time to defervescence, clinical success, in-hospital mortality, hospital length of stay, and need for additional antimicrobials. Main results Sixty-three patients were enrolled: 33 in the SI arm and 30 in the EI arm. The groups were similar with regard to age, gender, weight, estimated creatinine clearance, and duration of neutropenia. None of the patients in the EI arm withdrew due to practical complications of receiving EI cefepime. Twenty-three patients in the SI arm and 20 patients in the EI arm defervesced by 72 h ( p = 0.99). There were no differences in secondary outcome measures; however, patients in the EI arm appeared to have defervesced more rapidly (median 19 vs. 41 h, p = 0.305). Conclusion Administration of cefepime by EI for the treatment of febrile neutropenia is feasible. Larger clinical trials are necessary to determine if EI cefepime imparts a clinical benefit in the treatment of febrile neutropenia.

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Continuous Intra-articular Analgesic Injection Versus Continuous Adductor Canal Block in Postoperative Total Knee Arthroplasty

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120s00065 ◽

2020 ◽

Vol 8 (5_suppl5) ◽

pp. 2325967120S0006

Author(s):

Kadchan Limtharapond ◽

AVM Chumroonkiat Leelasestaporn

Keyword(s):

Pain Scale ◽

Hospital Length ◽

Opioid Consumption ◽

Hospital Length Of Stay ◽

Adductor Canal Block ◽

Adductor Canal ◽

Ambulatory Ability ◽

Significant Difference ◽

A New Technique ◽

6 Minute Walk Test

Continuous adductor canal block (CACB) provides effective analgesia after TKA but this technique requires skill of anesthesiologists and equipment such as ultrasonography. A new technique, continuous intra-articular analgesia injection (CIA) is developed recently and found good results. However, effectiveness of these two techniques after TKA is not established. Purposes: We determined whether, after TKA, patients with CIA versus patients with CACB demonstrated (1) decreased pain scores (2) greater ambulatory ability postoperatively (3) decreased daily opioid consumption and hospital length of stay Methods: Between October 2016 and October 2018, 50 patients underwent unilateral TKA at our practice site, whom 50% (n = 25) had CACBs and the others had CIAs. The results were collected in postoperative day (POD) 1,2 and 3. Results: The results were analyzed by SPSS V18 and used student T-test for measurement of mean visual analog pain scale, time up-and-go test, 6-minute walk test and daily total opioid consumption and knee society score. All results show no statistical significant difference between two groups. Conclusion: This study shows continuous intra-articular injection in postoperative TKA is as effective as continuous adductor canal block. It can be used as alternative in postoperative TKA.

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An Evidence-Based Review on Guided Imagery Utilization in Adult Cardiac Surgery

Clinical Scholars Review ◽

10.1891/1939-2095.3.1.22 ◽

2010 ◽

Vol 3 (1) ◽

pp. 22-30 ◽

Cited By ~ 16

Author(s):

Jesus Casida ◽

Suzanne A. Lemanski

Keyword(s):

Cardiac Surgery ◽

Psychological Health ◽

Guided Imagery ◽

Well Being ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Research Quality ◽

Therapeutic Modality ◽

Level Of Evidence ◽

Adult Cardiac Surgery

This article illustrates a comprehensive review, synthesis, and critical appraisal of the research evidence surrounding guided imagery utilization in cardiac surgery. By adding guided imagery in the “usual care” of adult cardiac surgery patients, pre- and postoperative anxiety and pain, as well as hospital length of stay may be reduced. However, in spite of fairly strong “level” of evidence, the limited number of studies and low research quality deter the full acceptance of guided imagery as a standard therapeutic modality in this population. Acute and critical care nurses can offer guided imagery to their patients based on the documented safety of its use and clinically significant findings that it may have a direct impact on patients’ recovery outcomes. Higher quality, methodologically rigorous, and larger-scale studies are warranted to establish the efficacy and standard utilization of guided imagery during perioperative and rehabilitative periods. Future studies should also address long-term outcomes, specifically on physical and psychological health, well-being, and overall quality of life after cardiac surgery.

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