scholarly journals Characterization of hospitalized patients who received naloxone while receiving opioids with or without gabapentinoids

2021 ◽  
Vol 11 (4) ◽  
pp. 225-230
Author(s):  
Payal H. Desai ◽  
Olesya Taylor ◽  
Kunal J. Shah ◽  
Kirk E. Evoy ◽  
Alyssa M. Peckham
Keyword(s):  
Respiratory Depression ◽  
Oral Morphine ◽  
Dose Intensity ◽  
Retrospective Chart Review ◽  
Medication Administration ◽  
Patient Specific ◽  
Analgesic Effects ◽  
Cns Depressant ◽  
History Of ◽  
Specific Factors

Abstract Introduction Gabapentin and pregabalin (gabapentinoids) can be given with opioids for opioid-sparing and adjuvant analgesic effects. In the context of certain comorbidities and high dosages, coadministration of these agents can lead to respiratory depression or oversedation, necessitating naloxone administration. Methods A retrospective chart review from January 2015 to December 2017 was conducted to include patients who received naloxone and opioids with or without gabapentinoids. Exclusion criteria included pregnancy or having received naloxone in the emergency department, intensive care, or pediatrics units. The primary outcome was to characterize differences between groups regarding comorbidities, history of renal or hepatic dysfunction, history of SUD, opioid tolerance, initiation and dose appropriateness of gabapentinoids, and dose intensity of gabapentinoids and opioids. Secondary outcomes were concomitant CNS depressant use and naloxone episodes for documented respiratory depression. Results Of 126 patients who met inclusion criteria, 36 received opioids and gabapentinoids (gabapentinoid group) and 90 received opioids alone (nongabapentinoid group). There were 136 naloxone episodes between the 2 groups. More than 50% of the naloxone episodes in the gabapentinoid group involved opioids of at least 90 oral morphine mg equivalents. Respiratory depression accounted for 39% and 15.8% of the naloxone episodes in the gabapentinoid and nongabapentinoid groups, respectively. Discussion There may be increased naloxone episodes among patients receiving opioids and gabapentinoids. Future studies are needed to evaluate the incremental risk of respiratory depression and oversedation as it pertains to concomitant medication administration and patient-specific factors.

scholarly journals Opioid toxicity due to CNS depressant polypharmacy: A case report

2021 ◽  
Vol 11 (2) ◽  
pp. 70-74
Author(s):  
Christine Lee ◽  
Annabelle Wanson ◽  
Sarah Frangou ◽  
David Chong ◽  
Katelyn Halpape
Keyword(s):  
Respiratory Depression ◽  
Opioid Use Disorder ◽  
Careful Consideration ◽  
Patient Specific ◽  
Chronic Obstructive ◽  
Opioid Use ◽  
Obstructive Pulmonary Disease ◽  
Cns Depressant ◽  
Combined Use ◽  
Specific Factors

Abstract The interaction between methadone and central nervous system depressants can cause serious adverse effects, including profound sedation, respiratory depression, coma, and death. This poses a challenge in the treatment of patients with concurrent psychiatric and substance use disorders as the combined use is often unavoidable. We report a case of a patient with opioid use disorder, mood disorder unspecified, chronic pain, and chronic obstructive pulmonary disease who experienced 2 serious episodes of CNS and respiratory depression due to polypharmacy-induced opioid toxicity. Careful consideration of pharmacokinetics, pharmacodynamics, and patient-specific factors was imperative to identify the suspected contributing medications: methadone, lorazepam, divalproex, gabapentin, and cyclobenzaprine. Cognitive and system factors that contributed to these adverse events and strategies to mitigate risk of recurrence were also identified.

scholarly journals Anesthetic Management of a Patient With Systemic Sclerosis and Microstomia

2020 ◽  
Vol 67 (1) ◽  
pp. 28-34
Author(s):  
Yoshiki Shionoya ◽  
Hatsuko Kamiga ◽  
Gentarou Tsujimoto ◽  
Eishi Nakamura ◽  
Kiminari Nakamura ◽  
...  
Keyword(s):  
Systemic Sclerosis ◽  
Respiratory Depression ◽  
Dental Treatment ◽  
Anesthetic Management ◽  
Moderate Sedation ◽  
Emergency Airway ◽  
Analgesic Effects ◽  
Anesthetic Agents ◽  
History Of ◽  
Skin Blood Vessels

Systemic sclerosis (SSc) is an autoimmune disease that can cause fibrosis in vital organs, often resulting in damage to the skin, blood vessels, gastrointestinal system, lungs, heart, and/or kidneys. Patients with SSc are also likely to develop microstomia, which can render dental treatment difficult and painful, thereby necessitating advanced anesthetic management. This is a case report of a 61-year-old woman with a history of SSc with microstomia, interstitial pneumonia, and gastroesophageal reflux disease in whom intravenous moderate sedation was performed using a combination of dexmedetomidine and ketamine for dental extractions. Both anesthetic agents are known to have analgesic effects while minimizing respiratory depression. Consequently, the increased discomfort caused by opening the patient's mouth and stretching the buccal mucosa was sufficiently managed, permitting an increase in maximum interincisal opening and completion of treatment without complications. Patients with SSc present with serious comorbidities that can negatively impact anesthetic management, so the implementation of an anesthetic plan that takes such risks into account is required. Furthermore, emergency airway management is likely to be difficult in patients with microstomia. For intravenous moderate sedation, combined use of dexmedetomidine and ketamine, which have analgesic effects while minimizing respiratory depression, may be particularly effective in patients with SSc and microstomia.

scholarly journals The Natural History and Treatment Options for Unruptured Intracranial Aneurysms

2012 ◽  
Vol 2012 ◽  
pp. 1-11 ◽  
Author(s):  
Joshua E. Loewenstein ◽  
Shaneze C. Gayle ◽  
E. Jesus Duffis ◽  
Charles J. Prestigiacomo ◽  
Chirag D. Gandhi
Keyword(s):  
Natural History ◽  
Intracranial Aneurysms ◽  
Treatment Guidelines ◽  
Treatment Options ◽  
Patient Specific ◽  
Endovascular Coiling ◽  
Unruptured Intracranial Aneurysms ◽  
History Of ◽  
Specific Factors ◽  
Angiographic Technique

Recent advances in angiographic technique have raised our awareness of the presence of unruptured intracranial aneurysms (UIAs). However, the appropriate management for these lesions remains controversial. To optimize patient outcomes, the physician must weigh aneurysmal rupture risk associated with observation against the complication risks associated with intervention. In the case that treatment is chosen, the two available options are surgical clipping and endovascular coiling. Our paper summarizes the current body of literature in regards to the natural history of UIAs, the evolution of the lesion if it progresses uninterrupted, as well as the safety and efficacy of both treatment options. The risks and benefits of treatment and conservative management need to be evaluated on an individual basis and are greatly effected by both patient-specific and aneurysm-specific factors, which are presented in this paper. Ultimately, this body of data has led to multiple sets of treatment guidelines, which we have summated and presented in this paper.

scholarly journals 296. Description of Super-infections in Hospitalized Patients with COVID-19

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S255-S256
Author(s):  
Geena Kludjian ◽  
Stephanie Spivack ◽  
Stefania Gallucci ◽  
Laurie Kilpatrick ◽  
Aaron D Mishkin ◽  
...  
Keyword(s):  
Chart Review ◽  
Retrospective Chart Review ◽  
Patient Characteristics ◽  
Positive Control ◽  
Patient Specific ◽  
Research Support ◽  
Patient Demographics ◽  
Secondary Infections ◽  
Specific Factors ◽  
True Infection

Abstract Background The rate of bacterial and fungal super-infections (SI) in inpatients with COVID-19 is unknown. In this study, we aimed to identify and describe patients that developed secondary infections while hospitalized with COVID-19. Methods We performed a retrospective chart review on patients admitted to our health system between March and May 2020 with confirmed COVID-19 by nasopharyngeal PCR. We reviewed patients with positive cultures from urine, blood, sputum, and sterile sites. Patients with positive cultures had cases reviewed to determine if they represented a true infection, defined by CDC criteria. SIs were defined as infections that occurred at least 48 hours or longer after the initial positive SARS-CoV-2 test. Additional data was collected on patient demographics, COVID-related therapies, types of infections, and outcomes. Results 902 patients were admitted with COVID-19 during our study period. Of these, 52 patients (5.8%) developed a total of 82 SIs. Tables 1 and 2 describe patient and infection characteristics. Patients identified as having a SI were admitted for a median of 30 days; 56% had mortality, and 39% of remaining patients were readmitted within 90 days. Table 1. Patient Characteristics Table 2. Super-infections Conclusion Overall, the rate of SIs in patients admitted with COVID-19 is low. These patients had a long length of stay, which may be either a cause of SI or an effect. Further analysis with matched COVID-positive control patients who do not develop SIs is needed to evaluate the risk of development of SIs in relation to presenting respiratory status, COVID-related therapies, and other patient-specific factors. Disclosures Jason C. Gallagher, PharmD, FIDP, FCCP, FIDSA, BCPS, Astellas (Consultant, Speaker’s Bureau)Merck (Consultant, Grant/Research Support, Speaker’s Bureau)Qpex (Consultant)scPharmaceuticals (Consultant)Shionogi (Consultant) Jason C. Gallagher, PharmD, FIDP, FCCP, FIDSA, BCPS, Astellas (Individual(s) Involved: Self): Speakers’ bureau; Merck (Individual(s) Involved: Self): Consultant, Grant/Research Support; Nabriva: Consultant; Qpex (Individual(s) Involved: Self): Consultant; Shionogi (Individual(s) Involved: Self): Consultant

Component resolved diagnostics in peanut sensitized children with and without a history of clinical reaction

2020 ◽  
Vol 41 (5) ◽  
pp. 336-340
Author(s):  
Yasmin Hamzavi Abedi ◽  
Cristina P. Sison ◽  
Punita Ponda
Keyword(s):  
Retrospective Chart Review ◽  
Clinical History ◽  
Specific Ige ◽  
Exact Test ◽  
Ara H 1 ◽  
Sige Level ◽  
History Of ◽  
Laboratory Procedures ◽  
Ige Mediated ◽  
The Relationship

Background: Serum Peanut-specific-IgE (PN-sIgE) and peanut-component-resolved-diagnostics (CRD) are often ordered simultaneously in the evaluation for peanut allergy. Results often guide the plans for peanut oral challenge. However, the clinical utility of CRD at different total PN-sIgE levels is unclear. A commonly used predefined CRD Ara h2 cutoff value in the literature predicting probability of peanut challenge outcomes is 0.35kUA/L. Objective: To examine the utility of CRD in patients with and without a history of clinical reactivity to peanut (PN). Methods: This was a retrospective chart review of 196 children with PN-sIgE and CRD testing, of which, 98 patients had a clinical history of an IgE-mediated reaction when exposed to PN and 98 did not. The Fisher's exact test was used to assess the relationship between CRD and PN-sIgE at different cutoff levels, McNemar test and Gwet’s approach (AC1 statistic) were used to examine agreement between CRD and PN-sIgE, and logistic regression was used to assess differences in the findings between patients with and without reaction history. Results: Ara h 1, 2, 3, or 9 (ARAH) levels ≤0.35 kUA/L were significantly associated with PN-sIgE levels <2 kUA/L rather than ≥2 kUA/L (p < 0.0001). When the ARAH threshold was increased to 1 kUA/L and 2 kUA/L, these thresholds were still significantly associated with PN-sIgE levels of <2, <5, and <14 kUA/L. These findings were not significantly different in patients with and without a history of clinical reactivity. Conclusion: ARAH values correlated with PN-sIgE. Regardless of clinical history, ARAH levels are unlikely to be below 0.35, 1, or 2 kUA/L if the PN-sIgE level is >2 kUA/L. Thus, if possible, practitioners should consider PN-sIgE rather than automatically ordering CRD with PN-sIgE every time. Laboratory procedures that allow automatically and reflexively adding CRD when the PN-sIgE level is ≤5 kUA/L can be helpful. However, further studies are needed in subjects with challenge-proven PN allergy.

Comparative Morbidity Profile of Elective vs Therapeutic Neck Dissection

2021 ◽  
pp. 019459982110089
Author(s):  
Quinn Dunlap ◽  
James Reed Gardner ◽  
Amanda Ederle ◽  
Deanne King ◽  
Maya Merriweather ◽  
...  
Keyword(s):  
Neck Dissection ◽  
Surgical Complications ◽  
Chart Review ◽  
Care Center ◽  
Tertiary Care ◽  
Retrospective Chart Review ◽  
Neck Surgery ◽  
Continuous Variables ◽  
Significant Difference ◽  
History Of

Objective Neck dissection (ND) is one of the most commonly performed procedures in head and neck surgery. We sought to compare the morbidity of elective ND (END) versus therapeutic ND (TND). Study Design Retrospective chart review. Setting Academic tertiary care center. Methods Retrospective chart review of 373 NDs performed from January 2015 to December 2018. Patients with radical ND or inadequate chart documentation were excluded. Demographics, clinicopathologic data, complications, and sacrificed structures during ND were retrieved. Statistical analysis was performed with χ2 and analysis of variance for comparison of categorical and continuous variables, respectively, with statistical alpha set a 0.05. Results Patients examined consisted of 224 males (60%) with a mean age of 60 years. TND accounted for 79% (n = 296) as compared with 21% (n = 77) for END. Other than a significantly higher history of radiation (37% vs 7%, P < .001) and endocrine pathology (34% vs 2.6%, P < .001) in the TND group, no significant differences in demographics were found between the therapeutic and elective groups. A significantly higher rate of structure sacrifice and extranodal extension within the TND group was noted to hold in overall and subgroup comparisons. No significant difference in rate of surgical complications was appreciated between groups in overall or subgroup analysis. Conclusion While the significantly higher rate of structure sacrifice among the TND population represents an increased morbidity profile in these patients, no significant difference was found in the rate of surgical complications between groups. The significant difference seen between groups regarding history of radiation and endocrine pathology likely represents selection bias.

scholarly journals Implementation of pharmacogenomic testing in oncology care (PhOCus): study protocol of a pragmatic, randomized clinical trial

2020 ◽  
Vol 12 ◽  
pp. 175883592097411
Author(s):  
Natalie Reizine ◽  
Everett E. Vokes ◽  
Ping Liu ◽  
Tien M. Truong ◽  
Rita Nanda ◽  
...  
Keyword(s):  
Clinical Laboratory ◽  
Drug Effects ◽  
Dose Intensity ◽  
Progression Free Survival ◽  
Clinical Decision ◽  
Drug Dose ◽  
Patient Specific ◽  
Drug Dosing ◽  
Patient Reported ◽  
Dose Modifications

Background: Many cancer patients who receive chemotherapy experience adverse drug effects. Pharmacogenomics (PGx) has promise to personalize chemotherapy drug dosing to maximize efficacy and safety. Fluoropyrimidines and irinotecan have well-known germline PGx associations. At our institution, we have delivered PGx clinical decision support (CDS) based on preemptively obtained genotyping results for a large number of non-oncology medications since 2012, but have not previously evaluated the utility of this strategy for patients initiating anti-cancer regimens. We hypothesize that providing oncologists with preemptive germline PGx information along with CDS will enable individualized dosing decisions and result in improved patient outcomes. Methods: Patients with oncologic malignancies for whom fluoropyrimidine and/or irinotecan-inclusive therapy is being planned will be enrolled and randomly assigned to PGx and control arms. Patients will be genotyped in a clinical laboratory across panels that include actionable variants in UGT1A1 and DPYD. For PGx arm patients, treating providers will be given access to the patient-specific PGx results with CDS prior to treatment initiation. In the control arm, genotyping will be deferred, and dosing will occur as per usual care. Co-primary endpoints are dose intensity deviation rate (the proportion of patients receiving dose modifications during the first treatment cycle), and grade ⩾3 treatment-related toxicities throughout the treatment course. Additional study endpoints will include cumulative drug dose intensity, progression-free survival, dosing of additional PGx supportive medications, and patient-reported quality of life and understanding of PGx. Discussion: Providing a platform of integrated germline PGx information may promote personalized chemotherapy dosing decisions and establish a new model of care to optimize oncology treatment planning.

Vocal Fold Injection Augmentation for Post-Airway Reconstruction Dysphonia: A Case Series

2021 ◽  
pp. 000348942110125
Author(s):  
Mathieu Bergeron ◽  
John Paul Giliberto ◽  
Meredith E. Tabangin ◽  
Alessandro de Alarcon
Keyword(s):  
Vocal Fold ◽  
Care Center ◽  
Case Series ◽  
Retrospective Chart Review ◽  
Pediatric Care ◽  
Voice Perception ◽  
Perceptual Evaluation ◽  
Airway Reconstruction ◽  
Vocal Fold Injection ◽  
History Of

Objectives: Post airway reconstruction dysphonia (PARD) is common and has a significant effect on the quality of life of patients. Vocal fold injection augmentation (VFIA) is one treatment that can be used to improve glottic insufficiency in some patients. The goal of this study was to characterize the use and outcomes of VFIA for PARD. Methods: Retrospective chart review from January 2007 to July 2018 at a tertiary pediatric care center. Consecutive patients with PARD who underwent VFIA, who had a preoperative voice evaluation and a follow-up evaluation within 3 months after VFIA (fat, carboxymethylcellulose gel, hyaluronic acid). Results: Thirty-four patients (20 female) underwent VFIA. The mean age at the time of the injection was 13.6 years (SD 6.1). Twenty patients (58.8%) had a history of prematurity and a mean of 1.8 open airway surgeries. After injection, 29/34 patients (85.3%) noted a subjective voice improvement. The baseline Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) overall severity score decreased by a mean of 5.7 (SD = 19.6) points, P = .12. Total pediatric Voice Handicap Index (pVHI) improved by 6.0 (SD = 19.5) points, from 57.4 (SD = 20.0) to 51.4 (SD = 17.2), P = .09. Functional pVHI subscore demonstrated a significant improvement, with a decrease of 3.4 (SD = 7.3) points, P = .02. All procedures were performed as an overnight observation and no complication occurred. Conclusion: Patients with PARD represent a complex subset of patients. VFIA is a straightforward intervention that may improve voice perception. Many patients reported subjective improvement despite minimal objective measurement. Further work is warranted to elucidate the role of injection in management of PARD

scholarly journals Factors Associated with Clinician Adherence to USPSTF Diabetes Screening Recommendations

2021 ◽  
Vol 12 ◽  
pp. 215013272110165
Author(s):  
Elaine Seaton Banerjee ◽  
Kyle Shaak ◽  
Nicole Burgess ◽  
Melanie Johnson ◽  
Beth Careyva
Keyword(s):  
Gestational Diabetes ◽  
Adult Population ◽  
Correct Diagnosis ◽  
Retrospective Chart Review ◽  
Diabetes Screening ◽  
Factors Associated ◽  
The Us ◽  
History Of ◽  
Missed Diagnosis ◽  
Significant Health

Introduction/Objectives: Diabetes and prediabetes impact nearly half of the US adult population and are associated with significant health risks but may be underdiagnosed. Effective screening may improve diagnosis and give patients opportunity to manage their disease. The purpose of this study was to determine screening rates, identify characteristics predictive of screening, and evaluate correct diagnosis of diabetes and prediabetes. Methods: Retrospective chart review of 71 433 patients eligible for diabetes screening, defined by completing A1c test within the 3-year study period. Results: A total of 31.3% of eligible patients received diabetes screening. Factors associated with screening include older age, female sex, non-white race, Hispanic ethnicity, Medicare or Medicaid insurance, higher BMI, and having a medical comorbidity. History of prediabetes or gestational diabetes were the strongest predictors for diabetes screening, but history of gestational diabetes was under-documented. Of those screened, 10.4% had a result consistent with diabetes and 51.8% had a result consistent with prediabetes. However, 52.9% of these patients had a missed diagnosis. Conclusions: Findings of this study indicate the need for uniform coverage for diabetes screening for all insurances, increased documentation of gestational diabetes to improve screening for patients with this history, and improving accurate diagnosis after screening is completed.

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

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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